Dr. Branimir Raduilov is one of the founders of Polyclinic Bulgaria, which combines all aspects of the outpatient medical care system. The facility’s process is directly linked to and administered by the technology company Consento, which Dr. Raduilov founded.
It is developing a cloud-based platform to support and ensure the implementation of the medical organization’s ambitious plans to create, test and introduce a new type of medical service.
Consento is among the founders of the Digital Health and Innovation Cluster Bulgaria (DHI Cluster Bulgaria), and its vision is to create a stable doctor-patient relationship, increase trust between them and at the same time significantly improve, facilitate and arrange clearly regulated communication between the parties.
Dr. Raduilov is an expert in organizing and optimizing processes in pre-hospital care, a consultant in eHealth, medical technologies, as well as the introduction and testing of models related to health services based on value rather than quantity. He has authored and co-authored publications related to optimizing medical services through innovation. Over the past 10 years, he has worked on numerous projects as a private investor, entrepreneur and consultant.
Dr. Raduilov, you are involved in the preparation of an analysis on the declining number of physicians in Bulgaria. What are the most important conclusions that you and your team came to?
The decline of working doctors and doctors of working age in general in Bulgaria has been talked about for many years, perhaps for decades now. However, specifics are lacking. Beyond the abstract thesis, so far we have heard from the media that surgical activity has stopped in a particular hospital due to a lack of anesthesiologists or that there is not a single rheumatologist in a certain number of regions of the country. This information is valuable, but in reality it is long overdue, since because this particular problem is now almost beyond repair. The goal of our team was to gather information about the upcoming impending crisis so that we could begin working to prevent them. It turned out that hospital care, while not well balanced within the country, was rather understaffed with physicians. In fact, the big deficit is in outpatient activity and especially in the field of general medicine. These are the activities that are close to the patient and have to be 10 – 15 minutes from his home by car or even walking distance.
We do not have enough information on remote areas, but the crisis is already creeping towards regional cities, including Sofia. Almost all working GPs are in retirement or pre-retirement age. There are no young people or people of mature age. We are now entering the stage where there is hardly anyone to introduce new people to the ‘craft’. In the context of the COVID crisis, we have become aware of the severe shortage of infectious disease specialists. A much more severe shortage of GPs is emerging. This is the largest specialty in terms of numbers of practitioners and rebuilding what has already been lost must start immediately. Otherwise the situation will become untenable.
As society changes slowly, technology will inevitably have to step in to make doctors’ work more efficient and more accessible. The possibilities being worked on are many and hardly anyone can give an exhaustive list. The developments in the field of artificial intelligence are interesting, but seem to be a long way from practical application. Telemedicine is moving at a rapid pace and there are already a number of platforms offering services in this area. The collection of medical data from equipment instead of medical staff is also undergoing rapid development, particularly in some areas of medicine. However, there is still a long way to go before we can talk about a significant effect at public health level.
To sum up, the main conclusions are:
- General medicine is the foundation of our health system.
- At present, this specialty is the least attractive.
- Investing in young people and changing working conditions is paramount for the preservation of this specialty and hence for society as a whole.
How can we attract more young doctors into pre-hospital care and where can the investment for this come from?
As a result of our profession, we medical professionals medics are pragmatic people used to dealing with suffering and death. This pragmatism brings with it the pragmatism of young people’s choice of specialty. In universities, medical students do not have access to outpatient activity. For example, in one university, General Medicine classes are taught in the Intensive Cardiology Unit. How can a pragmatic young person be expected to leave dump what they know (the hospital system) and venture into something strange and alien like the outpatient clinic? Not realistic. Hence the first major task – expanding student training towards outpatient and pre-hospital care.
Another major obstacle is the heavy administrative burden that outpatient doctors and especially general practitioners (GPs) carry. In practice, becoming a GP means starting a business where your personal services generate the main product. Accordingly, no one guarantees you an income. If your services are in demand, you will have income; if not, income is not guaranteed. At the same time, you face a huge amount of regulation associated with running the business. Don’t get me wrong – medicine is a responsible endeavour, patients’ rights and safety must be guaranteed, secured and protected, but in this chaotic and voluminous form, the regulatory framework discourages young people from undertaking such a risky venture. There is no way that technology cannot be part of the solution to these problems by supporting doctors in building a more efficient and successful business.
Last but not least, young people have grown up with technology. The first smartphone was produced in 2000. Children born then are now in their third year and will soon enter the workforce as graduate doctors. These young people are aware that the more advanced and in-demand a technology is in a profession/specialty, the more likely it is that a career in that field will be successful. The development and implementation of new technologies in outpatient medicine is key to attracting ‘fresh recruits’.
As for financial backing, there is currently funding for everything, as long as there are good ideas. European funds, Norwegian funds and targeted innovation funds are all good opportunities to fund pilot projects to transform thinking. In parallel, the Ministry of Health and the NHIF could provide earmarked funding for pilot projects in areas of interest.
What is actually the role of the state and the public health system in creating favourable conditions for companies that contribute to the development of healthcare in Bulgaria?
A basic rule in medicine is: “Above all, do no harm”. The approach should be careful and when there is sufficient evidence of the success of an innovation, the regulatory authorities should secure it with an appropriate regulatory framework to make this innovation applicable in practice. Doctors consult patients remotely every day, but there is currently still no regulatory document that defines ‘remote consultation’, stating says how it should be documented and what its consequences might be in the event of good or bad faith performance by the doctor. This is simply an example demonstrating the archaic status of the system.
Reforming and updating the regulations is the first important step. After that, there are a very large number of things that can and should happen. The public health insurance fund’s recognition of modern technologies is, of course, critical to their promotion. The right approaches to planning and implementing national eHealth systems should also not be forgotten.
Establishing pilot health facilities and stimulating pilot projects is the main way to test ideas for system change. This is a controlled environment in which to test them in real-life situations, by specially trained personnel and patients who have agreed to participate. This will prevent conflict, frustration in the future and ultimately lead to better services being brought into use. Pilot projects should be funded separately as innovations are funded.
How has the pandemic changed the way we look at medicine, and what changes are needed in its fields to respond adequately to the current challenge?
The shortage of specialists, of course, stands out clearly. But more interesting is the question of why even the available number of specialists has failed to achieve a better results. Let us not forget that the number of doctors per capita in Bulgaria is not very different from that in Germany. And the reported mortality rate is incomparable.
First of all, the logistics broke down quickly. For example, with regard to emergency care. Within the political world, there are always two topics themes – higher and more motivating salaries for employees and new, well-equipped ambulances. Occasionally, someone also mentions helicopters. At the same time, coordination between emergency care and the hospitals that have to accept emergency patients is practically non-existent. Did you know that, to date, hospitals with emergency units declare at the beginning of each duty period verbally, by telephone, to an emergency operator whether, how many and what kind of free beds they have? The result – patients who ride for hours in ambulances, and doctors from the CSMC who desperately plead with a colleague from yet another hospital to admit the seriously ill patient into the ambulance. Wasted human labour, an unknown number of deaths due to delays in intensive care available only to hospitalised patients.
On the other hand, it has become clear that there is no meaningful regulatory framework for online doctor-patient communication. It is not about payment. It is about protecting the rights of both parties, it is about documentation. There are protocols – a patient with a diagnosis must be given a certain set of tests, which must be commented on by a doctor, and then the appropriate therapy must be prescribed. At the moment, a patient needs to see a doctor first to get a ‘referral’, have the tests done and then see a doctor for a second time to get a therapy. It is pointless to have two visits and sometimes even one. In the context of COVID, this was particularly felt because of the need to comply with quarantine measures. It is also the reason why many people are no longer among the living – precisely because of the failure to carry out the necessary prophylaxis and adjustment in their therapy. If there were working telemedicine and adequate remote medical consultations, properly documented, of course, many of the chronically ill would still be with us.
What is the change you would like to see in public attitudes towards pre-hospital and hospital care?
Hospitals are massive structures with different human and financial capital than pre-hospital care. They have the ability to consciously respond to market incentives and inevitably offer different quality and affordability of care, especially when emergency care units are available. On the other hand, outpatient care is highly fragmented, giving it enormous flexibility but depriving it of vision and stability for development. That is where the focus should be.
In the coming years, I would like to see a gradual percentage increase in investment in the outpatient system – emergency, primary and specialist. Creating the conditions for a multiple increase in outpatient activities and the use of day hospital up to 48 hours to be the standard rather than the exception. The day hospital is an intermediate unit between inpatient and outpatient care. A patient may stay there from 1-2 to 48 hours. Thanks to the inpatient unit, in many cases people who initially come to the doctor in an unsatisfactory condition, dehydrated and exhausted, can be ‘lifted off their feet’ with the insertion of an abacus and a visit for infusion of medication systems during the day. This is a day hospital, with no need for hospitalization except only when such none is actually needed. We all know at least a few people who have sought a nurse or doctor “just for a system at home or in the office because we don’t want a hospital.” Of course, this is only applicable when the patient is not really up for hospital treatment. Yes, it is all perfectly possible, but regulated, documented and quality assured to be medically and humanly supportable as a service.
Quality processes and standards to be established in the delivery of the medical service. Payment for value, not for quantity, should be introduced. More patient-physician communication time to be provided and funded.
I would love it if people started to value their doctors and their work, rather than the ‘magic’ behind the equipment that they do not understand. It makes a lot more sense to have someone explain to you in plain language why it’s important to cut down on alcohol or what “enough exercise” means than to have your cholesterol level or blood count tested for the third time in a year. It makes a lot more sense to have someone take an interest in the fact that you have a parent who contracted a hereditary disease at a young age and start tracking and testing you in a targeted way than it does to have an unnecessary abdominal scan. This attitude of the Bulgarian society consumes a large amount of medical labour in hospitals and undervalues the same medical labour in the outpatient clinic. Invest in health education, prevention and health promotion.
How do you imagine the processes concerning people’s health in two decades and what is the role of DHI Cluster in this transformation?
20 years is too distant a horizon – we live in a world of limited resources and we need to be pragmatic even in our dreams and plans. Within 10 years, value-based health services will be designed and in place, not, as at present, pay-for-activity and ‘draw down budgets’. Health professionals will be working at the ‘top of their license’ and will be primarily concerned with that part of the service where they add most value to their patients. Only cloud-based technologies will be used – they will collect, store and automatically analyse individual and population data that can measure quality of life much more accurately. The administrative burden on medical professionals will be greatly reduced thanks to digitalisation and intelligent software. More medical professionals will be trained and will stay in the country to be knowledgeable and empathetic.
Then we will be able, within a horizon of 20 years, to raise the health indicators of the Bulgarian population and they will reach at least the average for the European community and not only years, but years of quality life will be added. A change is also needed in the patients themselves. They need to become proactive in looking after their own health, and technology will help them to do this to a great extent.
This transformation cannot be done without a vision and a plan to implement it. The DHI Cluster Bulgaria was created to support innovative companies and organisations in the field of digital solutions in healthcare. It is expected to be a leader of transformation and change public attitudes.
Building a digital healthcare ecosystem and establishing a sustainable and efficient healthcare environment for patients, medical professionals, society and institutions, is a very long way ahead in the future.