Digital healthcare is already a reality in 2018 Estonia thanks to all the e-solutions we have implemented in the past twenty years. But as technology speeds up the pace of innovation and development, so does society, and so do social risks. Today, with an ageing population and global trends of welfare retrenchment, providing a healthcare system that works for everyone may appear as a mammoth task. If there’s one thing we can take for granted, it’s that no one can rest on their laurels when the final goal is to make our countries a better place.
Riina Sikkut is Estonia’s Minister of Health and Labour since May of this year. We’re certainly talking about one of the people in Estonia with the clearest vision on how the future of healthcare looks like, what we have managed to accomplish with digitization, and what yet must be done to improve the state of health of Estonians.
In a country that has come a long way since the 90s in tackling social problems, despite the issues we are well aware still need to be addressed, it is our duty to keep strategies up to date and regard care as a common good. The fact that the digital sphere is going to be a crucial part of this process seems self-evident, but the ways to integrate care with technology are many.
In this thorough interview, Minister Sikkut tells us about opportunities and challenges lying ahead, and how we can be ready to meet them.
Riina Sikkut, Minister of Health and Labour of Estonia
Estonia is rapidly closing the gap with EU averages on health status indicators. How did digitization contribute to the country’s advancements in the provision of a better, more efficient healthcare?
The effect of digitization on our healthcare system is hard to sum up because it has played such a major role. Healthcare workers and professionals today cannot imagine having to maintain large archives of paper-based health records, because all healthcare data has been digitized. Patients no longer have to carry their health data when moving from one doctor to the next, because data moves with them via X-Road. This isn’t just a matter of convenience, but it is also a matter of quality: fewer gaps in the data means fewer treatment errors and better continuity of care.
Similarly, since 99% of prescriptions are digital, we now run decision support algorithms that detect drug interactions at the point of prescribing: this is another way to drive quality in healthcare. Emergency healthcare is likewise augmented by the e-ambulance system, which provides emergency teams with time-critical data about patients before arriving at the scene.
E-solutions also help us treat better from a distance. With digital prescriptions, patients don’t need to see a doctor anymore to get their prescriptions renewed, and it only takes the doctor 15 seconds to renew them. Similarly, e-consultations enable family doctors anywhere in Estonia to consult with specialists about their complex cases. For patients, this means that they have a window into specialist care even if they live far away from specialist care centres.
E-health data is also used in policy making to develop our healthcare system. For example, we can now decide over the distribution of ambulances based on e-ambulance data.
What’s next with regard to data usage for service integration and clinical decision-making?
For clinical decision-making, we consider algorithm-based data integration to be the future. Estonia has 10 years worth of e-health data and, by the end of the year, more than 10% of our population will have been genotyped. We are now working to ensure that these two data sources can be combined via decision support software to guide the prevention and care of disease at primary care level. In the future, we should also look into adding other data sources to these algorithms like social and environmental data, both of which have major implications for our health.
In September 2018, Estonia started a project, together with the International Foundation of Integrated Care (IFIC) and with the support of the Structural Reform Support Programme of European Commission (SRSS), which aims to contribute to a more integrated and person-centred provision of social, medical and vocational support services to people with disabilities and elderly with high support needs. The project will outline a strategy to the Estonian government which shall promote:
- improvements in the interoperability of registries and administrative datasets to specific cohorts of individuals with integrated care needs and vocational support;
- the development of measures and indicators through which to support quality improvement and assess performance;
- the introduction of performance-based financing and payment elements to incentivize integrated service provision;
- a closer cooperation between services administered at the central and local levels, as well as between local stakeholders.
One of the goals is to create the basis for building the administrative capacity, in the form of a dataset, to link resources on social, medical, and vocational services, to enable better-informed policy making and planning, and to monitor service delivery and outcomes.
In what ways can digital healthcare help Estonia in tackling social inequalities on life expectancy and the level of unmet needs?
Equity in healthcare is a key topic when discussing digitization. When we were writing the Council Conclusions on Health in the Digital Society, it was very important to us to have a reference to equity in them. The conclusions state clearly that digital tools should not increase existing health inequalities. Rather, they should increase equity. One way to do this is to use health data for policy making.
For example, we already know that only 82% of prescriptions get bought in Estonia. This means that more than 2 million medicines meant to treat people every year are never purchased. It is something we can look into now, and through that, we can find ways to ensure that people can get the medicines they need.
We can also train algorithms to find people most in need of medical attention. For example, we have already piloted a smart screening program for Chronic Obstructive Pulmonary Disease. Who is to say that in the future we won’t be able to apply this model to address the social determinants of health? If somebody loses their source of income, it puts them at risk of worse health outcomes. Smart algorithms will enable us to find those people and help them before ill health puts them at risk of falling further behind.
Preventing, other than treating – which innovations and projects can have an impact on the future of public health?
We will see a lot more genomic data being used in the prevention of common diseases. It is well known that we can use genes such as BRCA to estimate a high risk of breast cancer, but this is only the tip of the iceberg. In Estonia, we ran a study on familial hypercholesterolemia using the so-called “genome first” approach. Through that, we found roughly 40 people at very high risk of stroke, the vast majority of whom had never been diagnosed by the medical system. In the near future, we will be able to apply genomic insights into family practice to help detect people at risk for a variety of cardiovascular diseases.
The other trend that we cannot ignore is smart algorithms, which enable us to integrate and make sense of a vast amount of data to detect disease patterns before it’s too late.
Digital transformation is changing society and the way we deal with social risks in healthcare. In your opinion, how can innovation help us make ‘care’ work for everyone in Estonia?
One of the most valuable resources in medicine is time. It is valuable because it is so limited. We need time to deal with the most difficult cases in medicine, for example, to help people in difficult social situations. This is where digitization can help. Instead of taking time away from the doctor-patient relationship, it should enable healthcare workers to better focus their time on the people who need it the most.
Not everyone who goes to the doctor needs to see a doctor: they can be screened and counselled at a distance, sometimes by automated systems. This frees up a doctor’s time to deal with those patients for whom there is no better alternative.