Summary of audit results

The correctness, accuracy and timeliness of health data are a prerequisite for quality care, as they are the basis for making reasoned treatment decisions. The National Audit Office found that the health information of patients in Estonia is often incomplete: information is inaccurate or difficult to understand, and documents are submitted to the health information system late or not at all. Whilst direct errors in treatment resulting from such deficiencies are rare, poor data quality threatens the continuity of care, causes undue hardships for people and limits access to social benefits. Additional burden and costs also fall on health professionals and state agencies.

Key findings

The documentation of health services is inconsistent and incomplete. This jeopardises the quality and continuity of treatment. Incomplete health data, which is the basis for assessing people’s capacity for work and determining the severity of their disability, also hampers people’s access to social benefits and services to which they are entitled and which they may have an acute need for at a certain time. Some health care providers do not submit treatment summaries (epicrisis) at all or submit them late. There is a widespread understanding that data on paid services do not need to be submitted to the health information system, and this leads to data gaps. The content of documents is often difficult to understand and some information is missing. In 2024, 79% of epicrisis were submitted to the health information system in an outdated format, limiting data availability and usability.

The Health Insurance Fund’s oversight have been limited in scope, and supervision by the Health Board has not led to any substantial changes in the quality of documentation. The Health Insurance Fund mainly checks whether treatment invoices and documents were submitted, but more in-depth content checks – such as thematic checks (so-called targeted checks) and assessments of treatment requirements (clinical audits) – are rarely used because they are resource-intensive. Supervision by the Health Board focuses on the activities of individual health care providers, not on checking the overall quality of health data. Overall, the control activities carried out by the state agencies so far have not helped to systematically identify and eliminate documentation problems.

The developments of information systems have great potential but progress is slow. Documenting is inconvenient and burdensome due to outdated systems. The information systems of health care providers differ in design and functionality, making the development of a common documentation practice difficult. A large proportion of documents arrive in the national health information system in outdated data formats. The collection of national health statistics in its current form is also too resource-intensive, both for health care providers and the National Institute for Health Development. 

The management of digital development is unclear and fragmented. The Health and Welfare Information Systems Centre (TEHIK), the Health Insurance Fund and the Ministry of Social Affairs share tasks, but strategic priorities, responsibilities and work plans have not been clear. State agencies and health care providers have different expectations for the development of information systems and the updating of documentation requirements, and the lack of a common leader results in unpredictability and slows down the implementation of new solutions.

There was a long pause in the development of documentation. The Ministry of Social Affairs has until recently treated the incompleteness of documentation as an inevitability – the requirements are not up to date, there is no clear leader in the field and no decision has been taken to move to a modern international documentation standard.

Main recommendations of the National Audit Office

Recommendations of the National Audit Office to the Minister of Social Affairs:

• Update documentation requirements as a whole and consolidate them into a unified and clear legal framework, and decide, in cooperation with the stakeholders, which international terminology standards and classifications will be adopted in Estonia.
• Transfer to a national information system at the level of health care providers, which is modular, i.e. made up of independent but interoperable components, to reduce fragmentation, costs and duplication and to establish common data structures and standards across health care.

Recommendation of the National Audit Office to the Minister of Social Affairs in cooperation with the Director of Health and Welfare Information Systems Centre:

• Clearly define the areas of responsibility in the management of e-health development, ensure better coordination of developments and develop and extend automated controls.

Recommendations of the National Audit Office to the Minister of Social Affairs in cooperation with the CEO of the Health Insurance Fund and other stakeholders:

• Ensure that the Health Insurance Fund only pays the health care provider for treatment invoices if the service has been duly documented in the health information system.
• Create a solution for linking treatment invoices to medical records.

Recommendation of the National Audit Office to the Director General of the Health Board:

• Increase the focus of supervision on compliance with the requirement to submit documents to the health information system and on assessing the quality of documentation.