Czerw Aleksandra, Fronczak Adam, Witczak Karolina, Juszczyk Grzegorz
Medical University of Warsaw, Poland.
Ann Agric Environ Med. 2016 Jun 2;23(2):329-34. doi: 10.5604/12321966.1203900.
The Act on Information System in Health Care, dated 28 April 2011, imposes an obligation to record patients' medical documentation in an electronic form (EHR - Electronic Health Records) on the providers of health care services, starting from 1 August 2014. On 23 July 2014, an amendment of the Act was enacted, based on which the date of obligatory introduction of health records in paper or electronic form was postponed until 31 July 2017. At various health care entities there are two different methods of creating health records (HR); therefore, the implementation of the provisions of the Act poses a significant number of problems and complications.
The objective of the study is to present the starting point, progress, problems and forecasts regarding the implementation of electronic health records at health care entities which provide services within the scope of specialized outpatient care (SOC).
The subjects of this research were 475 health care entities which provide services within the scope of specialized outpatient care (SOC) operating in Poland. The applied research tool was a survey questionnaire. The applied research technology was a Computer Assisted Web Interview (CAWI). The research was conducted between February - April 2014. The data was analyzed with the chi-squared test of independence.
In the period of the research, 233 health care entities were at the stage of preparation for the implementation of HER: 116 - in the process of implementation; 72 - after implementation, and only 54 were already recording their documentation in an electronic form.
Most health care entities providing specialized outpatient care would not have complied with the provisions of the Act on Information System in Health Care had the deadline for implementation of EHR not been postponed. Five months before the date stipulated in the first version of the Act (August 2014), about 74% of health care entities covered by this study did not yet have a ready EHR system. The study also showed that 2 years is insufficient time for the entire process of informatization of a health care establishment.
2011年4月28日的《医疗保健信息系统法案》规定，自2014年8月1日起，医疗保健服务提供者有义务以电子形式（电子健康记录，EHR）记录患者的医疗文档。2014年7月23日，该法案进行了修订，据此，纸质或电子形式的健康记录强制推行日期推迟至2017年7月31日。在不同的医疗保健实体中，存在两种不同的创建健康记录（HR）的方法；因此，该法案条款的实施带来了大量问题和复杂情况。
本研究的目的是介绍在提供专科门诊护理（SOC）范围内服务的医疗保健实体中实施电子健康记录的起点、进展、问题和预测。
本研究的对象是波兰境内475个提供专科门诊护理（SOC）服务的医疗保健实体。应用的研究工具是调查问卷。应用的研究技术是计算机辅助网络访谈（CAWI）。研究于2014年2月至4月进行。数据采用独立性卡方检验进行分析。
在研究期间，233个医疗保健实体处于实施HER的准备阶段；116个处于实施过程中；72个已实施，只有54个已经以电子形式记录其文档。
如果电子健康记录的实施期限没有推迟，大多数提供专科门诊护理的医疗保健实体将无法遵守《医疗保健信息系统法案》的规定。在该法案第一版规定的日期（2014年8月）前五个月，本研究涵盖的约74%的医疗保健实体尚未拥有完善的电子健康记录系统。该研究还表明，两年时间对于一个医疗机构的整个信息化过程来说是不够的。
