The challenges that healthcare systems face are similar in all European countries: ageing society, increasing number of chronic diseases, and the need for more efficient use of resources. To maintain our healthcare systems and provide sufficient services also in the future, we need to lower the costs while improving the quality. Digitalization and innovation are two major enablers for these challenges.

The digital society

Estonia deliberately started to develop its digital way of living more than twenty years ago, when it was a very young country with limited resources. Today, digital health and care are present in everyday life, and acceptance of digital solutions is high in Estonia: 95% of health data is digitized, 99% of prescriptions are digital, and 100% of billing is done electronically. Citizens are communicating with the government online and can use almost all the state provided services without leaving their homes. The few exceptions are not set out because of technical restrictions: when getting married, it is just advisable to see your future partner in person at some point!

The Estonian digital society is built on two key elements: the universal digital ID (enables integrated services through which people can access public services, buy e-prescriptions, book doctor’s appointments etc.) and the X-road (X-tee in Estonian), a secure data exchange layer for safe and rapid transmission of data between a distributed set of databases and digital systems. Making use of a distributed digital infrastructure is more robust than using centralized ones, and it provides high-level cyber security.

Building a culture of trust

However, the success of the services does not only come down to technology. Most important is the mindset and building a culture of trust. In Estonia, patients “own” their personal data and control its use. To keep the system transparent, patients can also monitor who has accessed their data and when the data was accessed. Public and private actors are trusted to use data in the best possible way to create value-adding services for citizens and the society. As a result, Estonians are comfortable with sharing personal data when necessary. A survey  conducted by Estonian Connected Health Cluster indicated that 80% of the population would be willing to share the medical and lifestyle data that they have collected themselves [1]. The majority of the population would be willing to share their health data with their (family) doctor; almost one third would share it with their family nurse or other healthcare worker as well as with a friend or a family member.

Digitizing healthcare

The digitalization of healthcare follows these principles as well. It should aim for data driven solutions that improve the quality of care, save money and/or time, and deem the patient to be the focal point of care and curing. It is important to support patient engagement, create active and responsive care providers, and develop care support for chronic conditions. Finally, digitalization should move towards wellness support: monitoring vital signs and overall wellbeing to increase quality of life and strengthen prevention.

Conditions for data driven innovation are favorable in Estonia, at least from the patients’ standpoint. The survey conducted by CHC indicated that 75% of the Estonian population agrees with the statement that the health data they have collected digitally are useful for maintaining their health, preventing sicknesses, and improving medical care results. People strongly believe that using digital solutions for health monitoring increases people´s commitment to observing their own health.

Health service providers play a crucial role in implementing digital solutions. Almost two-thirds of the people feel that the role of a service provider is very important, and they would like their doctor or family nurse to recommend digital solutions in addition to the conventional methods for disease prevention and treatment. However, service providers, hospitals in particular, have a conservative approach towards exponentially growing digital solutions on the market. However, if one can demonstrate a clear need and an improvement using evidence-based approach, healthcare professionals are quick to learn and eager to change. One of Estonia’s biggest hospital, North Estonian Medical Center has stated: “It is very important that we first identify our needs and then look for solutions that address these needs, not vice versa, in which case you will first have a solution for which you are trying to find a need. In addition, it is crucial to involve end users from the beginning.”

The path to the future

The future belongs to evidence-generating medicine, which is one step beyond evidence-based medicine. Data driven innovation and personalized medicine are the key. By the end of 2018, more than 10% of the Estonian adult population (100,000 voluntary donated DNA samples) was genotyped by a government lead project with the aim of collecting genetic data and integrating it into everyday medical practice by giving people feedback on their personal genetic risks. The data will be linked with the national health information system, adding ten years of medical history stored in our nationwide health information system for developing a clinical decision-making tool in primary care[2].

At the same time, there are still many issues to overcome. Today, Estonia’s e-health is very system centric and needs to be brought closer to the end user. To enable this process, third party service developers are hoping that the central health information system will grant them access in the near future to further develop digital solutions for more efficient deployment of central systems and creating synergy with the government’s efforts. This next step will allow to link patient generated data or data collected by sensors with health information stored by doctors and allow us to reach the whole new quality in health and care.

You learn by doing – and what you learn depends on what you are doing

The future of e-Estonia holds a great promise and more. This approach is based on the fact that we learn by doing, and what we learn depends on what we are doing! In Estonia we strongly believe that this path will prove to be the necessary step towards providing sufficient services and thus maintaining our healthcare system in the future.