E-health equals endless clicking

Arstid operatsioonisaalis.


When will patients finally be delivered from the yoke of phone-calls to get to see a doctor? When will pan-Estonian digi-registration kick into gear? No-one dares to say.

While a IT-savvy surgeon of North-Estonian Regional Hospital (PERH) walks the facilities iPad in hand and surfing along in the colourful «computer game» of operation shots and research results while cooking up fresh solutions with the technology staff, all-Estonian e-health databases snail ahead like glaciers. 

The eyes of Raul Mill, board member at Estonian e-Health Foundation, light up as he draws mental pictures of doctors showing patients full-colour shots of their lungs, explaining how the picture might change if the dear man will get treatment and change his unhealthy habits.

«The same picture would go to the digital health history, and at home the patient, Jüri Tamm for instance, could open it up again and even share it with friends,» says Mr Mill, deeply e-dreaming by now. No semi-Latin chat anymore, grasped by the rare occasional patient.

In reality, things are a far cry. From the patient portal in use for long years, computer screens of patients (and any medical institution) will draw just some fragmented references to the patient’s health data. The pages could feature referrals, research results and what not; instead, one beholds a gaping hole. True – over the past few years, data transmission had done some decent development, but not all doctors are uploading all data prescribed by law. 

Mr Mill mentions a huge percentage concerning data that is to be found at the central information system. «Still, though with in-patient treatment it is 97 percent of all cases, then with out-patient treatment perhaps one doctor in three will actually send the data [to the system],» says he.

Outdated aims

At a recent University of Tartu Hospital conference, National Audit Office (NAO) performance audit expert Liisi Uder said the «issue is who owns the data».

«One of the peculiarities of Estonian health-care is that a patient does not move much; he usually only attends one health institution and is tied to that. And that institution is not overly interested in passing on the data,» said Ms Uder.

Ms Uder recalls an idea expressed by a hospital chief at a discussion of a NAO audit, a person exceedingly critical of e-health, that a patient may be in Tartu and a doctor in Pärnu does not need these data. «But the data belong to the patient and should be available at e-Health at any moment,» said Ms Uder.

Ms Uder shot an arrow of accusation towards social ministry – the ministry ought to explicitly require that e-Health options be used. «Social ministry, if willing, could get a whole lot done,» she said.

A whole host on e-Health solutions are being developed. NAO has advised to postpone the influx of new projects, and to take some to a tangible result – one that works. Ms Uder says the advice is now being followed.

According to Mr Mill, the curse of e-Health is that several large projects are «historic».

«They begun years ago and the initial requirements are not what is needed today; at places, the needs and what has been accomplished have not been sufficiently analysed,» said he. «E-Health development was launched in 2006, based on the premise of getting the central solutions ready and hand these over to be used; didn’t work. Now, all parties to the system are being involved. What also needs to be definitely considered is the application costs related to development of information systems of hospitals and family doctors, and to changes of working procedures.»

Mr Mill brings the example of specialist associations which tend to have very detailed desires regarding patient data that needs to be written down to cure him well. But when all the desires get included in e-solutions and a doctor needs to daily fill them, a shock hits. «When does one communicate with patients, having such loads of data to be put into the computer?» as the doctors doing their daily jobs.

In health care, there are multiple players involved; the larger hospitals have developed e-solutions of their own, which are increasingly used and within the hospital in its daily work, while constantly developed and updated. So far, there has not been much interest towards sharing their data and knowledge with others.

A good example of that would be the medical research picture bank, initially created separately by the two biggies – PERH and Tartu University Hospital, and then combined. Meanwhile, e-Health Foundation has created a central digital pictures system, to which a reference can be sent regarding medical research with a short description of research results.  

Currently, 80 percent of shots sit in the picture bank of the two big hospitals, and it has been decided that the very bank will be collecting all pictures taken in any medical institution. Pictures will not be collected at e-Health, but since this autumn it is possible, via health information system and the documents therein, to view all X-rays based in picture bank. 

Oceans of digital data

Experience shows digital solutions have been really clumsy for doctors to use. «Why must a doctor do so much clicking?» says Mr Mill of e-Health Foundation citing a question weighing on doctors, daily. 

«A doctor needs to log into his system, make an inquiry in the digital history, and in the worst case scenario receive the answer that the document isn’t there, or that the doctor has already had a look and ought to know by now. Or, on the screen there appears a summary of ten health files (the epicrises), and in order to what these say all need to be separately opened. Or the doctor may make an inquiry into the picture bank and again get a long list where every item needs to be clocked to find what is needed. We are working to have the doctors at once see what is vital on the screen,» he says.

According to PERH neurosurgeon Kahro Tall, the availability of  the need for data over Estonia, greatly varies specialty-wise. «My specialty, for instance, is very small; we have six-seven doctors in North Estonia and we treat two thirds of patients who come to us, and their data comes to our database anyhow,» said Mr Tall. «I have no urgent need for information whether anything had been done to my patient in Narva.»

Mr Tall noted that the database used is quite outdated, slow and time-consuming; in it, everything is carefully written down, but there’s too much froth for practical work.

«We have huge amounts of digital data – all is written down from the instant the patient steps in the hospital door. It is difficult to get data to analyse a patient and to get the dynamics. One has to click a lot and search under various dates,» described the surgeon.

He added that in PERH they are trying to make it all simpler and faster; to the point that in analysis it stands out in red colour where results differ from the norm.

Mr Mill said a solution of this sort has also been developed by a medical council, working at the e-Health Foundation since last year – to better show summaries of in-patient treatment.

«This can be applied after e-Lab will go into use, when analysis results will be collected in numbers, not texts as they are now,» he explained.

Essentially the same was said by PERH’s IT-chief Marko Kilk. «Looking at epicrisis: events appear at a totally random moment; we do a summary and send it someplace. But it could be that as new info comes and is vital for someone, we would post it to him,» said Mr Kilk.

Both Mr Kilk and Mr Tall underlined that the ability and willingness of doctors to use the contemporary IT-solutions is ever increasing, and that the age of a doctor matters not.

«What do you think: what do the kids of the doctors give them for birthday? iPads!» said Mr Kilk, hinting at a way an elderly doctor may make friends with a tablet computer – an item from another world.

Central digital register saga

A lot of resistance and controversy has whirled around creating a central system to book a doctor’s appointment. The option would mostly be important for patients, to have an easier time getting the «doctor date» and to be spared making the endless phone-calls.

Through a central e-registry, a patient would find the fastest and most suitable reception in any Estonian hospital. The information flowing through the system would also be important for Health Insurance Fund, to objectively assess how severe the lack of available receptions – for instance.

«Technically the solution is ready for centralised uploading and booking of the appointments; even so, the hospitals and other parties think this will not work before e-referrals start working,» said Mr Mill. «Therefore, we have been unwilling to do additional e-developments, not to waste money.»

With some hospitals, family doctors or even patients do have the option to book medical specialist appointment via digital registration. Mr Mill named West Tallinn Central Hospital, Tallinn Children’s Hospital, and PERH. «It used to be possible at East Tallinn Central Hospital, but at the moment they are developing a new booking system,» he said.

Probably, one day the central digital registering will come. In how many years, no one dares to tell. E-Health and Health Insurance Fund have ordered an analysis regarding tasks and functioning of digital registering. The two have agreed with hospitals, family doctors and social ministry that the prerequisite for digital registering shall be overall use of e-referrals and e-consultation. At the moment, the two prerequisites are slowly edging along.