More vigorous development of this area requires clearer and stronger leadership and oversight from the Ministry of Social Affairs. The correctness, accuracy and relevance of health data are necessary to make informed treatment decisions and smarter health policy choices. At present, the documentation of treatment is often incomplete, which threatens the quality and continuity of care and hinders the access of patients to social benefits.
Some medical institutions do not submit treatment summaries (case histories, epicrisis) at all or submit them late. More than 152,000 case histories were submitted late in Q1 2025 alone. There is a widespread understanding that data on paid services do not need to be submitted to the national health information system, which causes data gaps. For example, there are dental care providers that have entered information on treatment with a long delay or have not submitted any documents on their patients to the health information system. This means that if a patient wants to be treated by another dental care provider, the new provider will either start working without knowing anything about previous treatment or will have to rely on what the patients says.
“It’s more difficult and time-consuming for a doctor to treat a patient if he or she doesn’t have clear and reliable information about the patient,” said Rauno Vinni, audit manager at the National Audit Office. “If a case history is submitted late or not at all, the delay may be dangerous for the patient. A doctor may make erroneous treatment decisions if he or she cannot see the whole picture. For example, a psychiatrist prescribed more addictive drugs (benzodiazepines) than allowed for many years and failed to record most of the appointments in the national health information system: six patients had more than 650 appointments over 11 years, but only 7% of them were documented. However, if there is no data or it is incomplete, the next doctor or supervisor will not be able to see what treatment was given, whether it was justified, and what risks might arise. In the case of addictive medicines, decisions must be clearly justified and any alternatives considered must also be recorded.”
The quality of a patient’s health data also has a major impact on the social benefits and services provided to them. If the health data, which is the basis for assessing a person’s capacity for work or the severity of their disability, is inadequate or contradictory, it has an adverse impact on people’s access to social benefits and services to which they are entitled and that they may need acutely at that time.
The requirements for the formatting and collection of health data are scattered across many pieces of legislation and partly outdated, and health professionals still have to enter information in the health information system as if they were using the old paper forms. Although the Health and Welfare Information Systems Centre has created new data exchange standards, many health institutions can only send documents in the health information system in last generation formats due to outdated technical solutions – in 2024, 79% of case histories were sent in earlier formats. This limits the usability of the data and increases the risk of interpretation errors. “For example, a nurse sent immunisation certificates in an outdated document format,” said Rauno Vinni, audit manager at the National Audit Office. “As a result, they did not reach the national health information system and there is no information on which vaccines have been administered to the person.”
There is no systemic link between medical bills and health data. Health service providers often bill the Health Insurance Fund before the treatment has been entered in the health information system. Therefore, there is no automatic link between the treatment invoice and the case history, and a substantive verification of their conformity is obstructed. This means that the state pays for the service before there is evidence that it has been properly provided.
Fragmentation in systems and management hinders development. The multiplicity of IT systems used in health institutions is costly and an obstacle to uniform documentation. Outdated solutions make the formatting of health data time-consuming and cumbersome. The different organisation of work at institutions, including the fact that some health professionals do not consider the proper formatting and transmission of documents important enough, makes the development of a common practice difficult. The duration of an appointment is often not enough for writing all the necessary data down and entries are made outside working hours. “For example, a patient discovered on the health portal that he had been given a diagnosis and prescribed treatment by a family doctor even though the patient was not on this doctor’s patient list,” said Rauno Vinni, audit manager at the National Audit Office. “In another case, the outpatient case histories did not include information on all the medicines prescribed by the doctor, including prescription medicines: the number of the prescription, the active substance, the pharmaceutical form, dosage and number of administrations were not indicated. This can be dangerous for the patient’s health.”
Whilst there is great potential for further development of information systems, progress has been hampered by unclear division of roles, different expectations of stakeholders for the development of information systems and updating the documentation requirements, and fragmented management. This slows down both the updating of health data standards and the necessary transition to more modern solutions.
Recommendations of the National Audit Office
The recommendation of the National Audit Office to the Ministry of Social Affairs is to update the requirements for the formatting of health data and consolidate them into a unified, comprehensible framework. The National Audit Office also recommends limiting the use of outdated data exchange formats and establishing a transition to modern standards. Together with stakeholders, it is necessary to ensure a transition to a modular nationwide information system, which would reduce fragmentation and costs.
The recommendation of the National Audit Office to the Health Insurance Fund is to make the reimbursement of treatment invoices conditional on the health care provider having submitted the required health data to the national health information system. The National Audit Office also recommends increasing the volume of targeting and clinical audits, and expanding and automating standard queries.
The recommendation of the National Audit Office to the Health Board is to strengthen systemic risk-based supervision in addition to the complaint-based procedure and assess compliance with the requirements for the submission of data to the health information system and the quality of health data when checking licences.
The Health and Welfare Information Systems Centre should set clear priorities for the development of e-health, ensure coordinated implementation of developments and expand the system of automated inspections.
Background
The National Audit Office analysed the formats and quality control of documents sent to the health information system, the speed of receipt of case histories, the control measures of the Health Insurance Fund and the supervision of the Health Board over the documentation of health services. The complaints filed with the Ministry of Social Affairs and the Health Board about the formatting of health data were also investigated, and health institutions and doctors were interviewed. In addition, the Social Insurance Board was asked to assess the quality of the case histories used to establish the severity of a disability, and the Estonian Unemployment Insurance Fund was asked to analyse the additional queries made in the procedures for assessment of the capacity for work to identify patterns in the quality of documentation.
The health information system is a national database of outpatient case histories, referrals, test results and other medical information. In 2024, 14 million documents were submitted to this information system. Most of them were outpatient case histories (46%), responses to referrals (14%) and dental records (13%). The biggest number of documents was submitted by family doctors (5.5 million), hospitals (4.6 million) and medical specialists (1.5 million). The system gathers a person’s health history into a single, secure environment, where it is accessible to both the patient and medical institutions.
