S P R I N G 2022
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Diagnosis: e-Healthy Cover Story | 24
Estonia has revolutionized its medical sector and healthcare system with innovative e-solutions Life sciences | 28
Biomaterials boost Baltic exports Biotech | 32
High quality of life at 120: a very real possibility Law&Tax | 56
Subtle tax nuances make Estonia, Latvia and Lithuania competitive
2 | CONTENT
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Business in Picture
12
Politics: Three lights as a game changer in Germany
15
Guest Commentary
16
Baltic Business News
18
Business Agenda: Where you need to be
20
What’s hot? Upcoming cultural events
30
Best in Business: Companies to watch
56
Law & Tax: Subtle tax nuances make Estonia, Latvia and Lithuania competitive
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Energy: The future of gas and electricity prices is uncertain
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MY OFFICE:
Sanita Glovecka, head of Gjensidige Latvia
62 Woman in the Lead: Life is the sum of all our days, Interview with Kai Isand, an female leader from Estonian start-up scene
66 Green Economy: Turning birch bark into new product
24
COVER STORY:
Diagnosis: E-Healthy
68 Business Location: Riga: speeding up growth
72
Pandemic a chance: Pandemic brings growth, TestDevLab’s experience
76
Trade fairs: Recovery of the international exhibition market
86 AHK Members: Who’s new in AHK’s Baltic network?
88 Shooting star: Mental gym for emotional balance
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64
BALTIC CHAMPIONS:
Latvian furniture manufacturer Daiļrade koks
21/02/2022 08:13
24 | C O V E R S TO RY by ALE X ANDER WEL SCHER
Photo: Raeapteek
The old but modern Raeapteek in Tallinn
Diagnosis: E-Healthy Estonia has revolutionized its medical sector and healthcare system with innovative e-solutions. The small nation is a big leader in e-Health. All the infrastructure was in place before the COVID-19 pandemic – one medical institution has been in operation since medieval times.
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t is a must-see for any Tallinn tourist. The Raeapteek on the square beside the medieval Town Hall is considered one of the oldest pharmacies in Europe – and at the same time one of the most modern. It has continuously been in business in the same premises ever since the early 15th century and will celebrate its 600th anniversary this year. Back in the Middle Ages, the pharmacy sold a wide variety of medicine and potions that were concocted by the pharmacist on the spot. Some people came from far away to get their medical items which, back then, included peculiar goods such as
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black cat’s urine, earthworm oil and dried frog’s legs. Others undertook long journeys to receive advice and spiritual assistance in Raeapteek. Nowadays everything runs much faster. Patients only need to insert their personal ID card into a reader at the counter in the pharmacy to get their medication. This is made possible by the Estonian e-prescription system that immediately shows pharmacists what preparation the doctor has prescribed for the patient and how to dose it. They simply access the patient’s information from the system and
issue the medicine entered by the doctor electronically with the aid of an online form. Today, 99% of all prescriptions in Estonia are issued in this way – over 910,000 per month. The e-prescription system was launched at the beginning of 2010 and, although the transition from paper to digital hit some minor bumps, the uptake was very fast. Already at the end of the first year, 84% of prescriptions were issued digitally. Not least because the system instantly delivered convenience and saved time and effort for all involved. What’s more, visits to the
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THE PANDEMIC EFFECT: COVID -19 AND THE ESTONIAN HEALTH SYSTEM Photo: Estonian Tourism Board
COVID-19 has been challenging the health systems of almost every country in the world. Estonia is no exception, and its e-health infrastructure has proven to be both highly useful, yet unprepared for the crisis at the same time. While the rapid development and launch of new services, such as automatic sick leave letter admission, the track-and-trace app Hoia and a robot for calling patients, helped to contain the spread of virus, the healthcare information systems and databases ultimately lacked functional solutions for handling vaccinations. This even forced a return to paper in e-Estonia: family doctors had to exchange data via printed spreadsheets that needed to be filled out and entered into the computer by hand. “Irony of the digital state” is how a family doctor described the situation in an opinion piece for the Estonian public broadcaster ERR.
E-prescription in action: A woman collects a medicine from a pharmacy in Estonia by presenting her ID card
and access medicine in pharmacies across the Baltic Sea in Finland. Likewise, Finnish patients can also purchase medicine in Estonia with digital prescriptions issued in their home country. This cross-border exchange of e-prescription data has been operational since January 2019. Similar cooperation has also been launched with Croatia and Portugal. Other electronic crossborder health services are still limited in Europe. This is not a problem of technology, but rather of legislation.
doctor are no longer needed for repeat prescriptions. Patients can call up or email their doctor, and the medic can issue routine refills online with just a few clicks – it usually takes a mere 10 to 15 seconds. This has further reduced the administrative strain and brought the need to visit a doctor’s clinic to a minimum. Patients do not even have to go to the pharmacy either anymore but instead can log in to an e-pharmacy and order their medicine for home delivery for a small fee – a big advantage in COVID-19 times. Other changes and adaptions to the pandemic have proven to be more challenging, even in a country as digital as Estonia.
Easy, rapid and safe access to medical records
A survey on citizen satisfaction with health and healthcare in Estonia showed that 97% of its users are satisfied with e-prescription. Together with the e-tax return, it is the most popular and most frequently used e-service. Estonians are now even able to use their e-prescriptions abroad
The e-prescription as a centralised paperless system for issuing and handling medical prescriptions forms part of the e-health record system – the Estonian National Health Information System (ENHIS). It is a nationwide umbrella system that connects and integrates data
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from all medical institutions and health providers, such as hospitals, pharmacies and laboratories, to create a common record. It allows users to share defined medical documents, even though the providers may be using different systems or data formats. “We have a free market, so every institution can pick any software it wants. But we have created a central health information exchange platform which works like a repository where all the institutions have to send the agreed amount of standardized medical documents. And then other partners can request the necessary data”, the digital health expert Madis Tiik explains the overall architecture of ENHIS. The family doctor and former CEO of the Estonian e-Health Foundation has been involved in e-Health development projects in Estonia from the very beginning when they started in 2002.
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26 | C O V E R S TO RY
Patient-oriented system and services Each person in Estonia who has visited a doctor has a trackable online e-health history. The sole owners of the data are the patients, who have direct access to their own records, as well as those of their under-aged children and of persons who have authorized them to access their medical data. By logging into the patient portal digilugu.ee with their ID card, patients can see and review their medical history: past doctor visits including diagnosis and ambulatory epicrisis, current prescriptions, health scans, X-ray results, blood tests and lab reports, as well as their insurance status and medical bills reimbursed by the Estonian Health Insurance Fund. This information is also visible to their family doctor and other authorized healthcare employees who access the e-health record system in the same way. By locking or unlocking their medical records, patients can manage and control who has access to their data and
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Photo: e-Estonia Briefing Centre / Maris Orav
There are close to 40 million health documents in the e-Health system that can be exchanged in a matter of minutes and basically contain the entire medical history of the population from birth to death. All the data is accessible online for authorised healthcare providers and patients using their electronic ID card. It is backed by the X-Road, which allows a secure data exchange between databases in e-Estonia. Every month, more than 2.7 million queries are made in the system by the healthcare professionals and more than 2.5 million by patients. The integrity of the sensitive health information is secured by the KSI blockchain technology – Keyless Signature Infrastructure.
The starting page of the Estonian online patient portal digilugu.ee
efficient use of the doctor’s time and medical devices. The results were more than convincing, but the roll-out was not as smooth as expected. Doctors were initially worried that they would lose control of their schedule if patients could book appointments by themselves, but soon figured out the advantages of the system, especially in COVID-19times. It has now been joined by over 100 healthcare institutions in Estonia.
at what level. This makes it easy to get a second opinion from another doctor or change the healthcare provider – all data can be made accessible without the need to carry any paperwork around. Even more so since multiple telemedicine solutions are available in outpatient care, while doctor-doctor consultations take place online by using digital forms. YeYet the adoption had been slow before the COVID19 outbreak but several lockdowns led to a widescale uptake.
Built-in trust and transparency
To find and book a visit to doctors and health specialists, patients can use the national e-booking system which has been developed since 2019. In the self-service environment, patients can choose the date, time and doctor, and be notified ahead of their appointment. This started out as a pilot program in the North Estonia Medical Centre with the goal of taking the workload off the medical staff and ensuring a more
No healthcare provider is able to go ahead and check the medical records of patients as they please. All queries are registered by name and all activities are saved in a log. “Patients have full transparency on who has seen their personal information”, says Anna Piperal, managing director of the e-Estonia showroom in Tallinn, adding that this helps patients to protect their data. “This is not possible on paper. Never.” Going beyond this, the
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logbook system also mitigates insider threats and ensures that everyone uses the system as they should. “No one would be able to delete your blood type or your allergies or fake records without becoming known.” Violations and privacy invasions are punished severly. Some doctors have even lost their licenses to practice medicine because of unauthorised and illegitimate access to patient data. These serious sanctions prevent misuse. access to patient data. These serious sanctions prevent misuse. “You do not study for ten years to
lose your licence over a few wrong clicks, just to satisfy your curiosity”, says the e-Estonia advocate Piperal with conviction. Her job is to explain the digitization of her home country that is considered a role model in creating a digital society. Estonia’s health service has been digital for 13 years now and was rated #1 in the latest Digital Health Index of the Bertelsmann Foundation, with a clear gap to all other countries. The Annual European eHealth Survey, conducted in collaboration by HIMSS (Healthcare Information
BEHIND THE SCENES: E - ESTONIA, X- ROAD AND E - ID Estonia has been building up its e-government and the necessary IT infrastructure since the mid1990s, not long after regaining independence from the Soviet Union in 1991. Routinely referring to itself as “e-Estonia”, the country has been digitalizing almost every aspect of public life and made radical steps to eliminate paper in its interactions with citizens – often in partnerships between state institutions and private companies. Today, 99% of public services are available online and can be accessed by using a secure digital ID. Estonians only have to see the inside of public offices to get married or divorced, or for real estate deals. X-Road is the backbone of e-Estonia. Launched in 2001, the nationwide open-source software platform allows the various public and private sector e-service information systems to link up and function together. The X-Road enables them to share, exchange
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and harmonise the decentrally stored data through end-to-end encrypted pathways for offering services to Estonian citizens. The data is stored where it is created, with each entity administering its data separately. The infrastructure is supported by a “once only” policy, which determines that each citizen’s data and other information must be recorded only once and may not be duplicated. Digital access for citizens to all e-services is provided by an electronic identity card. The legal photo ID card with a special data chip can be used for identification purposes and enables Estonians to prove their identity online and produce legally binding digital signatures. The ID system is the residents’ bridge between the physical and digital world, and makes day-to-day activities painless in comparison to other parts of the world. It is secured by a 2048-bit public key encryption.
and Management Systems Society) and McKinsey, also sees Estonia as the leading country for e-health innovation in Europe. One of the main reasons for its pioneering role is that patient engagement, empowerment and trust-building were core components of ENHIS from the beginning. “The key point to e-governance and the healthcare system is confidentiality. This data is among of the most critical, crucial and sensitive in Estonian legislation”, emphasizes Piperal. Another advantage is the strongly connected ecosystem and nationwide partnership between health-related stakeholders in Estonia, who are committed to accelerating the adoption of e-service and digital health solutions – both in their home market and internationally. Many of them want to simplify, improve and speed up everyday life. Ultimately, however, the citizens are the users of digital technologies. They have to understand and be convinced of their added value. “This means that you have to design e-services that are user-friendly and easy to use, so that even the elderly can use them”, Piperal says, adding that the e-prescription is a “great example” of such a service because it does not require people to be digitally literate. All they have to do is go to their preferred pharmacy and present their ID card to get their medicine. Difficulties some patients might only encounter in Raeapteek when they try to get treatment with the ever-popular Claret – a spiced pharmacy wine created in 1467 in the pharmacy which is supposed to prevent 99 diseases. The distinguished substance is not yet available on prescription – neither digitally nor otherwise. But you can get it during a visit to or a guided tour through the historic premises.
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32 | B E S T I N B U S I N E S S
by ANDA A SERE, Labs of Latvia, exclusively for Baltic Business Quarterly
High quality of life at 120: a very real possibility Over the past century, our life expectancy has grown significantly. This is due to our access to vaccines, medications, and something as simple as higher standards of hygiene. Robust people are much less likely to die of easily treated diseases in their youth today; other issues have arisen and attracted the attention of the LongeVC venture capital fund.
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pecifically, the fact that people suffer from agerelated problems. These are often oncological and other diseases. ‘Longevity is the hottest field in biotechnology right now,’ LongeVC partner Sergejs Jakimovs said. Preventive and timely treatment is key here: treating oncological diseases as early as possible increases the chance of easier recovery, survival and high quality of life. The later you discover an oncological disease, the harder and more traumatic the treatment. While it may sound a little cliché, the main goal of the fund is to improve people’s life. Obviously, every venture capital fund seeks to earn profit, but LongeVC sees its primary purpose specifically in helping revolutionary longevity technologies develop. ‘If we don’t have the intellectual capacity to deliver a cure to Alzheimer’s disease to the world, we can approach the problem from a different direction, and provide the people who do have that capacity with resources. All in all, we’re combining forces,’ Sergejs said.
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The future belongs to biotech
LongeVC believes that the future belongs to the field of biotechnology. This is why its founders decided to set up a specialised venture capital fund worth 35 million euros, which it invests specifically in longevity start-ups. The fund focuses on businesses that develop therapeutics, as well as diagnostic devices, biomarkers etc. It invests 500 thousand to 1.5 million euros during the first round, and can increase this figure to 2.3 million during the second. LongeVC has so far invested in Insilico Medicine, Longenesis, Basepaws, Petsensus and Deep Longevity. ‘Our fund is very unique for its industry. No other fund has had such a powerful council,’ S. Jakimovs pointed out. The fund invests in technologies that could enter the market within the coming three to seven years. LongeVC mainly focuses on US companies. ‘Most of the intellectual property associated with biotech originates in research centres in the US. It is they who sell exclusive
licences and form spin-offs with high-level specialists. Creating a pharmaceutical company to develop new molecules from scratch would be very difficult in Latvia, and investors in the industry are incredibly picky about what country the team in question is working in,’ S. Jakimovs said. Life sciences and biotech need very powerful foundations, with research institutes, venture capital funds, and angel investors to provide funding for such endeavours. As an example, S. Jakimovs mentioned that some 500 angel investors and just as many venture capital funds orbited around Stanford. And whenever a spin-off shows up, they line up for an opportunity to invest in it. ‘Getting funding for projects created in Latvia is far more difficult. No one understands what you’re doing, and if they do understand, you’re told to come back again in 12 years, once you achieve certain development indicators,’ Sergejs pointed out. The fund also has a preacceleration programme. It works in a way that is different from typical acceleration programmes
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“We want to get average life expectancy to 120 years. And it’s not something we cannot achieve,” LongeVC partner Sergejs Jakimovs
Publicity photo
with a specific beginning that end with admitting a certain number of companies. LongeVC works with teams in their very early stages, on an individual basis.
Dying of cancer will get harder
The team has also set up a Longevity Science Foundation nonprofit. It is based in Switzerland, and has a goal of supporting longevity projects in their very early stages. ‘When we created LongeVC, we noticed that many projects never reached the stage, at which an investor would be prepared to provide them with funding. Many promising ideas die out just because they don’t get the early financing they need, usually in the form of grants. The availability of such funding is asymmetrical, as it often goes to various research institutes etc. The result is that smaller research projects don’t get any money,’ S. Jakimovs said. Longevity Science Foundation invests up to one million euros per project. The goal of this organisation is also to support projects that could radically improve people’s lives in the very near future. ‘We want to get average life expectancy to 120 years. And it’s not something we cannot achieve. I look forward to my generation getting to see this. We can hope that the coming years will bring revolutionary changes in the diagnostics and treatment of age-
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related diseases, and it’ll be much harder for our generation to, for example, die of cancer,’ he said.
Involvement in other projects S. Jakimovs revealed that initially, his interested was not in life science, but in the commercialisation of complex intellectual property. This is how he became acquainted with life sciences, and set up the medical tech start-up Koatum. It develops a multi-layer coating intended for people with various health problems and needs who get an implant: the coating helps the implants take without creating new problems. Currently the start-up is focusing on people with diabetes, osteoporosis and cardiovascular diseases. The project gave S. Jakimovs and his team an understanding of how the life science industry operates, how a product enters the market, how technologies are validated, and how research takes place etc. Simultaneously with the development of Koatum, he helped other medical tech
companies, mostly located in the United Kingdom, through their early stages: formulating the strategy for protecting their intellectual property during preclinical research, as well as other aspects that help attract investors. Koatum provided the knowledge of the difficulties associated with organising clinical trials, which then led to the creation of Longenesis. This start-up provides assistance in organising clinical trials faster, finding more success in attracting clients, collecting data correctly, and ensuring that the patient is in charge of their personal data, and consents to their use. S. Jakimovs and Emīls Sjundjukovs work in both of the companies. The other co-founders are different in each of them. For example, the Longenesis team also includes Bitfurry and Insilico Medicine. ‘Longenesis and Koatum are two radically different businesses: Longenesis is a software and digital health project, while Koatum makes a specific coating for implants,’ Sergejs said.
21/02/2022 13:05
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Publicity Photos
Revolutionising stroke care by NICOLINE SCHRÖDER
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the hospital and rehabilitation sector, the need for more personnel has long been known, and since the Covid-19 pandemic, this problem has become even more urgent. This lack of resources is especially problematic in areas where time is of the essence, such as stroke rehabilitation. When a stroke survivor has finished receiving acute care, there are only 12 to 18 months’ time to successfully regain their lost abilities, otherwise the strokeinduced impairments may become permanent. Rehabilitation facilities and personnel, however, do not always have the resources to provide the best care for each stroke survivor, and this has long-term consequences, such as permanent disabilities, unemployment, and a life-long dependency on welfare payments. Vigo’s founder Kristaps Krafte realised the importance of stroke rehabilitation and the existing systemic problems during his
The digital stroke rehabilitation tool Vigo is a game-changer for stroke survivors with mild to moderate stroke impairments
studies at Copenhagen Business School. “And he came up with an idea for a rehabilitation process, of making it more flexible, economically efficient and clinically efficient and cheaper here”, explains Vigo co-founder Janis Slezins, who, as a trained neurosurgeon, had witnessed this exact predicament himself daily. Vigo is a digital stroke rehabilitation tool for stroke survivors with mild to moderate stroke impairments. Once the stroke patient is ready to leave acute care, their doctor can give Vigo the patient’s background information, such as disabilities and mood. This information is used to tailor the programme to the patient’s specific needs. At home, the stroke survivor will participate in daily rehabilitation exercises relating to their
mobility. Motivational training and psychotherapeutics are included in the process as well, as they are necessary for the overall well-being of the patient and the long-term success of the rehabilitation work. The mobility exercises are programmed to not only be individually suitable for each patient, but are also meant to challenge the patients to go further and keep trying to improve. As for the psychotherapeutical part of the programme, patients are asked to report on their wellbeing every day and they then can interact with a chat-bot. With help of the iPad’s camera, Vigo can monitor the patient’s progress and help them recover. Using a digital stroke rehabilitation solution like Vigo can help relieve the already thinly stretched care sector, and it allows for patients to receive the best-possible care to fully recover from a stroke. Thanks to extensive clinical testing and trials, Vigo is an EC-marked medical product and has helped hundreds of patients to return to their lives before the stroke. Soon, Vigo will be covered by the government for patients in Latvia, showing again that digital innovation made in Latvia is a game-changer.
Both founders of Vigo – Janis Slezins (left) and Kristaps Krafte
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