3.1 Electronic Referrals (E-Referrals)

With the aforementioned in mind, it is worth expanding on the outlined system of legal regulations with norms constituting aspects of the health care system digitalisation process in Poland, and which came into force during the COVID-19 pandemic. It should be indicated that these are not of a uniform nature. The first group includes solutions introduced at a predetermined time, which were introduced irrespective of the specific epidemic situation. Conversely, the second category comprises instruments implemented in connection with the provision of health care services in these specific circumstances.

With regards to e-referrals,⁹ which is an aspect of the health care system digitalisation that falls within the first of the above groups, it should be clarified that the obligation, existing since 8th January 2021, to issue referrals in electronic form applies only to specific documents, recorded in the Medical Information System (Pol.: System Informacji Medycznej SIM). This is because not all referrals issued to enable the patient to access specific health services are of such a nature. The list established by way of a regulation of the Minister of Health¹⁰ lists specific types of medical services, taking into account the manner of their financing and the rules of their implementation. The electronic form referral includes: outpatient specialist services financed from public funds, excluding specialist advice – speech therapy, as well as publicly funded fetal echocardiography examinations, publicly funded gastrointestinal endoscopic examinations, publicly and non-publicly funded nuclear medicine examinations, publicly funded magnetic resonance imaging examinations, publicly and non-publicly funded computed tomography examinations, hospital treatment, therapeutic rehabilitation, health resort treatment and rehabilitation. However, referrals for other services, such as drug programmes, can still be issued in paper form. Similarly, this encompasses diagnostic tests or certain procedures that are performed for a patient as part of specialist advice, hospitalisation, as well as in the absence of access to the ICT system (for example, system failure) and in the case of issuing a referral for a person of unknown identity.

3.2 Electronic Medical Records

Another indication of digitalisation, not directly resulting from the unique epidemiological situation, can be seen in the field of electronic medical records. However, the aforementioned solution is not a brand-new instrument. As early as 1st January 2019, healthcare institutions were obliged to keep certain documents in an electronic form such as disease, health problem or injury diagnosis information, test results, refusal of hospital admission justifications, health services provided and possible medical orders – in the case of a patient being refused admission to hospital, information for the doctor referring the recipient to a specialist clinic or hospital treatment concerning the diagnosis, treatment method, prognosis, prescribed drugs, foodstuffs for special nutritional purposes and medical devices, including the usage period and dosage method, as well as scheduled control visits and information sheets from hospital treatment.¹¹

Over time, the above obligation incorporated additional documents, e.g., laboratory test results with descriptions and diagnostic test descriptions other than the above. Electronic medical records¹² are documents created in an electronic form with a qualified electronic signature, a trusted e-signature, a personal signature or by way of confirming the origin and integrity of data available in the ICT system made available free of charge by the Social Insurance Institution, i.e., prescriptions, referrals, orders for supplies and repairs and vaccination cards, as well as documents which it was obligatory to keep in the form of electronic records at an earlier date.¹³ In addition, since 1st July 2021, the healthcare provider is obliged to ensure that it is possible to exchange the data contained in the electronic medical records via the SIM system.¹⁴ The listed catalogue of documents is to be expanded to include all documentation maintained by the healthcare provider. The above solution is intended to improve the system of medical record circulation between healthcare providers, guaranteeing proper cooperation and giving assurance of comprehensive care for patients. Automatic access to electronic medical records is available to designated entities: the medical employee who created the electronic medical records containing the patient’s personal data or individual medical data, the medical employee practising at the service provider where electronic medical records containing a patient’s personal data or individual medical data has been created in connection with his/her practising at this service provider if it is necessary to carry out diagnostics or ensure continuity of treatment, as well as the doctor, nurse or midwife providing healthcare services to the service recipient under the healthcare services provision agreement in the field of primary healthcare and all medical personnel in a situation that is life-threatening for the patient.¹⁵ In other cases, access to medical records requires the consent of the patient or his or her legal representative, while indicating the scope of time and subject matter of data access.

3.3 Teleconsultations

Given the need to reduce direct contact between patients and medical professionals in the COVID-19 pandemic era, teleconsultation provided in primary care has become essential. Crucially, these services have been included as part of publicly funded benefits since November 2019. A teleconsultation is a health service provided remotely using ICT or communication systems, and carried out as part of primary health care (PHC) by a doctor, nurse or midwife who provides services at a PHC provider. This can especially take the form of a conversation over the phone, a video conference or exchange of electronic correspondence (emails). The dynamic increase in the amounts of teleconsultations practiced observed during the COVID-19 epidemic directly influenced the necessity to develop organisational standards regarding their provision. Within the scope of the implemented principles, which changed three times during the time the state of the epidemic was in force,¹⁶ the duties of the primary care provider and the teleconsultation provider have been listed. These include, above all, obligations towards the patient regarding the provision of information. One such obligation that should be emphasised is providing the patient with information about the terms and conditions of teleconsultation provision, including the patient’s right to express their wish to have personal contact with relevant medical staff, specifying, e.g., the services to be provided through direct patient contact only, how the date and time of the teleconsultation is to be determined or how to establish contact with the patient. It is also worth mentioning their report duties towards the National Health Fund, which in turn allow the latter to monitor the health services provided in this form, but also it should be indicated that there is a necessity to record the provision of teleconsultation services in the medical documentation and to conduct it maintaining confidentiality. Wider use of teleconsultation in the pandemic was also fostered by complementary digitalisation tools, such as the aforementioned e-prescriptions, e-referrals or e-notes.

3.4 Public Financing of Health Services Provided under the Telemedicine Model

The COVID-19 pandemic also increased the scope of publicly funded health services delivered using ICT or communications systems. Some of them were reimbursements covered regardless of the epidemic situation, while others only during the state of epidemiological threat or the state of epidemic emergency. The first group includes such services as the provision of advice and visits in the field of palliative and hospice care in a home setting with the use of ICT systems or other communication systems, provided that such a procedure does not pose a risk of causing the deterioration of the patient’s health condition,¹⁷ guaranteed benefits within the scope of nursing and home care services within the framework of long-term care, provided under home conditions by a long-term home care team or long-term home care nursing service,¹⁸ as well as outpatient guaranteed benefits within the scope of psychiatric care and community (home) mental treatment and addiction treatment, which can be provided with the use of ICT systems on condition that the availability of personnel required to provide them at the place of benefit provision is ensured.¹⁹ Other services have only been approved temporarily (during the state of epidemiological threat or the state of epidemic emergency). They include the provision of guaranteed benefits (within the scope of haemodialysis and haemodialysis with 24-hour stand-by services) by an authorised physician, using the ICT systems or communication systems, if this manner of provision of benefits does not pose a threat to a patient’s life or could lead to a deterioration of his/her health condition, and a nurse with appropriate qualifications is present at the patient’s side.²⁰ This also covers the scope of guaranteed benefits in the area of therapeutic rehabilitation, provided under conditions of outpatient, home or day wards, a possibility of providing medical advice, with counselling or therapeutic visits using ICT systems or communication systems having been admitted, if this method of providing healthcare does not pose a threat to the deterioration of the health condition of the benefit recipient.²¹ Due to the cessation of the special circumstances (state of an epidemic or an epidemic threat), there are currently no legal bases for the refunding of the above services provided with the use of information and communication (ICT) systems.