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National Health Information System

Partner Institute: 
PRAXIS Center for Policy Studies, Tallinn
Survey no: 
Ain Aaviksoo
Health Policy Issues: 
Neue Technologien
Current Process Stages
Idee Pilotprojekt Strategiepapier Gesetzgebung Umsetzung Evaluation Veränderung/Richtungswechsel
Implemented in this survey? nein nein ja nein nein nein nein
Featured in half-yearly report: G-politik in Industrieländern 6


In October 2005 the Government decided to establish a National Foundation of eHealth to implement the ?Estonian Health Information System (NHIS) development plan 2005-2008? ? a nationwide framework (database) that facilitates the exchange of diffuse health information for all stakeholders within the health system. The strategy has been under preparation since 2000. The total planned investment by central government is over 2.5M Euros, of which 85% comes from EU structural funds.

Purpose of health policy or idea

The main purpose of National Health Information System (NHIS) is to develop nationwide framework (database) that facilitates the exchange of diffuse health information, currently available only in local databases and information systems that often are not able to communicate with each other. The goal is defined as the shift from institution-centered to patient-centered health information system available across the country. The goal is ambitious: the fully functional NHIS should be implemented within 3 years - by the end of 2008.

The NHIS should collect all information concerning health services that an individual receives during the whole life by different institutions within the health care system. The centerpiece of the policy idea is to manage centrally the database of main (critical) health information about all individuals and register of links to additional information that will be stored diffusely in participating organisations' health systems. Separate project within the strategy is to improve health registries - harmonise all existing registries to common principles and establish some new ones (e.g. national injury registry). The Government is also responsible for the development of standards for information sharing and creating a legal framework to balance free exchange and protection of medical data.

The functions that will be facilitated centrally are ordering and filling of electronic prescription, appointment booking, providers' cost reimbursement and reporting, collection of national health and vital statistics, all health registries.

Ministry of Social Affairs is planning to facilitate the implementation through the coordinated development of standards, financial support for adaptation and linking of existing information systems, and massive training. Indirect motivation methods are active PR-campaign and legal incentives to promote the uptake.

Key stakeholders are believed to be health professionals (users) and providers (running cost payers). In order to achieve better ownership by them, public bodies and representative organisations of providers and professionals shall establish a private not-for-profit E-Health Foundation (EHF), which is the implementing agency for the whole strategy (except legislation). EHF will further outsource main development work through international procurement from private sector, which is believed to enhance the efficiency and technological competence.

Main points

Main objectives

Specific aims are:

  • better, faster and more competent health care service for patients;
  • more informed patients, regarding their health data;
  • improved health statistics;
  • reduced paperwork for doctors;
  • easier use of secondary opinion for patients;
  • integrated patient health monitoring throughout health system;
  • good nationwide platform for compatible future eHealth solutions.

Main components of the National Health Information System are:

  • Digital Health Record, containing critical information about all individuals in Estonia;
  • digital appointment booking system;
  • digital prescription system;
  • digital medical image database;
  • digital blood-bank database;
  • national health registries;
  • national medical informatics' standards.

Type of incentives

Ministry of Social Affairs is planning to facilitate the implementation through:

  • coordinated development of standards;
  • financial support for adaptation and linking of existing information systems;
  • massive training of users;
  • PR-campaign;
  • mandatory legal incentives.

Public organisations plus providers' and professionals' representative organisations shall jointly establish a private not-for-profit E-Health Foundation (EHF), which is the implementing agency for the whole strategy (except legislation). EHF will further outsource main development work through international procurement from private sector, which is believed to enhance the efficiency and technological competence.

Groups affected

Providers, Healthcare professionals, Purchasers, insurers


Characteristics of this policy

Innovationsgrad traditionell innovativ innovativ
Kontroversität unumstritten recht kontrovers kontrovers
Strukturelle Wirkung marginal recht fundamental fundamental
Medienpräsenz sehr gering recht hoch sehr hoch
Übertragbarkeit sehr systemabhängig recht systemabhängig systemneutral

If implemented as planned the initiative will be unique in the global context - medical information from birth till death of all individuals of the whole country connected in a single system. However, the final scope of the project is not yet known and there are huge risks involved.

Political and economic background

The strategy is in a way the result of normal development in Estonia, where technological advancement has always been high in political agenda. While very influential political document in Estonia is the formal agreement of ruling coalition, it is noteworthy that last two government coalitions have prioritised eHealth development at national level as means to improve health system efficiency, but also as an important eGovernment application. Also public polls have shown health care as an area where majority of people expect more internet-based and other eHealth applications developed.

National Health Information System has been in all versions of the Ministry of Social Affairs' strategy since 2000 when it was first introduced as part of Estonian Health Project 2015. Additionally eEurope Initiative and eEurope Action Plan by the European Commission have increased the confidence of policymakers in their decisions, although the strategy is not justified by any external demand.

Historically all health care providers have developed their own information systems and so far National Health Insurance Fund has been the main driver for development work, requesting all claims data electronically since 2002. This, for obvious reasons, has caused the information systems in use to focus on claims data processing rather than clinical work process support. Thus, National Health Information System was launched to establish new platform for universal medical and health information exchange between different operators in the system.

Purpose and process analysis

Current Process Stages

Idee Pilotprojekt Strategiepapier Gesetzgebung Umsetzung Evaluation Veränderung/Richtungswechsel
Implemented in this survey? nein nein ja nein nein nein nein

Origins of health policy idea

The idea was first introduced by the Estonian Health Project 2015, which was initially a preparation for the follow-up loan to the first World Bank finaced health system improvement project (1995-2000). Main concept of current strategy dates back to 2000, general features were prepared by 2002, when Estonian Health Project 2015 was terminated and Health Division of the Ministry of Social Affairs took fully over the responsibilities for the entire process. In 2003 separate Department of Health Information and Analysis was established for the practical development of the strategy.

Most active stakeholders have been family physicians and the second largest regional hospital - Tartu University Clinic. Most influencial public promoter of electronic health care information has been Estonian Health Insurance Fund (EHIF), which started developing electronic processing of claims data in 1999 and since 2002 accepts only electronic reimbursement claims from all providers. Since 2002 there are electronic sick leave certificate and electronic prescription in the pipeline; now these are part of National Health Information System initiative.

First individual providers have been developing their own systems since the first half of 1990s. As several attempts to agree on voluntary standards for information exchange have failed most providers have been rather supportive to the idea.

Estonian Health Project 2015 supported Family Physicians' Society in the development of central web-based electronic health record for family physicians, which is now up and running.

The general aim of the National Health Information System is increase the quality of health care provision by enabling safe and accurate health information exchange universally throughout the country. It is not intending to amend an information system of any individual provider, but create standards, central warehouse of links and provide financial assistance to cover the training needs of users (doctors and nurses) and small technical integration cost.

Between 2002 and 2005 several analyses have been mandated by the Ministry of Social Affairs for the preparation of the strategy, including ethico-legal analysis, business analysis and feasibility analysis. All these have described several challenges, that are expected to be solved within the implementation.

Great majority (85%) of the funding for the project is expected from European Commission structural funds, total budget is 2.6M Euros within next 3 years. Even though the Ministry of Social Affairs is responsible for the whole implementation, in October 2005 the Ministry established not-for-profit E-Health foundation together with several hospitals and professional organisations. Additionally all major development work will be outsourced through public procurement process. In October 2005 first state procurements - national medical informatics standards and national information system main developer - were declared. Both are international procurements and signed contracts are expected in January 2006.

Initiators of idea/main actors

  • Regierung: High priority to e-solutions in all sectors, but with unclear strategic priority setting
  • Leistungserbringer: Generally rather supportive to the idea itself, but smaller hospitals much less enthusiastic; universal scepticism about administrative capacity of the Ministry
  • Kostenträger: National Health Insurance Fund has been actual driving engine for all present ICT developments, they are cautious about current strategy
  • Patienten, Verbraucher: Extremely weak representation in the whole process
  • Medien: Media is following carefully everything that is happening in healthcare, also technological innovation is important topic

Approach of idea

The approach of the idea is described as:

Innovation or pilot project

Within institution - Tartu University Clinic (regional university hospital) electronic medical record project (beta-testing in 2005)
Pilot project - Estonian Health Insurance Fund electronic claims reimbursement application (fully operational since 2003)

Stakeholder positions

There is no opposition to the general idea - Estonia and Estonians are quick adapters when it comes to information technology. Main problem for everyone is the means if implementation and the ambiguity of the targets plus lack of clear business model. All stakeholders have their own expectations from the new initiative.

Probably the most sceptical about the whole project are academic professionals. However, in Estonia medical or health informatics as a scientific research area is non existent.

Public polls show great support to all e-initiatives, and improvements in health care using improved electronic solutions is in the very top of people's wish-list. For them it is hope for better access to services and better information flow between different specialists who treat them. However, citicens have not been part of the development process of the National Health Information System project.

Family physicians expect to reduce redundant reporting and paperwork, but also share better information with other specialists.

Hospital managers also expect increased efficiency from improved information exchange and reduced labour costs.

Probably the least enthhusastic group are majority of specialist physicians and nurses - main users of current provider information systems, as they see very little benefit for their practical work. The exception are few specialites (like radiologists) or other enthusiastic doctors, who see the potential in telemedicine. For them the main tool is still the initerface of  their relevant employer's information system, which is not directly part of the National Health Information System initiative. It is expected, that the national system will promote individual systems to develop further, but so far the claims-collection driven system development is keeping the expectations on the practical use of the project for individual physician or nurse rather modest.

In 2004 two separate documents were prepared by the Ministry of Social Affairs: The Vision and The Development Plan of the National Health Information System. These documents form base for the implementation process. They were mostly developed by different IT and management companies, finally discussed in the circle of stakeholder representatives as defined by the Ministry. Also the project was presented in several occasions on professional meetings, but so far public discussion among health professionals has been very modest.

Actors and positions

Description of actors and their positions
Ministry of Social Affairssehr unterstützendsehr unterstützend stark dagegen
Ministry of Economics and Communicationsehr unterstützendsehr unterstützend stark dagegen
Ministry of Financesehr unterstützendneutral stark dagegen
Family physicianssehr unterstützendunterstützend stark dagegen
Hospital managerssehr unterstützendunterstützend stark dagegen
Physicianssehr unterstützendneutral stark dagegen
National Health Insurance Fundsehr unterstützendneutral stark dagegen
Private Insurerssehr unterstützendunterstützend stark dagegen
Patienten, Verbraucher
Patient Representation Societysehr unterstützendneutral stark dagegen
Professional medical publicationssehr unterstützendneutral stark dagegen
Public mediasehr unterstützendunterstützend stark dagegen

Influences in policy making and legislation

MoSA has openly stated, that in order to implement the strategy  according to current plan, it needs substantial changes in legislation, mainly to facilitate free data exchange between participants in the information system, but recognising very high data protection standards for medical information.

Issues like institutional licencing and access granting may not solve major problems with intrainstitutional access to information system, which is out of direct scope for national HIS. So far, willingness and ability to invest into information systems is very different by providers.

Preliminary process of law-making has been started by the Ministry of Social Affairs. It is defined currently as new Health Information Act, but no draft is available as of today.

Actors and influence

Description of actors and their influence

Ministry of Social Affairssehr großsehr groß kein
Ministry of Economics and Communicationsehr großgroß kein
Ministry of Financesehr großsehr groß kein
Family physicianssehr großgroß kein
Hospital managerssehr großsehr groß kein
Physicianssehr großgering kein
National Health Insurance Fundsehr großgroß kein
Private Insurerssehr großgering kein
Patienten, Verbraucher
Patient Representation Societysehr großkein kein
Professional medical publicationssehr großgering kein
Public mediasehr großgroß kein
Ministry of Economics and CommunicationMinistry of Social AffairsPrivate InsurersFamily physicians, Public mediaHospital managersPatient Representation SocietyPhysicians, Professional medical publicationsNational Health Insurance FundMinistry of Finance

Positions and Influences at a glance

Graphical actors vs. influence map representing the above actors vs. influences table.

Adoption and implementation

Adoption of the initiative is dependant on all formal participants (operators) in health care system. Interesting approach by the Ministry of Social Affairs is that together with all development work they also outsource the stakeholder involvement and agreement facilitation process. The board of newly founded E-Health Foundation is expected to become the main facilitation mechanism for different interests of stakeholders. The hope is based on the fact that most stakeholders (except patients) are formally represented in the board.

Until now the details of the implemenation process are not set - they are expected as soon as the E-Health Foundation is operational and main development partner has been selected.

Separate risk for implementation rises from high sensitivity of data protection issues in Estonia. For instance in Estonia no national health registry is allowed to provide data for scientific research without written consent of each individual in the registry. To tackel this the main development partner has to have in their team a PR-expert and sound PR-plan to sell the idea to wide public.

Monitoring and evaluation

It is known from the discussion with the relevant specialists in the ministry that there will be plan for monitoring implementation, but so far it is not publicly available yet.

Major outcome indicators have been defined as "operational electronic prescription system", "operational electronic booking system" etc

Expected outcome

It is not easy to decide on the expected outcome of the whole policy. Main problem is the ambitiousness in one hand and ambiguitiy in the other hand of the whole undertaking.

As the project consists of a series of smaller projects it is highly likely that many of them will reach main gols. Electronic prescription, electronic appointment booking, and digital image archive for instance.

The major component - National Health Information System in its narrow sense - is very complicated and even its scope will be truly defined only after negotiations with the Ministry of Social Affairs and the main development partner.

Biggest risks are uncertain goals and differences in expectations by stakeholders, also legal aspects from data protection point of view.  Additional risks arise from the potential incompatibility of time-frame, scope and planned budget.

The policy is in itself extremely important and valuable. In as sense it is widely accepted that proper use if ICT is one of the main enablers of quality and efficiency improvement in health care. Although it is also stated so in the Vision of National Health Information System, it is not immediatley transferred into implementation plan, and more importantly, is not adequatley supported with commitment by individual providers and health professionals.

Main problems and concerns are related to insufficient administrative capacity in the Ministry of Social Affairs, which is amplified by ambitiousness and ambiguity of the major goals at the same time.

The crucial phase of the project are negotiations between the Ministry and the main developer of the project. In order to suceed the scope, cost, time-frame must be set in balance, proper monitoring process has to be agreed and no individual interest group should try to gain more than is possible within reasonable compromise.

First real assesment can be given within next 6 months after the new institutions (E-Health Foundation) and main developer have started to work.


Sources of Information

  1. Development plan for Health Information System [Tervise infosüsteemi arengukava; in Estonian], Ministry of Social Affairs, December 2004
  2. Vision for Digital Health Record [Digitaalse terviseloo visioon; in Estonian], Ministry of Social Affairs, November 2004
  3. Leego, E. E-Health initiatives in Estonia. Baltic IT&T Review. 2005; 2 (37): 67-69

Author/s and/or contributors to this survey

Ain Aaviksoo

Empfohlene Zitierweise für diesen Online-Artikel:

Ain Aaviksoo. "National Health Information System". Health Policy Monitor, October 2005. Available at