Taavi Kotka is the government of Estonia's chief information officer. One of his responsibilities is the ongoing development of eGovernance, Estonia's sophisticated system of public digital services. When asked, he will tell you emphatically, "eEstonia is the way we refer to our eGovernance system. If you want to talk about eEstonia, I am the right guy!"
Mr. Kotka's official title is deputy secretary at the Ministry of Economic Affairs and Communications. He plays a key role in information technology and new digital services for the benefit of Estonian society. He says that the work he does for eGovernance involves "finding new paths where there is no previous experience. No one else in the world has ever done it."
He may well be right.
Far from the traditional centers of high-tech innovation, Estonia is a pioneer in the development and implementation of integrated digital government services. A small, young northern European country on the Baltic Sea, Estonia shares borders with Russia to the east and Latvia to the west. Now a democratic republic, it was once part of the Soviet empire but became independent in 1991 as the Soviet Union faltered and fell.
Estonia has created one of the most successful systems of its kind in the world, offering its people streamlined, online access to services in healthcare, education, banking, elections and business. With a vision as bold and brash as the engineers and government officials who created its Information Technology infrastructure, Estonia brings a degree of integration to its online administrative offerings unmatched anywhere else in the world.
Here is an example of integration at a very practical level, involving medical and administrative digital services: When applying for a driver's license, individuals must pass a medical examination. The results of the exam are automatically sent to the department of transportation, and if the individual is deemed physically able to drive, the doctor signs off electronically. In addition, in the spirit of transparency, the individual can see in his or her data online and see that the doctor has shared the medical decision with Transportation officials.
Estonia's technological achievement impacts many aspects of everyday life, but it is best viewed in two main areas: eGovernance - the administration of government services and regulations; and eHealth - the digital joining together of patients, their medical records, their doctors, hospitals, and other health care professionals.
Estonia, according to Kotak, is creating a nation without borders. To this end, the country allows a measure of citizenship to foreigners living anywhere in the world. The program is called eCitizenship, and benefits to eCitizens include making it easier to start a business or open a bank account. eCitizenship provides access to many other government services, but not voting. Kotak describes eCitizenship as a "digital identity" supported with fingerprint and facial recognition security features. Individuals attempting to create a false identity, however, need not apply - "we authenticate the person on a high level compared to what the bank is doing. We are more secure."
A key component of digital identity in Estonia is the electronic personal identification card. Every citizen is issued a card, and government mandates its use. Artur Novek, implementation manager and architect at the Estonian eHealth Foundation, explains its use: "Wherever I need identification, I can show this card. It has a chip that I can use for electronic services and to identify myself safely." Users are required to enter their PIN (personal identification number) when using the card to access services.
Adds Novek, "I lose my card, nothing happens because the person has to know the pin to use it. I can close down this card. I can call the police to do so." He notes that individuals also apply for the card at the police department.
According to Novek, almost everyone in Estonia uses the identification card. With one million three hundred thousand citizens the nation boasts one million two hundred thousand card users. About twenty percent of the population will use the card on a given day.
A seemingly revolutionary idea, eCitizenship, along with many other innovations, has been invented and implemented in an effort to solve the many problems facing Estonia. Taavi Kotak says, "Estonia's economy is decreasing. We have a negative birth rate. Our population is yearly decreasing by five thousand people. At the same time, we always want to be wealthier and catch up with Sweden and Finland."
eCitizenship is an attempt to encourage new people to come to Estonia, grow the population, and find new trade partners. "Immigration", Kotak asserts, is not the solution. "No one wants to come to Estonia. They either go to Sweden or Norway, because of social benefits. Estonia has no benefits, so it is an obvious choice. We have a limit [one thousand two hundred] on how many immigrants can come to Estonia every year and we never reached that limit."
The goal, he says is to increase the population up to ten million. He believes that by doing so, Estonia's Gross Domestic Product will double. One specific digital innovation cited by Kotak that has helped Estonia's bottom line is the ability of the government to track sales, a program resulting in millions of Euros in revenue flowing into the government's coffers. Through the system, companies declare all sales and purchases over one thousand Euros: "The companies gave all their business secrets to the government. This shows the maturity of the companies and the information culture in Estonia."
Kotak admits, however, that fraud still exists to some degree in cash businesses. "Cash is a problem. We use this system for sums over one thousand Euros. Taxi drivers and hairdressers are not over one thousand Euros. We let them be. Today, most people pay with credit card. We plan to introduce a cash free society."
Another benefit to the economy is the effect of transparency that the eGovernance system promotes. "There is no corruption in Estonia," claims Kotak. Technology, he believes, prevents corruption throughout the country.
Over time, Estonians have learned to trust the eGovernance system because they have seen the results of participation. Getting things done is much easier - even to the extent that, as Kotak tells us, no queues exist in the country. Imagine going to the DMV for a driver's license and not having to wait in line! Estonians have become comfortable with eGovernance, as have entrepreneurs who have seen it working well in the private sector, with eBanking, Facebook, and Instagram. One feature of the system that Kotak believes puts Estonia far ahead of most countries is the practical use of digital signatures for signing off on documents such as applications, medical reports, and business agreements. In fact, according to Kotak, digital signatures have become so commonplace in Estonia that, "If you approach an Estonian with a business contract in paper, they are suspicious. It's all digital. I only sign physically when I have contracts with foreign companies. The rest of Europe has not seen the benefits of digital signatures. They have only seen governments struggling to spend money on huge reforms."
eHealth is the other major initiative in Estonia's system of integrated digital government services. eHealth focuses on the collection and maintenance of patient records, the processing of digital prescriptions, and the collection of health data. The largest eHealth project by far is the electronic health records system. All healthcare providers are required to send medical reports to the system, and the system is accessible to all providers and patients.
eHealth is an outgrowth or extension of the eGovernance system. According to Dr. Ain Aaviksoo, deputy secretary general for eServices and Innovation, Ministry of Social Affairs, and a key player in the strategic development of eHealth, Estonia already had six years of experience with digital services in 2008 when eHealth was introduced. Individuals were already filing their taxes and doing their banking electronically. To the already existing system, engineers added secure logins and IDs.
Initially, just one hospital connected into the system. Others followed, and by 2012 about ninety five percent of inpatient care was covered - plus forty percent of outpatient care. There is less participation, however, among small-scale providers, such as small dental practices where the investment in technology may be prohibitive.
"We built a system based on trust and transparency," says Dr. Aaviksoo. "The public controls their personal data....Users can see who has accessed their data. Users see the name of their doctor or the police officer who has viewed their data. That transparency gives Estonian citizens the feeling of security that their data cannot be misused. I would categorize the eHealth system of Estonia as a trustworthy entity."
He is also certain that patients have developed confidence in the efficacy of the system. Patients now naturally assume that their physicians will have all the medical information they need about them readily available, including the reports of previous visits, detailed diagnoses, visits to any other medical facilities, lab test results, radiology test results, and more. Indeed, doctors can see everything that has been recorded about a patient, and patients and doctors can now base their conversations on the same information.
eHealth stores detailed information on patients' medical procedures as well as laboratory data. Time critical information is also immediately available, including important diagnoses, allergies, recent prescriptions, main operations, and injuries. Pushing the concept of access to critical, time-sensitive information even further, a new emergency system accessible through iPads is available.
Artur Novek explains that each emergency vehicle is equipped with an iPad on which the eHealth program is run. Emergency personnel can obtain the patient records they need while still in the field, extracting information as they work with a patient. The program has been dubbed eAmbulance. The police and the firefighters use a similar system.
All information in the eHealth system is centralized and cannot be altered once the doctor digitally signs the patient record. According to Novek, some information does remain in the individual care providers' information systems. Some also remains in devices and systems not connected to the main system. And some, Novek adds, "is still on paper and in the head of the doctor." Billing information and medical images do not reside in the main system: the Estonian Health Insurance Fund collects billing information and the National Picture Archive collects medical images.
While other nations struggle with implementing a digital prescription system, Estonia has succeeded in setting up a very successful one. According to Novek, when the project began running in 2010, in spite of startup problems, over ninety percent of Estonians used digital prescriptions in the first full year of operation.
Taavi Kotka, Estonia's chief information officer, seems proudest of the digital prescriptions component of eHealth. "ePrescription impacts everybody. Everybody needs medicine at some time. In most countries, you need to go to your doctor to renew a prescription. In Estonia, you can call your doctor for a renewal. The doctor will send the prescription digitally to the pharmacy."
The high level of use of prescription is having a significant impact on society. Kotak cites research indicating that digital prescriptions can reduce the number of abortions being performed, as women needing renewals of their contraceptive prescriptions are more likely to call in their renewal requests than schedule a visit to the physician.
Kotak as observed many changes as a result of ePrescriptions: "The normal thing is that people get well in hospitals, and they do not heal at home. People lack discipline. At the hospital, there is discipline. You need to take your pills. The ePrescription system reveals undisciplined patients. The doctor can view if patients collect their prescription at the pharmacy. Previously, if the patient claimed that the medicine was not working, the doctor might double the dose."
Looking ahead, Kotak sees a time not far away when chips can be placed in every pill, and doctors can monitor every swallow. As he puts it, "If you take the pill, the chip tells the computer that the pill was taken. In the future, doctors can follow the pill. I see that this solves a problem of poor medical adherence. You cannot cheat this type of system. Not only will the doctor see this information. Your family can also remind you to take your medication."
eHealth contains a digital registration function with a central system for referrals and appointment booking. However, according to Artur Novek, usage is low. "I do not know why the hospitals show a low interest in digital registration systems. Perhaps, this is due to the fact that hospitals have their own booking systems. Hopefully in the future everyone will use the central systems."
eHealth allows for the collection and analysis of national health statistics. Data is coded and classified, with restrictions on access to the data and depersonalization of entries making it very secure and ensuring patient privacy. Researchers can then extract any statistics they need, looking at medications, diagnoses, and specific health problems. Artur Novek notes that the system's technologies are now being linked to the Estonian Genome Center where personalized medicine is being researched. Joining health care data with human genome information, and he sees a future where the success of treatments can be predicted and health outcomes improved. He adds, "In five to ten years, we may integrate healthcare statistics with environmental indicators. This can improve our predictive capability. We will be able to analyze how environmental factors impact health on a national level."
Novek believes that the next step to take is to develop and provide decision support systems to patients. Support can include recommendations about appropriate diet, exercise, and other lifestyle choices based on their current health conditions. Patients would be able to view such information in their Patient Portals. Genetic risk assessments could also be factored in to further help patients manage their health.
He is also anticipating progress in one undeveloped area of eHealth: eldercare. Novek's goal here is to integrate social care records with healthcare records. "We work to improve the information about people who live with disabilities. We try to assess their capabilities and send that information to various governmental agencies that are involved in their care." But homecare services lack automatic access to the eHealth system. Doctors of their own volition can open records and share information, he admits, much more must be done.
Dr. Aaviksoo agrees that the elderly are not yet well served by eHealth, and he believes Estonia lacks the funds to develop an eldercare system. "Today, frail elderly people are simply allocated somewhere without thinking about the funding or the responsibility. Instead, we should focus on the patients, the services that this person needs, and how to integrate the relatives." He foresees someday using technologies to avoid institutionalizing people by finding services for the elderly within their own communities.
Along with eldercare, Dr. Aaviksoo hopes for other major improvement in the functioning and uses of eHealth. "One improvement is if we prevent diseases instead of measuring how well we treat them. Another improvement is if we stop viewing patients as objects and rather see them as masters of their own health. We need high patient engagement. These changes are the measure of true successes."
When this writer asked for a tour of Novek's own eHealth patient portal, he was happy to oblige. The portal features a very secure log-in, with keys for signature and identification. As we view his information, we see that Mr. Novek is insured, the name of his family doctor, and the fact that he has given other family members access to his patient information. He, in turn, has been granted access to his wife's information. No permission is needed, he tells us, to enter his daughters' portals. He shows us his portal's Logbook where he can see the names of everyone who has accessed his patient record.
He has the option to close down individual documents or even his whole record to doctors, but he doesn't really explain why someone would want to do that The Portal also displays details his correspondence history. It shows a request he made for some documents from his doctor, the results from an x-ray. As he explains: "I had the x-ray at the West Central Tallinn Hospital. The hospital sent my results to my family doctor. I could view these results."
Other links from the main page allow him to consent to blood transfers and organ donations. We can see the medical certificate allowing him to have a driver's license, his reported health status, active prescriptions, vaccinations, and immunizations. Inactive prescriptions are also available, dating back to 2009.
He shows us how to add commentary to his Patient Portal dashboard. For example, if he is feeling sick, he can report the symptoms to his doctor, who can then add them to his medical record.
He mentions that one thing he cannot do is book appointments with his doctor. The portal does, however, provide links to doctors' websites where he can book appointments. Nor can Novek, on his own, correct mistakes in his medical records. As a safety measure, once the patient record has been digitally signed, the information is locked. The patient must request of the doctor to change the incorrect information.
So Far, So Fast
How has Estonia been about to accomplish so much in so little time?
Artur Kotak has a succinct answer: "We have no legacy policy. A legacy policy is a policy that is difficult to change because it has been a policy of the past. That is something that all the Western Europe countries and the United States are struggling with."
As Dr. Aaviksoo, explains, Estonia, upon independence from the Soviet Union, was determined to leave behind the antiquated ways of the Communist system and start fresh, building a new, modern society. "In 1991, Estonia regained independence," he tells us. "At the same time, the Internet was born. The Estonina people wanted to leave everything old behind. At the same time, everything that was new was instantly considered beneficial. We skipped checkbooks for electronic banking. We skipped copper wiring. We immediately used light cable. Mobile phones were rapidly adopted.... We had the opportunity to start anew. Many people worked in the public sector with great enthusiasm.... From the beginning, we decided to integrate information technology across different departments. We did not even have different departments when we started! Everything was managed from the Office of the Prime Minister."
The public and private sectors agreed enthusiastically that building a technologically-advanced country would benefit the whole of society. The private sector, according to Dr. Aaviksoo, even paid to train citizens how to use the new eBanking system, thus opening new business opportunities for business.
Regarding the eHealth initiatives, he attributes their rapid development to the young age of Estonia's government ministers -- many people in high positions under the age of forty. With youth came the propensity for bold decisions. When he began working on eHealth, he says, "Estonia was the only place on the planet where the government could immediately start to work at a large scale."
"Today," he adds, perhaps thinking back to the days of Soviet domination, "we live in a transparent society. With eGovernance, no political party can take over the whole country."
William A Haseltine is Chair and President of ACCESS Health International. This article is based on interviews in Estonia conducted by Sofia Widen of ACCESS Health International with Taavi Kotka, Artur Novek, and Dr. Ain Aaviksoo. The full interviews are available on the ACCESS Health website www.accessh.org.