The Covid-19 pandemic has left not only patients with unanswered questions, but also healthcare practitioners. On Monday 23 March 2020, the South African president, Cyril Ramaphosa announced a 21-day national lockdown from 26 March 2020 to 16 April 2020, which has left many healthcare practitioners in South Africa uncertain on how they can safely continue to practice medicine and whether they can, (like in many other countries), proceed to practice telemedicine.
The Health Professions Council of South Africa ("the HPCSA") introduced guidelines regulating the practice of telemedicine in 2014 with the objective of regulating delivery of healthcare services at a distance to South African communities in under-serviced areas. The HPCSA opined that all telemedicine services should involve a servicing healthcare provider and a consulting healthcare practitioner. Essentially telemedicine was only allowed to afford specialty or consultant care in under-resourced environments. It was an imperative of the guidelines that a consulting healthcare practitioner conducted a face-to-face consultation and physical examination of the patient in a clinical setting while a servicing healthcare practitioner could communicate information, advice, intervention or patient information from a remote location. Telemedicine or Telehealth as is known in other countries has not been accepted by the HPCSA in any other form. Notably, on 9 March 2020 (just a few days after widespread publication of the Corona virus outbreak in South Africa), the HPCSA released a media briefing admonishing service providers and medical schemes for promoting models of treatment that replace face-to-face consultations with patients.
After the lock-down various medical associations called upon the HPCSA to review its strict stance with respect to telehealth/telemedicine.
On 26 March 2020 the HPCSA published a guidance note on the application of telemedicine guidelines during the Covid-19 pandemic ("the guidance") which replaced the word "telemedicine" with "telehealth". The HPCSA note provided that "telehealth is only permissible in circumstances where there is an already established practitioner-patient relationship" (own emphasis added). In other words, the guidance note would only apply to patients already known to practitioners and would not extend to new patients. Notably, this is major departure from the HPCSA's previous stance where no telemedicine or telehealth without direct consultation was tolerated in any circumstances. Whilst this is a significant departure from the 2014 Telemedicine Guidelines, the medical fraternity does not believe that these Guidelines sufficiently protect medical practitioners and patients in the Covid-19 crises.
On 27 March 2020, the South African Medical Association ("SAMA") released a media statement disagreeing with the guidance provided by the HPCSA and stating that the new guidelines are wrong and dangerous. SAMA asks the question as to why would a healthcare practitioner need a prior relationship with a patient in order to give advice about Covid-19? SAMA questions the restriction placed on healthcare practitioners and argues that a pre-existing relationship is not necessary.
SAMA argues further that the restriction, amongst others, creates risk for patients' health as patients should rather stay indoors and comply with the national lockdown by obtaining medical advice telephonically. The guidance therefore contradicts the stance of President Ramaphosa and Health Minister Mkhize who have both advocated the use of telemedicine during this Covid-19 pandemic, and aggravates the iniquity suffered by patients who have financial and structural barriers.
On 3 April 2020 the HPCSA amended the Telemedicine Guidelines ("the amended Guidance") to provide "Telehealth should preferably be practised in circumstances where there is an already established practitioner-patient relationship. Where such a relationship does not exist, practitioners may still consult using Telehealth provided that such consultations are done in the best clinical interest of patients."
The ideal remains that a healthcare practitioner is provided with the necessary personal protective equipment to be able to consult a patient face-to-face. The challenge during this pandemic is that the equipment is very limited in availability and sometimes even impossible to obtain. Also, the ability of patients to travel to centres of healthcare is restricted in times of lockdown, especially for patients who rely on public modes of transport. This results in telemedicine being the safer option to provide healthcare to a patient and still ensure the safety of both the healthcare practitioner and the patient (not to mention those who may be exposed to the patient in transit).
Whilst the utilisation of telemedicine sounds proper and efficient, it still raises challenges for the healthcare worker. In South Africa during the Covid-19 pandemic has raised the following queries:
- Patients call in with conditions unrelated to the Covid-19 pandemic because of fear of contracting the virus should they consult the healthcare practitioner in person?;
- Patients may not describe their symptoms accurately in order for healthcare providers to fully understand their condition, especially in the case of children who cannot describe their symptoms;
- There may be language barriers, which ties in with the latter point where, due to language barriers, descriptions of symptoms get "lost in translation" as healthcare practitioners may not fully understand what a patient is saying, more especially in a country where there are 11 official languages as opposed to a country which is homogenous and has one official language;
- Patients often over-exaggerate their symptoms and as a result the healthcare practitioner may be misled and prescribe medication inappropriately;
- Inaccurate diagnoses may be made.
The latter issues make it difficult for healthcare workers to consult with new patients via telemedicine, as it is believed that the ability for a proper history to be obtained by the healthcare practitioner will be compromised. It is certainly recognisable that it is easier for healthcare workers to provide accurate diagnoses and treatment of a patient if the patient is known to them.
Telemedicine is, however, useful during the current pandemic in screening patients who are suspected to have Covid-19. The screening questions are standard and this essentially minimises the risk of the virus being spread from the patient to the healthcare practitioner, who will in turn pass the virus onto other patients and/or the healthcare practitioner's family and the community.
In other cases, it is our suggestion that the use of telemedicine should be in line with the HPCSA's objectives as provided for in the guidelines by conducting telemedicine with a servicing healthcare provider and a consulting practitioner and should be in the best clinical interest of the patient. In addition, telemedicine should only be used as an adjunct to normal medical practice and should only replace face-to-face consultations where the quality and safety of patient care is not compromised and the best available resources are used in securing and transmitting patient information.
It is not entirely clear whether the Minister of Health has approved the Guidance note or the amended Guidance note and whether he will intervene with directives or regulations during this period. Unfortunately, in the interim, healthcare providers may be increasingly exposed to the Covid-19 where equipment and resources become more and more scarce.