Estonia has only 1,3 million people, but is famous worldwide for its digital governance. Healthcare wise, 95% of healthcare data is in digital form, some of it supported with blockchain technology.

What does all this mean — is data structured? How supportive is the system for digital health startups? And how did the country, where only 6.5% of the GDP is spent on healthcare, achieve the level of digitization many countries only dream of?

The answer is relatively simple: Estonia had a forward thinking government in the nineties. “For example, fax machines were never used, because we went straight to digital solutions,” explains Hannalore Taal, Chief eHealth Specialist at the Estonia Ministry of Social Affairs.

Listen in iTunes, Stitcher or Podbean.

Since 2008, Estonians have electronic health records, which they can access online. For comparison, the first efforts for nation-wide EHRs in the US hardly began around that year.

At the moment, 95% of health data in Estonia is digitized. All citizens have an online health record and physicians are by law required to transmit the data to the record, so every doctor has access to time critical data of patients such as diagnosis, vaccination, allergies, treatment, pregnancy.

While healthcare data management seems impressive, a lot of documents are still stored in pdf formats, which makes analysis harder than it would be if the data were in a structured format. Analysis to measure national healthcare trends cannot be done in real time but is done retrospectively.

“The hope is, that with machine learning data analysis will be faster. For cases such as influenza tracking in the winter, the National institute for health development is investigating health data directly from GPs databases, not electronic healthcare records,” says Hannalore Taal, who has a Master’s degree from the Tallinn University of Technology in Healthcare Technology, and started her career in the healthcare sector as a physiotherapist. Seeing the possibilities of helping larger populations of patients with digital solutions, she began looking at digital health from an entrepreneurial perspective as well. She is currently a part of the team of a startup called Cognuse, which provides online speech therapy. As in many other countries, the startup was facing a lot of challenges in sales and scaling due to lenghty processes and demands for healthcare apps. A positive shift occured when the team started positioning the app as an educational tool, with the direct to consumer offers for teachers and kinder-gardens.

The digital health startups options

The good digital infrastructure and the national forward-thinking mindsetv offer healthcare startups in Estonia a few opportunities. For one thing, they can approach the health insurance fund for evaluation and reimbursement on tenders announced a few times a year. Connected Health Estonia is an ecosystem builder, connecting healthcare institutions, healthcare insurance fund. It funds startups who have a proof of concept but perhaps lack scaling in practice. Same as researchers, healthcare startups can get access to anonymized patient data stored in electronic healthcare records, but only with an application through the ministry.“The process is quite lenghty and unfriendly at the moment, but eventually, a system enabling patients to give consent for sharing their data with third parties, will be put in place,” says Hannalore Taal.

Estonia KSI blockchain is used to mitigate internal threats to data. “All actions leave a trail, and patients can see who was accessing the data. If an access of a worker can’t be justified, measures follow.”

The state of healthcare

The state on digitization is impressive in Estonia, especially in light of the low budget for healthcare (6.5% of GDP), which can in some countries be named as an excuse for lack of investment in national digital infrastructure.

However, the country is facing similar public health issues as other countries.

According to WHO, deaths from cardiovascular diseases have fallen sharply, but along with cancer and external causes remain the leading causes of mortality. The proportion of people reporting that they are in good health is among the lowest in the EU, with the largest gap between rich and poor of any country. Estonians of all incomes face high levels of unmet need — highest in Europe — Only 0.7% of Estonians report costs as a barrier to access, and the same small proportion cites geographic reasons. In fact, waiting lists are the cause of unmet medical need (11.3%) and seem to impact on lower and poorer income groups. They were ‘run up’ in the aftermath of the financial crisis as a deliberate policy but also reflect on wider issues such as poor care coordination, misaligned incentives in primary care and poor linkages with social care.

As mentioned by Hannalore Taal, quality of life is a problem for many, and access to care is especially worse in remote areas. Digitization predominately serves younger, tech-savy generations. The elderly could benefit from adapted solutions such as phone call and message based reminders an information. One of the solutions with an impact to everyone though, is the drug-drug interaction checker which helps identify potential unwanted interactions.

Learn more by listening to the full talk in iTunes, Stitcher or Podbean.

Some questions addressed:

• - 95% of health data in Estonia is digitized — what format is the data in, is data structured, can it be analysed?

• - How is blockchain incorporated and how do you see the vibrant buzz around blockchain in healthcare, which was especially strong last year?

• - In an emergency situation, a doctor can use a patient’s ID code to read time-critical information, such as blood type, allergies, recent treatments, on-going medication or pregnancy. The system also compiles data for national statistics, so the ministry can measure health trends, track epidemics, and make sure that its health resources are being spent wisely. How does that work — in what format is personal information included in national statistics? How do you protect privacy? Is data anonymised first before reaching national statistics, etc…?

• - Estonia was the first country in the world that has implemented a nationwide EHR system in 2008, registering virtually all residents’ medical history from birth to death.” Is this statement correct and if so — how did you dealt with digitizing existing paper records from the past? Let me elaborate a bit further: most paper systems that are embracing EHRs now, will not be transforming past paper records in the digital ones, only new information will be digital.

• - How does the strong digitization help population health since while Estonians have witnessed the strongest gains in life expectancy of all EU countries, particularly after age 65 but these years gained are spent in worse health than elsewhere in the EU?

• - The national healthcare system is progressive in digitization: how does that translate in the innovation ecosystem. Can companies access any of the national data, how is innovation encouraged for startup development, etc.?