Bulgarian E-Health Overview

Peter Stanchev

1, 2

and Elvira Foteva

Institute of Mathematics and Informatics, Bulgarian Academy of Sciences, Sofia, Bulgaria

Kettering University, Flint, USA

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-

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

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.

Fourth International Conference on Telecommunications and Remote Sensing

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

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

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

Figure 1: Main modules of the current National Health Information System

Fourth International Conference on Telecommunications and Remote Sensing

Figure 2: Regional modules of the current National Health Information System

2015

2016

2017

2018

2019

2020

Ministry of

Health

Database 1

Ministry of Health

Database 2

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

Medical Software

Certification

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

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.

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World Health Organization, 2015. Trade, foreign policy,

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story021/en/

World Health Organization and International

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http://www.who.int/ehealth/publications/overview.pdf

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https://ec.europa.eu/digital-agenda/en/news/ehealth-

action-plan-2012-2020-innovative-healthcare-21st-

century

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