1. introduction
Primary health care is the place of first contact of a patient with the status of beneficiary with the health care system, within which access to preventive, diagnostic, therapeutic, nursing and rehabilitation health care services financed from public funds is to be ensured (art.2 of the Act of 27 October 2017 on primary health care, Journal of Laws 2020.172, hereinafter: u.p.o.z.). The purpose of primary health care is (Article 3 of the u.p.o.z.):
1) Providing health care for the recipient and his/her family;
2) the coordination of health care for the recipient in the health care system;
3) assessing the needs and establishing the health priorities of the population under care and implementing preventive actions;
4) Identifying, eliminating or reducing physical and mental health risks and problems;
5) Providing preventive health care and health promotion adapted to the needs of different population groups;
6) Providing education to the recipient on responsibility for their own health and creating health awareness.
An epidemic emergency has been officially introduced in the territory of the Republic of Poland from 14 March 2020 until further notice in relation to the SARS-CoV-2 virus infection, and this decision has had a number of consequences in terms of patient rights. One of the consequences is the introduction of new rules for the provision of guaranteed primary health care services . In relation to COVID-19, the decision was made to generalise the provision of the above-mentioned benefits using telemedicine or communication systems. Of course, the legal basis for the development of telemedicine in Poland, as well as its practical implementation itself, date back much earlier , however, the introduction of the pandemic state from one day to the next posed new challenges for patients, doctors, nurses and midwives of primary health care (further: POZ), for which most of them were not prepared substantively, organisationally, socially and psychologically.
The public message from health sector managers to out-patients - was quite unequivocal - that during a pandemic, in situations where there are no absolute indications for personal contact with medical staff - we should limit ourselves to teleportation, because in this way, as a society, we will limit potential and actual outbreaks of infection, and, what was less discussed, this will allow for a rational management of personal protective equipment by medical staff.
The first so-called COVID Act in Article 7(4) and (11) introduced a provision for a period of 365 days from the entry into force of the Act (Article 36(3) of the COVID Act), according to which doctors and dentists, nurses, midwives and other healthcare providers fulfilling the conditions indicated in the regulations may provide healthcare services in relation to COVID-19 through a teleinformation system made available by a unit subordinate to the Minister of Health competent in the field of healthcare information systems, called "teleportation" . Entities providing health services via teleportation have been obliged to keep medical records in the form of a teleportation card. The teleportation card contains:1) patient identification: a) name and surname, b) PESEL number, and if there is no PESEL number, series and number of another identity document, c) date of birth and gender, if no PESEL number was assigned, d) address of residence, e) e-mail address, f) telephone number for contact; 2) identification of the person providing teleportation: (a) name and surname, (b) professional title, (c) number of the right to practice the profession; (3) information on the health condition and the recommended diagnostic and treatment process: (a) diagnosis of the disease or health problem, (b) recommendations, (c) information on issued certificates, prescriptions or referrals, (d) other information relevant to the treatment process. Teleportation cards are to be kept for a period of 30 days from the date of cancellation of an epidemic emergency or an epidemic state (Article 7(7-9) of the COVID Act).
In order to ensure the quality of health services provided in primary care by members of the primary care team in the form of teleportation, the Minister of Health issued a regulation of 12 August 2020 on the organisational standard for teleportation in primary care (hereinafter: standard) . A valuable guideline for the provision of teleportation and at the same time an attempt to practically address the provisions of the above-mentioned regulation are undoubtedly: "Guidelines of the national consultant in family medicine on teleportation in primary care provided during an epidemic caused by the SARS-CoV-2 virus" (guidelines)
2 Principles of teleportation in primary care
Teleportation in primary care is a healthcare service provided at a distance using ICT or communication systems (para.2 of the Standard). Teleportation in primary care is intended to be a tool that, by providing health care at a distance, will increase the safety of the patient and staff, limiting direct contact to clinically justified situations. At the same time, teleportation cannot be the only form of service provision (guidelines).
The provision of health care services to patients in the POZ within the framework of the teleportation requires that they are familiar with the rules of this form of contact with the POZ staff. For this purpose, the legislator has detailed the patient's right to information on the type and scope of health services provided as part of the tele-treatment in the text of the regulation of the standard in question (Article 12 of the Act of 6 November 2008 on Patient Rights and Patient Ombudsman Dz.U.2020.849 t.j., hereinafter: u.p.p.). The patient has the right to receive information from his/her primary care provider on the conditions for the provision of tele-treatment, taking into account the patient's right to declare during the tele-treatment his/her wish for personal contact with the relevant medical personnel. The patient has the right to receive information about the conditions of the tele-treatment both at the place of service and on the website of that provider, and also by telephone if the patient so requests. The information provided is intended to cover the following (paragraph 3 of the standard).
1. information about the ICT or communications system. It is the responsibility of each primary care provider to make public the information with which systems the primary care provider provides teleportation. According to the guidelines of the national consultant in family medicine on teleportation in primary care provided during an outbreak caused by the SARS-CoV-2 virus, teleportation can be provided, among other things, in the form of telephone advice, video call and, in justified cases, also by email. Various models of teleportation are possible.
2. How to set a teleportation date. Any healthcare service, whether provided in direct contact with the patient or at a distance using ICT or communication systems, should be provided by prior appointment, which may be by telephone or electronic means (e.g. e-registration, e-mail).
3. the way in which contact is established between the HCP provider and the patient for the purpose of providing the tele-treatment and how it is provided. Punctuality in making appointments should be observed. Medical staff should contact or be available at the scheduled appointment time, e.g. the doctor/nurse/midwife contacts the patient or the patient contacts the doctor/nurse/midwife at the scheduled appointment time.
4. patient identification. The person providing the tele-treatment (i.e. the PCP, PCP nurse or PCP midwife respectively) is obliged to confirm the patient's identity(⸹ 3 point 4 r.s.o.p.o.z.):
a. on the basis of: (a) surname and forename(s), (b) date of birth, (c) gender designation, (d) address of residence, (e) PESEL number, if assigned, in the case of a newborn, the mother's PESEL number, and in the case of persons not assigned a PESEL number, the type and number of the identity document, (f) if the patient is a minor, totally incapacitated or incapable of giving informed consent, the surname and forename(s) of the legal representative and the address of his/her residence; - communicated by him/her through information and communication systems and:
b. on the basis of the data indicated in the medical records or in the declaration of choice, or
c. upon presentation of proof of identity by the patient, when providing healthcare in the form of video advice, or
d. using an electronic patient account created by confirming the patient's identity in person or authenticating a user of an ICT system using an electronic identification means issued by an electronic identification system connected to a national electronic identification node;
5. Three attempts to contact the patient. The PCP is obliged to make at least three attempts to contact the patient, at an interval of not less than 5 minutes, in order to provide a teleportation. In the event of three unsuccessful attempts to contact the patient, the medical staff may abandon further attempts to provide a teleportation. Failure to contact the patient within the agreed teleportation period, will result in the teleportation being cancelled.
6. Personal contact with the patient. The person providing the teleportation, on the basis of the subjective examination and after analysing the patient's available medical records, including those made available via the telemedicine system, must determine whether the teleportation is sufficient for the health problem being addressed, or inform the patient of the need for a face-to-face health service if the nature of the current health problem makes it impossible to provide the health service by teleportation.This circumstance should be determined in consultation with the patient or the patient's legal guardian. In other words, during the teleportation, the doctor/nurse/midwife assesses the patient's condition, determines whether the teleportation is sufficient for the current health problem, whether a personal visit, a home visit or another medical service will be necessary. According to the guidelines, work should be organised in such a way as to minimise the number of patients in the outpatient area at the same time. The principle of an empty/pre-empty waiting room is recommended, while at the same time ensuring that the patient can have direct contact with the PCP staff (guidelines).
7 The patient's right to participate in the teleportation of a loved one. In accordance with Article 21(1) of the A.P.P.: At the patient's request, a person close to him or her may be present during the provision of health care. Exercising this right of the patient is particularly important for people who, due to age or illness or other circumstances - want a person of their choice to participate in the teleportation procedure. According to the principle:" four ears are better than two". The doctor/nurse/midwife does not have to agree to the participation of persons close to the patient. It is an autonomous decision of the patient. Medical personnel may object to the participation of relatives in the provision of telehealth services to the patient only on the grounds of an epidemiological risk or the health safety of the patient (Art. 21(2) of the A.P.P.).
8. certification of teleportation in the medical record. The person providing the healthcare service shall annotate in the medical record that the healthcare service has been provided via telehealth;
9 Confidentiality. The patient has the right to respect for the confidentiality of his or her personal data and the right to confidentiality relating to him or her (Articles 13 and 24 of the A.P.P.). It is the duty of the person providing the healthcare service to carry out the tele-treatment under conditions that guarantee confidentiality to the patient and possibly also to the person accompanying the patient.
10. Security of personal data. It is the obligation of the HCP provider to ensure that no unauthorised persons have access to information transmitted via ICT systems or communication systems in connection with the provision of a tele-treatment. Thus, the provision of information to the patient concerning his or her health status, including the digital reproduction of medical records, via ICT systems, obliges the HCP provider to use technical and organisational solutions to ensure the transmission of electronic documents in graphical and textual form. The ww information must be transmitted to the patient in a way that ensures its integrity and protection against unauthorised use, accidental or unlawful destruction, loss, modification, unauthorised disclosure or unauthorised access.
11. Professional requirements of staff. Telehealth services are provided by out-of-hours physicians and by out-of-hours nurses and midwives within the scope of their professional qualifications and competence (Article 8 of the A.P.P.).
12 Instructions to the patient or their legal guardian. Within the framework of a tele-visit, if there are medical reasons for doing so, it is possible to issue electronic documents (e.g. prescription, referral or sick leave), as well as documents issued in paper form, for collection at the clinic's registration desk. As with a face-to-face visit, the issuing of a referral to a patient for diagnostic tests, to specialist clinics or to a hospital should be justified by the patient's state of health. A patient to whom an electronic document is issued has the right to receive information from the person issuing it on how it will be implemented; e-prescription, e-referral, e-referral for medical devices. In addition, the patient has the right to receive information on how to carry out an order for additional tests, especially laboratory or imaging tests, and the possibility for the patient to set up an Internet Patient Account;
3. giving teleportation to children
The national consultant in family medicine, in a guideline on teleportation in primary care given during an outbreak caused by the SARS-CoV-2 virus, noted that teleportation in children should be carried out with great caution. It was noted that in children, the course of the illness, especially the infection, can quickly lead to a change in the child's condition from good to severe. During teleportation, in addition to standard management, the following elements should be taken into account:a. The experience of the parents and their ability to adequately care for and observe the child,b. The history collected from the child's parent/guardian may be less certain than that collected directly as for an adult patient,c. particular care should be taken if symptoms such as persistent fever, lethargy or excessive agitation, severe headache, unexplained rash, severe abdominal pain, repeated vomiting/diarrhoea, difficulty/unwillingness to take fluids, features of dehydration are present.If the capacity of the clinic and the child's parents/guardians allows, video counselling should be used. Face-to-face visits should be carried out with safety precautions related to the risk of SARS-CoV-2 infection and in accordance with current guidelines.
4 Summary
Despite the ongoing pandemic, every patient has the right to health services conforming to the requirements of the current medical knowledge, which should be understood as the patient's right to undertake medical actions towards him/her with the use of medicinal products and/or medical devices aimed at preserving, saving, restoring or improving his/her health, as well as other medical actions resulting from the treatment process or separate regulations governing the principles of their performance. The aforementioned rules of organisation of the provision of health care services within the framework of primary health care - constitute a specific mechanism of standardisation of the organisation of the process of provision of health care services to the patient within the framework of teleportation and are to be a guarantee of the patient's health safety and the quality of health care services provided.
Material for the Institute for Patients' Rights and Health Education was prepared by Dr Dorota Karkowska, Legal Adviser, as part of the 'Network for Health' project.
The 'Network for Health' project is implemented with a grant from the Active Citizens - National Fund programme funded by Iceland, Liechtenstein and Norway under the EEA Funds.