Bulgarian E-Health Overview
Peter Stanchev
1, 2
and Elvira Foteva
3
1
Institute of Mathematics and Informatics, Bulgarian Academy of Sciences, Sofia, Bulgaria
2
Kettering University, Flint, USA
3
Ministry of Health, Sofia, Bulgaria
pstanche@kettering.edu, efoteva@mh.government.bg
Keywords: E-Health, World Health Organization, Bulgarian Ministry of Health, Health Information Systems, E-Health
card
Abstract: The paper presents: (1) the strategy of the World Health Organization and ways of delivering E-Health; (2)
discusses the EU Health 2020 policy, EU support, EU projects, goals in the field of E-Health; (3) Bulgarian
National Health Strategy (2014-2020), integration and connectivity in healthcare through the national health
information system and real access to patient information about their own health; Bulgarian E-Health
electronic medical systems, Bulgaria E-Health foundation.
1 INTRODUCTION
According to the World Health Organization (WHO)
(World Health Organization, 2015) E-Health is the
transfer of health resources and health care by
electronic means. It encompasses three main areas:
The delivery of health information to health
professionals and health consumers, through the
Internet and telecommunications.
Using the power of information technology
and e-commerce to improve public health services,
e.g. through the education and training of health
workers.
The use of e-commerce and e-business
practices in health systems management.
The benefits of E-Health for patients include:
easier access, better quality, speed and convenience,
awareness and participation in control; and for
doctors: reducing the administrative burden,
eliminating unnecessary documentation, timely and
ease of access information for finding evidence-based
solutions, easier communication, ways to plan
activities more effectively.
The Bulgarian E-Health systems should:
Improve the quality of information services for
all sides involved in health care;
Define health information standards, regulating
the information interaction among all participants in
the healthcare process;
Provide the information necessary for
monitoring the health of the population at different
levels and the quality of medical services;
Provide information for planning and control of
financial flows in healthcare;
Attain unification with health information
systems of the European Union and WHO.
The paper is organized as follows: Chapter 2
presents the strategy of WHO for E-Health. Chapter
3 discusses the EU E-Health plans. The Bulgarian
Ministry of Health E-Health activities are presented
in chapter 4. Chapter 5 describes the current state and
the future of the Bulgarian E-Health electronic
medical systems. The paper ends with conclusions.
2 THE WORLD HEALTH
ORGANIZATION STATEGY
The World Health Organization published in 2012 its
National E-Health Strategy Toolkit (World Health
Organization and International Telecommunication
Union, 2012). It reflects the growing impact that E-
Health is bringing to the delivery of health care
around the world today, and how it is making health
systems more efficient and more responsive to
people’s needs and expectations. It is divided into
three parts: National E-Health vision, National E-
Health action plan and National E-Health monitoring
and evaluation. WHO’s key undertaking within E-
87
Stanchev P. and Foteva E.
Bulgarian E-Health Overview.
DOI: 10.5220/0005889900870092
In Proceedings of the Fourth International Conference on Telecommunications and Remote Sensing (ICTRS 2015), pages 87-92
ISBN: 978-989-758-152-6
Copyright
c
2015 by SCITEPRESS Science and Technology Publications, Lda. All rights reserved
Health is to provide independent advice and
assistance to countries towards the long-term
development of sustainable national E-Health
solutions in relation to strengthening health systems
performance and the capacity for countries to gather
and analyse health information. WHO delivers E-
Health in 3 ways: (1) As a knowledge-broker and
facilitator between nations and the International
Community at large; (2) By developing and sharing
best practices and standards precipitated from
successful E-Health implementations; (3) By
working directly with Ministries of Health to address
their technical and strategic needs for E-Health and
Health Information.
3 EUROPEAN COMMISSION E-
HEALTH PLANS
The European Commission published in 2012 its E-
Health Action Plan 2012-2020 - Innovative
healthcare for the 21st century (European
Commission, 2012). The vision of the Action Plan is
to utilize and develop E-Health to address several of
the most pressing health and health systems
challenges.
Health 2020 is the new European health policy
framework. It aims to support action across
government and society to: significantly improve the
health and well-being of populations, reduce health
inequalities, strengthen public health and ensure
people-centred health systems that are universal,
equitable, sustainable and of high quality. It has two
strategic objectives, constructed around equity,
gender and human rights and improved governance
for health.
European Commission support can be divided
into three main areas: co-financing of projects,
support to awareness-raising events (in particular to
the annual High-Level Presidency E-Health
conferences) and running structures for awareness
and networking building, best practice sharing and
policy development.
The goals of the main EU E-Health projects
are to:
Test and demonstrate new models and tools
for health and care delivery;
Support the translation of findings into the
clinic and other health and care settings to: improve
health outcomes, reduce health inequalities, and
promote active and healthy ageing.
Some of the EU projects are connected with
the overview of the national laws on electronic health
records in the EU Member States (European
Commission, 2013, Overview of the national laws on
electronic health records in the EU Member States
National Report for Bulgaria).
Common E-Health challenges observed in
Europe are:
Ownership and governance of E-Health,
developing and delivering on national E-Health
strategies and managing the burden of ongoing
system development and maintenance;
Developing and adopting appropriate
legislation to allow for E-Health;
Ensuring security, privacy, identity
management and ethical issues;
Workforce issues: education, awareness and
retraining;
Acceptance of solutions by health
professionals;
Regionalization (within country) can be both a
strength and a weakness;
Digital literacy issues are contributing to a
delay in E-Health adoption.
4 THE BULGARIAN MINISTRY
OF HEALTH E-HEALTH
ACTIVITIES
The Bulgarian Ministry of Health published in 2013
a National Health Strategy (2014-2020) (The
Bulgarian Ministry of Health, 2013). It includes the
development of E-Health as an essential tool for
ensuring the effective functioning of the health
system. A National Health Information System
(NHIS) will be developed to provide public access
through an electronic identifier managing health
records, electronic prescription, etc. This will take
place through the following steps:
Development of mandatory standards for
health information and statistics;
Development of policies for security and
interoperability of the healthcare information
systems;
Establishment of a national health information
system and ensuring public access to the system
through an electronic ID.
Some of the main system functionality will allow:
The use of a secure user interface to exchange
information in real time between physicians, patients,
laboratories, insurance company;
Management of the electronic health record of
the patient;
Providing information to the public and health
education;
Distribution of telemedicine services in
diagnosis, treatment and surgery.
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88
Development of E-Health is a government
priority and this is clearly indicated in the
Government Programme for sustainable development
of the Republic of Bulgaria (Government Programme
for sustainable development of the Republic of
Bulgaria 2015).
The main EU recommendations for including E-
Health in Bulgaria are:
Need of a well-established health strategy, as a
precondition for access to the structural funds (ex-
ante conditionality criteria);
Need of an action plan of this strategy before
planning the investments needed;
Adoption of EU standards for interoperability
should guide the investments in E-Health;
Continuous and strong involvement in EU
initiatives, such as joint actions and the eHealth
Network.
In E-Health, a reform facilitator final report on
Health Financing Diagnostic and Review of
Envisaged Reforms (Final report, 2015) is written
that Bulgaria is rich in technology resources, but it
seems that the country is now falling behind its peers.
The Ministry of Health is well placed to play a
significant role in encouraging cooperation among all
health stakeholders, but before that it must resolve the
fundamental issue of the National Health Insurance
Fund system.
Expected results of applying the plan are:
Integration and connectivity in healthcare through a
national health information system and real access to
patient information about their own health.
There is also a non-profit, non-governmental
organization functioning in Bulgaria - The Bulgaria
E-Health Foundation. It was established with the
purpose of boosting the development of E-Health on
national level as part of the electronic government of
the Republic of Bulgaria. The necessity of speeding
up the health reform in Bulgaria requires the
development of electronic healthcare as a cornerstone
in our health system. In this process the Foundation
works together with all participants and interested
parties in the healthcare process the Ministry of
Healthcare, the National Health Insurance Fund,
private health insurance funds, hospitals, GPs,
pharmacies, laboratories, medical doctors and
patients (E-Health Bulgaria Foundation, 2015).
5 BULGARIAN E-HEALTH
ELECTRONIC MEDICAL
SYSTEMS
An essential tool for ensuring the effective
functioning of the health system is the integration and
connectivity of healthcare by building a national
health information system and ensuring public access
to the system through an electronic identifier. A
unified information system of health care is the basis
on the development of which E-Health will be built
with its main components: electronic health records,
electronic prescription, electronic referral, electronic
portal, etc. Its implementation allows for more online
administrative and health services sector activities,
providing access to information about the patient‘s
own health, improving relations between different
levels of the system, improving the quality of medical
services and making the spending of public funds for
health care more effective.
The Bulgarian E-Health electronic medical
system has to include information about:
Patients to improve treatment, thanks to
evidence-based medicine and provide a way to
involve patients in decisions about their health;
Medical and health professionals - for quick and
easy access to information, diagnosis and for
performing complex remote interventions, as well as
access to specialized education and training
resources; with the support of medical research,
effective management and dissemination of medical
knowledge;
Managing the health care system - to improve
access and dissemination of best practices for
planning and management of healthcare for the
benefit of patients and society;
Civil society - in order to better health education,
a healthy lifestyle, prevention, information, health
resources and opportunities for the health system to
be able to influence the management of the health
system at the local and national level.
The Bulgarian Ministry of Health needs systems
in health policy planning including:
“What-if” systems that model different policy
parameters and attempt to compare results;
Simulation systems that similarly provide
guidance on policy decisions based on the simulation
of random epidemiological or environmental or
macroeconomic events;
Geographic Information Systems that can create
a full “health map” of the country;
Systems aimed at monitoring and enforcing
quality standards across the health sector;
Budgeting systems, National Health Accounts
analytic systems and accounting systems.
The structure of the current National Health
Information System is given in Figure 1. Processing
of the claims includes: electronic files submitted by
hand or by e-mail. Different databases are used by
regions and types of claims. There is one point
missing, a uniform mechanism and database for
processing, approval and storage of all claims. There
is no control of funds and optimizing payments
Bulgarian E-Health Overview
89
software. The system has two cores, an Enterprise
Resource Planning (ERP) core (Core 1) for managing
the financials, and Core 2, which provides the
centralized claims-processing step at the central site
in Sofia. Hospital claims, the largest per-unit cost
claims must now bypass the claims adjudication
system altogether and proceed to the payment module
with seemingly little scrutiny. Some of the regional
modules used in processing claims are given in Figure
2.
The current problems of using NHIS (P. Moskov,
2015) could be summarized as:
• Lack of a comprehensive information picture of
the activities in the healthcare system;
• No mandatory application of health information
standards;
• No statistically valid planning;
No quantitative rational control of the quality
and effectiveness of medical activities.
The following steps will be taken in the next five
years:
Creation of an Electronic Health Record for each
Bulgarian citizen;
Creation of a National Health Information
System and its infrastructure (portal data center,
electronic identification) available to all entities of the
health system (natural and legal, public and private);
• Creation of electronic prescriptions;
• Construction of health and medical standards;
Construction of pharmacy-therapeutic practices;
Development of a unified medical ontological
database;
• Creation of a Statistical Center;
• Further development of statistical standards;
Creation of sets of metrics for quality
management.
Work will be based on the following principles:
• Leading role of the state;
• Use of existing initiatives and systems;
Providing a gradual process of construction in
accordance with our long-term vision;
• Protection of existing investments;
Security and access to regulated information in
accordance with the regulations;
• Mandatory use of health information standards;
Uniform requirements and equal access to
information;
Broad consensus and involvement of all
stakeholders.
The steps in the next five years are given in Figure
3.
Figure 1: Main modules of the current National Health Information System
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90
Figure 2: Regional modules of the current National Health Information System
2015
2016
2018
2019
2020
Ministry of
Health
Database 1
National E-
Health Portal
Medical
Nomenclatures
National Statistics Centre
Medical Ontologies
Medical
Standards
Standard Information System 1
Standard Information
System 2
Medical Good Practices
Medical Records 1
Medical Records 2
Health
Legislation
Medical Administrative Services 1
Medical Administrative
Services 2
Health
System
Analysis
Telemedicine
NHIS - core1 + E-
medical Records + E-
Prescription
NHIS - core 2
NHIS - core 3
Technical Support 1
Technical Support 2
Technical Support 3
Human Relation 1
Human Relation 2
Human Relation 3
Project Management 1
Project Management 2
Project Management 3
Figure 3: Steps to be taken in the next five years for building the new National Health Information System
Bulgarian E-Health Overview
91
6 CONCLUSIONS
WHO has both a normative and a supportive role to
play in the member states in the field of E-Health.
WHO and the European Commission are committed
to bringing together representatives of all member
states to advocate for the development of a national
E-Health strategy, the adoption of standards for
interoperability and promoting the implementation of
E-Health with the aim of attaining Universal Health
Coverage.
The Bulgarian Ministry of Health is working
to bring E-Health to citizens. E-Health is essential to
an efficient and sustainable health system. Bulgaria
needs interoperable systems to attain E-Health
solutions.
At present in Bulgaria there exist hospital
information systems, software for providers of
outpatient care, small databases for different medical
practices, an NHIF system at different centres and
agencies.
There is no single system at the moment that
unifies and enables communication between different
information systems and databases. There is an action
plan and a road map for building a National E-Health
system over the next five years.
REFERENCES
World Health Organization, 2015. Trade, foreign policy,
diplomacy and health, E-Health, retrieved August 10,
2015, from: http://www.who.int/trade/glossary/
story021/en/
World Health Organization and International
Telecommunication Union 2012, National eHealth
Strategy Toolkit Overview, retrieved August 10, 2015,
from:
http://www.who.int/ehealth/publications/overview.pdf
European Commission, 2012. Digital Agenda for Europe,
eHealth Action Plan 2012-2020: Innovative healthcare
for the 21st century, retrieved August 10, 2015, from:
https://ec.europa.eu/digital-agenda/en/news/ehealth-
action-plan-2012-2020-innovative-healthcare-21st-
century
European Commission, 2013, Overview of the national
laws on electronic health records in the EU Member
States National Report for Bulgaria, retrieved August
10, 2015, from: http://ec.europa.eu/health/ehealth/
projects/nationallaws_electronichealthrecords_en.htm
The Bulgarian Ministry of Health, 2013, National Health
Strategy (2014-2020), retrieved August 10, 2015, from:
http://www.mh.government.bg/media/filer_public/201
5/04/08/nacionalna-zdravna-strategia_2014-2020.pdf
Government Programme for sustainable development of the
Republic of Bulgaria 2015, retrieved August 10, 2015,
from: http://www.government.bg/cgi-bin/e-cms/vis/
vis.pl?s=001&p=0211&n=132&g=).
Final report, 2015, E-healtha reform facilitator Final
Report on Health Financing Diagnostic and Review of
Envisaged Reforms, May 2015, advisory services
agreement between the Ministry of Health of the
Republic of Bulgaria and the International Bank for
Reconstruction and Development, retrieved August 10,
2015, from: http://www.mh.government.bg/media/
filer_public/2015/06/16/final-report-on-health-
financing-diagnostic-and-review-of-envisaged.pdf
E-Health Bulgaria Foundation, 2015, retrieved August 10,
2015, from: http://www.ehealth-bg.org/en/
P. Moskov, 2015, The reform of the healthcare system,
retrieved August 10, 2015, from: http://www.mh.
government.bg/bg/novini/aktualno/dnes-ministr-d-r-
petr-moskov-iznese-prezentaciya-p/
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