Aims and scope
The centralized digital patient registration project is part of a wider eHealth initiative in Estonia that revolves around the efficiency of patient movement between different health care providers through the centralised digital patient registration, digital referrals and also e-consultation. These different initiatives are meant to operate in conjunction, as they have limited impact in isolation. The solutions operating together are meant to reduce waiting times for citizens and reduce costs for both health care providers (fewer double bookings, empty and unnecessary appointments, thus reducing concurring resource costs as physicians are not subjected to wasted workhours) and patients (easier to book an appointment and communicate with health care professionals). The registration system itself offers more options for making appointments and provides an additional communication channel between the patient and the health care provider.
The issue of inefficient patient movement and system transparency was at the core of creating the innovation. The current decentralized health care service provision results in patients having to make appointments through a decentralized system, which included contacting individual health care providers through individual channels. This resulted in a lack of a comprehensive overview of the available opportunities for patients and the health care sector. Individual health care providers offer different communication channels for making appointments and several have developed digital booking systems. Yet, these systems lack compatibility with each other and there are differences in the level of sophistication and digital complexity.
The result of the project – implemented in 2019 – was a centralized digital patient registration portal, where all the joined health care providers are inquired about the possible appointment slots of physicians. This information is then uploaded to a centralized location, enabling the patient a comprehensive overview of the available opportunities. To develop this eHealth technology, the following actors were involved in the project: the Health and Welfare Information Systems Centre (henceforth TEHIK), Ministry of Social Affairs, North Estonian Medical Centre, Other public health care providers, developers, developers of the hospital information systems and Health Insurance Fund as well through contractual negotiations.
The platform interacts with each health care providers’ information system (four existing information systems with public health care providers), during which the system provides information regarding the free appointments and the appointments made by individuals within the system. The health care provider information systems provides daily updates regarding all possible appointments. The system operates with identification for which patients use the national identification card with the option to do it with id card or mobile ID. For patients with referrals the data is obtained from the health information system, which is a centralized system that stores the health data of each patient. All health care providers are obligated to upload referrals to the health information system, which then provides the centralized digital patient registration the necessary documentation about the patients’ need. The innovation relies on standard components, standard java, browser and applications with little technical innovativeness. Data exchange occurs on HL7 message standards, which is an international and common standard within the Estonian health care system. These functionalities are possible with these technologies due to their widespread usage, which simplifies widespread implementation. The aim of the project was to use well-known components and rely on their centralised application on the national level, which highlights the innovative nature of the solution. The use of general components and the national digital infrastructure were key to enable the implementation of the solution.
Main collaborative innovation conditions
The centralized digital patient registration has been a longstanding initiative and the core ideas were mostly established by the coordinating actors at the offset of the project, which was influenced by the historical legacy and interests on the national level to reorganize the eHealth system. The governmental actors reflected their initial vision through the design of an initial prototype, which conveyed their specific vision both to health care providers and technical actors. This limited the possibility of new ideas being proposed and implemented despite the goal of TEHIK to garner the maximum amount of acceptance possible (I1).
However, before the development phase, the coordinating actors did engage in an extensive period of collecting feedback from various health care providers by providing them an opportunity to test the prototype and its functionalities. Additionally, both the Ministry of Social Affairs and TEHIK held meetings to engage health care providers into the process. The meetings were both bilateral and multilateral which allowed to consider the position of each actor. It did result in certain shifts, as it became clear that initial plans to implement an opportunity to pay for visit was unfeasible, as a centralized solution was unable to ensure the transactions between the patients and the health care providers. However, most substantive propositions have remained part of a roadmap, as mainly technical issues were considered.
The public health care providers were involved throughout the project to various extent. The key actor for providing the perspective of the health care provider was the North Estonia Medical Centre (NEMC), who was involved at the start of the project. The initial phases of the project limited other health care providers’ engagement to information dissemination and consultation, as they could offer feedback on the initial prototype. After the eHealth tool was piloted in the North Estonia Medical Centre, other public health care providers within the Hospital Network Development Plan were involved more extensively, as they started making developments within their existing digital solutions. The changes revolved around relevant work processes for making appointments and developments to the existing systems to handle the requests for free appointments. Additionally, private health care providers who volunteered were additionally engaged. The representatives of health care providers were also engaged, as the Estonian Hospitals Association and Family Physician Association were engaged in the steering committee.
The engagement of health care providers was necessary for guaranteeing the widespread implementation of the centralized digital patient registration, as its benefits are ultimately dependent on the amount of joined health care providers. The engagement of the health care providers was crucial for the governmental actors, as it improved their perception regarding the work processes surrounding digital booking.
Implications and lessons learned
The innovation process was strongly affected by past reform attempts. The solution relies on existing digital infrastructure and its success is dependent on how the health care sector incorporates eHealth initiatives as a whole. The prior failed initiatives strongly affected the approach of governmental actors towards a more coercive approach, which limited the health care providers’ ability to negotiate the concepts surrounding the solution. The health care providers have therefore retained a critical view of the project itself with a limited level of enthusiasm towards improvements.
It was very beneficial that the problem itself was widely accepted amongst different actors and the coordinating actors made their own perspective very clear from the start, leaving limited space for deviation. The dissemination activities conducted by the coordinating actors (both TEHIK and Ministry of Social Affairs) resulted in a well communicated vision at the moment the project was initiated.
The collaboration process had varied success. The developers were very positive regarding the open environment created by the coordinating actors. However, the late involvement of other health care providers besides the North Estonia Medical Centre created difficulties in perceiving the internal processes of the other healthcare providers and the possible errors that may arise.
Successful implementation was the result of learning from past mistakes in technical aspects, engagement of a health care provider from the start thus incorporating their perspective, opting towards a more coercive approach and TEHIK’s role as the coordinator. In combination, they enabled a climate where the actors were able to implement the solution at a limited timeframe.
The centralized digital patient registration project highlights that the successful implementation of a complex project requires very strong leadership and a strict scope. The health care providers had strongly varying interests and accommodating to each of their needs makes it very difficult to implement a successful solution. The strong support from the administrative and political leadership enabled the necessary authority to convince health care providers to implement the eHealth solution. This partnership had a large number of stakeholders and the perceptions regarding the benefit of the solution varied due to existing levels of technological sophistication that were resultant of the previously decentralised nature of booking appointments.
To read more about the case study, see D7.1 – Practices of external collaboration for service delivery. Comparative case studies on external collaboration in eHealth partnerships report.
About the Authors
Steven Nõmmik, Tallinn University of Technology
Veiko Lember, Tallinn University of Technology