Expert Workshop Module V
1. Visiting the Technomedicum of Tallinn University of Technology
(http://www.tm.ttu.ee/index.php?option=com_content&task=view&id=15&Itemid=29;)
Technomedicum of Tallinn University of Technology (TM), a research, educational and development institution, was set up in 2006 to create an innovative and interdisciplinary research unit combining efforts of Tallinn University of Technology, hospitals and other healthcare organizations. R&D activities of TM cover medicine, technology and biomedicine, degree studies related to medicine, biomedicine and technology, relevant continuing education courses as well as teaching of medical disciplines organized by other TUT academic units on the master and doctoral level.
2. Visiting the Competence Centre for Cancer Research of Tallinn University of Technology
(http://www.vtak.ee/)
The aim of the Competence Centre for Cancer Research is to improve the quality of cancer therapy by developing and implementing new diagnostic platforms and offering the pharmaceutical industry new cancer drug candidates. Currently the project portfolio of CCCR involves 7 projects in drug development and 3 in diagnostics.
3. The Estonian Genome Centre project introduction
The Estonian Genome Center, University of Tartu
The Estonian Biobank is a population-based biobank of the Estonian Genome Center of the University of Tartu (EGCUT). The project is managed according to the Estonian Gene Research Act and all participants have signed the informed consent form. The cohort size is currently 48500, and it reflects closely the distributions observed in the Estonian population. All subjects are over 18 years old and are recruited randomly by the general practitioners (GP) and physicians in the hospitals from among the individuals visiting the GP offices or hospitals.
A Computer -Assisted Personal Interview (CAPI) is conducted with every participant during their 1-2 hour visit to the doctor’s office. It includes questions regarding personal data (place of birth, place(s) of living, nationality etc.), genealogical data (family history, four generations), educational and occupational history, life-style data (physical activity, dietary habits – FFQ, smoking, alcohol consumption, women’s health, quality of life). The medical history and the current health status are recorded according to the ICD10 codes, the medication data according to the ATC. Additional data are collected from the psychiatric patients (MINI and SSP interview). The anthropometric measurements, blood pressure (in the sitting position at the end of the interview), and the resting heart rate are measured during the visit and 30-50 ml of venous blood is collected into the EDTA Vacutainers. These containers are transported to the central laboratory of the EGCUT at +4-6 ⁰C within the 24-48 h period. The DNA, plasma and WBC are immediately isolated and stored in aliquots in MAPI straws in liquid N2 for further use. Some of the DNA is diluted to 100 ng/µl (measured with Nanodrop) and aliquoted into 96 well plates for genotyping or sequencing. All procedures are carried out according to the ISO 9000-2008 and LIMS.
The EGCUT employs 32 people working in the fields of biobanking, biostatistics and bioinformatics, technology core, human genetics, and IT development. The GWAS experiments have been performed with 2700 subjects with Illumina CNV370 according to the Illumina protocol and the next 1000 are in progress with human OmniExpress array. Metabochip data are from 1000 cases and 1000 controls, immunochip data from 1000 cases (psoriasis) and 1000 controls (in progress). 2200 subjects for the GWAS were selected randomly from the country and are used as the universal controls. A part of them (1100 subjects) have their RNA isolated from venous blood for gene expression studies, and their serum and plasma analyzed with regard to 40 biochemical parameters at the UT hospital.
Vision of eCitizen Hannes Astok
Thinking about e-health and e-medicine as a citizen
I would like:
- The data of my previous health analysis and treatment to be available for my doctor at a click of a mouse, and that I wouldn’t have to run around the town searching for information about whether I had chickenpox in 1965 or 1966.
- To be able to register a doctor’s appointment myself without having to wait on the phone for hours and hours in the call waiting line.
- To be able to directly access information on what doctors have written about my wonderful health without having to beg to see my health history at the hospital and decipher doctors’ incomprehensible handwriting.
I don’t want:
- Regardless of how noble the purpose is, for anyone to study my health data without me giving them a prior permission to do so.
- Technical problems of electronic systems to interfere with the real treatment done by doctors, because patients are still treated by doctors and not by computers.
- My data to leak under any circumstances, i.e. I don’t want a memory stick with my or my fellow citizens’ data to be lying around in a central city park.
The effect of the national EHR project on health care processes
eHealth platforms have been applied all over Europe including the Estonian National eHealth Information System – Estonian EHR. Estonian EHR emphasizes sharing of patient information and networking experts across organizations. Estonian EHR emphasises citizen empowerment and citizens’ active participation as well.
We believe that
Networking for the purposes of acting both as ad-hoc and permanent teams of professionals in the management of complex illnesses and disorders is an established way of working.
Process lines, workflow management and shared data spaces are established practices.
Decision support by consulting colleagues and other experts for second opinions or by referring patients to other specialists are regular features of modern healthcare.
Interactive patient participation has gained in importance with patient empowerment and a deeper understanding of the role of the patient in solving health problems.
Assessing the Economic Impact of the Estonian Electronic Health Record System. Results of PENG analysis
The project aimed to evaluate the impact of the implementation of a nationwide Electronic Health Record (EHR) system. The analysis of potential costs and benefits associated with the implementation of the EHR was carried out on the basis of the PENG method, an IT-evaluation tool designed for the healthcare sector. The method has enabled to integrate both the tangible and intangible aspects of EHR. Type II diabetes was used as a model disease in calculating the benefits for patients, healthcare providers and the society as a whole. Consequently, it was possible to develop a framework for evaluating future e-health projects in Estonia and construct policy recommendations. The results showed that the majority of EHR benefits will be realised for the society which enables to promote e-health on a national level and further develop a comprehensive healthcare system.
Policy recommendations from „Digimpact“ and eHealth
While the DIGIMPACT project was mostly about developing a methodology for assessment of country-wide health record system, several policy implications can be drawn already from the work. The methodology looked at the potential and costs of ICT on health care service provision from three perspectives: those of the service provider, the patient and society. It was assumed that information technology will not only lay the foundations for completely new products and services in health care, but also that it will create new ways of providing and managing services. This will result in changes to the way that work and business is organised, and the rules that govern how organisations operate are already changing. Policy recommendations that the presentation will touch upon were developed from the understanding that several preconditions are needed and important risks to be mitigated in order to deliver the full benefits of any national electronic health record system.
Opt-out in Estonia, Dr. Andres Soosaar, Mr. Ants Nõmper, Estonia
Protection of privacy provided by Convention for the Protection of Human Rights and Fundamental Freedoms has three facets in regard of information systems. These are confidentiality, integrity and accessibility of data. In order to estimate whether or not the information systems comprising the whole population’s health data are advancing the protection of privacy the situation before and after the launch of the national EHR system needs to be compared on the basis of these three aspects. This presentation is dealing with this question concluding that privacy protection improves with implementation of EHR system. This result gives the opportunity to retain the opt-out consent system used for health data processing even before the lauch of the national EHR system.
Implementation of nationwide eHealth platform from the hospital’s perspective
Dr. Peeter Ross, radiologist, health IT expert, East Tallinn Central Hospital
Mart Einasto, Member of Executive Board, Tartu University Hospital
This presentation compares changes in hospital processes and IT setup made in order to connect to the nationwide eHealth platform in Estonia in two Estonian hospitals.
East Tallinn Central Hospital (ETCH) was the first health care provider successfully connected with the Estonian nationwide Health Information System (EHIS) in December 2008. Tartu University Hospital (TUH) joined to the system almost a year later. Both of hospitals started preparations for integration in 2006 and implementation of various components took place in successive phases, however the implementation strategy was different. ETCH concentrated at the initial period of the implementation to develop an electronic patient record (EPR) compatible with the EHIS. EPR was customized to contain standardized health data and communicate with the EHIS using agreed data exchange standards. Because the central system was developed parallel with hospital integration, ETCH encountered occasional integration problems leading to additional programming work. The main changes were new formulas of electronic medical documentation and introducing e-prescription. TUH was just in the process of changing main hospital information system. This made easy to adapt with new health data standards but had to face with the confusion of end users, who hardly made difference between new hospital and nationwide systems. The second part of implementation was adoption of hospital rules and procedures updated according to the state level legal changes made to implement EHIS. Thirdly, a lot of attention was paid on the training of hospital personnel. This contained additional training of more than 900 hospital employees in ETCH and about 2300 in TUH. Training included computer skills, new workflow and security issues. Finally, to achieve necessary level of data security, ETCH introduced the ID-card as the compulsory device to log in to EPR. TUH has a five year transitional period that ends with ID-card as compulsory device.
The adoption of new hospital processes and updating the information system was needed in order to connect to the nationwide eHealth platform. Therefore, developments to EPR as well as changes on the organisational level were made. The initial integration with the EHIS only took a short time period. Also, the succeeding new services of the EHIS, such as ePrescription, were implemented shortly after their launch by the Estonian eHealth Foundation or Health Insurance Fund. Successful integration was achieved because of close cooperation of the hospital personnel, state authorities and and IT companies. The commitment of hospital management on all organizational levels was of utmost importance.
Implementation of nationwide eHealth platform from the hospital’s perspective
Family practice (FP) is in an ideal position to be at the forefront of e-health. There are now about 5 million FP consultations taking place annually and computers are used for clinical purposes by almost all of FPs. Family practices were the first health care providers in Estonia who took over electronic patients records and it happened already in the middle of 1990s. Already in 1998 92% of the FDs regularly used for some purposes computer in their everyday practice: either for electronic laboratory test ordering, saving the patients’ information, managing the registration or recall system, making the bills etc. Therefore it was expected that FDs would also be the most active in implementing the e-health possibilities in their practice. However, at the beginning of June 2010 only 30 family practices were actively participating in the actual data exchange. In June 13% of all of the ambulatory discharge letters were sent to the system by FDs, the rest 87% were sent by specialists. Probably, most important problems of inactive use are related to our software. Although in FP there are four biggest software service providers, only one (Perearst2) was able to make all necessary changes in order to join with the e-health system. Hovewer, the changes in software have not been made in the most appropriate way for FDs.
Regardless of the not so successful start, FDs believe that e-health is our future. Certainly, the FDs are the health care providers who most need the development of the e-links with school-health, local social system, social insurance board etc.
eHealth Innovations for Healthcare
Healthcare is not just a commodity that can be simply weighed-against all other commodities in a society; and, it is often viewed mainly in the context of reactive elimination of disease. Ubiquitous access to affordable, high-quality healthcare is an essential component of any knowledge-based society in order to keep its population active and thriving without creating a financial burden that inhibits economic growth and degenerates social well being.
Innovations in healthcare primarily center around
1) providing a steady and reliable continuum of care from hospital to home,
2) establishing secure, self-managing and private electronic medical records (EMR) that eliminate the danger and expense of paper-based systems, while offering the most cost effective approach to managing care and treatment, and
3) virtual collaboration environments that enable doctors and nurses to work as teams spanning many different specialties, departments and even vast physical distances.
