Large populations, geographic disparities and legacy infrastructure problems can derail national health IT projects. Estonia suffers from none of these factors.

The Baltic state implemented a national EHR in 2009 at a cost equivalent to €7.50 (roughly $10 USD) per citizen.

Madis Tiik, CEO of the Estonian E-Health Foundation, who managed the project, described the short path to a fully integrated EHR network currently used by 47 pecent of the country's residents.

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Launched in 2009, the EHR is built on Estonia's X-Roads network, Tiik told attendees of eHealth Week 2011. X-Roads is a secure gateway service architecture that hosts 3,000 e-services available to Estonian citizens. In January 2010, the eHealth Foundation launched a companion health insurance system for claims, reimbursement and prescription management.

"In many countries, I have seen that the task is to integrate the healthcare system," said Tiik. "There is also the concept of the personal health record. In Estonia, we decided that all this functionality will be in our national EHR."

All end-users of Estonia's EHR system can access their full personal health records. There's nothing a physician can see that a patient cannot. And with nearly half the country's residents using the system within two years of its launch, the project appears viable for the long term.

[See also: EU Task Force to promote cross-border health IT advancements.]

To date, the rate of ePrescriptions in Estonia's healthcare system is around 80 percent. A full 100 percent of radiological images, excluding dental, are now stored in the PACS. But most impressively, more than 95 percent of the country's doctors are currently using the EHR.

The true difference in scale for a small country's EHR project is discernible in the price tag. Estonia's entire EHR project cost €10 million, or a mere €7.50 per citizen. When revealing concrete metrics, Tiik encouraged attendees not to fixate on the numbers, acknowledging the diminished set of challenges for a country of Estonia's size (1.37 million residents as of a 2010 census).

Tiik wasn't boastful of Estonia's success. He listed the challenges ahead (sustainability, chronic disease management, efficiency of patient pathways, innovation in health models) and identified what the Foundation could have done better (begin by analyzing business processes in healthcare, support endusers with financial incentives).  

As if to clear up a misconception, Tiik concluded his presentation with a summary of the work ahead for nations looking to emulate Estonia's success: "eHealth is just healthcare management of the 21st century. It's not an ICT project."