Following the President's address on 23 March 2020, South Africans may be wondering how to obtain access to health services from healthcare practitioners during lockdown. Although exemptions to restricted movement include seeking medical care and purchasing medicine, the reduced availability of public transport and reprioritising of healthcare resources may mean access to healthcare services is practically curtailed.
'Telemedicine' (defined as the delivery of healthcare and the transfer of health information across distances using information communication technologies such as email and telephone calls, video links and social networks) offers some reprieve, by allowing patients to consult with healthcare practitioners without either patient or provider travelling or leaving their homes. This is a totally compliant lockdown solution which has recently been given a limited stamp of approval by the Health Professions Council of South Africa (HPCSA).
Although telemedicine technologies may be useful in these uncertain times - there are, however, limits as to what kinds of healthcare services may sensibly be provided in this way – there are also important ethical and legal considerations to be aware of.
Who can use telemedicine and what can it be used for?
Some healthcare practitioners will face real challenges in consulting electronically, like anaesthesiologists and surgeons. Many other healthcare practitioners may easily establish a telemedicine practices like: general practitioners, dieticians, nutritionists, bio kineticists, occupational therapists, speech therapists, audiologists, psychologists and psychiatrists to name a few. Radiologists and pathologists may also have success in telemedicine. Also, arguably, any follow-up discussion or telephone call by a medical practitioner to their patient can also be deemed a form of telemedicine.
There are, however, inherent limitations in conducting telemedicine consultations - a treating practitioner may not be able to obtain a full clinical picture from a remote viewpoint which could lead to incorrect prescriptions being made, symptoms being missed and possibly an incorrect diagnosis. These are real concerns.
What are the basic principles?
Prior to the Presidents declaration of a national disaster, the HPCSA issued a media statement stating that it did not regard telemedicine as a replacement for normal face-to-face healthcare, but as an add-on which is meant to enhance access to healthcare for South Africans who are disadvantaged or outside the reach of health services.
One day before the commencement of the national lockdown, however, the HPCSA sent a communication to practitioners in which it made a ruling with specific reference to the COVID-19 pandemic. Additional guidance was also provided on the HPCSA's existing Guidelines for Good Practice in Telemedicine (Guidelines).
The latest communication contains the following guidance from the HPCSA related to telemedicine/telehealth – (applicable only during the COVID-19 pandemic):
- Telemedicine (or telehealth, as the broader term used for all forms of health consultation with patients using telephonic or virtual platforms of consultation) is only permissible in circumstances where there is an already established practitioner-patient relationship, except for Telepsychology and Telepsychiatry which is permissible even without an established practitioner-patient relationship;
- Practitioners may charge a fee for services rendered through a telehealth platform; and
- Where practitioners are in doubt whether a telehealth consultation will be in the best interest of the patient, they are encouraged to advise patients to present themselves for a face-to-face consultation to seek assistance at a healthcare facility closest to them.
The concession for telemedicine/telehealth to be rendered via digital/electronic platforms is a significant development for both the profession and the patient and a good call in this time as health and healthcare is likely to be strained across the board.
Notably, although the gates have opened slightly for telemedicine/telehealth - initiating a practitioner-patient relationship for the first time via electronic means is risky and not advisable, apart from telepsychology and telepsychiatry (at least for the period of the pandemic).
What should you consider if you are using or intending on using telemedicine/telehealth?
Check your consent forms and update - The HPCSA's recent pronouncement has not relaxed the requirement for properly constituted consent forms. Many practitioners make use of standard consent forms which envisage only face-to-face consultations. These practitioners must update their consent forms if they wish to consult using telemedicine technologies. Practitioners should also ensure that their consent forms are tailored specifically to telemedicine/telehealth. The Guidelines require that consent to the use of telemedicine/telehealth technologies must be obtained in writing and signed by the patient (or guardian) and by a witness. Electronic forms and digital signatures may need to be used in the current lockdown environment.
Comply with other existing legislation and pronouncements - The Guidelines deal with the scope and use of telemedicine/telehealth by practitioners, with the latest letter by the HPCSA providing some new exceptions. Practitioners must, however, stay guided by the permissions, rights and responsibilities placed on them by existing healthcare legislation and pronouncements by statutory bodies such as the Health Professions Council, Nursing Council and Pharmacy Council.
Choose the best telemedicine technologies for your practice - Practitioners should ensure that they have technologies which enable them to provide uninterrupted care, treatment and services. The requirements will vary depending on individual circumstances and the type of service provided. The Guidelines recommend that when using videoconferencing or similar forms of technology which enable the practitioner to replicate a face-to-face interaction a: webcam and a microphone; speakers (or headphones); and stable internet connection are used.
Keep up ethical and professional requirements - Keep proper records and ensure patient confidentiality. Taking a proper history from patients becomes more important if face-to-face contact is minimised. The HPCSA emphasises that treatment based solely on questionnaires or standardised non-personal input does not constitute enough care.