Patient summary of an Estonian citizen to a foreign doctor
Overview of the service of patient summary
Patient summary is a supplementary, but not an exhaustive information source for a doctor who is treating a patient from another country (who has joined the service).
The patient summary must not be the main basis for determining treatment or diagnosis, because it is never gives a complete overview of the patient's health history, and data loss or data generalisation may occur when information moves between countries.
Patient summary is a service in constant development, which is improved based on users’ feedback and extended according to joining EU countries.
Agreed datasets can be found here: https://www.riigiteataja.ee/akt/128082020014
The health data of Estonian patients are transmitted to the foreign doctor in agreed data blocks. The data is obtained on the basis of requests from the health information system. The data received in response to requests are converted into data exchange messages established by the European Commission.
The foreign doctor may see the following data of an Estonian patient:
- The patient’s allergies and unwanted reactions, coded according to disease classificator ICD-10 (International Classification of Diseases) in the health information system, together with their dates of registration will be displayed to a doctor abroad in a coded and translated manner.
- Information about allergens will be displayed in the patient summary only in Estonian, as this is the information that is included in the free text field in the health information system, and it is not possible to code and translate this kind of information.
- The patient’s chronic or repetitive diseases according to ICD-10 classificator will be displayed to a doctor abroad in a coded and translated manner. The forwarded diagnoses include diabetes, schizophrenia, asthma, haemophilia, etc. The full list of displayed diseases have been listed in the publication “Relevant chronic diseases“ published by TEHIK: https://pub.e-tervis.ee/classifications/Olulised%20kroonilised%20haigused/1.0
- Information about medicines prescribed and bought in the last 6 months will be displayed in a coded and translated manner.
- Medicines injected during immunisation will be displayed in the section Immunisations.
- Information about medical appliances will not be coded or translated, as there is no summarised information about the patient’s medical appliances.
- If the patient’s health information includes data about operations, in the framework of which additional appliances listed in the price list of the Estonian Health Insurance Fund have been documented (e.g. bone screw, heart stimulator, etc.), it will be displayed to a doctor abroad in Estonian, in the section of the source data of health information, in a PDF-format.
- Information about surgical procedures will not be coded and translated to a doctor abroad, as the level of detail of the Nomesco surgical procedures classificator NCSP used in Estonia and the list of the most relevant surgical procedures used by the European central system is too different (the European list is more general), therefore significant data loss occurs.
- If the patient has surgical procedures listed according to NCSP classificators in the health information system, the info will be displayed to a doctor abroad in Estonian, in the section of the source data of health information, in a PDF-format.
- All diseases coded according to ICD-10 together with case definitions and diagnosis, and the beginning and end date, will be displayed to a doctor abroad in a coded and translated manner.
- Diagnoses on referrals and diagnoses, which are documented as preliminary, will not be displayed in the anamnesis of diseases section.
- The data of patients’ immunisations in the health information system (name of vaccine, date of immunisation and registration number of dose) will be displayed to a doctor abroad in a coded and translated manner.
- Earlier and not complete immunisation data may also be displayed in a PDF-document.
- The information about the period and quantity of consuming tobacco products and alcohol will be displayed to a doctor abroad in a coded and translated manner.
- The data will be taken from the latest health declaration in the health information system.
- Results of measuring blood pressure, if this data is available on the health information system, will be displayed to a doctor abroad in a coded and translated manner.
- There may be numerous cases of blood pressure measurements in the health information system. To the doctor abroad, only the latest date of measurement and the systolic and diastolic blood pressure results will be displayed.
- If this information is available in the health information system, patient’s blood group and rhesus factor, and the time of their measurement, will be displayed to a doctor abroad in a coded and translated manner.
- Data about pregnancies will not be coded and translated for a doctor abroad.
- If a patient is pregnant (the fact of determining pregnancy is available in the health information system with a compliant ICD-10 code) and no more than 9 months have passed from the starting date of the case in the framework of which an ICD-10 code was documented, the starting date of the case in the source data will be displayed for a doctor abroad as the date of registering the pregnancy.