Electronization of medical documentation

27.10.2023

The overall gradual computerisation of healthcare will not be avoided even in the medical documentation. Let's take a closer look at the plans and objectives contained in the pending amendment to Act No. 372/2011 Coll., on health services and conditions of their provision (Health Services Act), as amended. Among other things, Act No 325/2021 Coll., on the computerisation of health care, as amended, which is referred to in certain places in the amendment under discussion, speaks of the computerisation of health care.

(on the photo: ARROWS Prague team together with several colleagues from the tax and accounting firm ARROWS tax)

Why is there a need for the computerisation of healthcare and medical documentation itself?

The primary reason for the computerisation of healthcare is to improve the accessibility and quality of healthcare throughout society and also to increase the involvement of citizens in their own health care. As regards the computerisation of medical records themselves, although the legislation already allows for the maintenance of medical records in both paper and electronic form, or a combination thereof, the technical requirements for maintaining them in electronic or combined form are not sufficiently defined.

However, it is necessary to point out that the full transition to an exclusively electronic form of medical documentation is a rather long-term goal and it will take a long time to get to this point. The standard for the moment remains rather a combined form.

What does the amendment bring?

First and foremost, the amendment provides us with a new definition of medical records, which will now be conceptualised as a set of information held, processed and stored by a provider for the purpose of providing health services to a particular patient, regardless of whether it was obtained from the patient, from another provider or other persons, or by the provider's own activities.

At the same time, it also provides a new negative definition of medical records, which includes information obtained by a provider in connection with the provision of health services, including from medical records processed by the provider, if the purpose of their processing is not the provision of health services to a specific patient, but solely for another purpose. This other purpose may be, for example, supporting documents and documents for billing health insurance companies.

Mention of the record identifier is also welcome. Although the Health Services Act currently deals with this concept, it lacks a definition. The amendment redefines this concept in Section 55a(1) as a unique identifier in the format specified by the e-health standard issued under the Healthcare Electronicisation Act. Thus, although the amendment still does not contain a definition of this concept and health service providers are thus not given a closer look at what exactly such a record identifier should represent, there is at least the prospect that this concept will be defined in the future.

Furthermore, the same provision deals with the authorisation of medical records, or parts or extracts thereof, when they are transmitted to another person in electronic form. The amendment refers here to both qualified and departmental means (time stamps, seals and electronic signatures), which should be made available to providers by the Ministry of Health, free of charge.

Another novelty is the rules for sharing medical record data. The amendment leans towards practicality in this respect and introduces the possibility for health service providers to share medical record data for research or statistical purposes. Of course, anonymisation or pseudonymisation of the data is a matter of course, so that no link to a specific patient can be inferred. However, this raises a data protection issue, mainly because pseudonymised data, unlike anonymised data, are still considered personal data. A more appropriate specification and clarification of these provisions of the amendment would therefore be needed.

However, this information will now no longer be considered as medical records and can therefore be shared for these purposes without further delay. There is also a benefit in terms of harmonisation in the sharing of medical record data between healthcare providers, where there will be a single output format from the electronic medical record.

In addition to the sharing of medical record data between providers within the Czech Republic, the amendment also takes into account international cooperation, namely the sharing of electronically maintained medical records. Thus, it seeks to create conditions and standards for the generation and international sharing of a standardised report, using trust building tools and the eIDAS regulation. However, there is a similar problem related to the protection of personal data.

In conclusion, therefore, the amendment does introduce some uncertainties, which we will have to deal with, and we have a long process ahead of us before the full computerisation of healthcare. On the other hand, it is certainly beneficial for the following work on the process of electronicisation of healthcare. Apart from the above, it is important to mention that the amendment also deals with the concept of telemedicine, which was discussed in the article by Mgr. Barbora Dlabolová (available here: https://www.arws.cz/novinky-v-arrows/telemedicina-v-roce-2023-kde-jsme-a-kam-smerujeme)