The health information systems in

Romania where to?

Dan D. Farca 1*

1. National Center for Health Statistics and Informatics, Bucharest, Romania

Abstract: N/A.

Key words: e-health, Romania

* Dan D. Farca , PhD, National Center for Health Statistics and Informatics, Buchare st, Romania ,
rmrr@rmrr.ro

In the second half of 2010, the European Commission, through the Information Society
and Media Directorate General, performed - by a project assigned to a German company an evaluation of the health computerization (e-Health, e-sntate in Romanian) in the
European Union countries, focusing on the health information systems. The key-questions,
reflecting the main issues of concern for Brussels, were the same for each country:
What is the computerization strategy and policy in the health field?
What documents are there to this purpose?
For example, is there a logbook for computerization?
What is the part played by the Ministry of Health in this process?
What competency centers are there in this field?
What is the situation of standardization and how is the interoperability among the
components of the health information systems ensured?
How are the professionals in the sanitary field rewarded for using the information
technology?
What evaluations are made in order to monitor the above?
Each countrys report also aimed at underlining the stage of the specific applications
concerning the electronic health record and telemedicine.
The answers to these questions, subsequently included in the report, could be no different
than the well-known ones: in Romania, there is no official document as to any strategy or
logbook for health computerization, the only competency center dedicated to the field has
just been disestablished, there is almost no kind of standards to be abode by, each
designer or beneficiary inventing new codifications (which will later on hinder
interoperability to a great extent, both among the components of the national information
system, and among the international ones), and almost all of the experienced
professionals in health informatics were forced to leave the system, while the few who
decided to stay are systematically ignored by the Ministry of Healths management.
The statements above may be shocking and must doubtlessly be argued in detail, as it
happened in the abovementioned report. I think that some of these arguments could also
interest the readers of the Viaa medical (eng. Medical Life) weekly publication, so I
shall take the liberty to comment upon the most important ones in the following.
Starting at least in 1992, the e-health field saw the elaboration of several documents acting
as leading project or strategy. After the year 2000, these were developed in association
with the Ministry of Communications and Informational Society (MCSI) itself, in order to
integrate them into the larger project called e-Romania. In September 2008, the Ministry of
Health (through the Calculus and Sanitary Statistics Center), organized a working group
for a computerization strategy reuniting representatives of the main parties concerned:
MCSI, the National Agency of Health Insurances (CNAS), the Doctors College, the
National School of Public Health and Sanitary Management, the Romanian Society of
Medical Informatics, HL7 Romania, etc. The group elaborated a strategy proposal which
was left to gather dust in a drawer, mainly because the governmental team changed. In
2009, a private company benefiting of a Phare program elaborated another strategy. But
this strategy was ignored as well. In May 2010, the Ministry of Health issued a decision to
establish a new strategy commission, a commission almost immediately forgotten,
because of some other changes in the Ministrys management. At the end of 2010, the
problem reemerged, just to go into oblivion again.
All of the abovementioned strategy proposals took into account the main provisions of the
EU e-health action plan (2004), which demanded a unitary and interoperable information
system, organized around a unique group of national databases, accessible to all actors

concerned. Unfortunately, none of the e-health strategies suggested was officially adopted
(and accompanied by a decision to enforce its observance). Consequently, disconnected
computerization programs continued to be launched, following local initiatives and
interests, ignoring the real problems of the sanitary system as a whole.
At present, in Romania there is no authority to coordinate the e-health policy and to
represent a technical partner for the European Commission in common targets, such as
the interoperability in the e-health field, at European level. Law no. 95 from 2006,
concerning the health reform, stipulated that the Ministry of Health should create an
integrated information system for the management of public health, including data on
transmissible diseases, emergency care, community assistance, hospital information,
health insurance cards, etc. The Strategic Plan of the Ministry of Health for 2008-2010
underlined once more the necessity for an integrated information system for health
services, with patient monitoring. Nevertheless, the Ministry of Health manifested, in these
last years, only a marginal interest in the e-health field, more to manage several
computerization programs launched chaotically. Among the four ministers in the last four
years, none met the specialists in the system at least once, to discuss about the e-health
problems. For certain time periods, one of the ministers councilors got involved into such
matters, but only for the computerization programs already running. Answering the
periodical invitations for common e-health actions sent by the European authorities, the
Ministry of Health sent to Brussels Ministry representatives chosen randomly, and these
representatives did not have the interest or the possibility to ensure the engagements
taken are met. For example, in August 2007, the minister of health signed, in Romanias
name, the Letter of Intent containing the commitment to participate in the Initiative for a
pilot-project of e-health interoperability on a large scale, commitment which was not
supported by facts. The frequent replacements of the 1st and 2nd level officials in the
Ministry partly account for this situation.
The technical and monitoring activities concerning the e-health strategy therefore claim for
a competency center characterized by continuity, unaffected by political changes. In the
last 20 years, the Ministry of Health did not have, in its proper structure, more than 1-3
informatics professionals, whose activities were mainly targeted at the problems of the
calculus equipment in the Ministry. Yet, the Calculus and Sanity Statistics Center (CCSS)
represented a competency center even from 1970. Responsible for the codifications and
statistics in the health field, it created, starting from 1971, a computerized system for the
documentation of all the doctors in Romania, the sanitary units, the medical devices, but
also records of chronic patients, inquiries, statistics and other applications. Part of these
applications function even today. From 1977, CCSS was appointed, by Ministerial Order,
the responsible for the health computerization in Romania, status reconfirmed several
times later on. But, after 1990, the Ministrys support for the CCSS decreased gradually,
the personnel were restricted, and the informatics specialists left in the search for better
wages. However, until recently, the CCSS still contained several informatics
compartments, including a small bureau for e-health strategies and projects, involved in all
of the abovementioned strategies, and another bureau, for e-health research and
standardization. CCSS had also been the only organization to make evaluations of the ehealth equipment and activities in Romania. Just that, on July 1st, 2010, the Ministry of
Health decided that the CCSS (meanwhile renamed CNOASIIDSB) be cancelled as
independent institution, and several specialists be dismissed.
It was not just a mere coincidence that the funds for the Academy of Medical Sciences
were withdrawn at the same date, condemning the most prestigious forum of the
Romanian medical research to dismissal, a forum involved right after 1990 in the health

informatics as well, through an expert commission. Another two professional

organizations, which could have constituted competency centers in the field, namely: the
Romanian Society of Medical Informatics (SRIM), and HL7 Romania, affiliated to the
dedicated international structures, with excellent ties with the specialists in other countries,
were systematically ignored by the Ministry of Health and were never granted any official
support whatsoever.
Because of the lack of authority, of a strategy, and of a mediation organism in the field of
e-health, for 10-15 years now, various actors in Romania have been launching their own
health information systems, databanks, without taking into consideration the
computerization already present or the developing projects. Thus, data collection lines
doubled, solutions already available were reinvented, ad-hoc codifications, completely
disconnected, proliferated, and all these led to incoherencies and severe interoperability
problems, both inside the county and, in the future, with other countries as well.
Sometimes, the equipment distribution came ahead of defining the programs needed to
use it. So there was money, including European funds or funds from the World Bank, but
the Ministry of Healths priority was to spend it on punctual projects, not on integrating the
informatics applications into a coherent national system, meant to solve the real health
problems.
This was also the spirit in which, at the beginning of 2010, the Ministry of Healths
management meant to show that the future of the national health information system
would from now on be in good hands, owing to CNASs project called the Unique
Integrated Information System (SIUI), comprising this year the following: the electronic
health record, e-prescriptions and the electronic health card. Without wandering away to
largely debated topics, such as length of operation, costs and technical problems of the
SIUI project, its main destination being of a financial-accounting nature, we must underline
the fact that the CNAS does not seem the right institution for such a target. Even if,
apparently, most of the money is lost here, a national health information system should
have started with a documentation of the whole population and not only the population
benefiting of a health insurance, with all the doctors and sanitary units, not just the ones
having concluded a contract with the CNAS, but especially it should have had in view not
only the services or products discounted with the CNAS, but the numberless determinants
and parameters of the entire populations health status, data which, quite normally, has
nothing to do with the CNAS. We should not forget that there are large population
categories insured with other agencies, specialized (army, public order, justice) or private.
Much the same, there are more and more high-performance private hospitals and medical
networks, which discount their services with private insurers. It is a natural tendency for
the sanitation of the health services, tendency which should not be discouraged by
imposing state monopoles.
Just as an example, concerning the electronic health card, which the CNAS is currently
working on, we could notice that, for some years now, the Ministry of Administration and
Internal Affairs has also been discussing about the electronic identity card, and it was
proposed that it should also include health information, the same included on the health
card. Certainly, for simplicity, the identification codes of the persons in the two cards will
be different Thus, there will be two population records, the CNAS one only comprising
the insured individuals. I also mention that, at present, Romania participates, through
several entities, in several European funded projects for the interoperability of the
electronic health record, together with institutions from Italy, Spain, etc. The project is
aimed at, among others, the hundreds of thousands of Romanians working abroad, who
will need health services, at a certain moment, based on electronic cards. Would just a bit

of strategic thinking not have been enough to find a unique solution to all these actions,
subsequently applied individually?
But the functions of a national health information system are much larger than the ones
above. Such a system shall have to guarantee, in emergency situations, the access to the
health data of all Romanian citizens (not just the insured ones), and, in the future, of the
foreigners in Romania as well, shall have to have teleradiology, teleconsulting,
telediagnosis and telemonitoring functions, a second approval in distant places, shall have
to include records of chronic patients, to contribute to scientific research and the medicine
supported by evidence, etc. In the spirit of the EU e-health action plan (2004), the health
information system, such as it was proposed in the abovementioned strategies, was to be
organized around a unique group of national databases (population, units of medical
assistance, health professionals, drugs, codification, standards, etc.), also insuring the
coherence with the records of the Doctors, Dentists, and Pharmacists Colleges, the CNAS
records, etc. Thus, the double collection, processing or evidence of the data would be
eliminated, and there would be premises for promoting decisional support instruments, in
order to exploit to the maximum the existent data fund. Thus, complying with the security
and confidentiality demands, the information would be at the disposal of the Ministry of
Health, the health insurers, the professional organizations, but especially the doctors in all
the units: hospital and ambulatory, public and private, insured or non-insured. Such a
system would generate health statistics for all situations (not just the ones covered by the
social insurance system), including the compulsory accounts to the WHO, Eurostat,
UNICEF, etc, the statistics of births and deaths, in cooperation with the Population
Register Center, with the National Institute of Statistics and so on.
In a farther perspective, this information system, built around the citizen, could be enlarged
towards prevention applications, gradually integrating more and more health determinants,
such as: educational level, hygiene, amount of exercise taken, quality of inhabiting, of
transportation, of nourishing, air and water quality, etc., the emphasis lying on the
mechanisms of prognosis, simulation, optimization and early intervention, which shall allow
for the improvement of the health status at a national level, with an even better planning
and usage of the available resources.
The only chance to accomplish such a computerization of the health protection sector, with
a sensible usage of the available resources, would be for those who decide upon the
allotment of public funds for e-health projects to adopt and abide by three main conditions:
1. To facilitate the consensual accomplishment, by all parties concerned (the Ministry of
Health, MCSI, CNAS and other insurers, professional unions, companies, etc.), of a
national health strategy, meant to take into account the e-health applications, existent or
under development, other computerization projects at a national level, and the strategies
and projects in other European countries. The strategy should also include codifications
and standards meant to insure, among others, an extensive interoperability.
2. To establish a permanent body of specialists, subordinated to the Ministry of Health, but
with the representation of the main structures and institutions concerned. This body should
have the necessary resources to develop and update the strategy (in successive editions,
function to the new necessities, innovations and technological demands), and to monitor
the compliance of the public e-health projects with this strategy.
3. To insure a legal framework which should allow for the public funding of only those ehealth projects which meet the strategy adopted, fact certified by the permanent body of

specialists dedicated to strategies. A governmental decision would be useful in this regard,

given the involvement of other ministries as well (MCSI for e-Romania, the Ministry of
Internal Affairs, for the population registers, etc).
Apart from the above, some complementary measures would also be necessary, such as
the provision of a sufficient number of specialists in health informatics, given the fact that,
for now, in Romania, this profession is not even officially recognized.
The one who will say that the measures above need funds, which do not exist for now,
should think that the damages, given the lack of such measures, are hundred times higher.
As for the other possible motivations, coming from the ones who will say that suc h
measures are unrealistic, no other comment is needed.