Guardtime, Nortal, Helmes. Based on the names alone, you wouldn’t know that these vibrant multinational tech companies have rather humble Estonian origins. Their histories stretch back decades and were, at least in one case, dreamt up by a couple of ambitious software developers.
Yet, in many ways, they are increasingly not Estonian at all. Guardtime’s headquarters these days are in Lausanne, Switzerland, and the digital security company has offices from Berkeley to Singapore. Nortal is run from Tallinn, but in the past few years, it has acquired subsidiaries in Seattle and Düsseldorf. And Helmes, the Tallinn-based business software alchemists, maintains offices in Belarus, India, and Latvia, with consulting boutiques in San Diego and New York.
Estonian tech has been branching out vigorously, and part of its core offering is e-health services.
Guardtime, for instance, has fashioned its KSI blockchain technology to support a solution called real-world data (RWD). RWD enables healthcare data to be used in clinical trials and personalized medicine in an aggregated, anonymized way, leapfrogging many legal and technical limitations.
Nortal has recently worked with partners in Germany and the United Arab Emirates to craft SimplyGO. This application will allow airlines and immigration officials to check a traveler’s COVID-19 status before their trips. Helmes is building hospital information systems together with partners in Scandinavia and Asia. Estonian e-health is going very global. But why?
A confluence of factors
“It’s a confluence of several factors,” said Taavi Einaste, a partner at Nortal and CEO of its new German subsidiary in Düsseldorf. “We cannot ignore the fact that we are relatively small, and healthcare is relatively centralized,” he said.
In federated countries like Germany, where policies are often set at the state level, and healthcare systems operate independently, upgrading to e-health solutions is a cumbersome, painstaking process. There are many meetings, much deliberation, but Estonia’s ease in implementing its solutions is absent. It will take time for similar systems to be available in Germany or the US, for that matter. There are legal hurdles to overcome, variabilities in data collection.
“I think it’s more complicated than it’s made out to be,” said Einaste of implementing e-health. “When people say that it is complicated, it is difficult to convey how complicated it really is.”
The Estonian experience
The Estonian experience though has encouraged companies like Nortal to keep on pushing. The company, which is also widely known for its e-governance offerings, can develop e-health solutions for customers no matter where they are based. In the past five years, especially, it has intensified its e-health outreach. Estonia certainly has the experience to share, with a system based on centralized electronic health records accessible by most clinicians and patients using digital identity cards. Underpinned by Guardtime’s KSI blockchain digital security technology, data is both dispersed and uniformly accessible, ensuring its safety, validity, and its accessibility.
Yet making the Estonian experience accessible to others is not simply a copy/paste job. One does not simply dispatch three Tallinn technicians to Tokyo to digitize Japanese healthcare overnight.
“I have seen so many presentations where someone has talked about the Estonian way, how it is so perfect, and how you should do it the same way, and you can see how it really kills the vibe,” said Einaste. “In reality, circumstances are different, political realities are different, legal realities are different and cultural attitudes are different,” he said. “I don’t think there is any place on Earth where people can do the same exact thing.”
There is no Nortal project, therefore, that has been completely modeled on the Estonian system. Everything is customized for the particular user. In Finland, Nortal has worked on digitizing hospital records, while in Germany, it works to make healthcare data available at a national level. The company has been at work, for instance, on introducing an e-prescription service in the federal state of Hessen, which may lay the ground for a German way of offering such a service. There is also, of course, the SimplyGo app, crafted with partners in Germany and the UAE.
“We sell the Estonian experience,” noted Einaste, “but we don’t sell Estonian solutions.”
A unique worldview
At 46, Ain Aaviksoo, CMO of Guardtime, has seen the entire Estonian digital health story unfold. In the late 1990s, he worked as a medical doctor, and he also served as undersecretary for e-services and innovation at the Estonian Ministry of Social Affairs for several years. The real historical transition, in his words, occurred in the early 2000s, when funding became available to support a new e-health program. By the latter part of the decade, Estonia had established a health information system and an ePrescription service. Yet much of it was based on X-Road, the software backbone of Estonia’s e-services, meaning the building blocks were already in place.
“The Estonian e-health system takes advantage of X-Road and the overall Estonian digital public administration,” said Aaviksoo. “There wasn’t anything like that anywhere else in the world.”
From the get-go, though, the Estonians focused on data integration, making information in one place available in another. “We have the full care continuum, available to all healthcare workers,” noted Aaviksoo. “All documents are visible to both healthcare workers and patients, too,” he said. “That was coded in the DNA of the Estonian e-Health system right from the beginning.”
First real-world data …
Guardtime has been around for two decades now, yet e-health has been a specific business offering for just the past five years. Aaviksoo himself came on board in 2018, and the firm’s real-world data solution has been in development since roughly that time. It enables information from sensitive clinical records to be made visible in an aggregated form to pharmaceutical companies and payors without breaching privacy rules. This will allow drug developers to bypass some of the clinical trial processes’ more arduous steps: obtaining data and consent for its use.
“Indeed, we are preparing the first implementation in Sweden for finding patients,” said Aaviksoo. “With the real-world data engine, you can send your query to the datasets, then send requests to patients who meet the criteria. If they respond, you can start the trial quickly. Usually, this is done through a doctor. It costs a lot of money, and it is quite tedious.”
… then the WHO comes calling
Guardtime is also collaborating with the Estonian government and the World Health Organization to pilot a digital vaccination certificate program. The government and the WHO signed a memorandum of understanding just last week. The envisioned secure certificates would enable custom officials to assess the validity of documents that prove immunity to COVID-19. Rather than querying a centralized database, customs officials will simply check the digital vaccination certificate’s validation signature by a traveler. The ambition is to have such a system rolled out across Europe, and a pilot study will soon begin.
“Since the service to provide these kinds of certificates is available, we claim that within three to six months, all of Europe will use these kinds of certificates,” said Aaviksoo. “Instead of playing bingo as to what country you can visit based on infection rates, you can put in place rules that are based on individual risk rather than very arbitrary and generalized geographical risk.”
‘A successful Scandinavian country’
“What is the inspiration for all this? How did it all start? We wanted to be a successful Scandinavian country, but had fewer resources than our Nordic neighbours.” This is how Kristi Pool, a partner at Helmes, who is responsible for e-health solutions worldwide, explained Estonia’s digital health infrastructure development. She noted that the Estonian state’s smaller budgets in the early years led policymakers to turn to digital solutions. They could not afford the public sector largess of neighboring Scandinavian countries. “We wanted to have a world-class country, but even today, we don’t have so many public servants to take care of people,” said Pool. “This was responsible for all of these digital leaps.”
Helmes is responsible for the digital prescription system, which is one of the most ubiquitous of Estonia’s e-health services. Rolled out in 2011, it allows anyone holding an identity card to walk into any pharmacy and access their medicine without any need for a written prescription from a doctor. The service remains Helmes’ most widely known offering, even though there were some hiccups initially.
“When we launched it, it crashed immediately,” noted Pool. “No one in Estonia, public servant or analyst, could have predicted that on the day when pensioners received their pensions, the first thing they would do would be to go to the pharmacy.” After some fine-tuning, the system was upgraded and has worked since.
Spreading good karma
These days, Helmes is involved in telemedicine projects in Norway and Sweden and is negotiating with Japanese clients. Like Einaste and Aaviksoo, Pool said that solutions must be customized according to local conditions. There is no one-size-fits-all software product to sell.
“There are various reasons why you can’t copy Estonia, mainly because there is no country like Estonia in the world,” she said. “To some extent, we do sell our system as a product, but by the end of the day, we might have to rewrite all of it.”
Yet the hard work to expand e-health is worth it; she noted, a sentiment that Einaste echoed.
“I’m convinced that Estonia has a lot to offer,” said Einaste. “I see this as a way to give back,” he said. “It’s good karma for us, and we have to do this. Our own experience is just a starting point.”
Taavi Einaste (Nortal), Ain Aaviksoo (Guardtime), and Kristi Pool (Helmes) will gather to discuss Estonian e-Health solutions at a forthcoming Digital Discussion on November 11th.