Since 1 January 2019, electronic medical documentation (EDM) has been operating in Polish healthcare institutions. This obligation was introduced by the Healthcare Information System Act.
Currently, the requirement applies to three types of documents. These are the hospital treatment information sheet, the hospital admission refusal sheet and the specialist doctor’s written information for the referring doctor. It is worth noting that the regulation of the Minister of Health of 11 December 2018 repealed the obligation to keep other documents in electronic form. The regulations do not currently introduce the obligation to use electronic medical history (hospital) and health and disease history (outpatient units).
The resignation from this provision resulted from the fact that, in the opinion of the Ministry of Health, service providers were not ready to meet this requirement yet. However, the Ministry announces that the repeal of the provision in the current regulation does not mean that these plans will be abandoned. Obligations concerning the conduct of EMD will be introduced in other legal acts. This will be in particular the Act of 28 April 2011 on the information system in health care.
Initially, the deadline for introducing electronic medical documentation was set for 1 August 2014, but then it was postponed several times.
According to the PMR survey, one third of private hospitals have already completed the digitisation process. At the same time, only 18% of transformed hospitals boast about the final stage of this process. These are hospitals operating as companies with State Treasury shareholding or local government units. 22% of public hospitals admit that they have implemented particular elements of digitalization.