History of Romanian Medical Informatics: Learning from the Past to Reshape the Future George I

History of Romanian Medical Informatics: Learning from the Past to Reshape the Future George I. Mihalas1, Lacramioara Stoicu-Tivadar2 1 Academy of Medical Sciences, Timisoara Branch, Romania 2 University Politehnica Timisoara, Romania

Summary 1 Introduction 2 Historical View on Medical Objectives: The paper presents a review of the history of medical Medical informatics, as an interdisciplinary Informatics in Romania informatics in Romania, starting from the pioneering works, domain, has developed in the second half relating the present, and foreseeing the future. of the last century as a natural application 2a Pioneering Period Methods: Major milestones of the development of this field have of computer science technology in various The socio-political context during the late not been simply enumerated, but described within the specific fields, including healthcare. However, the 60’s and the beginning of the 70’s in Roma- socio-political frame, grasping the entire context over the last relationship with the bio-medical domain nia was favourable to the promotion of new four decades in Romania. Two main perspectives have been had some unique features, transforming areas, especially those linked to technological traced: education and training in medical informatics and imple- medical informatics into one of the most developments. The communist party was mentations in healthcare. dynamic disciplines, unveiling new as- committed to demonstrate the capacity to cope Results: Four distinctive historical periods are identified and the pects, raising new problems, facing new with the worldwide technological advent and major events of each period are described in a critical manner. challenges, pushing the development of computer science was among the areas which The history of the Romanian Society of Medical Informatics is new technologies, and promising high- enjoyed strong official support. The emphasis presented in a separate chapter. The last section is dedicated to er care quality and new approaches to was on industrial applications; however, a the present state of the field in Romania. healthcare and adjacent fields. Moreover, couple of small research groups were created, Conclusion: The history of Romanian Medical Informatics spans besides the fast-technological advent, the approaching various topics, including medical many years and is rich in content. The Romanian Society of major socio-political changes of the last applications of computer science research, e.g. Medical Informatics is mainly the result of the efforts undertaken two decades of the 20th century, especially Dan Farcas and Vasile Baltac from Timisoara by an enthusiastic and sound professional community, trying to in Europe, left their mark over the devel- worked on the modelling of inter-neuronal continue the tradition, to achieve new goals, and to work as an opment of medical informatics in various connections [3], and Mihai Angelescu and active member of the international biomedical/health informatics countries. Therefore, a historical approach Nicolae Mihalas in Arad proposed a diag- community. to our domain should not be reduced to a nosis system for gastrointestinal diseases1. mere list of events, actions, or people, but However, the impact of such research was Keywords should rather interpret them, highlight the low and collaborations with scientists from Medical Informatics/history; technology development; education; major achievements, and trace the trends other countries were very difficult; we only health information systems; Romania throughout each period [1]. had access to some East European scientific Our paper attempts to offer the reader journals and the participation in international Yearb Med Inform 2018:243-51 such a view over the birth and development scientific events was very limited. Actually http://dx.doi.org/ 10.1055/s-0038-1641203 of medical informatics in Romania within its almost any external individual contact could specific socio-political environment, with its raise suspicions of a hidden illegal activity. ups and downs, marking the milestones, and All external contacts had to be initiated, or, at analysing the present state. For the historical least, approved by the authorities. part, we followed the staging proposed in Things started to partially change after a [2], presenting the difficulties encountered seminar on medical applications of infor- at the beginning, the efforts conducted to matics organized in 1969 in Bucharest for promote research and education, the role of the leading staff of the MoH by IBM’s Vien- industry, the relations with governmental na branch where speakers from Karolinska institutions, and international collaborations and activities. The last part presents our re- 1 The program was presented in a regional cent activities and plans for the near future. conference without printed volume.

IMIA Yearbook of Medical Informatics 2018 244 Mihalas et al.

University, Sweden, were invited. Soon after, The Computer Centre of the Ministry supported by Jan van Bemmel and other the Centre of Statistics of the MoH was creat- of Health was equipped in 1976 with a Fe- scientists, to organize yearly meetings in ed; later it became the Computer Centre of the lix-256 computer (the Romanian version of Prague (period 1985-1990). The location MoH and a leading institution involved in the IBM-360), used mainly for health statistics was excellent: beyond the “iron curtain”, implementation of information technology in and hosting various databases. In 1978, the inside the communist block, accessible to the Romanian healthcare system [4]. newly created Central Institute of Informatics people from Eastern Europe, but also close In the early 70’s, the political context resulting (ICI) - the official coordinator of all nation- and easily accessible from Western European from Romania’s position against the invasion al programs dedicated to the introduction countries [1]. of Czechoslovakia generated an enthusiastic of information technology in all domains By 1985, the Computer Centre of the atmosphere, which, unfortunately, lasted only (industry, transport, local administration… Ministry of Health, led by Dr. Ovidiu a couple of years. In that period, most central etc.) - initiated an ambitious project - SIROS Popescu, started a series of courses (similar institutions and territorial authorities were (Information System for Healthcare), planned to nowadays Continuous Medical Education equipped by computer centres. Education to be structured in three levels: central, ter- - CME programs) for the medical staff from and training of professionals in this new area ritorial, and healthcare units. Unfortunately, the whole country, following the course became a real need; informatics became a this project proved to be too expensive and structure we offered to medical students in mandatory discipline in almost all technical unrealistic; only a couple of components at the Timisoara, and adding some specific ap- schools yielding a new generation of well-pre- central level were completed and, eventually, plications for healthcare units and hospital pared computer scientists. The fast devel- ICI abandoned the project [4]. However, the management. These courses were developed opment of information technology imposed idea of creating a national information sys- by Dr. Dan Farcas and his team. The main frequent “update meetings”, transformed into tem for healthcare remained on the list of the merit of these courses was their contribution annual scientific conferences “Informatics future projects of the Romanian leadership. to raising the awareness about the potential for Management”, which started in 1975 By the beginning of the 80’s, the Institute use of information systems in healthcare, as in Cluj-Napoca. In 1977, the third edition of Medicine in Timisoara (today “Victor most of the attendants of these courses had of the conference introduced a new section Babes” University of Medicine and Pharma- leading positions either in hospitals or at the dedicated to medical applications, held as a cy) managed to obtain an M-18 microcom- level of local healthcare authorities. separate National Symposium in Satu-Mare, puter for research purposes, especially in In the late 80’s, some hospitals (Clinical thus marking the first official event solely preclinical disciplines (biophysics, normal Hospital “Fundeni” and Military Hospi- dedicated to medical informatics in Romania. and pathological physiology, pharmacology tal in Bucharest, Town Hospital Borsa in etc.). A library of statistical programs was Maramures county, District Hospitals in developed. This had a major impact, espe- Tirgu-Mures and Craiova…etc.) started to cially among the young staff of the university, develop components of hospital information 2b Childhood and Youth Period with several doctorate-level students also systems: patient databases, early forms of The first National Symposium of Medical expressing their desire to learn how to process electronic health records (EHRs), hospital Informatics in Satu-Mare (1977), coordinated their experimental or clinical data by them- resource management, personnel databases… by Dr. Virgil Enatescu, was a milestone in selves. This context created the conditions etc. But the most significant work was per- Romanian medical informatics. It gathered to propose a course of medical informatics formed in medical research, mainly in univer- around a hundred of participants (physicians, to medical students. After overcoming some sity laboratories and clinics. The involvement healthcare providers, engineers, and mathe- initial bureaucratic obstacles, the course was of healthcare authorities was minimal. maticians). At that time, it became very clear introduced as an optional course in 1984. The The experience of that period, especially that the use of computers in medical practice success was obvious, granted by the modern from the courses organized by the Computer and research was a process which had just structure of the content, built on a Western Centre of the MoH, was synthesized in a started, the complexity of applications was model. Indeed, we should mention here the monograph of Medical Informatics, reward- expected to be high, and the medicine of the support received from Prof. Jan H. van Be- ed in 1990 with “Gheorghe Marinescu” Prize future would rely to a great extent on techno- mmel who sent us several articles about the of the Romanian Academy [6]. logical developments, including information medical informatics courses that were held in technology. This was the start of subsequent the Netherlands [5]. Hence, we had a mod- annual meetings, initially called “MEDINF”, ern and comprehensive structure of medical now known as “RO-MEDINF”. A commu- informatics courses from the very beginning. 2c Consolidation Period nity of professionals from various domains, Practical works were mostly limited to demos, The last decade of the twentieth century interested in medical informatics, was formed but even the few hands-on hours were very was the period of a great change throughout since the first edition of the National Sympo- attractive and had an “addictive” effect. Eastern Europe, which had an impact on all sium. The community has been growing year An important and specific factor for the aspects of social life, including education after year, becoming the present Romanian period was the possibility to keep external and healthcare. Population expectations and Society of Medical Informatics (RSMI). contacts thanks to Jana Zvarova’s initiative, initiatives showed a major sudden change,

IMIA Yearbook of Medical Informatics 2018 245 History of Romanian Medical Informatics: Learning from the Past to Reshape the Future

while institutions, legislation, resources, kineto-therapy, and nursing) [11, 15]. By and including (high-) performance software and mentalities remained far behind. That is the end of this decade, medical informatics as well as a carefully organized program for why some actions or events are difficult to had gained the status of a mandatory and training the staff involved in the exploitation be correctly interpreted and/or understood, independent discipline in the syllabus of all of the project. comprising a mixture of -sometimes contra- medical schools in Romania. Thus, the second part of “3409-RO” dictory - features. A positive effect was brought in by the turned into a new ambitious project entitled In the medical informatics domain, the development of an adjacent field – medical “Healthcare Medical Information System” most important event in Romania took place (bio)engineering. New faculties integrated – HMIS [17], with an initial budget of ~18 in the spring of 1990 in Sibiu, when the par- this field in their curriculum in Iassy (F. To- M$ and a potential extension of another 22 ticipants in the annual national conference policeanu, 1994) and Bucharest (A. Morega, M$. It was built with the support of external of medical informatics decided to organize S. Kostrachievici, 2010), and there were spe- consultancy, generating high expectations. and create the Romanian Society of Medical cific programs in Timisoara (D. Dragulescu HMIS was structured on three layers: central Informatics. This had a strong impact and and M. Tascau, 1995) and Cluj-Napoca (R. level (MoH), territorial level (district public will be detailed in a separate chapter. Ciupa, 1995). health authorities), and local level (all healthcare units of a district: hospitals, policlinics, dispensaries, rural health centres, ambulance a) Education and Training b) Implementations in Healthcare services, and blood collection centres). The Several major reforms and concerted actions The political context of the early 90’s in first phase comprised both central and terri- started in parallel in 1990 at a nationwide Romania favoured an intense external coop- torial levels as well as one of the 42 districts scale. The educational system underwent eration and healthcare was a sector which was of Romania, as a pilot district. The project major changes: universities gained more included in several programs with external provided expenses not only for hardware and independence, curricula and syllabi could be funding, mostly from the World Bank. While software but also for training and manage- decided by their senates. Hence, it was not for education and training, developments ment. The analysis of the system started in surprising that by 1992 all medical schools in were relatively smooth and uniform, the 1995 with the technical specifications, but,

Romania included medical informatics as a implementation of information systems and due to several bureaucratic obstacles and mandatory discipline for medical students in of various information technology (IT) ap- frequent changes at the highest level of the all specialties – general medicine, dentistry, plications in the healthcare system was quite Ministry of Health, the contract was signed pharmacy, and nursing [7]. The structure of uneven, often having to overcome unexpected only in 1998 with the project integrator, Sema the courses in Timisoara served as a model obstacles. One of the first big project frames, Group France - winner of the auction. The for most of them and it was close to the Eu- called “3409-RO”, with a total cost estimate initial completion deadline was postponed ropean curricula [8] and IMIA recommenda- of ~150 M$, started in 1991. It was dedicated from mid-1999 to the end of 2000, when it tions [9]. In most cases, medical Informatics to “rehabilitation of healthcare in Romania” had to be ready for exploitation and planned courses included biostatistics [10]. and included an IT (Information Technology) to be flagged as a political success by the The PhD program in medical infor- component of ~2 M$ [4]. Results were not leaders of that time. Finally, by the end of matics, which started officially in 1992 in spectacular, as the budget was split into sev- 2000, a number of some 230 servers and more Timisoara as well, was created to allow eral small independent projects, being spent than 900 PCs were installed in 320 different students to approach advanced research mainly on infrastructure components at the places, including an intranet network with topics and to cover the growing need of central level and for some big hospitals (buy- X25 connections, firewalls, the R/3 package high-level professionals [11]. ing computers), as well as for the implemen- of SAP for resource management, an adapt- The central objective of the period was tation of some courses. A good example of a ed version of Grenoble University Hospital to develop a coherent strategy for medical successful project was the system developed information system for electronic medical informatics education in Romania [12]. The by the ambulance service in Bucharest [16]: records (France), Hematos software for blood objective was almost entirely achieved due to the information system was integrated within transfusion, Comshare for decision support, the annual meetings of the RSMI, which repre- the emergency call centre, with an accurate TeamLinks for document management, and sented a milestone for subsequent actions [13]. track of all calls and available personnel, its an Oracle database management system2. A specific feature of this period was the implementation led to a substantial reduc- More than 400 persons attended the set of fact that information technology became tion in call response time and an increased over 25 training courses. accessible. There was no specific develop- satisfaction of both staff and population. ment dedicated to medical education, the But, in most cases, the applications were focus in most departments moved towards limited to the fulfilment of routine tasks. This 2 References about the old versions (period the development of laboratory practical allowed us to learn how important it was to 1996-1998) of the software are no longer available; some companies have works [10,14]. Specific courses and prac- develop a long-term strategy and to build a disappeared, others still exist but their tical works were developed for various large project relying on a thorough analysis websites do not contain information about medical specialties (dentistry, pharmacy, of the complexity of the healthcare system, their old products.

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Unfortunately, even though it was con- never been completed and most of the new the country as specialists trained for our sidered to be much better prepared than the equipment was transferred to other govern- academic research projects found better paid previous projects, the results were far below mental institutions [4]. jobs in other sectors. Our legislation has not expectations (an official report phrased it as However, this period also had a positive given any help in this regard. “modest results”) with just a few components dimension, not related to the weak results The contents of educational programs actually functional. This project became of governmental projects: the (private) free also improved during this period. The new a “case study” for a further analysis [18], market started to show up; several compa- context imposed new targets: adapt contents revealing several objective and subjective nies started to offer various IT products for to get closer to practical applications, get in- factors which generated this “failure” – a hard physicians and healthcare units. Despite they volved in bio-medical research, and provide and expensive lesson. We can cite here some had a minor role in this period, they grew and healthcare informatics professionals. Several major factors which had a dramatic impact: their presence influenced the next decades. collaborations with similar departments (1) the entire organizational framework of the from abroad or with research groups started Romanian healthcare system had changed with very good results [21]. The National during the implementation of the project - the 2d Maturity Period Council for Scientific Research launched at- National Health Insurance House (NHIH) tractive research programs, which lasted just The general trend at the end of the 90’s and at had just been established in 1997, taking a couple of years ago, since, unfortunately, the beginning of the new century in Eastern over some responsibilities from the MoH. the funding was drastically reduced during Europe was to get aligned with European Although all healthcare institutions remained the economic crisis. values and standards, which would facilitate the same, the information circuits changed The efforts to initiate an educational external contacts. The enlargement of EU and the contractor’s proposals to update some program for health informatics professionals became a priority for most European leaders. parts of the project struck the inflexibility of encountered several obstacles: the lack of a Romania became a “candidate country” in the regulations imposed by the creditor; (2) coherent strategy of the Ministry of Health, 2004 and a “EU member state” in 2007. Our there was no strategy at the governmental lev- a long lasting ambiguity between the re- external contacts extended and more and more el to ensure the continuity of major projects, sponsibilities of the Ministry of Health and young scientists benefited from scholarships accompanied by frequent changes at deci- the newly created National Health Insurance or were involved in European projects. sion-making levels or of the legislation; (3) House, an inefficient communication between unbiased/fair professional consultancy was the Ministry of Education and the Ministry of missing (for example, the recommendations a) Education and Training Health, the inertia of the Ministry of Labour to avoid some inappropriate or non-interop- Several programs to favour the inclusion of to update the list of professions to include erable components); (4) the terms used in Eastern countries in European projects were “healthcare informatician” as an official po- the contract were sometimes ambiguous or initiated or got extended versions (Tempus, tential job…etc. However, an important step not fully equivalent to the translated terms, Erasmus) [19,20]. An intense bidirectional was made in 2009, when a master program generating misunderstandings or conflict exchange of professionals took place. Ro- for “Healthcare Information Systems”, coor- situations; and (5) it was impossible to keep mania received consistent and sustained dinated by Prof. Lăcrămioara Stoicu-Tivadar, the staff trained especially for this project support mainly as bursaries to facilitate the was introduced at the University Politehnica in the system. We can also add the dramatic participation of young Romanian scientists Timisoara, Faculty of Automation and Com- drop of the national currency exchange rate in international conferences. Support came puters. The program had a modern curricu- in that period which decreased the capacity to from several persons among whom we lum [22], and lectures were updated yearly. fulfil the tasks without exceeding the budget, should mention at least Bernard Richards The program was very well received by the the acceleration of technological advances (more than 25 full bursaries for attending students, with a rising demand during 2016 (by the time of delivery, some of the initially the 1996-1998 Harrogate conferences of and 2017. The program prepares well-trained ordered products were already obsolete) and, the Health Group of the British Computer professionals to support the digital healthcare finally, the mismanagement of the project in Society), Rolf Engelbrecht (22 bursaries domain. Unfortunately, the impact on the various places or moments. The saddest part for Medical Informatics Europe (MIE) 2000 specific labour market is still modest since was that despite the evidences, intermediate conference in Hannover), and Jana Zvarova the healthcare system is in a chronic finan- notifications and recommendations were (over 10 participants at EuroMISE courses cial crisis and hospitals have not shown yet disregarded, and a final report prepared by in Prague). All these exchanges had a visible any interest in recruiting new professionals, an ad-hoc nominated commission qualified impact - the main characteristic of the period postponing sine die the refreshment of their the project as acceptable, smoothing the way was a marked increase of the qualitative level professional health informatics staff. to start an expensive rollout without a new of both education and research. Unfortu- One of the trends encouraged by the auction. In the new version, big hospitals nately, two other negative parallel processes RSMI is to foster the introduction of digital remained on the list, but some of them de- also showed up: the “brain-drain” boomed, technologies by interdisciplinary teams clined the offer as they had already started to several young well-trained specialists left (MDs and ITs)to develop new and attractive implement other solutions. The rollout has the country and there was a drain within methods in medical education [23].

IMIA Yearbook of Medical Informatics 2018 247 History of Romanian Medical Informatics: Learning from the Past to Reshape the Future

b) Implementation in Healthcare a major step towards the computerization ented towards financial and administrative The failure of the “Healthcare Medical of current medical practices. The success applications but there were also concerns Information System” – HMIS project was of SIUI implementation is acknowledged: for patient management and diagnosis, perceived as an unfulfillment of the MoH, healthcare leaders consider that it provides with a trend to extend the medical record. while the newly created National Healthcare mostly positive outcomes but other users Among the most used applications, we can Insurance House (NHIH) took over the objec- complain and accuse it of having numerous mention the Hospital Manager developed tives and the funding of the previous plan. The shortcomings. In almost ten years of opera- by InfoWorld, or Hipocrate developed by reaction of the MoH was weak, they seemed tion, the system has had numerous “failures” Romanian Soft Company. rather happy to get rid of such a task. The that sometimes literally blocked the current Additional independent projects were redesigned project, renamed SIUI (Unique medical activity. implemented during the maturity period, with Integrated Information System, ~120 M€) and Several weak features can be reported. an impact on the medical world, mainly under coordinated by the NHIH started with a big First, the system is incomplete and only cov- the frame called PNCDI (National Plan for delay (in 2002 instead of 1999), having its first ers people who have the classical mandatory Research, Development, and Innovation [26]) components implemented in 2008 [24], with a social health insurance. Although NHIH is the coordinated by a national agency – CNCS systematic extension every year (some com- largest health insurance house in Romania, (National Council for Scientific Research) ponents being still under construction). The it is not the only system, and there are also and the Ministry of Information Technology or SIUI system preserved the main requirements other health insurance houses (e.g. the Health the Ministry of Health. We can mention here of the previous project – i.e. to cover all levels Insurance House of the Army) and a private two significant examples. One example is the and to comprise all citizens. All units of health system. Moreover, all medical activities, MediNet network coordinated by Marius Mar- services (hospitals, dispensaries, pharmacies, treatments, or drugs are not reimbursed or ginean and having Prof. Vasile Stoicu-Tivadar physicians, therapists…etc.) and all insured covered by the health insurance policy, and the as IT manager [27]. It was a national general citizens received a unique identification code corresponding information may be omitted practitioners network (with 100 GPs at the and an associated card; all services were in the patient record. Interfaces are not very start and 60 at the end), targeting 2% of Roma- recorded. The simple introduction of these friendly and the system is often qualified as nian population. Participating GPs had smart procedures brought a noticeable improvement difficult to use. The project did not impose software called MedINS and they were report- of the quality of data bases, reported activities, standards to assure interoperability with ing information to the network in a very easy and resource management, by eliminating the similar European systems, which will proba- and smart manner. The project participants duplicates of persons or services, allowing for bly raise new problems soon. There are also were trained during 3 meetings. Very well a fast reporting process and a better monitor- intense discussions about exaggerated prices received by the medical staff [28], the project ing and control of resources [4]. paid for some components. was a success. Another important project and The SIUI system is quite complex [25]. In addition, given that the use of SIUI was the first of this kind in Romania was developed Besides the main module, dedicated to con- (almost brutally) imposed by NHIH, healthcare in 2007, managed by Sorin Puscoci form the tracting, reporting, billing and settlement, professionals, starting with general practi- National Communications Studies and Re- four other big modules perform specific tasks: tioners, were compelled to either learn how to search Institute (INSCC Bucharest), related • ERP – electronic resource planning; use SIUI-based programs or to use other friend- to AAL (Ambient Assisted Living): the aim • SIPE – information system for electronic lier programs, which should have the same was to implement an eldercare solution with prescription, implemented since 2012; operational functioning. Indeed, the private hardware and software support [29]. • CEAS – electronic cards for healthcare sector was quick to react and several compa- insurance (the present card is just a key nies filled the market with various alternative to allow the physician to access a patient’s applications, covering not only the production record); of mandatory reports in the format required by 3 Romanian Society of • DES – electronic health record, in use NHIH, but also adding new features to the pa- Medical Informatics since 2015, including a summary of vital tient record or facilitating the management of data (minimum data set for emergency care units. If general practitioners represented 3a Foundation, Objectives, the first target, soon new applications were situations), the full medical history, the Organization, and Structure data of the current consultation and a list developed to address all medical specialties of attached documents. needs – dental offices, pharmacies, polyclinics The community of people interested in the …etc. Some private companies have already field of medical informatics took contour The SIUI portal [25] contains several other conquered significant shares of the Romanian since the first National Symposium of details and documents for reporting, includ- market (e.g. Syonic, Softeh, Sterio). Medical Informatics in 1977. It comprised ing the nomenclatures and guidelines for Hospitals have been in the forefront of people with various backgrounds, especially various situations. software developers’ attention just prior to engineers, physicians, and mathematicians. The development and the implementation the launch of IT projects by the Ministry The real existence of this community was of the SIUI system certainly represented of Health. Initial products were mainly ori- confirmed by the series of annual confer-

IMIA Yearbook of Medical Informatics 2018 248 Mihalas et al.

ences held since then. However, it was not cu-Tivadar seconded by Gabriela Georgescu, was sporadic and much lower than our expec- formally registered as a professional asso- Elena Podoleanu, and Marius Marusteri, as tations while the National Health Insurance ciation and had no organizational structure vice-presidents, and Mihaela Vida-Crisan as House completely ignored our events. until the revolution of 1989. secretary. While RSMI members were at the The consequent activity of the RSMI The official foundation of the Romanian beginning mainly academics and researchers, board along the years ensured the continuity Society of Medical Informatics in 1990 companies came by in the last few years. of the series of national conferences. The [30] came as a natural confirmation of the They supported the conferences and filled-in audience was in general very good as well existence of this community. As stated in practical and economical issues. A new trend as the scientific level. Registration fees were its Statute: is now visible: young multidisciplinary teams kept as low as possible. Proceedings volumes “The Romanian Society for Medical Infor- are forming, combining people from different were published for most editions. RSMI also matics, RSMI, is a legal entity registered as professional areas (physicians, engineers, introduced prizes for best papers. A full list a scientific, professional, non-governmental nurses, informaticians, or mathematicians). of these meetings as well as other details organization aimed to promote the activities RSMI has six working groups covering about RSMI are available in[30]. in the development of medical informatics in various major areas of interest: education, RSMI has good contacts with other Romania and to represent the activities in the EHR and interoperability, medical imaging, professional associations: ProRec Romania country and abroad. The activities of RSMI portable devices, dentistry informatics, and (a member of EuroRec), the Society of concern the stimulation and co-ordination of nursing informatics. Dental Informatics, the Romanian Society the activities of its members in promoting The legislative frame for professional as- of Medical Bioengineering, the Romanian medical informatics in the country and the sociations in Romania is mostly designed for Society for Applied Medical Informatics, support of international co-operation in this large associations. However, RSMI is a rath- the National Society of Pure and Applied field, which implies: organizing scientific and er small society (there is no paid staff, and Biophysics, the Association of Family professional conferences, symposia, courses, all activities are performed on a voluntary Physicians, the Romanian Association for exhibitions, and a collaboration with related basis), which results in difficulties in various Telemedicine and Space Applications for organizations for such activities; publishing instances and when participating as a legal Health, and HL7 Romania. RSMI had, with scientific, professional, and educational partner in national or international projects, each of them, at least one common event or documents and papers in the field of medi- and promoting initiatives or participation to cooperation within a project. cal informatics; disseminating information official meetings or delegations. Considering Another aspect of RSMI activity con- about conferences, publications, and links to the average living standard level, member- cerned the exploitation of the potential websites on medical and health informatics; ship fees are low, almost symbolic. expertise of our members. Such expertise promoting scientific and professional contacts had been exploited even before the official with similar societies at the international foundation of RSMI. In 1986, the Centre of level; actively supporting scientists to attend 3b National Activities, Relations Health Statistics and Information (CCSS) international meetings; collaborating with of the MoH organized a series of training Romanian Academy and the Academy of with Governmental Institutions and courses with RSMI members serving as lec- Medical Sciences in medical informatics Professional Associations turers. In the spring of 1989, the Romanian research; collaborating with medical and However, despite all these hurdles, several Academy created a Commission of Medical technical universities in developing education activities have been successfully carried informatics, chaired by Dr. Dan Farcas. Later and training in medical informatics.” out, mainly focused on the organization of that same year, the Academy of Medical RSMI has now around 120 members, national conferences and the participation Sciences established a Commission of Infor- a member count which remained almost in EFMI (European Federation for Medical matics, chaired by acad. Stefan Milcu. The stationary for the last decade. Informatics) or IMIA (International Medi- creation of these commissions had a strong The first president, elected in 1990, was Dr cal Informatics Association) events. When impact on the way medical informatics was Virgil Moga from Sibiu, a cardiologist, and organizing national conferences, contacts perceived: this recognition at an academic organizer of the national symposium in 1990, were made with different governmental level was a key to open new doors and make followed in 1994 by Dr Virgil Enatescu from institutions, central authorities, universities further steps, like the introduction of medical Satu-Mare, a psychiatrist, and the father of and research institutions, other professional informatics as a mandatory discipline in the RoMedInf conferences. The position of associations, and several companies. The medical curricula or starting programs at president was given to Prof. George Mihalas echo to our invitations was in general very the PhD level. in 1998, seconded by Dan Farcas, Ioana Moi- good, especially from universities and some The leaders of the Ministry of Health sil, and Andrei Achimas-Cadariu (replaced software companies that could even sponsor tried to initiate similar actions, oscillating in 2002 by Mihai Tarata) as vice-presidents, our events, while the Academy of Medical though between selecting a group of experts Tiberiu Spircu as scientific chair and Mar- Sciences became the co-organizer of several from CCSS and creating a commission iana Bazavan as secretary. Since 2010, the editions of our series of conferences. Howev- with experts from the whole country. Both presidency is held by Prof. Lăcrămioara Stoi- er, the support from the Ministry of Health solutions were alternatively adopted, with

IMIA Yearbook of Medical Informatics 2018 249 History of Romanian Medical Informatics: Learning from the Past to Reshape the Future

long periods of inactivity, thus depriving market economy. The concern at the Euro- rope in 2008-2010, EFMI honorary fellow this structure of any continuity. pean level about monitoring such a unique in 2012, IMIA WG History vice-chair since In recognition of the professionalism of historical process was practically translated 2014, and founding member of IAHSI – the our members, RSMI was often invited to by designing specific programs to stimulate International Academy of Health Sciences send experts to present lectures on various international and inter-regional coopera- Informatics. Lacramioara Stoicu-Tivadar is topics by companies involved in the promotion so as to facilitate a smooth transition. chair of EFMI WG HIIC, was EFMI secre- tion and the organization (often in tandem An initiative down this line came in 1996 tary in 2012-2014 and is EFMI vice-presi- with other institutions or companies) of from Marcelo Sosa Iudicissa, who worked dent since 2014. events on medical or healthcare “hot topics” at that time for the European Commission, of the moment. proposing the creation of a dedicated EFMI WG - Medical Informatics in Countries in Transition (MICIT). A similar WG (Health 4 Current State of Medical Information for Development - HID) was 3c International Activities also established in IMIA by Nora Olivieri Informatics in Romania and Even before the official founding of RSMI, from Argentina. These working groups or- Recent Activities Romania was represented at the level of ganized several workshops over time, with “contact person” in IMIA since 1986 (ap- overcrowded audiences and lively debates, 4a Education and Training proved in Prague by Prof. Shigekotu Kaihara, presenting all kinds of challenges and obsta- Medical Informatics is a mandatory disci- on the recommendation of Prof. Jan H van cles encountered in various places. Romania pline in all medical undergraduate studies. Bemmel). RSMI became an official IMIA held the chairship of HID (2001-2004) There is a master level for health information member in 1994 (voted at the General As- and MICIT since 1998. In 2007, after the professionals at polytechnic universities in sembly in Dresden). Later that same year, inclusion of most East European countries Timisoara and Bucharest as well as PhD RSMI joined EFMI, at the Council meeting to the EU, the term “country in transition” programs in medical informatics. IMIA held along MIE’94 in Lisbon. Romania has was no longer used and the EFMI WG was recommendations are followed. Educational been represented at all EFMI and IMIA renamed as “Health Informatics for Inter-Re- programs must fulfil the standards imposed meetings and conferences since then, be- gional Cooperation” -- HIIC. We are proud by the ARACIS agency (Romanian Agency coming one of the most active members to mention that the presence of Romanian for Quality Assurance in Higher Education despite this has been difficult, mainly due participation was often noticed, not only in [33]), which is responsible for the accredi- to financial reasons, the workshops organized by these WGs, but tation of all the educational institutions in The political context in the early 90’s in in general in various European and interna- Romania. Eastern Europe, including Romania, was tional conferences on medical informatics. favourable to international contacts. Initia- The success of national conferences and tives came from both sides. Thus, during that the numerous contacts with foreign specialists period, we were happy to have close contacts allowed us to dare to also organize interna- 4b Healthcare Implementations with several healthcare informaticians who tional events. Thus, in 2001 RSMI organized The National Health Insurance House attended our conferences with the first wave the first EFMI Special Topic Conference (NHIH) has introduced SIUI, a complex being represented by a delegation from the (STC) in Bucharest entitled “Healthcare information system that covers almost all UK, i.e. Graham Wright, Helen Betts, Jean Telematic Support in Transition Countries” healthcare units in Romania, with a good Roberts, Bernard Richards et al., with whom [31], which was a real success, being one of reporting system to the central level. It in- we started systematic contacts, which resulted the few conferences in our country which cludes components dedicated to electronic in the cooperation within a couple of Europe- received a good support from the Ministry prescriptions, healthcare insurance cards, an projects, most of them within the Tempus of Health. Another STC was held in 2006 in and patient electronic health records. If frame [19, 20]. The extension of external Timisoara on the topic “Integrating Biomed- SIUI had brought an actual improvement to collaborative contacts in European projects ical Information: from e-Cell to e-Patient” resource management, it would still have to also had a positive impact on our research [32]. It had a large audience, being actually a solve several issues, e.g. a poor design and activities. Several scientific events have been joint event running in tandem with a EuroRec an infrastructure that hardly covers the needs. organized in the last two decades by RSMI, meeting, with a session of the “Semantic Indeed, user acceptance has been very low, sometimes together with other societies with Interoperability” European project as well as and the project paid no attention to making adjacent activities, as mentioned above. with our national RoMedInf. the system interoperable with IT components A specific historical feature of the last At the end of this section, we can men- previously existing in the Romanian health decade of the 20th century was the transition tion that two members of our society also information system or with similar programs of several countries of Eastern Europe from occupied leading positions in EFMI and in other European countries. totalitarian to democratic political regimes, IMIA. George Mihalas was EFMI president On the other hand, the private sector did and from a centralized economy to an open in 2006-2008, IMIA vice-president for Eu- perform well. Most users choose to use addi-

IMIA Yearbook of Medical Informatics 2018 250 Mihalas et al.

tional or alternative programs, with interfac- In 2014, the Academy of Medical Sci- 4e Future Perspectives es friendlier than SIUI. Several hospitals had ences established a Commission on Medical The present optimistic forecast for the Roma- their information system before SIUI was Informatics and Data Protection, whose pur- nian economy is expected to have a positive launched, and they just made the adaptation pose was to become an “Observatory”, able impact on the development of an e-health needed for the reporting components in order to offer good quality surveys over various sector that could promote the implementation to satisfy the NHIH imposed format. A posi- features of this domain in Romania. of several pending plans. This will have an tive point should be noticed here: NHIH en- impact also on medical informatics education couraged the contributions from the private and training at all levels. The newly created sector that could help users get digitalized, 4d Medical Informatics Research Commission of Medical Informatics and e.g. the SIUI portal [25] offers all technical Data Protection of the Romanian Academy specifications needed by developers to build and Scientific Activities of Medical Sciences has been involved in compatible applications, including nomen- Research activities are mainly carried out in bridging central institutions and creating a clatures and coding systems. universities and may be of three types: partici- common platform. This should help the de- The Ministry of Health has its own in- pation to European, inter-regional, or national velopment of a coherent and realistic e-health formation system, with a virtual network projects, collaborative actions between various strategy that could answer the numerous still comprising all public health authorities at departments (clinical, engineering, fundamen- unsolved issues, taking into account the needs the district level. tal medical research, public health…etc.), and activities within doctoral or master programs of human resources in the field. in the preparation of theses or dissertations. For RSMI, the major objectives for the near future are to bring more and more young 4c Legislation, Standards, and The scientific level is in general good or very good, sometimes yielding excellent results. people to healthcare informatics to work on Government Involvement Most private companies involved in biomed- the major international topics such as sys- Romania’s accession to the EU in 2007 had ical/health informatics have their own R&D tems medicine and artificial intelligence, to positive consequences on the legislative departments. There is no national strategy in promote interdisciplinarity, to contribute to the development of knowledge in these areas, domain and helps comply with European this direction and central institutions are less standards. However, since EU only makes involved in these activities. to cooperate with companies having research recommendations in the domain of health- The participation in both national and works in these domains, and to be a voice in care, the Romanian health law is not fully international conferences is good. At the relation with local and national authorities. aligned with the one of other European national level, there is one journal on this countries. The sensitive issue of data pro- domain: Applied Medical Informatics (AMI) tection is regulated by law 677 of 2001 [36], led now by Prof. Sorana Bolboaca, [34], which was amended several times. The and published quarterly since 1995 by Iuliu 5 Discussions and Conclusions National Authority for the Surveillance of Hatieganu University of Medicine and Phar- Personal Data Processing [34] has already macy in Cluj-Napoca. The journal, officially – Lessons Learned prepared the guides and the Romanian registered by the National Council of Sci- Romanian medical informatics history is rich translation of the last version of the Gen- entific Research, is indexed in international in years and content. Its development followed eral Data Protection Regulation (GDPR) databases (Copernicus, EMBASE…etc.). the natural way in parallel with computer 2016/679 [35], which should be applied as An important scientific event is represent- technology applications in all domains, in- of May 25th 2018. ed by the periodic RoMedInf conferences cluding medicine and healthcare. As expected, As far as the standards in medical infor- organized by RSMI. RoMedInf 2017 was the footprint of the socio-political context matics are concerned, besides the National held in Timisoara, on 23-24 November 2017. yielded specific evolution, marking the events Agency for standards, in 2006 HL7-Roma- It was a jubilee event, marking the “40th with distinctive features. Each period has nia was founded, contributing to the further birthday” of the conference since the first had its good and bad parts. Political seclu- adoption of standards in Medical Informatics. national symposium of medical informatics. sion of the pioneering period has partially The involvement of governmental insti- The program comprised five plenary sessions, limited the practical results, despite the great tutions in healthcare informatics activities with a foreign keynote speaker, Prof. Jaime enthusiasm of the pioneers. The first lesson (other than the ones included in the imple- Delgado. The 36 oral presentations and 10 learned is: “Science is a shared thesaurus mentation of SIUI) was, in general, very posters were distributed among eight parallel and documentation is essential for achieving low. NHIH showed no intention to have any sessions. The audience was very active, espe- good and practical results”. The temporary contact with RSMI specialists and ignored all cially in the session on Nursing Informatics political relaxation of the 70’s brought in an the invitations to attend our conferences. They and in the panel on Education. The papers will impulse in all areas, raising the trust in our rather relied on external expertise, which be published in the AMI journal [36]. Details capacity to join the main stream of scientific seemed to be sometimes quite inappropriate, about the program and the four prizes can be progress. In a period of very fast technological yielding poor results and low user acceptance. found on RSMI website [30]. developments, the role of periodic meetings,

IMIA Yearbook of Medical Informatics 2018 251 History of Romanian Medical Informatics: Learning from the Past to Reshape the Future

especially the international conferences, by Different Approach. Acta Informatica Medica for Healthcare: RENEHEMA Tempus Project became obvious. Other lessons learned are: 2014;22(1):6-10. Experience. In: Richards B (editor). Tri-partite 2. Mihalas GI. Evolution of Trends in European bridges: Educators, Providers and Users. Tempus “An (international) meeting equals six months Medical Informatics. In: Masic I, Mihalas G CME-0255-96 Seminar Proc. Sinaia; 1998: 19-27. in a library” and “Have faith, go and share (editors). Contributions to the History of Medical 20. Lungeanu D, Mihalas GI, Bazavan M, Dimitriu R, your results, too”. Informatics. Sarajevo: Avicena; 2014. p. 85-102. Sima R. Communication Between higher educa- 3. Farcas D. Experiences of Modeling the Activity of tion and industry. In Richards B (Ed): Tri-partite The big political change of the 90’s broke bridges: Educators, Providers and Users. Tempus down all formal barriers. However, the eco- Neuronal Networks by Means of Electronic Digital Computers. Elektronische Informationsverarbei- CME-0255-96 Seminar Proc. Sinaia; 1998:28-36. nomic divide endured, limiting the access to tung und Kybernetik (E.I.K.). Berlin: Akademie 21. Lungeanu D, Dimitriu R, Bazavan M, Sima R, Richards B, Neame R, et al. Medical Informatics the newest technologies. Moreover, as the Verlag 1966;2(4):213-21. Educational Tasks Seen from Practical Prospec- drop in various previous constraints was not 4. Farcas D. Informatica de sanatate [in Romanian]. tive. Proc. MIE’99. Stud Health Technol Inform replaced by an organized frame, the efforts Bucuresti: Ed. Univ. Carol Davila; 2014. 1999;68:497-9. were dissipated towards various directions, 5. Mihalas GI: Romanian medical informatics and 22. http://siis.aut.upt.ro/ (last accessed on Jan 20th represented by small unrelated projects, professor Jan H. van Bemmel’s support - Dr. Ho- 2018) [in Romanian]. noris Causa bestowed by Victor Babes University. 23. Nicola S, Stoicu-Tivadar L, Virag I, Crisan-Vida offering in the early 90’s an image of rather Methods Inf Med 2006;45(6):668-70. M. Leap motion supporting medical education. chaotic developments. The involvement of 6. Popescu O, Enatescu V, Farcas D, Mihalas GI, 12th IEEE Intl. Symposium on Electronics and governmental institutions was welcome from Petrescu O, Popa S. Informatica Medicală [in Telecommunications (ISETC’16), Timisoara, this point of view, several initiatives merged Romanian]. Bucuresti: Editura Medicală; 1988. Romania; 2016: 153-6. 7. Mihalas GI. Health Informatics Education for 24. http://www.cnas.ro/ (last accessed on Jan 20th 2018) into larger projects prepared with external Pharmacy Students in Romania. Proc MIE’97. [in Romanian]. consultancy and a legislative frame has Stud Health Technol Inform 1997;43:702-6. 25. http://siui.casan.ro/cnas/node (last accessed on Jan emerged. But the frequent high-level changes 8. Hasman A, Albert A, Wainwright P, Klar R, Sosa 20th 2018) [in Romanian]. had a strong negative impact on the success M (editors). Education and training in health in- 26. http://uefiscdi.gov.ro (last accessed on Jan 20th 2018). of these projects. More lessons learned are: formatics in Europe. Stud Health Technol Inform 1995;25. 27. http://cnsmf.ro/proiecte/proiecte-finalizate/ “A coherent development of a domain needs proiectul- gp-medinet/, Medinet GP project (last 9. Recommendations of the International Medical th a sound legislative base, a reliable organiza- Informatics Association (IMIA) on education in accessed on Jan 20 2018) [in Romanian]. 28. Stoicu-Tivadar L. Sisteme informatice aplicate în tional frame, a strong and continuous political health and medical informatics. Methods Inf Med servicii de sănătate [in Romanian]. Timişoara: Ed. support as well as a deep involvement of 2000;39:267-77. Politehnica; 2005. 10. Mihalas GI, Lungeanu D. Computer simulation competent professionals”. 29. Stoicu-Tivadar V, Stoicu-Tivadar L, Puşcoci S, Be- programs for teaching biostatistics to medical The progress of Romanian medical infor- rian D, Topac V. Web Service-based Solution for an students. In: Richards B, De Glanville H (editors). Intelligent TeleCare System. In: Fodor J, Klempous matics during the last decade was visible in “Current Perspectives in Healthcare Computing” R, Paz Suárez Araujo C (editors). Recent advances academic activities (education and research) Proc HC 96 Conference, Harrogate; 1996:353-8. in intelligent engineering systems. Springer; 2012. as well as in industry and IT implementations 11. Mihalas GI. Doctoral Level in Medical Informatics 30. www.srimed.ro (last accessed on Jan 20th 2018)[in in Romania. In: Brender J, Christensen JP, Scherrer in healthcare. However, the dialogue between Romanian] JR, McNair P (editors). Proc MIE 96, Stud Health 31. Mihalas GI, Engelbrecht R, Bazavan M, Hofdijk all stakeholders is still feeble, limiting the Technol Inform 1996;34:910-4. J, Naszlady A (editors). Healthcare Telematic rise to the true potential. “Progress is the 12. Mihalas GI, Lungeanu D. Strategy for Medical In- Support in Transition Countries. Timisoara: formatics Education at the University of Medicine Eurobit; 2002. result of a collective work”. and Pharmacy in Timisoara. Yearb Med Inform This historical survey helps us to better 32. Reichert A, Mihalas GI, Stoicu-Tivadar L, Schulz 1997:113-9. S, Engelbrecht R (editors). Integrating Biomedical understand the important role of RSMI, as 13. Mihalas GI. Milestones in Romanian Medical Information: From eCell to ePatient. Amsterdam: a professional organization, in assuming its Informatics. Med Arh 2004;58(1 Suppl 2):84-5. IOS Press; 2006. 14. Mihalas GI, Lungeanu D, Kigyosi A, Vernic C. 33. http://www.aracis.ro/nc/en/aracis/ (last accessed role to coagulate all these forces, bringing its Classification Criteria for Simulation Programs contribution to both the national and the inter- on Jan 20th 2018) Used in Medical Education. Medinfo 1995;8 Pt 34. http://www.dataprotection.ro/ (last accessed on Jan national development of medical informatics. 2:1209-13. 20th 2018) 15. Mihalas GI, Lungeanu D, Vernic C, Kigyosi A, 35. https://gdpr-info.eu/ (last accessed on Jan 20th Petrescu M. Medical Informatics for “Allied” Pro- 2018) Acknowledgement files. Stud Health Technol Inform 2000;77:546-8. The authors wish to thank Dr. Dan D Farcas, 36. http://ami.info.umfcluj.ro/index.php/AMI (last 16. Rîpanu A, Oprisan M. Evaluation of the Com- accessed on Jan 20th 2018) former director of the Centre of Health puter-Based Dispatching System for Emergency Statistics and Information (CCSS) of the Medical Dispatch. Stud Health Technol Inform 2000;77:244-50. Ministry of Health, for the rich bibliography 17. Farcas D. The Health Management Information made available to the authors. System of Romania. Proc MIE’99. Stud Health Correspondence to: Technol Inform 1999;68:140-5. Prof. Dr. George I Mihalas 18. Mihalas GI. Analysis of Barriers in Implementation Academia de Stiinte Medicale Filiala Timisoara of Health Information Systems - EFMI conference UMF Victor Babes References introductory address. Stud Health Technol Inform P-ta Eftimie Murgu nr. 2 1. Mihalas GI, Zvarova J, Kulikowski C, Ball M, 2008;134:21-6. 300 041, Timisoara van Bemmel JH, Hasman A, et al. History of 19. Filip F, Mihalas GI, Dimitriu R, Jipescu I, Lungea- Romania Medical Informatics in Europe – A Short Review nu D, Popescu A, et al. Communication Networks E-mail: [email protected]

IMIA Yearbook of Medical Informatics 2018