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Excluding those related solely to pharmacotherapeutic protocols, Bulgaria lacked a centralized and dynamic system for oncology clinical guidelines. Existing guidelines were typically paper-based or static digital documents, developed independently by various scientific groups, with infrequent updates. As a result, many healthcare professionals relied on disparate or outdated sources, leading to inconsistencies in multidisciplinary diagnostic and treatment practices. This was evident in smaller hospitals, where access to current international standards was limited, and among junior healthcare professionals in training, who lacked structured, systematized guidance. This fragmented approach led to discrepancies in diagnostics, treatment decisions and follow-up care, ultimately impacting patient outcomes.
To standardize oncological practice nationwide and to enhance the quality and consistency of clinical decision-making, the Bulgarian Joint Cancer Network (BJCN), in collaboration with BGO Software, launched the MORÉ e-Guidelines platform in 2022. This novel digital infrastructure is designed for the systematic development, peer-review, and dissemination of multidisciplinary oncology clinical guidelines. The platform operationalizes the GRADE (grading of recommendations assessment, development and evaluation) framework and is structured to support guideline formulation through PICO (population, intervention, comparator, outcome) question methodology. Dedicated expert panels, stratified by cancer type and clinical domain (for example, breast cancer, lung cancer, colorectal cancer, supportive care), collaborate to generate evidence-based recommendations that encompass the full continuum of care, including prevention, diagnosis, therapeutic algorithms and long-term follow-up.
Since its launch, the platform has enabled experts to collaboratively review and synthesize the latest systematic reviews and research findings to draft Bulgarian-adapted guidelines. The system allowed real-time editing and version control, and guidelines were approved through consensus in BJCN assemblies.
Today, the platform hosts updated guidelines across multiple oncology disciplines. Bulgarian oncologists are increasingly integrating the e-guidelines into routine clinical practice, particularly during multidisciplinary team meetings. Notably, when new evidence or therapies emerge, the relevant expert board can promptly update the guideline on the platform. Certified by the Accreditation Council of Oncology in Europe, the e-guidelines platform has been formally recognized as a dynamic, authoritative reference for national oncology standards and clinical best practices. However, despite its methodological rigour and alignment with international best practices, the initiative has not yet been formally endorsed or integrated by the Ministry of Health.
Enablers: A strong visionary leadership paired with a strong evidence-based mindset created ideal conditions for the successful inclusion of digital solution into evidence-based decision making in cancer care. The collaboration with a tech company provided the necessary IT expertise to build a customized platform, designed to fit clinical needs (Resources). Alignment with prevailing EU policy trends, particularly the emphasis on integrated care and the harmonization of best practices, provided further validation of BJCN’s approach. This strategic alignment not only resonated with European partners but also fostered increased engagement from national stakeholders.
Barriers: Despite efforts toward European certification, a primary challenge remains the institutional neglect and lack of formal recognition by the Ministry of Health and the Bulgarian Physicians’ Union, particularly concerning their role in overseeing continuous medical education in oncology (Governance). On a practical level, achieving consensus among experts from diverse institutions and specialties proved complex, with the formulation of clinical guidelines requiring extensive deliberation. Resistance to adopting digital platforms was observed among some senior practitioners who favoured traditional, paper-based manuals, necessitating targeted training and sustained advocacy to support adoption. While user feedback facilitated iterative improvements to the platform’s usability, ensuring its long-term functionality requires continued technical support. Moreover, maintaining the relevance and accuracy of clinical content demands enduring engagement from the expert community and consistent allocation of resources to sustain the platform over time.
The MORÉ e-Guidelines platform has improved access to standardized, up-to-date clinical guidance for oncologists across Bulgaria. Future developments will focus on the enhancement and strategic expansion of the platform. A key priority is to broaden recognition and adoption by other countries and scientific organizations. This will facilitate direct access to evidence-based recommendations within clinical workflows, supporting harmonized, high-quality cancer care across healthcare systems. BJCN is also exploring AI tools to help scan new research and possibly suggest updates to the guidelines, making the revision process even more responsive. Further, there is interest in developing patient-facing versions of the guidelines (in lay language) via the platform to empower patients in decision-making. Currently, the initiative is a part of a core instrument within the upcoming EU Commission-supported CURTAIN project (Beating Cancer ineqUalities thRough liTerAcy IN Europe, launching in September 2025).
Lessons learned: The Bulgarian experience demonstrates how digital infrastructure, combined with a clear evidence-based methodology, can successfully transform clinical practice. It aligns closely with the objectives of Europe’s Beating Cancer Plan (EBCP), particularly in reducing disparities in cancer care and promoting equitable access to guideline-based treatment. Further, the initiative underscores the critical role of multidisciplinary collaboration and highlights that technological tools should be embedded within broader systems of governance, education and continuous professional development. The MORÉ e-Guidelines model offers a replicable template for other countries seeking to standardize and elevate cancer care delivery.
For more information
MORÉ e-guidelines: https://app-eguidelines.more-darzalas.com/home
Contact
For further details on this case study, please reach out to obs-pace@obs.who.int.
