2.8. Person-centred care

2.8.1. Patient information

The main place for personal health information is the Patient Portal (www. digilugu.ee – TEHIK, 2023), the output of the ENHIS introduced in 2008. The Patient Portal provides comprehensive information related to the use of health care services; it allows patients to fill in health declarations, apply for health certificates and book appointments (option available from 2019). The main aim of the portal is to make health information available to patients and health professionals, thereby improving the continuity and integration of care. Patients have the right to decide who can access their personal information. In addition, Estonian residents have access to personal information such as insurance coverage, benefits received, reimbursed costs of health care services and medicine use through the State Portal (www.eesti.ee – Riigiportaal, 2023), which as a patient portal uses digital authentication for privacy protection (see section 4.1.3 Information technology and e-health) (Table2.2). As part of the new-generation health information system project, the patient portal is being updated with a new user-friendly interface and new services. The updated patient portal will be called Terviseportaal and the first updated electronic services have been available since spring 2023. The renewal phase will be completed by the end of 2023.

Table2.2

Information related to health insurance, services, benefits and other entitlements is available from a variety of sources. The EHIF provides online reports on health services and benefits utilization, as well as lists of contracted health service providers and quality indicators. It also publishes information about entitlements on receiving cross-border care in the EU. More than half of Estonian citizens (59%) use the State Portal as their main source of information on work incapacity and health care benefits, followed by their family physician (29%) and the EHIF information line (19%) (Kantar EMOR, 2022).

The EHIF maintains a website (www.Ravijuhend.ee – Tartu University & EHIF, 2023) that compiles the national guidelines and related patient materials. The Health Board manages a vaccination information website (www.vaktsineeri.ee – EHIF, MoSA & Health Board, 2023) and Poison Information Centre Infoline website (www.16662.ee – Health Board, 2023). In addition, the NIHD manages a health information platform (www.terviseinfo.ee – NIHD, 2023b) and dedicated websites on alcohol, HIV, drug prevention and harm reduction, nutrition and tobacco. The sites include information resources on services as well as internet-based counselling services. During the last year, 11% of the Estonian population have visited these national portals (Kantar EMOR, 2022). The NIHD’s dedicated websites are in Estonian and Russian, and have become a valuable source of information for residents of other countries as well, with 78% of Internet traffic on www.alkoinfo.ee (NIHD, 2023a) coming from abroad, 72% on www.narko.ee (NIHD, 2023d) and 46% on www.hiv.ee (NIHD, 2023c) in 2022. Health service providers are legally obliged to provide information on the availability, accessibility and prices of services, which is mostly done through the websites.

Since 2012, the EHIF has been reporting selected quality indicators of hospitals in the Hospital Network Development Plan (HNDP). In 2016, it published the first report on quality indicators of selected medical specialties, including the information on the performance of family physicians under the umbrella of the family physician quality bonus system (QBS). The EHIF releases this information on an annual basis (Table2.2) (see sections 7.1.1 Transparency and 7.4 Health care quality).

In addition to the national authorities, in recent years more health care providers have made patient information (for example, patient guidelines, replies to complaints) accessible on their websites (Table2.2). The information is available in Estonian, selectively in Russian and increasingly in English, and recently also in Ukrainian to ensure access to relevant information for Ukrainian refugees who have arrived in Estonia.

2.8.2. Patient choice

The EHIF provides almost universal coverage and its range of benefits is broad (see section 3.3.1 Coverage). As Estonia has a single-payer system, there is no competition or choice between different purchasing organizations. Since 2006, patients have been able to choose their health care provider from among the EHIF’s contractual partners. Before that, the choice was limited to the contracted providers of the EHIF regional department where a given patient was registered (Table2.3). At the PHC level, all Estonian citizens should register on a patient list with a family physician of their choice. Family physicians may refuse an individual if the list is full or if the person does not live in their catchment area (see section 5.3 Primary care). A referral also gives the patient a free choice of specialist or a provider, such as a hospital, which only 65% of the population are aware of (Kantar EMOR, 2022). However, this freedom of choice may be constrained by waiting lists or proximity to the provider. Providers without a contract with the EHIF are freely accessible to anyone willing to pay out of pocket.

Table2.3

2.8.3. Patient rights

Although there is neither a definition nor a single law on patients’ rights, the principles of the Declaration on the Promotion of Patients’ Rights in Europe (WHO Regional Office for Europe, 1994) have been incorporated into several legal acts (Table2.4). First of all, the Estonian Constitution states that “everyone has the right to the protection of health”. The Law of Obligations Act defines the contractual relationship between the patient and the doctor, and requires the involvement of patients in decisions regarding their own health. Health care providers need a signed, written informed consent before providing health services to patients. Doctors must inform patients about their concerns and the required services. The Act also states that a provider cannot promise the success of an operation or a recovery. According to the Health Insurance Act, patients have the right to a second opinion, and the Health Services Provision Act ensures that everyone has access to emergency care. The Personal Data Protection Act covers the provisions to ensure the confidentiality of personal health information.

Table2.4

Quality standards for health care services and the conditions of health care facilities are regulated by different legislative acts. Although standards are specified and include requirements for easy accessibility for all, in reality many older facilities do not fully meet the mobility needs of disabled people.

The Health Services Organization Act and the Law of Obligations Act jointly regulate the complaint procedures for health services and make the health care provider responsible for malpractice and low quality of health services. Most complaints are settled directly between the health care provider and the patient, and there are no official data on how often this occurs. The patient has the right to have the case heard in court and the Health Board can impose a fine or withdraw the licence of the health care provider concerned. For dissatisfaction of health service quality, a patient can also turn to the Health Board, which can initiate an inspection. If a patient’s health is suspected to have been harmed or if there are serious quality problems, official complaints are lodged with the Health Care Quality Expert Commission, which acts under the MoSA. The judgements of the Commission can be used to support the court appeal. This approach will be effective until 1 July 2024, when the new Health Care Provider’s Mandatory Liability Insurance Act, which was passed in April 2022, will come into force. This act requires all health care providers to have liability insurance. The Health Care Quality Expert Commission will also cease to exist and be replaced by the Liability Insurance Reconciliation Commission.

In 2021, the Health Care Quality Expert Commission managed 168 patient complaints (Table2.5); 42 (25%) were related to malpractice, of which 32 (66%) were related to medical errors. Since 2005, the total number of complaints has increased considerably, particularly since 2016. A substantial rise in the number of complaints could indicate a rising awareness about this tool among the population in Estonia. The Health Care Quality Expert commission is the only expert on patients’ rights in Estonia.

Table2.5

Another mechanism for patient participation, in addition to representation on the EHIF Supervisory Board, is the patient advisory committees. These committees were established in 2019 at some hospitals, starting with Kuressaare Hospital and Tartu University Hospital and followed by others. The purpose of the patient advisory committees is to advise the hospital management board on the development of health care services, and to help bring the perspective of patients and their caregivers to the fore. The committees work on a voluntary basis.

Since 1996, the EHIF has conducted annual surveys on patient satisfaction with various aspects of the health system. The scope of the surveys has been broadened over time and now also allows for longitudinal observations. In general, population satisfaction with access to health services and their quality has been relatively high over the years.

2.8.4. Patients and cross-border health care

Insured individuals are entitled to receive services covered by the EHIF in the other EU Member States, Iceland, Liechtenstein, Norway and Switzerland. Directive 2011/24/EU on patients’ rights in cross-border health care sets out the conditions under which a patient may travel on their own initiative to another EU country to receive medical care and be reimbursed. Furthermore, based on European Commission Regulation 883/2004, insured Estonians can use the European Health Insurance Card to receive health services abroad under equal conditions and tariffs as nationals of the Member State. Treatment is paid for by the EHIF during a temporary stay. Travel costs are not covered.

In addition, every insured person can apply to the EHIF for pre-authorization when treatment is not available in Estonia or when the patient is planning treatment abroad. Treatment cannot be denied if it is included in the Estonian basic benefit package and cannot be provided in Estonia within a medically justifiable time limit. EHIF payments for health care abroad have increased from €1.4 million in 2008 to €5.8 million in 2020 and dropping to €3.0 million in 2021, possibly as a result of the COVID-19 restrictions (EHIF, 2021b). Information on the authorizations granted by the EHIF is available and published in the annual reports. In 2021, 31 persons were referred for treatment abroad, eight for examinations, and 38 for unrelated bone marrow donor search through the Finnish Red Cross. In the last five years, more than two thirds of cross-border health care was provided in Finland, Latvia, Germany and Spain (EHIF, 2017, 2018, 2019, 2020a, 2021b).

Cross-border health care is supported by an innovative and forward-looking exchange of health data with Finland, Croatia, Portugal, Poland and Spain, enabling the use of cross-border digital prescriptions in these countries. This is the result of an EU-wide initiative launched in 2017 to expand the cross-border data exchange and digital prescribing to other EU countries.