ESTONIA: Estonia’s Health Data Audit Highlights Gaps in Data Quality, Standards and Governance
All healthcare providers in Estonia are required to maintain clinical records of the care they provide and submit the relevant records to the national health information system. However, the data is often inaccurate, incomplete or untimely. Some health information is difficult to interpret, while treatment summaries are submitted late or not submitted at all. National Audit Office concluded that improving data quality requires stronger stewardship, clearer documentation requirements, better coordination of digital development and more effective quality controls. Without reliable data, healthcare professionals and patients face additional burdens, and continuity of care may be compromised.
In its audit Ensuring the Correctness, Accuracy and Timeliness of Health Data, the National Audit Office of Estonia examined whether health data submitted by healthcare providers to the national health information system is accurate, complete and up to date. Healthcare providers are required to submit treatment summaries, referrals, test results and other clinical documentation to the system. In 2024, approximately 14 million documents were submitted — equivalent to more than ten documents per resident in a country of 1.37 million people. This illustrates both the scale of the system and its importance for healthcare delivery.
However, the audit found that treatment summaries are frequently submitted late or not submitted at all. In the first quarter of 2025 alone, more than 152,000 treatment summaries (epicrises) were submitted after the required deadline. Some healthcare providers, particularly in dental care, fail to submit documentation altogether. As a result, important health information may be unavailable when needed, affecting continuity of care and limiting the reuse of data for healthcare management, oversight and policymaking.
The problems identified by the audit are not only organisational, but also legal and technical. Requirements for the collection and documentation of health data are spread across more than 20 legal instruments and continue to reflect the processes originally designed for paper-based records. Data is often exchanged as complete documents rather than as structured, reusable data elements. Although more modern data exchange standards are available, many healthcare providers continue to rely on outdated formats. In 2024, 79% of treatment summaries were submitted using older data-exchange formats. This limits the usability of data, restricts the scope for automated quality controls and increases the risk that important information is unavailable or difficult to interpret.
In some cases, the use of obsolete formats prevented data from reaching the national system altogether. For example, immunisation records submitted in an outdated format were not available in the system, leaving patients and healthcare professionals without reliable information on administered vaccines. The audit also found that approximately 22% of documents submitted to the health information system were not subject to automated quality controls, reducing assurance over the quality of the data collected.
Fragmentation is another major barrier. Healthcare providers use more than 30 different information systems, leading to inconsistent documentation practices and increasing the complexity and cost of data exchange. At the same time, responsibility for digital health development is dispersed across several institutions. Differing priorities, unclear accountability and insufficient coordination have delayed the adoption of modern standards and hindered the transition to more modular and interoperable systems.
The audit also highlighted that treatment invoices are not systematically linked to the corresponding clinical records. As a result, public funds may be used to pay for healthcare services before the relevant clinical documentation has been submitted to the health information system, limiting the ability to verify that services have been properly delivered and documented.
The National Audit Office recommended that the Ministry of Social Affairs modernise documentation requirements, bring them together within a clearer and more coherent framework and establish a clear transition path away from outdated data formats. The audit also called for the development of a modular nationwide health information system, stronger automated quality controls and a clearer link between reimbursement and the submission of required health data.
