Temperature rising: eHealth heats up

Photo: Liis Treimann

Freshly out of his job, Estonian eHealth Foundation head Raul Mill accuses social ministry in hammering on with a reform potentially in violation with law. The ministry thinks the only way to make eHealth work is grabbing the wheel.

«I cannot agree with the changes offered by social ministry, somewhat unilateral and occasionally not quite according to law,» says Mr Mill to explain why he resigned this week after four years in office.

Mr Mill overflows with criticism. Though the state had delegated a number of tasks to the foundation since 2005, he claims, the social ministry now wants to grab part of these. A plan by the ministry’s vice chancellor Ain Aaviksoo would strip the foundation of all strategic planning and leave with IT-specialists only. Meanwhile, a strategic e-services council would be created at the ministry complete with a development team. Even Mr Mill sees the need for the former, while development and project management might still remain at the foundation.

On top of that, the ministry has sent into Riigikogu a proposal to cut 22 percent i.e. half a million euros from the foundation’s next year budget. And also, there’s the precept to lay off fifth of staff.

More than the cuts, Mr Mill is disturbed by the essence of the issue. Firstly, the state is in a valid contract with the foundation and such robbing of tasks would violate that. «Such a unilateral change, should it happen, is not quite correct legally,» says Mr Mill. The more so that the foundation’s founders also include doctors and hospitals and Mr Mill says that Aaviksoo has not sufficiently consulted with the representatives of the latter in the council. Mr Mill says the abrupt steps are not supported by Estonian Union of Medical Emergency and Estonian Hospitals Association, to list some.

Quality endangered

Mr Mill says users of the service will lose out because when ordering medical e-services and business management is handed to the ministry, there will be a danger of the quality of service going into decline. «Ain (Aaviksoo – O. K.) is an excellent visionary and creator of concepts. But there is room for development in the more detailed planning of the changes, and in reaching joint agreements. The details have not been thought through,» says Mr Mill.

This Tuesday, he even sent a letter to Riigikogu social committee chairman Aivar Kokk (IRL), asking for an analysis if the dangerous game played by the social ministry is worth risking the e-services.

The standoff comes with a peculiar undercurrent dating back to 2011. Few know that Ain Aaviksoo also run for eHealth head as a rival to Mr Mill. Both made it to the final rounds and the council ended up selecting Mr Mill. Mr Aaviksoo’s moment arrived in December 2014 as a selective committee for top managers picked him the e-services vice chancellor at social ministry i.e. essentially the new boss of Mr Mill.

And indeed, since this May, as chairman of the e-Health Foundation, Mr Aaviksoo has laboured hard to bring about change. As this Tuesday the government confirmed the new e-strategy, the controversy between the old competitors Mr Aaviksoo and Mr Mill peaked.

«In the distribution of roles between social ministry and the foundation we had such differences that an effective cooperation would have been complicated,» admits Mr Aaviksoo. But he rules out any revenge or even finding any faults explicitly with the job Mr Mill was doing.

The matter being complex, we need to travel back in time. As we know, the low key sounding eHealth Foundation was established in 2005 by social ministry, hospitals and doctors so as to form an independent competence centre for developing and applying medical e-services. While new e-services have mushroomed, most are not too handy to use or are not compatible among themselves.

Rather recently, only the digital prescription was in active use in Estonia. Use of digital health file and digital picture has been meagre, and since its birth the digital registration has failed to function. The latest example is the e-ambulance – the idea being that the patient’s information reach a doctor at a hospital before the ambulance arrives with the individual.

«The e-ambulance existed in the vehicles and with the brigades, but that it also reach the screen of the doctor at the emergency medical department in the hospital had been left out of the project. There are many such examples. Again, we may find fault with the components not added thereto,» said Mr Aaviksoo.

The stones got a-rolling in 2014 as National Audit Office passed a severe judgement on Estonian eHealth. In its report, it gave two main pieces of advice: bring development of strategies under social ministry competency, and halt the development of new e-services until the old ones have been fixed.

«The need for this change has been confirmed to me since the day I stepped into office,» says Mr Aaviksoo. He will not deny that a lot is on the balances: the government demands decent development and is ready to support financially. During the next five years, the plan is to boost investments into e-healthcare to €20m a year. «Spending such money is only justified if we will be able to show where we will have an at least fivefold return financially,» said Mr Aaviksoo.

Time saved

The economy would come from managing to save time spent by patients and doctors via e-services. For instance, a trend among the five in the strategy would be all kinds of remote services up until patients having sensors attached at homes sending doctors real-time info. The aim is to adopt at least one new e-service a quarter starting next year, or update an existing one.

The directives on how to reach the goal are contained in a fresh e-health strategy. The initial step prescribed is the very reorganisation of management. «If e-health technology and policy are developed separately, the split will only grow. Therefore, the change is very forceful,» explained Mr Aaviksoo.

It is impossible to explicitly state who is right in the situation created. An expert consulted by Postimees said that over time the eHealth Foundation council has developed into a kind of an abscess, and the conflicting interests in it are what actually applies brakes on development of e-services.

The main puppeteers in the council are the major hospitals fighting for the market and lacking the desire to develop certain e-services. Primarily, we are talking about such services as might boost the competition, increase working load for doctors, or give the patients more say. An example of that would be the digital registration, or an option for patients to assess quality of medical help received. A failure by Mr Aaviksoo to alter that and a flop of the strategy might fell and kill Estonian eHealth.