Reforming the Bulgarian healthcare system amidst a pandemic - the adoption of electronic medical referrals   

The COVID-19 pandemic has brought about a series of important changes in many spheres of life. We are looking at an ongoing legislative, regulatory, labour, societal and cultural adaption to what appears to be an unprecedented challenge of our time.

The Bulgarian public healthcare system makes no exception and has found itself in need of urgent adjustments in order to respond to the immediate demands and needs caused by the pandemic. Bringing public healthcare services to the online space has been a long-awaited process, but this month marked a positive step in the right direction thanks to the adoption of electronic medical referrals. In this way, doctors will be able to remotely issue medical referrals for PCR tests in the presence of 2 out of 11 COVID-19 symptoms. This would reduce the risk of medical practitioners being in direct contact with infected patients or with potential carriers. Instead, the medical consultation will be realised via telephone call. For now, the legislation does not specify a limit on the number of electronic medical referrals that can be issued. The PCR test will be covered by the state budget.

Together with protecting medical practitioners, this long-awaited change would prevent the accumulation in medical establishments of patients or people with flu-like symptoms and would thus eliminate the need for green corridors for people seeking immunisations or annual check-ups.

There are certain exceptions to the rule of free access to PCR tests, namely:

1. Hospitalised patients

2. Contacts of infected individuals, but lacking symptoms

These exceptions raise certain issues. Firstly, the contact persons of an infected individual are a group of high risk since they may not manifest any symptoms, but may be carriers of the virus. Furthermore, to be able to verify whether a person has been cleared of the virus, until recently, the person had to obtain two negative PCR tests. This practice was adopted at the beginning of the pandemic, but hospitals no longer implement it. If the patient wishes to know whether they have been cleared of the virus, they have to cover the costs of a PCR test themselves. Anоther example are the donations of blood plasma, where a negative PCR test is also required, but again is not covered by the state.

The procedure for the issuance of a medical referral for a PCR test is quite simplified:

1. A person who exhibits at least 2 of the 11 symptoms (fever, dry cough, tiredness, loss of taste and/or smell, difficulty breathing or shortness of breath, muscle pain, headache, diarrhea, nausea and vomiting, sore throat, oxygen saturation less than 92% or less than 88% (in particular cases)) of COVID-19(1) needs to contact their GP. 

2. The GP enters the data in the medical referral form provided by the Ministry of Health.

3. Upon completion, a code is generated.

4. The code displayed on the GP's screen should be dictated to the patient.

5. The patient then provides the code to the laboratory and can subsequently benefit from a free PCR test.

This step towards digitalising the Bulgarian healthcare system has many positive effects. To begin with, patients, especially those with severe symptoms, will be saved the nuisance of personally visiting their GPs and then being redirected to a specialist medical practitioner in order to assess the presence or absence of symptoms. Another huge benefit of electronic medical referrals for PCR tests is the elimination of the possibility of infection between patients in doctors’ waiting rooms. A certain relief for patients is also the lack of fee for a telephone consultation with a GP.

Nevertheless, certain issues are already being observed in terms of logistics. Not all GPs have access to the electronic referrals system. Studies show that in regions such as Plovdiv and Vratsa, the percentage of doctors with access ranges from 100 to 70%, for regions such as Ruse, Veliko Tarnovo and Shumen, the percentage varies from 50 to 33, and in large regions such as Varna, Burgas and Blagoevgrad, the percentage is below 5.

Another specific to bear in mind in the context of electronic medical referrals is the frequent amendment and supplementation to the National Framework Agreement for Medical Activities between the National Health Insurance Fund and the Bulgarian Medical Association for 2020 – 2022. An example of these ongoing changes is the Annex of 03.12.2020, pursuant to which patients with a positive antigen test were also given the opportunity of a free PCR test.

E-health, although slowly and cautiously, is indeed entering the Bulgarian law and medical practice. Despite the fact that for now electronic medical referrals can only be issued for PCR tests, many healthcare professionals believe that this is the beginning of the end of queues in doctors’ waiting rooms, as well as of the pile of documents that doctors need to fill out on a monthly basis.

(1) Article 223h, para. 2 of the National Framework Agreement No. РД-НС-01-4 of 23 December 2019 for medical activities between the National Health Insurance Fund and the Bulgarian Medical Association for 2020 - 2022, amended by Agreement No. РД-НС-01-4 -5 of 26 November 2020 (promulgated, SG, issue 101 / 27.11.2020)