In Estonia, the digital nation, pandemic prompts another round of e-Health innovation – e-Estonia
IT’S A THURSDAY in December, and Madis Tiik is driving along the pine-lined, snowy roads of south Estonia to get to an office in Võru, a town of about 12,000 people, to oversee local physicians’ shift to handling cases remotely. Yesterday he was at offices in Hiiumaa, an island in the Baltic Sea, and Haapsalu, a resort town on the northwest coast, to do the same. Tiik is undaunted by his rigorous schedule because he is an e-Health impresario, someone who helped build Estonia’s e-Health infrastructure years ago, and who has pushed that envelope ever since.
Estonia, nicknamed “e-Estonia,” is renowned as the digital nation, after all. It is known widely for its e-governance solutions, such as i-voting and e-Residency, but it has also been at the head of the pack in digital healthcare too. Residents of this Northern European country of 1.3 million carry a secure digital identity which allows them to access a bevy of online health services, such as ePrescription, where prescription data is entered into a patient’s electronic health records and accessible by a pharmacist on site.
There are also eReferral, eAmbulance, and other offerings. Data is deposited into DigiLugu, a portal where patients and physicians can access EHR data.
All of this infrastructure was in place before the COVID-19 pandemic began two years ago, but most patients still continued to book appointments by phone and visit their doctors at the office, behavior that has been forced to change during the crisis, as people infected with SARS-CoV-2 must be isolated, making it impossible for doctors to manage them any other way than remotely. Making that shift, to providing most healthcare services digitally, has actually proved to be more challenging, even in a country as welcoming to digital solutions as old habits are hard to change.
“All of our digital solutions have been available since 2009,” notes Tiik. “But the working style or process of how we deal with our patients’ complaints is the same as it was before the digital era,” he says. “We are still working as if it’s an analog world and the process hasn’t entirely changed.” This is why Tiik is making the rounds, an evangelist of sorts, helping to assist doctors within his network with moving ever more robustly toward remote healthcare management.
Positive to change
By almost all metrics, the COVID-19 pandemic has had a terrible toll on Estonia. As of December 2021, more than 1,800 people had died from the disease, outbreaks of which have forced several lockdowns, and pushed the domestic healthcare system to the brink, as it has around the world. But if there is a silver lining to this ominous cloud, it has been that Estonian healthcare has had to become even more digital.
Estonia’s deep bench of IT companies quickly went to work to produce a track and trace app called Hoia, for instance, when the pandemic struck. Public-private sector partnerships also delivered a robot for calling patients, that could do within minutes what could take the Estonian Health Board days to accomplish. A health service portal for patients was also rolled out, as was an eBooking app for vaccination appointments, and, last but not least, a vaccination certificate created by TEHIK, the Health and Welfare Information Systems Center, the Estonian Ministry of Social Affairs, and Guardtime, a firm that provides a solution based on KSI blockchain technology.
According to Karilin Engelbrecht, a spokesperson for TEHIK, the Hoia app has been downloaded 293,663 times as of December 2021, and the vaccination certificate 700,000 times.
“I think many countries don’t even have a fraction of these kinds of tools that we have;” says Kiik. “No one has this environment and it’s definitely a big advantage in Estonia. The country’s physicians have also had to adjust their routines to using such applications, as well as learning to work remotely, something that has long been necessary to make healthcare more efficient.
New opportunities
“I am positive about using the crisis to change some things,” says Tiik. “Change is always difficult, but the crisis has given us an opportunity.” Since Estonia already had a digital environment in place, he adds, it hasn’t had to build anything new, only to streamline or add new services. “This is part of the Estonian mindset,” remarks Tiik. “We are flexible and move fast.”
According to Peeter Ross, a professor of e-Health at Tallinn University of Technology, Estonia was better prepared for the pandemic than most countries given the bedrock of its e-health infrastructure. Still, changes in the healthcare system in reaction to the COVID-19 crisis were nearly immediate. Authorities were forced to rethink data flows, for instance, as infectious disease data was previously collected at longer intervals, such as on a weekly or monthly basis, and now there was a demand for nearly hour-by-hour updates on infections and hospitalizations.
“The system was built in a way that wasn’t time-critical,” notes Ross. “Yet because of the ecosystem we have, it was easy to reengineer the data flow and introduce new services based on our e-health infrastructure.”
New workflows
One result was a new workflow where COVID-19 test results would be automatically sent from national laboratories to the country’s health information system so that patients could also access their test results in real-time. Forecasts, calculations, and solutions were also made available via the Estonian Health Board’s Coronavirus Database. Another change that happened was the ability for patients to file for sick leave digitally. Previously, by law, they were required to see a doctor to assert working incapacitation, but that was impossible with isolated patients. “This was implemented almost instantly,” Ross says.
In general, more physicians began to adopt Estonian e-health apps and telemedicine platforms too, some of which had been around for years but hadn’t experienced widescale uptake. That trend hasn’t lasted. “In 2020, telemedicine was bigger than face-to-face medicine,” notes Ross, “but when the lockdowns ended, people returned to more face-to-face contact. “This only proves that we need to change our mentality,” he says. “Digitalization is not a silver bullet. It requires more training of physicians, patient engagement, and empowerment.”
A telemedicine boom? No, and yes.
As with its e-health infrastructure, Estonia also had a variety of telemedicine providers in the market at the start of the COVID-19 crisis, among them MinuDoc, Viveo Health, for synchronous patient-to-doctor video telemedicine; and Dermtest, for asynchronous doctor-to-doctor telemedicine and care management for dermatological conditions.
MinuDoc, based in Tallinn, offers users access to video consultations with doctors via its platform, which was built in line with both local and EU legislation and provides privacy not offered by other platforms like Zoom or Teams. According to Tarmo Pihl, CEO, and founder of the firm, pairing an offering with MinuDoc with Estonia’s electronic health records has unlocked the opportunity to offer health services from anywhere. “This is the future if you consider half of the issues being referred to doctors could be treated remotely,” says Pihl.
Yet adoption was slow and the market was still nascent and dispersed before COVID-19. “The pandemic has been really disruptive,” notes Pihl. “All of a sudden people were in high need of these services.” The greatest shift, says Pihl, has been in perception at the government level, which has warmed to the idea of moving to telehealth platforms. “The state is very inert to changes,” says Pihl. “But in crisis situations, the state starts to look for new solutions,” he says. “COVID-19 has had a positive influence on how these services will be created in the future.”
Rising awareness
“Overall awareness of the need for digitalisation has risen in Estonian healthcare,” agrees Priit Kruus, CEO of Dermtest, which provides a digital toolbox for skin and wound care. “Clinicians understand better what digitalisation means,” he says, “that it is not only about technology but more about process redesign and change management.”
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