Read more
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relied on disparate or outdated sources, leading to inconsistencies in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.
