Print version ISSN 0256-9574
SAMJ, S. Afr. med. j. vol.101 no.6 Cape Town June 2011
Cutting-edge telemedicine venture freezes as official bodies frown
Hello Doctor, a new telemedicine business providing cheap, accessible health information and advice, put its call centre on ice last month after the Health Professions Council of South Africa (HPCSA) said it was violating patient rights.
The CEO of the new venture, Andrew Milne, said the freeze was a precautionary move 'to protect clients and our doctors from being exposed to any issues that might arise from the uncertainty the HPCSA has created'. Annoyed at what appeared to be kneejerk condemnation by the HPCSA based on 'superficial and incorrect' press reports and their not having bothered to contact his company, Milne said the new service actually extended patient rights and filled a vital access and affordability gap, wholly in line with national health care priorities (preventive and primary health). He claimed it was comprehensively researched and met all ethical criteria.
'Hello Doctor does not employ any doctor nor does it undertake medical services,' he emphasised.
Using an eponymous new weekly health, medical and lifestyle television show (SABC 3, 17h00 -18h00 on Sundays) produced by Dr Michael Mol as its springboard, Hello Doctor's service includes tele-consultations (300 participating GPs projected to reach 1 000 by year-end) with online or overthe-phone credit card payment (R200 per consult) or a monthly subscription (unlimited access), plus a free 'real-time' webbased medical advice service. Discretionary prophylactic medicine prescriptions, chronic illness medicine prescriptions for established diagnoses and acute medicine prescriptions via partner clinics or pharmacies using 'physician extenders' (nurse or pharmacist) are also on offer via telephone.
Hello Doctor has signed up courier pharmacies Medipost and Pharmacy Direct while other pharmaceutical partners include Dis-Chem, We Care Independent Pharmac y Network and Medi+Rite Pharmacies. It intends to have signed up 500 independent pharmacies by August. The company believes it can effectively engage with 30% of cases currently dealt with at primary health care level and that by making health care accessible and convenient (referring where appropriate), it can boost preventive medicine.
Council condemnation illconsidered - telemedicine company
The HPCSA's denouncement was based on reports that Hello Doctor and another telemedicine joint venture between Sanlam and MTN called MTN Health were offering 'sick notes by SMS', and medicine consultations and prescriptions over the phone. Milne denied that sick notes by SMS were ever part of their business.
HPCSA acting CEO, Marella O'Reilly, referred both initiatives to the Council's Undesirable Business Practice Committee, adding 'we are truly concerned about the advice the public might be getting from these unethical operators'. She said that any organisation 'offering a doctor - just a call away' breached doctor-patient relationship protocols, patient confidentiality and informed consent, to cite but a few examples. Warning that any doctor involved in what the HPCSA deemed to be an obvious contravention of ethical rules and regulations would be investigated, she said 'as a general rule' health care practitioners were required to do a physical examination and assess a patient in order to make a correct and proper diagnosis. O'Reilly conceded that her Council was still developing telemedicine guidelines (in addition to those already developed by the national department of health for under-developed communities). She said these had been drafted and sent to the Medical and Dental Professions Board (MDPB) for input - meaning they will only be ready 'in a couple of months'.
Chairperson of the South African Medical Association (SAMA), Dr Norman Mabasa, echoed O'Reilly about face-to-face examination being necessary for ethical management, adding, 'if there's a loophole in ethics or law being exploited here it must be closed'.
The anonymity of the consulting doctor ('how does a patient verify that they are who they say they are?') posed another major ethical dilemma and he commended the HPCSA for 'being so vocal'.
We've done our homework - now do yours
Hello Doctor's Chairman, Craig Townsend, welcomed 'any form of constitutionally acceptable and reasonable regulations or directives that the HPCSA may pass, subject to them being in accordance with the SA Constitution, the Competition Act and the Consumer Protection Act - with particular emphasis placed on patient rights'.
Milne said he found it 'ironic' that the HPCSA was urging the public not to make use of 'these unknown offerings' for purported violation of patient rights 'when the council doesn't itself know what these offerings are'. It appeared the Council had issues of its own with certain of its restrictive and anti-competitive rules and regulations under the Competition Act, for which it had applied for exemption and was still engaging the competition authorities on. He asked whether these Council rules and regulations did not warrant scrutiny under the new Consumer Protection Act.
Milne welcomed any engagement with the HPCSA that would result in patients and consumers 'from all income groups having the opportunity to receive access to highquality, cost-effective and accessible health care' and was 'convinced' that any probe would find Hello Doctor 'clinically sound and in good health'. He told Izindaba that the HPCSA had contacted them several days after the controversy appeared in the press and that an appointment had been set up with O'Reilly in Pretoria for 10 May to try to iron out any legitimate ethical problems.
He and his clinical director, Dr Steve Holt, who has built a thriving business supplying appropriately qualified doctors to the emergency medicine units of 15 private hospitals, had spent two years researching telemedicine internationally. 'It's been hugely successful in other countries and our challenge was to enter the local market in a way that could provide quality health care to the whole spectrum,' he added. Their clinical governance rules and triage system meant that only the appropriate group of primary health care problems would be addressed. If a patient was unsuitable for the system then they'd be encouraged to consult with their doctor or go to an emergency department.
Izindaba learnt that the complaint to the HPCSA came from the Society of General/ Family Practitioners.
'We're not trying to take work away from other doctors, in fact we believe that this process, if embraced by doctors, will complement their practices and grow the referral base of patients,' Milne said.
'We're very encouraged by everything we hear from government about public/private sector partnerships and the Minister's positive views on telemedicine, especially when it comes to the National Health Insurance Fund next year, he added.
Milne said that compared with the face-toface consultation cost of between R280 and R360, their telephonic consultation cost of R200 could drop ever further 'when we work with medical schemes and get volumes'. He said Hello Doctor was in negotiations with Sanlam (which is the health provider to MTN Health telemedicine) to provide clinical assistance for their recently launched service.
'Our business model is a private sector website and call centre in the employed but uninsuredmarket with aGPnetworkandHIV management company called Careworks.' In the public sector they were partnering with the now decade-old Telemedicine Africa (CEO, Dr Moretlo Molefi, former director of the Telemedicine Unit at the Medical Research Council), which had already won several government tenders to provide a telemedicine system into the public sector. There was also a public sector strategy that would allow rural nurses to upload technology to [Hello Doctor] doctors to help them extend their scope of care.
Doctors divided on the issue
SAMA reiterated that it supported telemedicine 'as a concept', but this had to be regulated appropriately and implemented in consultation with the medical profession. SAMA applauded the HPCSA for fulfilling their mandate of protecting the ethical integrity of the medical profession.
A quick review of opinion among members on SAMA's website reveals strong feelings with comments ranging from 'this is the future of medicine', and 'yet another way for unscrupulous money-grabbers to abuse the public's naïve trust in our profession', to 'it's natural to be suspicious of new trends - South Africa is years behind America where safe telemedicine has been practised for many years'. One doctor described the new initiatives as 'an outrageous, unethical minefield for both patients and doctors participating in this charade', and another said 'this so-called drive to save costs is unethical as it is in contravention with all forms of ethical behaviour'.
Time will tell as the HPCSA reviews its initial response after meeting with the entrepreneurs - and does its homework to see whether they did theirs.