Turkey's e-Health Activities A Country Case Study

Author: Nihat Yurt, M.D.
Date: 1 July 2008
Turkey’s e-Health Activities
A Country Case Study

Contents
List of Abbreviations..................................................................................................................... 2
List of Figures .............................................................................................................................. 3
Executive Summary ...................................................................................................................... 4
Country Profile............................................................................................................................. 6
E-Health Project ........................................................................................................................... 8
Saglik-Net and Hospital Integration ............................................................................................. 11
Public Health Informatics ............................................................................................................ 14
Basic Health Statistics Module..................................................................................................... 15
Family Medicine Information System........................................................................................... 17
National Health Data Dictionary (NHDD) .................................................................................... 18
Health Coding Reference Server .................................................................................................. 20
National Health Information System ............................................................................................ 21
Saglik-Net Portal ........................................................................................................................ 22
Decision Support System............................................................................................................. 22
Teletraining................................................................................................................................ 23
Telemedicine.............................................................................................................................. 23
Geographical Information System ................................................................................................ 25
Digital Security........................................................................................................................... 25
E-Health Capacity Building......................................................................................................... 26
Conclusion ................................................................................................................................. 27
Annex: A Country Profile for Turkey ........................................................................................... 30
Annex: B Interview List .............................................................................................................. 31
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List of Abbreviations
ATC Anatomic, Therapeutic, Chemical Classification System
BHSM Basic Health Statistics Module
CHRMS Core Health Resource Management System
FMIS Family Medicine Information System
GIS Geographical Information
GNAT Grand National Assembly of Turkey
ICD-10 International Classification of Diseases
ICT Information and Communication Technologies
IMR Infant Mortality Rates
IT Information Technologies
ITU International Telecommunication Union
MHDS Minimum Health Data Sets
MoH Ministry of Health
NHC/MIS National Health Care Management Information Systems
NHDD National Health Data Dictionary
NHIS National Health Information System
PSTN Public Switch Telephony Network
TUBITAK Technical and Scientific Research Council
WG Working Group
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List of Figures
Figure 1 Life Expectancy at Birth in Turkey “2010-2050 Estimates”
Figure 2 Proportions of Computer and Internet Use (%)
Figure 3 Saglik-Net Backbone of Turkey
Figure 4 The target of Saglik-Net by 2009
Figure 5 Schematic diagram of Saglik-Net
Figure 6 Hospital MIS Survey 2004
Figure 7 Hospital MIS Survey 2006
Figure 8 % distribution of deaths in the national level by major disease groups
Figure 9 2010, 2020 and 2030 Estimates for deaths caused by Cardiovascular Diseases by sex
Figure 10 Family Medicine Information System’s Architecture
Figure 11 Minimum Health Data Sets
Figure 12 Health Coding Reference Server
Figure 13 Telemedicine Architecture
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Executive Summary
When we make an overlook to the informatics projects implemented by the Turkish
Ministry of Health, they satisfied the requirements for institutional needs. However, Health
Transformation Programme launched in 2003 was the beginning of a new era in health
informatics and e-Health, and institutional informatics projects have been replaced by more
added value citizen centric e-Health Projects.
E-Health studies which are professionally conducted by the Turkish Ministry of
Health are based on the studies on Turkey Health Information System Action Plan which
were started in 2003 and completed in January 2004. This plan was prepared as a result of a
very intensive work with 10 separate working groups including governmental institutions,
universities and non-governmental organizations. It can be said that the e-Health studies
which are still underway, progresses in the framework of this document.
All the activities which are aimed to be conducted on issues of statistics, monitoring
and evaluation and quality generally was suffering from a common problem. The problem
was that the data which was collected from the field and on which statistical and analysis was
done and measurements were made in accordance with the quality criteria were not defined in
the same way by relevant institutions and persons. In other words, a terminological unity
could not be ensured on the data which was used. This situation caused such results as the
desired and given data is not the same in essence and the goals which were targeted might be
damaged by collecting the data on the field.
To tackle with the issue, the National Health Data Dictionary (NHDD) is developed
and published in June 15th 2007 in the scope of the e-Health Strategy. There are 46 data sets
and 261 data elements defined in the National Health Data Dictionary.
Improvements on the Primary Health Care service in Turkey caused the common use
of information technologies. The problem of wrong/ lacking information and bad quality has
occurred because the data has not collected from the place where produced. It is now, almost
solved with the Family Medicine Information System (FMIS), which is implemented with the
Family Physician application. The data concerning the processes carried out by Family
Physicians can be delivered to the Ministry electronically and securely by FMIS. The
application of FMIS is one of the concrete e-Health applications, which will find the
possibility of the most common usage in the entire country.
Total numbers of family physicians using FMIS are 4.300 and 12.721.364 citizens
Electronic Health Records are registered to the system as of June 2008. FMIS is expected to
cover nation-wide by the end of year 2009.
The National Health Information System is in fact a compilation of Saglik-Net, the
National Health Data Dictionary, Minimum Health Data Sets and the Health Coding
Reference Server together with some other technologies such as digital security mechanisms
in order to provide a nation-wide infrastructure for easy and efficient sharing of electronic
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health records in the form of minimum health data sets. The aim is to collect health data from
all healthcare institutions scattered over the country as in the case of pilot Family Medicine
Information Systems. This time, the nodes will be the Hospital Information Systems mostly.
The NHIS has a centralized architecture. The servers are residing in the Ministry of
Health premises in Ankara. Currently, the HL7 v3 messages are prepared by the consortium
and as the communication protocol, Web Services will be used. The test servers are currently
available for testing by the software companies, healthcare institutions and individuals.
Technical guidelines have prepared and the HL7 v3 messaging definitions are provided to the
interested parties as well. The software companies will have to comply with these standards
developed by the consortium and refereed by the Ministry of Health. In this way,
interoperability among NHIS servers and various Hospital/Lab/Clinic/etc. information
systems will be provided. The load tests of the centralized architecture have already been
completed thus no problem is expected with the incremental involvement of healthcare
institutions in the system.
The first action of the e-Transformation Turkey Short Term Action Plan which was
published in the Official Gazette in December 2003 was the development of the National
Information Society Strategy. After an intensive work co-ordinated by the State Planning
Organization the Information Society Strategy and the attached Action Plan approved by the
High Planning council dated 11/07/2006 by number 2006/38 has been take into force after
published in the Official Gazette dated 28/07/2006. 111 Actions took place in the Strategy. In
the action plan, 4 actions were taking place under the responsibility of Ministry of Health
were, Establishment of the Health Information System, Data Sharing between Blood Banks,
Online Health Services and Telemedicine Systems.
Turkey’s Telemedicine project proposes to compensate the lack of experts in imaging
area, to get the second opinion in complex cases, to increase the quality patient care and to
provide best diagnosis and cure for the patients. It is implemented in 18 Ministry of Health
Hospitals.
As known, there are many initiatives to introduce Electronic Health Records under the
umbrella of e-Health to serve the administrative and citizen needs. Ageing population,
changing expectations of patients, new health threats and increasing costs of healthcare
delivery are highlighted in various numbers of plans and programmes. Healthcare IT solutions
are now providing enormous benefits and especially e-Health’s supports to those problems are
widely proven. Terminology systems’ role is obvious to reach the ultimate goals of e-Health.
There needs to be a strong political will to reinforce the Information Processing
Departments in line with the Information Society Strategy needs and reorganize them by
enriching with the necessary multi-disciplinary human resources. It is especially important in
the health sector because of its complexity and coverage. Hopefully, an international effort
addressing this issue may help the countries to build capacity in the e-Health domain.
5

Country Profile
Turkey is a Eurasian country that stretches across the Anatolian peninsula in southwest
Asia and the Balkan region of south-eastern Europe. Turkey is situated between 36-42°
northern latitudes and between 26-45° eastern longitudes. Its area is 814.578 square
kilometres.
Turkey borders the Black Sea in the north; Commonwealth of Independent States
(Armenia, Georgia, Nahcevan), Iran in the east; Iraq, Syria and the Mediterranean Sea in the
south; the Aegean Sea in the west; and Greece and Bulgaria in the northeast. The Straits carry
importance for Turkey and Black sea countries. Moreover, the Bosphorus Strait and the two
bridges on it (Bosphorus and Fatih Bridges) connect Asia and Europe on the land.
In the south, Turkey is very close to North Africa countries. In short, Turkey is located
between Europe-Asia and Africa continents. Land border of Turkey is 2.753 km. in total.
Turkey has the longest land border with Syria (877 km.). Turkey has land borders with
Georgia (276 km.), Armenia (316 km.), Nahcevan (Azerbaijan) (18 km.), Iran (454 km.), Iraq
(331 km.), Bulgaria (269 km.), and Greece (212 km). The coastline of Turkey’s four seas is
8.333 km. (Anatolia coast 6480 km., Thrace coast 786 km., The Islands coast 1067 km). Thus
total border line of Turkey reaches to 11.086 km. Anatolian Peninsula is bounded by
highlands on the east, north and south, and is a semi-arid plateau. North Anatolia in the north
and Toros Mountains in the south extend along Black sea and Mediterranean coasts and meet
in the east. Median altitude of Turkey is 1,130 meters, yet there are regional differences:
while the altitude is 500 meters in the West, it reaches up to 2000 meters in the East.
Climate in Turkey varies in terms of temperature and precipitation due to land shape
and heights. Annual precipitation averages about 500 millimetres; yet it rises to 2,000
millimetres in Rize along the Black Sea coast, and falls below 300 millimetres in some parts
of Central Anatolia. Typically, the summers are hot and dry, and the winters are bitterly cold,
rainy, windy and with frequent heavy snowfall in the Central and Eastern Anatolia Regions.
In the summers, temperature does not vary greatly between the regions but in the winters
significant temperature variations are observed in different regions. Winter temperature
average is below –10°C in the east, while it average about +10°C in the South.
Since the foundation of the Republic, Turkish administrative structure has been shaped
by 1924, 1961, and 1982 Constitutions. The Constitutions declares that Turkey is a Republic
with a parliamentary system and the will of people is vested in the Grand National Assembly
of Turkey (GNAT). All constitutions adopted basic individual, social and political rights and
the principle of separation of powers (legislative, executive, and judiciary). GNAT is the
legislative body of the Republic. 550 members of the Parliament are elected by general vote
of the people every five years. The President of the Republic is elected by the parliament and
stays in duty for seven years. The Council of the Ministers is the executive body and
composed of the Prime Minister and the Ministers. Judiciary power belongs to the Supreme
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Court (Constitutional Court), Supreme Court of Appeals, Supreme Court of Military Appeals,
Council of State, court of administration and justice, and military courts. Administrative
organization of the Republic of Turkey is divided into two, namely “Central Administration”
(state) and “Local Administration Institutions”. Central administration is divided into two as
capital organization and provincial organization. Local administration bodies are divided into
two categories; those bodies based on locality (local government organizations) and those
based on services provided (public institutions). The capital city of Turkey is Ankara and is
the second biggest city after Istanbul. Official language is Turkish.
2000 General Population Survey: Population was 67.803.927 and growth rate was
18,3 % in 1990-2000 periods. Average population growth rate in urban areas was higher than
the country average (27 ‰ in provinces and 26,4 ‰ in district) while it was rather low in sub
districts and villages (4,2 ‰). The census of Turkey was 70,586,256 as of December 2007.
Average life expectancy in Turkey is gradually increasing. 7% of Turkish population
is above 65 years old. Older population ratio is 9% in rural area, while it is 6% in urban
settlements. The ratio of the older population is the highest older population ratio in the
demographic history of Turkey. The increase in the older population could have been caused
by two reasons: rapid decrease in fertility, and life expectancy increase in all age groups. Life
expectancy at birth is 69.1 among men and 74.0 among women, 71.5 in total for 2006.
Figure 1 depicts Life Expectancy at Birth estimates in Turkey for 2010-2050. As it is
seen, life expectancy years were estimated as 72.0 years in total for 2010; 72.7 for 2015; 73.5
2050.
for 2020, 74.4 for 2025; 75.5 for 2030; 76.4 for 2040; 76.6 for 2045; and 77.3 for
Figure 1 : Life Expectancy at Birth in Turkey “2010-2050 Estimates” 1
Turkey has achieved success in reducing infant mortality rates (IMR) in the last few
years, and while IMR was 150 per 1000 live births in 1970s, it has been reduced to 21.7 per
1000 live births in 2007. However, IMR in Turkey is significantly high when compared to EU
average (8 per 1000 live births).
1 Source: TURKSTAT (Turkish Statistics Institution), 2007
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According to the results of ICT Usage Survey on Households and Individuals carried
out in 2007 by Turkish Statistical Institute, 18.94% of households have access to the Internet
at home. According to the survey results 79.39% of households with Internet access at home
connect to Internet via PC. Broadband connection (ADSL etc.) is the most widely used
Internet connection types with 78.03%.
Proportion of computer and Internet use of individuals are 29.46% and 26.67%
respectively.
Graph 1: Proportion of computer and Internet use (%)
%
40
30
29,46
37,00
26,67
33,85
Turkey
Urban
20
16,36
14,21
Rural
10
0
Proportion of computer use
Proportion of Internet use
Figure 2 Proportions of Computer and Internet Use (%)
Numbers of telephone (PSTN) subscribers were 18.831.616 in 2006.2 84% percent of
the population have mobile phones. Mobile phone penetration is higher than PSTN.
E-Health Project
When we make an overlook to the informatics projects implemented by the Turkish
Ministry of Health, they satisfied the requirements for institutional needs. However, Health
Transformation Programme launched in 2003 was the beginning of a new era in health
informatics and e-Health, and institutional informatics projects have been replaced by more
added value citizen centric e-Health Projects.
E-Health studies which are professionally conducted by the Turkish Ministry of
Health are based on the studies on Turkey Health Information System Action Plan which
were started in 2003 and completed in January 2004. This plan was prepared as a result of a
very intensive work with 10 separate working groups including governmental institutions,
universities and non-governmental organizations. It can be said that the e-Health studies
which are still underway, progresses in the framework of this document.
2 TURKSTAT (Turkish Statistics Institution)
8

The working groups and respective coordinators were;
WG1 Action Plan Working Group, Ministry of Health
WG2 Health Information Standards Working Group, Turkish Medical Informatics
Association
WG3 Health Identifier Working Group, Ministry of Health
WG4 Minimum Health Data Set/Sets Working Group, Hacettepe University
WG5 Security and Confidentiality of Health Related Data Working Group, Turkish
Medical Association
WG6 Early Warning Systems for Health Threats Working Group, Ministry of Health
WG7 Virtual Private Network for Healthcare Working Group, Turkish Telecom
WG8 Training Working Group, Higher Education Committee
WG9 Telemedicine Working Group, The Scientific and Technical Reearch Council
of Turkey
WG10 Coordination and Monitoring Working Group, State Planning Organization
These working groups conducted the assessment of the current situation, projects,
initiatives, and policy studies in their respective fields. National Health Information System
Action Plan is finished at the end of May, 2003 by Action Plan Working Group and published
on January 2004.
In the framework of the e-Transformation Turkey Project which was initiated under
the coordination of the State Planning Organization within the framework of the Urgent
Action Plan, Ministry of Health has undertaken the coordination of e-Health Study Group.
The Short Term Action Plan including 74 actions which was published on the Official Gazette
by the Prime Ministry’s Circular dated December 4, 2003 and numbered 2003/48 consists of
15 actions concerning e-Health. 15 e-Health actions were determined by giving priority
among Turkey’s Health Information System Action Plan.
In addition, Turkey’s e-Health Project was proposed to the International
Telecommunication Union (ITU) by taking the future needs into consideration. The proposal
was accepted and the actions initiated cooperation with senior consultant Dr. Salah MANDIL
who gives high-level consultancy services on the issue of e-Health in many countries in the
world. Turkey’s e-Health Project is one of the rare supports provided by the ITU for Turkey.
With the support of ITU the Ministry’s Information Technologies experts have prepared
detailed road maps for Turkey’s e-Health Strategy and Application in October and November
2004.
Turkey’s e-Health Strategy covers the following activities:
1) The enhancement of the existing MoH Wide Area Network into a National Health
Information Platform (tentatively called Saglik-Net) hosting and enabling access to nationally
required systems and services, by all Turkey health sector institutions.
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2) The strategic and technical importance of preceding the introduction of a “Family
Physicians system” with the conception and core development of a National Health Care
Management Information System, or NHC/MIS, based on individual MISs in each health care
institution which should, as far as possible, be a “national solution” optionally offered to, and
not imposed upon, any and all interested hospitals and health centres.
3) The adoption of national standards for data items, entities and related procedures,
and the development of the current and new content of health information in Turkey in
accordance with such standards, and its storage in a National Health Data Dictionary that
should be accessible over Saglik-Net.
4) The development and operation of a National Electronic Medical Records system,
that is functionally tied to the Electronic Patient Records components of the Health Care MISs
referred to in (2) above.
5) The expansion of the existing security measures of Redundancies, Firewalls, Anti-
Virus, Passwords, etc. to cater for profound Digital Security of all health care transactions that
ascertains the Identification and Authentication of all users; and the Integrity, Confidentiality
and Non-Repudiation of all health care messages and transactions.
In the scope of the e-Health activities, health information standards which are the
health services’ preliminary needs have been specified and started to be applied; within the
terms of the Transformation in Health Program, the project of information system has been
completed for the Family Physicians; the coordination necessary for the exchange of
electronic data between the health service providing and health service financing was ensured,
a protocol was signed and projected between the Ministry of Health, Ministry of Finance,
Ministry of Labour and Social Security and Hacettepe University, the needs were determined
concerning the issue of e-signature for providing the security, privacy and confidentiality
regarding health records and the cooperation platform was formed with universities in order
to establish the human resources who are trained in the field of health information.
The first action of the e-Transformation Turkey Short Term Action Plan which was
published in the Official Gazette in December 2003 was the development of the National
Information Society Strategy. After an intensive work co-ordinated by the State Planning
Organization the Information Society Strategy and the attached Action Plan approved by the
High Planning council dated 11/07/2006 by number 2006/38 has been take into force after
published in the Official Gazette dated 28/07/2006. 111 Actions took place in the Strategy. In
the action plan, 4 actions were taking place under the responsibility of Ministry of Health
were as below:
• Establishment of the Health Information System
• Data Sharing between Blood Banks
• Online Health Services
• Telemedicine Systems
10

These actions are mostly completed and the studies carried out to establish the “health
data operation centre” under the scope of eHealth Project has reached the last stage.
Currently, the “health data operation centre” is able to store health records; further progress is
being made for gathering data from all over the country.
As shown in Figure 3, all the servers, that is, the National Health Data Dictionary
Server, the Minimum Health Data Sets and the Health Coding Reference Server are available
from the Saglik-Net network. Among the users of the network, currently the Family Medicine
information and Telemedicine are connected; the other types of users (primary, secondary,
tertiary healthcare providers, payer institutions, family physicians, etc.) will be connected by
2009. The software companies in Turkey have to comply with these standards developed by
the Ministry of Health. In this way, interoperability among National Health Information
servers and various Hospital/Lab/Clinic/etc. information systems are provided. The Electronic
Health Records are based on HL7 Clinical Document Architecture (CDA) and uses the
National Health Data Dictionary, the Minimum Health Data Sets and the Health Coding
Reference Server’s coding systems.
Figure 3 Saglik-Net Backbone of Turkey
Saglik-Net and Hospital Integration
By the year 2004, the existing network of the Ministry of Health, which is run over the
national backbone, was already in good condition as the technical communication
infrastructure. However, the main regular uses in the Ministry of Health were the legacy
systems (e.g. Personnel, Financing, Health Statistics), e-Mail and access to Internet. However,
the great majority of the health sector (hospitals, clinics, laboratories, etc.) who need it the
most had no such links.
11

As of June 2008, some statistics concerning the number of healthcare institutions and
physicians in Turkey are as follows:
• Number of Hospitals: 1215 (855 hospitals are belonging to the Ministry of Health)
• Number of Health Centres: 5007
• Number of Village Health Station: 7676
• Number of Physicians: 98203
In order to exploit the true benefits of existing network, Saglik-Net was recommended
by ITU. Saglik-Net is the conversion of the existing LAN-WAN into a true health network
platform providing linkages, services and data repositories (e.g. minimum data sets of
Electronic Health Records) to all authorized parties in the health sector. This National Health
Platform should be recognized, respected and trusted as the secure national platform for
everything that is Health Information, either systems or services or both.
Saglik-Net is operational now and it is still being developed. As of June 2008, the
progress is as presented in Figure 3 above. The dotted lines are for the nodes that are almost
completely connected.
2009.
The target of the Saglik-Net is to reach the network of the following Figure 4 below by
Figure 4 The target of Saglik-Net by 2009
A schematic diagram of Saglik-Net is given figure 5 below.
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Figure 5 Schematic diagram of Saglik-Net
According the Ministerial Circulars number 2007/94 and 2008/18 it is compulsory for
the hospitals to use the NHDD’s data sets and transfer these data sets by using the HL7 V.3
message standards which is also issued as a technical guideline by the last Circular. The
deadline for the Ministry of Health hospitals is the end September 30th. Remaining university
and private hospitals it is January 2009.
Figures 6 and 7 below depict the hospital information systems and its basic module’s
penetration comparing the years 2004 and 2006 respectively. There is a significant increase
owning hospital information systems by the hospitals between 2004 and 2006. A new hospital
management information system survey has been prepared for the year 2008 and the results
will be available by November 2008. All Ministry of Health Hospitals which are total 855 by
have hospital management information systems.
Figure 6 Hospital MIS Survey 2004 Figure 7 Hospital MIS Survey 2006
More than 60 vendors are producing hospital information systems in the Turkish
market and selling them to the hospitals. Approximately 7-10 of the vendors are bigger in
13

scale of the production than the remaining. For example, one of the vendor’s hospital
information systems is running more than 100 hospitals.
Ministry of Health has issued a request for information (RFI) document in 2006.
Those who are interested were invited to the Ministry for interview. There were 15 companies
interested for the RFI document. According the RFI it is asked for a solution for the hospital
management information systems at least having the core modules as part of the National
Health Information System which were admissions, Discharge & Transfers, Minimum Data
Set of Patient Records, Order Entry, Laboratory, Pharmacy and Patient billing. During the
information meeting the vendor’s raised the issue that the awarded vendor would have
enormous advantages and the Ministry would create monopoly. The answer from the Ministry
of Health site was: the established system would not create monopoly, it will only be
implemented some selected hospitals and it will be a proposed solution not obligatory. The
answer was not satisfactory for the vendors. For balancing the competition the second option
is chosen. To issue Minimum Health Data Sets and technical guidelines for the complying
with the Data Centre established within the Ministry of Health. It is elaborated in the National
Health Data Dictionary Section.
Public Health Informatics
There are several methods Ministry of Health is using to collect health data. Core
Health Resources Management Program is mainly used for human resources management,
stocks management and investment monitoring. Basic Health Statistics Module is elaborated
below. Comprehensive web-based hospital information forms are used for instant data needs
from hospitals infrastructure and assessment of current conditions. There are web-based
applications such as Patient Rights and etc. used through the Ministry of Health web site 3 .
Field coordinators are responsible to aggregate and represent the health data before a senior
management visit take place in a province. For the data which can not collected through an
information system usually produced on a collaboration basis with the universities by using
scientific and sample survey methods.
Considering the causes of mortality in childhood, perinatal deaths lower respiratory
system infections, congenital anomalies, diarrhea and meningitis are among the first five
preventable causes. 4
Figure 8 depicts % distribution of deaths in the national level by major disease groups.
Cardiovascular disease is the number one cause of death, with 205,457 deaths (47.73% of
total causes of death). Among the cardiovascular diseases are ischemic heart diseases,
cerebrovascular diseases, rheumatic heart diseases, inflammatory and hypertensive heart
diseases. The ratio of deaths caused by cardiovascular diseases is 43.89% (102,386) among
male population, and 52.27% (103.071) among female population.
3 www.saglik.gov.tr
4 National Burden of Diseases Study, Ministry of Health, 2003
14

Figure 8 % distribution of deaths in the national level by major disease
groups 5 Figure 9 presents the estimates of deaths from cardiovascular diseases among both
sexes in the years 2010, 2020, and 2030. Deaths from cardiovascular diseases are estimated as
to be 134.700 in 2010 and 235.567 in 2030 among men; and 123.411 in 2010 and 180.530 in
2030 among women.
Figure 9 2010, 2020 and 2030 Estimates for deaths caused by Cardiovascular
Diseases by sex
Basic Health Statistics Module
Health statistics from 81 Provincial Health Directorates, Public Hospitals and Public
Health Centres can be sent to a web-based central database located within the Ministry of
Health which is also the part of the Saglik-Net.
5 National Burden of Diseases Study, Ministry of Health, 2003
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The data which is sent from health institutions to Provincial Health Directorates and
then to the Ministry’s central units and the data sent with the BHSM electronically are
evaluated on a level that is found necessary by decision makers and compiled and reported in
order to meet the management’s needs on site. The BHSM consists of the Ministry’s central
organization and all the Provincial Health Directorates.
There are certain statistics, criteria and indicators which can display a society’s health
level. For example, the rate of baby mortality, rate of mother birth, rate of parental mortality,
total fertility rate, population per doctor, population per bed, etc. by using these indicators.
The society’s health situation can be followed, the effectiveness of programs which are
conducted can be measured, possible needs can be determined for health services and the
society’s health level can be compared with the health level of other societies or countries.
Certain report titles available in the module are:
• Demographical Reports
• Bed Situation Reports
• Hospital Services Reports
• Mother Mortality and Monitoring
• Reports
• Infant and Child Monitoring Reports
• Disease Reports
• Immunization Reports
• Environmental Health Reports
• Village Clinic Work Reports
• Reports of Combating Tuberculosis
• Reports of Combating Malaria
However, the program is effectively used in small or medium populated provinces;
there are still some problems in terms of evaluating the big provinces health statistics. One of
the main reasons lying behind is the lack of adequate human resources to use and improve the
system both at provincial and Ministry of Health’s Central organization. Several departments
of the Ministry of Health has own statistics unit.
According the law “Public Financial Administration and Control” numbered 5018 and
dated 10.12.2003, Strategy Development Departments has been established in all Public
Agencies including the Ministry of Health. Within the department a new statistics unit has
been established. One of the main functions of the new statistics unit is to co-ordinate the
overall health statistic activities carried under the several departments of the Ministry. It is
expected that Saglik-Net platform will serve the needs for most of the health statistics
concerns.
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Family Medicine Information System
Improvements on the Primary Health Care service in Turkey caused the common use
of information technologies. The problem of wrong/ lacking information and bad quality has
occurred because the data has not collected from the place where produced. It is now, almost
solved with the Family Medicine Information System (FMIS), which is implemented with the
Family Physician application. The data concerning the processes carried out by Family
Physicians can be delivered to the Ministry electronically and securely by FMIS. The
application of FMIS is one of the concrete e-Health applications, which will find the
possibility of the most common usage in the entire country.
FMIS application is based on the principle that each individual’s having a family
physician to take care of his health. Thus, everybody will have a physician whom he
addresses directly in every issue concerning his health problems. This unity of physician and
patient deriving from the nature of the application of FMIS provides an important opportunity
in terms of recording the health records in accordance with a certain discipline. FMIS
application follows an individual from the time of conception and maintains the information
on his health. The individual’s development in his mother’s womb, the method of birth and
other information on his birth are entered in the application of FMIS and kept in the
information bank under the doctor’s surveillance. This data will be an important resource of
information in curing the individual’s future health problems.
The FMIS will be close to the individual from his birth until his death. When
necessary, he will carry out the vaccination for babies and children and birth control of the
pregnant women, closely follow the patients’ health and give them advice. The FMIS will
visit examine and cure the patients who can’t visit him due to his health problems at their
homes.
In short, the FMIS will be close to each individual who depends on him in all of his
health problems from his birth until his death.
The Family Medicine Information System is applied first in Düzce province in
September 15, 2005. Until the end of August 2007, the system has been deployed in 12
provinces. The deployment of the system still continues. Therefore, the number of the
provinces that the system is deployed reached up to 21. The deployment will continue in 2008
and after.
Total numbers of family physicians using FMIS are 4.300 and 12.721.364 citizens
Electronic Health Records are registered to the system as of June 2008. FMIS is expected to
cover nation-wide by the end of year 2009.
The system architecture is presented in Figure 10 below.
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Figure 10 Family Medicine Information System’s Architecture
National Health Data Dictionary (NHDD)
All the activities which are aimed to be conducted on issues of statistics, monitoring
and evaluation and quality generally was suffering from a common problem. The problem
was that the data which was collected from the field and on which statistical and analysis was
done and measurements were made in accordance with the quality criteria were not defined in
the same way by relevant institutions and persons. In other words, a terminological unity
could not be ensured on the data which was used. This situation caused such results as the
desired and given data is not the same in essence and the goals which were targeted might be
damaged by collecting the data on the field.
To tackle with the issue, the National Health Data Dictionary (NHDD) is developed
and published in June 15th 2007 in the scope of the e-Health Strategy. There are 46 data sets
and 261 data elements defined in the National Health Data Dictionary.
The Meta data definitions and format determined within the NHDD will establish a
reference for the information systems used at health care institutions. Thus, even if different
applications are used at health care institutions, the format of the data will be the same.
Therefore, when it is requested, demanded from relevant institutions, each institution will be
able to obtain the data from the Minimum Health Data Sets (MHDS) to be established by
choosing from the data defined within the NHDD.
NHDD is a dictionary which is a reference on the issue of health in the entire country.
As the data elements to be used at the institutions where the health services are furnished on
different levels is defined within the NHDD, the data which were recorded by complying with
same standards will be able to be requested from relevant institutions, if needed. These data
groups to be used on this new structure which will become a national standard on the issue of
data collection are called Minimum Health Data Sets (MHDS).
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The data groups used for data collection are called Minimum Health Data Sets
(MHDS) and are formed from the NHDD as shown in Figure 11. In other words, MHDS
define the data sets which emerge at the time of presenting a certain service, for example,
Infant Monitoring Data Set, or Pregnant Monitoring Data Set. Currently Health MHDSs are
completed and work is in progress for developing the other two sets, namely, Administrative
and Financial.
Currently, it covers the most critical health data but in the future, these data sets will
be extended to the full Electronic Health Record schemas. Some example MHDS are:
• Citizen/Foreigner Registration MHDS
• Medical Examination MHDS
• Prescription MHDS
• Pregnant Monitoring MHDS
• Cancer MHDS
• Inpatient MHDS
Figure 11 Minimum Health Data Sets
The data which have been collected on papers until now will be able to be delivered
directly to our Ministry in a quicker and more correct way by using the infrastructure of
developed communication and information technology by the help of the MHDS system.
Furthermore, MHDS will be a changing and an updateable structure. In other words, when a
new data has to be collected from the field, MHDS will be updated in certain periods and
changed in a way to meet the need. This approach will obtain a more comprehensive structure
after adding administrative and financial data sets to other data sets which were initially
developed for the purpose of collecting the health data.
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In addition, the procedures which should be followed in order to carry out all these
processes will provide the Ministry of Health with the possibility of obtaining a stronger
discipline in evaluating health outcomes and developing health policies.
Health Coding Reference Server
The aim of the Health Coding Reference Server is to provide a complementary basis
with the NHDD. However, it’s not sufficient to define the data. Certain data elements need a
coding/classification system. If the aim is to collect and evaluate the data throughout the
country, a common coding/ classification system should be used throughout the country for
this data.
Actually many examples like plate codes, postal codes, etc. have taken their places in
our daily lives. However, we can’t see the same standardization in the health sector
sufficiently. Therefore, the data which are needed to be coded gathered from the data
collected in the field of health in a system called the Health Coding Reference Server
(HCRS). System codes published in the Health Coding Reference Server (HCRS) are:
ICD-10, Drugs, ATC(Anatomic, Therapeutic, Chemical Classification System),
Associations, Clinics, Specialization, Careers, Budget Tariffs, Health Application
Instructions, Supplies, Vaccines, Baby Monitoring Calendar, Pregnant Monitoring Calendar,
Child Monitoring Calendar and Parameters.
FMIS
Vendors
Clinics
Hospitals
Payer Institutions
Figure 12 Health Coding Reference Server
The HCRS is shared with an open technology XML web services and used in software
projects which were developed in the issue of health. HCRS is used as a reference, all the
information and data systems which are used at health care institutions are defined and they
use the same codes. This work means that minimum data sets which are aimed to be collected
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y the Ministry are standardized. HCRS is accessible through the Saglik-Net Portal and a
schematic diagram of its usage is shown in Figure 12 above.
National Health Information System
National Health Information System (NHIS) is built upon all the systems that have
been explained so far in the e-Heath and Saglik-Net section.
The NHIS is in fact a compilation of Saglik-Net, the National Health Data Dictionary,
Minimum Health Data Sets and the Health Coding Reference Server together with some other
technologies such as digital security mechanisms in order to provide a nation-wide
infrastructure for easy and efficient sharing of electronic health records in the form of
minimum health data sets. The aim is to collect health data from all healthcare institutions
scattered over the country as in the case of pilot Family Medicine Information Systems. This
time, the nodes will be the Hospital Information Systems mostly.
The NHIS contract was granted to national consortium (Vestel-DataSel-Birim) in
February 2007. The project is approaching to its final stages. The NHIS has a centralized
architecture. The servers are residing in the Ministry of Health premises in Ankara. Currently,
the HL7 v3 messages are prepared by the consortium and as the communication protocol,
Web Services will be used. The test servers are currently available for testing by the software
companies, healthcare institutions and individuals. Technical guidelines have prepared and
the HL7 v3 messaging definitions are provided to the interested parties as well. The software
companies will have to comply with these standards developed by the consortium and
refereed by the Ministry of Health. In this way, interoperability among NHIS servers and
various Hospital/Lab/Clinic/etc. information systems will be provided. The load tests of the
centralized architecture have already been completed thus no problem is expected with the
incremental involvement of healthcare institutions in the system.
A technical workshop organized by the Ministry of Health with the participation of
hospital information system vendors to comply with HL7 standards and National Health Data
Dictionary’s Minimum Health Data Sets. (The workshop was continuing when the report was
under preparation) A test platform (TESTBATN) has been prepared by METU-SRDC team to
help the vendors to accommodate quickly to Saglik-Net platform.
It should be noted that the data flow is not one-way, that is just from the healthcare
institutions to NHIS servers. The authorized parties will also be able to query and retrieve the
healthcare records from the NHIS servers. So, sharing of medical records among healthcare
providers is possible.
It is expected that by year 2009, it will be possible to collect data from 90% of the
field (primary, secondary, tertiary healthcare providers, payer institutions, family physicians,
etc.).
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Saglik-Net Portal
Saglik-Net Portal studies were introduced in mid 2007 by the Ministry of Health in
order to function as a point of access to health related information on the Web. The aim is to
present continuous information to different levels of users through a standard interface from a
unique address6. The components of the portal are; announcements, data presenting
interfaces, applications, decision support system, forums and the management interfaces. The
Saglik-Net Portal is also designed to integrate with the e-Government Gateway7 which is still
under construction. When a citizen access the e-Government Gateway in order to search
health related issues such as news, diseases information and etc. the Gateway will route to
Saglik-Net Portal. Or a citizen can directly access to the Saglik-Net Portal by using the direct
web address.
The most important functionality of the Saglik-Net Portal is that, with the introduction
of electronic identity cards, it will act as a Personal Health Record (PHR) System. Through
the portal, the citizens will be able to access their Electronic Health Records, make online
reservations and make Tele-consultation with the family physicians.
These functionalities will be possible since the portal will be totally integrated with the
National Health Information System. Till the end of 2008, it is expected that the portal will be
available to all citizens with complete functionalities.
Decision Support System
A Decision Support System has been built on the Saglik-NET. It is first implemented
over the Family Medicine Information System. Reports regarding Turkey’s health profile
from the Family Physician Medicine Information System ensure the decision makers allocate
the resources efficiently.
Through the system, including the legacy systems which are Core Health Resources
Management System, Basic Health Statistics Module, New Performance Monitoring System,
Patients Rights Information System and etc. several reports can be produced for meeting the
requirements of the Ministry of Health’s planning, monitoring and evaluating function.
6 www.sagliknet.saglik.gov.tr
7 www.turkiye.gov.tr (The gateway is not publicly open. It is in test phase and some certain
agencies can access with ip control)
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Teletraining
A protocol on receiving satellite communication and video conference service between
the Ministry of Health and Turksat8 was signed in order to spread the tele-training services
(remote health services) between the Ministry of Health’s Training and Research Hospitals to
make it possible to access distance learning and digital libraries and spread medical training.
There are 46 Training and Research Hospitals, General Directorate of Health
Education and Ministry of Health’s central organization in the scope of the protocol. Videoconference
tools and services are set up for all 46 hospitals.
However, the system is not used effectively since its establishment. The system usage
data will be available after the evaluation of the 2008 hospital information survey by
November 2008.
Telemedicine
The “e-Transformation Turkey Project” that was part of the 58th and 59th Government
Urgent Action Plan was launched in 2003 and coordination of “e-Health Group” assigned to
the Ministry of Health as mentioned above in the e-Health section. Information Society
Action Plan was taken into action on 28.07.2006 in Official Paper with reference no 26242
after approval by High Planning Council on 11.07.2006 with reference no 2006/38. That
Action Plan includes 4 actions, which one of them is to implement telemedicine systems.
Telemedicine project proposes to compensate the lack of experts in imaging area, to
get the second opinion in complex cases, to increase the quality patient care and to provide
best diagnosis and cure for the patients.
Health care services are provided in Radiology and Pathology in the scope of
telemedicine by using Information and Communication technologies in the secondary and
tertiary health care pilot hospitals. Also it is expected to compensate the lack of experts and
will provide reports for first or second opinion.
Pilot project includes 18 State Hospitals throughout the Turkey. 13 of them defined as
Sending Hospitals (require consultation) and 5 of them define as Receiving Hospitals
(providing reporting services). All the Receiving hospitals are situated in Ankara province.
Ministry of Health Data Centre which manages the telemedicine services defined as
Telemedicine Centre and behaves as a gateway between Sending and Receiving hospitals.
The pilot project started in 2007. Telemedicine infrastructure has been established in
all pilot hospitals at the end of the 2007.
The telemedicine service aims to provide following benefits:
8 National Satellite and Communication Company
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• It will be used in the fields of diagnose, treatment, training, management, research,
medical follow-up and treatment control, evaluation of patients in natural disasters
and big accidents, decision of triage and pre-transfer planning and community’s
health.
• The quality, effectiveness and productivity of health services will increase.
• Specialty centres will provide consultancy services to each other by the help of
telemedicine.
• Secure exchange and share of electronic information will increase.
• It will cause the productive use of limited resources and encourage the patient
satisfaction.
By the end of December 2007;
• Telemedicine equipment is established and IT infrastructure is strengthened in
selected hospitals.
• Full PACS system is established in two state teaching hospitals.
• Telemedicine centre established.
• Project extended to include Tele-EKG and Tele-Biochemistry between Van
Province and Bahcesaray District which are in the eastern part of Turkey.
• Telemedicine services are fully operational.
• Training services are completed to the hospital staff.
Telemedicine architecture is presented in Figure 13 below.
Figure 13 Telemedicine Architecture
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Over one thousand of images are reported by using the telemedicine system since
January 2008. It is in the evaluation phase. Telemedicine project will be extended to the other
selected state hospitals by 2008.
It is planed to include elderly care and remote monitoring of the patients with chronic
diseases in the telemedicine services.
Geographical Information System
Geographical Information System (GIS) is an application which can be integrated with
the Core Health Resource Management System (CRMS) and other systems in order to process
certain institutions like hospitals, village clinics and health houses on the map; to carry out
geographical and non-geographical inquiries and analyses on the basis of region, province,
district and unit.
With this application;
• Visualization of healthcare institutions’ locations and health equipment on the
basis of province and district on the map is possible.
• In cases where the institutions’ personnel or investment planning depends on
demographic and geographic values, the geographical information system is used
for analyses.
• Statistics which depend on the numeric criteria like the population per doctor and
the population per bed can be viewed on the screen easily.
• The closest first and second degree health institutions to the point which is clicked
on the screen can be displayed on the screen.
• The organization’s data is displayed on the geographical and demographic data.
• GIS is still in development stage and more integration actions with the other
information systems of MoH are on the way.
Digital Security
The Technical and Scientific Research Council (TUBITAK) is the authorized
responsible for providing solutions in Digital Security in Turkey. For this purpose, TUBITAK
is developing the National Electronic Identity Verification System and the Smart Identity
Card. These solutions will be available for both individuals and institutions.
A pilot study has been started under the umbrella of Information Society Strategy
Action Plan. Health and insurance sectors are determined for the first pilot implementation.
The pilot implementation is taking place in Bolu province together with all family
physicians, public/private healthcare institutions and pharmacies. By the end of 2008, 10,000
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citizens will have smart cards in Bolu where all healthcare related institutes will be connected
to National Electronic Authentication System.
Other than this project, digital signatures are operational since 2004 and mobile
signatures are operational since 2006 in Turkey by law and the integration of FMIS with these
mechanisms have already been realized.
E-Health Capacity Building
The Turkey’s e-Health Strategy and its implementation plan are carried out under the
responsibility of the Ministry of Health. The responsible Department within the Ministry is
the Information Processing Department. Currently, there is a dedicated e-Health team and
shared responsibilities within the team according the e-Health activities. Turkey’s e-Health
project is a large scaled project which is similar to many other countries e-Health programmes
and efforts. In terms of long term sustainability of a project like this requires a high level
institutional organization.
The establishment of the Information Processing Departments in the public agencies
goes back to the 1980’s. Some public agencies established their organization laws including
the Information Processing Department. Bu other will not succeed to issue in the
establishment laws. Instead, some agencies preferred the establishment on the Ministerial
approvals. The “e” wind which is emerged from the global initiatives such as e-Europe in the
year 2000 after the Lisbon Strategy affected the Turkey’s Information and Communication
Technology efforts through a more disciplined way.
In several national congresses and seminars organized in the country especially leaded
with one of the highest respected non-governmental organization Turkish Informatics
Association9, the issue for strengthening the roles of Information Processing Departments and
conversion of them as a real Information and Technology Departments reporting to the top
senior management is raised. Because, the name “Information Processing” is somehow old
fashioned and undermines its real functions and duties. It is perceived by some senior officials
who are lack of ICT knowledge as technical support departments only dealing with some
hardware and software problems.
The e-Turkey initiative, e-Transformation Turkey Project and Information Society
Strategy studies are carried out with the active contribution and activities of the Information
Processing Departments on behalf of their agencies. As mentioned in the e-Health section
above, the latest action plan in force is the Information Society Action Plan consists of 111
actions. Action 68 addresses the institutional capacity building responsible for the duties
related to the e-Transformation activities. However, the goals of this action item are not
realized yet.
9 Turkish Informatics Organization is established in 1971 and plays important roles in the field.
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There needs to be a strong political will to reinforce the Information Processing
Departments in line with the Information Society Strategy needs and reorganize them by
enriching with the necessary multi-disciplinary human resources. It is especially important in
the health sector because of its complexity and coverage. Hopefully, an international effort
addressing this issue may help the countries to build capacity in the e-Health Domain.
There are very few universities providing Master of Science and Doctorate post
graduation in the Health Informatics field. Mainly, the interest groups of students are
technical engineering background graduates and medical doctors. There is no incentive
currently for those students to select Health Informatics as a post graduate education. But it is
an emerging area and in the future the trend may change.
Conclusion
There are several international e-Health initiatives taking place to promote health and
provide better healthcare by using ICT. On of the most important concern is interoperability.
To achieve the interoperability issue there is a need to collaborate at international level
in the health informatics standardization area. Standardized terminologies and its
implementation needs harmonized efforts from governments, NGOs and private sector.
Standardized terminology activities should take into account the lack of actual
implementation and international compatibility even in developed countries. Due to the
variations in the specific needs and the points of view of the countries, it is understandable
that these variations will lead varieties in terminology systems’ implementations, as well.
As known, there are many initiatives to introduce Electronic Health Records under the
umbrella of e-Health to serve the administrative and citizen needs. Ageing population,
changing expectations of patients, new health threats and increasing costs of healthcare
delivery are highlighted in various numbers of plans and programmes. Healthcare IT solutions
are now providing enormous benefits and especially e-Health’s supports to those problems are
widely proven. Terminology systems’ role is obvious to reach the ultimate goals of e-Health.
In standardized terminology activities, active collaborative actions among the
countries are crucial and a global minimum requirement consensus has to be identified. This
has significant importance in terms of interoperability. In other words, minimum requirements
for implementation of standardized terminology will serve as a core for all countries and
prevent digital divide.
There is also need legislation background for e-Health projects and programmes. In
terms of security, privacy and confidentiality of the individual health record strong policy
documents and laws are required and perceived by all stakeholders and citizen itself.
One of the emerging areas in the eHealth domain is tele-health services for elderly
care and remote monitoring of patients with chronic disease. So the there will be a shift from
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telemedicine to tele-health in the near future. There are already significant investments in the
field. The governments also have to build partnerships with stakeholder to implement solution
for their country specific needs.
For long term sustainability of e-Health Projects and Programmes institutional
capacity building opportunities is mentioned in the above section. The information and
communication technologies are changing so quickly and there is a need to organize capacity
for change management in IT as well.
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Bibliography
1. Turkey’s e-Health Strategy, Ministry of Health & ITU, October 2004
2. E-Transformation in Health, Ministry of Health, September 2007
3. National Health Information System Action Plan, January 2004
4. E-Transformation Turkey Project, State Planning Organization, 2003
5. Information Society Strategy and Its Action Plan, June 2006
6. RIDE Project, A roadmap for interoperability in e-Health Systems, EU’s 6 th
Framework Project, Prof.A.DOGAC
7. Health at a Glance Turkey, Ministry of Health, 2007
8. 2008 Annual Programme, State Planning Organization
9. Yearly Statistics from Turkish Statistics Institution, Higher Education Council and
State Planning Organization.
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Annex: A Country Profile for Turkey
Major eHealth challenges
% spent GDP on HC 6.6%
Healthcare
e-Health Legislation
Hospital beds per capita 0,028
Systems
Long term sustainability
Immunization coverage (DTP3) 90%
Infrastructure
Examples of eHealth work
% births attended by skilled staff 83%
Family Medicine Information System
Healthcare Physicians per capita 0,0014
National Health Information System
people capacity Nurses per capita 0,001
Saglik-Net (Health-Net)
% of GDP spend on ICT 3,4%
National Health Data Dictionary
Internet users per capita 0.34
Health Outcomes
Child mortality rate 21,7 Mobile phone subscribers per capita 0.84
IT systems
Life expectancy (male) 69,1 Population covered by mobile telephony 84%
infrasructure
Life expectancy (female) 74 Electric power consumption (kWh per capita) 2.7
Ability to pay GNI/capita 9.000 USD Electrical outages (days) No outages
National Information Policy Present Cost of a 3 minute mobile phone call (US$) 0.8 USD
Current Policy
National ePolicy Present Undergraduate/postgraduate training on ICT 100485/7209
National eHealth Policy Present Continuing education on ICT 100485
Citizen Protection Policy Present IT People eLearning in health sciences N/A
Peace capacity Schools connected to the internet 27.000
Implementation barriers Stability Technicians and researchers in R&D (per M) 4600
Cultural diversity No barriers
Telephone employees per capita 0,27
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Annex: B Interview List
Name&Surname Title Institution
Nihat AKPINAR Head of Deparment of Information Processing Ministry of Health
Recep CAKAL Head of Information Society Department State Planning Organization
Ahmet SARICAN Deputy General Director for Census and Citizenship Affairs Ministry of Interior Affairs
Prof. Dr. Asuman DOGAC Director of Software Research and Development Centre Middle East Technical University
Selçuk KAVASOGLU Head of Management of Information Centre State Planning Organization
Mahir ÜLGÜ M.D. Deparment of Information Processing Ministry of Health
Ahmet ÖZÇAM I.T. Consultant Ministry of Health
Furkan CİVELEK Assistant Planning Expert State Planning Organization
31