Caron Jack

Telemedicine – A Need For Ethical And Legal Guidelines in South Africa

Abstract Background: Telemedicine is viewed as a new way of offering medical services. It is seen as a means of overcoming the growing shortage of health practitioners is developing countries. The aim of this paper is to highlight the need for the formulation of guidelines for the ethical practice of telemedicine in South Africa. Methods: Full-length, peer-reviewed journal papers were obtained for review by searching the electronic databases Pubmed, CINAHL and CAB International, using the Boolean-linked keywords ethics AND telemedicine, ethics AND telecare, ethics AND telehealth, and ethics AND ehealth. Additional searches were made of Google Scholar using the same search strategies, and of the web pages of national telemedicine associations. Results: A total of 152 relevant papers were identified. Twenty-one telemedicine guidelines were obtained. Only four countries and one international association have developed ethical guidelines. Several medical disciplines have established national guidelines for their speciality. Common ethical issues identified include the doctor-patient relationship, informed consent, confidentiality, data security, adequacy of records, data standards and quality, clinical competence, licensure and medical responsibility. These are discussed with reference to the developing world where appropriate. Conclusion: Resource constraints and other issues relevant to developing countries may require the formulation of guidelines that do not necessarily conform with those of the developed world. It is in the interests of patients and practitioners that ethical guidelines for the practice of telemedicine are developed for South Africa. If telemedicine in to be used to overcome shortages of health practitioners, it in important that contentious issues are resolved in a pragmatic way that is appropriate to our circumstances and in the best interests of the majority of our population.

The relationship between asthma and ambient air pollutants among primary school students in Durban, South Africa

We examined the prevalence of asthma among students in Grades 3 and 6 at a primary school located in the highly industrialised South Durban Industrial Basin. After baseline interviews and methacholine challenge testing (MCT), students completed bihourly symptom logs during an 18-day study period. Continuous measurements of ambient contaminants at the school included sulphur dioxide (SO2), oxides of nitrogen (NOx), and respirable particulate matter less than 10 µm (PM10). Generalised estimating equations were used to examine associations between lagged fluctuations in ambient air pollutant concentrations and daily reported symptoms. Among the 248 participants, 52% had asthma of any severity; including 11% with moderate to severe persistent asthma. On MCT, 21% of the children had marked (PC20 ≤ 2 mg/ml), 29% had probable, and 19% had possible airway hyperreactivity. Concentrations of air pollutants at the school during the study period fell below international and South African standards and guidelines. Increased lower respiratory symptoms (cough, wheezing, chest tightness or heaviness, and shortness of breath) were strongly and consistently associated with prior day fluctuations in ambient levels of both SO2 and PM10 in both single-pollutant and two-pollutant models. We note the important role of local stakeholders in implementing and conducting this study.

Why is telemedicine a challenge to the regulators

Regulators feel that telemedicine presents challenges. In part this is because of the assumption that telemedicine is new and unproven, and must therefore be regulated in order to protect the patient. Regulation requires clear and careful definition of what is to be regulated. The Health Professions Council of South Africa’s proposed definition of telemedicine has deficiencies. Telemedicine is not new, nor is it a special discipline or a new branch of medicine. It involves the use of information and communication technologies in the provision of health care over distance. This includes the telephone. Instead of proposing a one-size-fits-all approach to regulations and guidelines, a more pragmatic approach to issues such as signed, written consent, prior doctor-patient relationship and licensure is required. It is proposed that regulators should seek to find deficiencies in existing guidelines and regulations and address these if required, and that clinical, operational and ethical guidelines should be developed by the governing bodies or associations of the various clinical disciplines using information and communication technologies in the provision of health care. An enabling regulatory environment is required if we are to realise the goals of improved access, service delivery and quality of care for the rural communities of South Africa through telemedicine.

Pitfalls in computer housekeeping by doctors and nurses in KwaZulu-Natal: No malicious intent

IntroductionInformation and communication technologies are becoming an integral part of medical practice, research and administration and their use will grow as telemedicine and electronic medical record use become part of routine practice. Security in maintaining patient data is important and there is a statuary obligation to do so, but few health professionals have been trained on how to achieve this. There is no information on the use of computers and email by doctors and nurses in South Africa in the workplace and at home, and whether their current computer practices meets legal and ethical requirements. The aims of this study were to determine the use of computers by healthcare practitioners in the workplace and home; the use and approach to data storage, encryption and security of patient data and patient email; and the use of informed consent to transmit data by email.MethodsA self-administered questionnaire was administered to 400 health care providers from the state and private health care sectors. The questionnaire covered computer use in the workplace and at home, sharing of computers, data encryption and storage, email use, encryption of emails and storage, and the use of informed consent for email communication.Results193 doctors and 207 nurses in the private and public sectors completed the questionnaire. Forty (10%) of participants do not use a computer. A third of health professionals were the only users of computers at work or at home. One hundred and ninety-eight respondents (55%) did not know if the data on the computers were encrypted, 132 (36.7%) knew that the data were not encrypted and 30 (8.3%) individuals knew that the data on the computers they were using were encrypted. Few doctors, 58 (16%), received emails from patients, with doctors more likely to receive emails from patients than nurses (p = 0.0025). Thirty-one percent of individuals did not respond to the emails. Emails were saved by 40 (69%) recipients but only 5 (12.5%) doctors encrypted the messages, 19 (47.5%) individuals knowingly did not encrypt and 16 (40.0%) did not know if they encrypted the data. While 20% of health professionals have emailed patient data, but only 41.7% gained consent to do so.ConclusionsMost health professionals as sampled in South Africa are not compliant with the National Health Act or the Electronic Communications Transactions Act of South Africa or guidelines from regulatory bodies when managing patient data on computers. Many appear ignorant or lack the ability to comply with simple data security procedures.

Ethical considerations of mobile phone use by patients in KwaZulu-Natal: Obstacles for mHealth?

Abstract Background mHealth has the potential to facilitate telemedicine services, particularly in the developing world. Concern has been expressed about the confidentiality of health information that is relayed by mobile phone. Aim We examined the habits and practices of mobile phone use by patients in KwaZulu-Natal, South Africa. Methods We conducted a descriptive survey of two patient populations: 137 urban patients attending private practitioners and 139 patients in remote rural areas attending outpatient departments in Government-funded hospitals. The questionnaire covered several domains: demographics, mobile phone use, privacy and confidentiality and future use for health-related matters. Results Two hundred and seventy-six patients completed the questionnaire. We found that a third of our participants shared their mobile phone with others, 24% lent their phone to others and more than half received health-related messages for other people. Mobile phone theft was common, as was number changing. Thirty-eight percent of the people were not able to afford airtime for more than a week in the past year and 22% of rural patients were unable to keep their phone charged. Mobile phone signal coverage was significantly worse in the rural areas than in urban areas. Conclusion This study highlights the legal and ethical ramifications that these practices and findings will have on mHealth programmes in our setting. Healthcare providers and regulators will need to consider how patients use and manage their mobile phones when developing services and regulations.

Language, cultural brokerage and informed consent - will technological terms impede telemedicine use?

Introduction. Telemedicine provides a solution to treatment of economically and geographically compromised patients and enhances the level of care. However, a problem has arisen in safeguarding patients’ rights to informed consent. Objective. To determine the impact of language, translation and interpretation barriers on gaining legally valid informed consent in telemedicine. Design. Forty-one key words relevant to computer terminology and concepts required to gain informed consent for a telemedicine encounter were selected and sent for translation into isiZulu, the local indigenous language of KwaZulu-Natal, South Africa. A questionnaire with the list of words was developed with three domains covering information communication technology (ICT) use, ICT terms and ethics terms. This was administered to patients at four outpatient departments in rural KwaZulu-Natal hospitals. Results. Of the 54 participants, 50 (92.6%) did not know or understand the term ‘telemedicine’, 49 (90.7%) the term ‘video conference’ and 49 (90.7%) the term ‘electronic records’. Words such as ‘consent’ and ‘autonomy’ were understood by less than a third of the participants. Only 19 individuals (35.2%) understood the word ‘consent’, and only 4 (7.4%) understood both the words ‘consent’ and ‘telemedicine’. Conclusions. The results of this study show that obtaining informed consent for a telemedicine consultation is problematic. Alternative ways of gaining informed consent need to be investigated.

Informed consent for telemedicine in South Africa: A survey of consent practices among healthcare professionals in Durban, KwaZulu-Natal

Background. The Health Professions Council of South Africa is drafting guidelines to regulate the practice of telemedicine. These emphasise the need for signed informed consent for all aspects of the consultation process, including data transmission and storage. Objective. To survey current practices relating to gaining informed consent both in routine clinical practice and when using information communication technologies (ICT). Methods. A cross-sectional descriptive study was undertaken using a self-administered questionnaire. It surveyed healthcare professionals’ habits and practices of obtaining informed consent in clinical practice scenarios and when using the telephone, fax and email for communication and healthcare provision. Results. A total of 193 doctors and 207 nurses completed the questionnaire. Fewer doctors took written consent than nurses, with a range of 2.6% when examining a patient to 8.3% when ordering a special examination. A significant difference was observed for all activities. Of the 67.4% doctors and 50.7% nurses who faxed patient information, only 35.3% of doctors and 42.9% of nurses obtained informed consent to do so and less than half of those obtained written consent. Few used email to send patient information, with specialists being most likely to do so among doctors (p<0.0001). Of all healthcare professionals who used email, 40.7% obtained informed consent to do so. Conclusions. Written informed consent is not routinely obtained from patients during clinical examination or when using ICT for the transfer of patient information. The issue of informed consent for telemedicine remains unresolved in South Africa.

Cold comfort for health care workers? Medico-ethical dilemmas facing a health care worker after occupational exposure to HIV

Abstract Following exposure to the human immunodeficiency virus (HIV) it is advisable for the health care worker (HCW) to take post-exposure prophylaxis. A prerequisite for this is the establishment of the HIV status of the HCW and the patient. Ordinarily, this would be preceded by the ascertainment of the HIV status of the HCW and the patient. This should be done as soon as possible after exposure, usually within 24 hours. If the exposure takes place when the patient is under anaesthetic, which is often the case, consent for HIV testing is not readily forthcoming and this poses an ethical dilemma. A similar dilemma is posed by a patient who, having awoken, is not in a position or is unwilling to give consent. This paper discusses the ethical and legal constraints on the HCW and the employer in circumstances where the patient is not in a position to give consent. The paper concludes by restating the need to respect confidentiality and the autonomy of the patient and that informed consent is paramount in testing for HIV status. The paper proffers the view that testing the patient will not substantially alter the course of action open to the HCW and, in any event, will do little to allay the fears of HCWs.

A South African perspective to medical law and ethics in nursing : getting basic principles right

The legal requirements for informed consent and confidentiality of patient information are clearly specified in chapter two of the National Health Act (NHA). Along with informed consent, the right to privacy is enshrined not only in the Constitution but also obligations to recognize this right are set out in the NHA. The study aims to survey the habits and practices of healthcare providers working in the public and private sectors in Durban, KwaZulu-Natal, when obtaining informed consent in clinical practice. A quantitative descriptive questionnaire was developed to investigate how nurses take informed consent in various clinical scenarios. A total of 207 nurses completed the questionnaire and the data was analyzed using Chi-squared, T-test and Z-tests. While 84.5% took consent to examine a patient, only 56% did so when ordering a special investigation with 19.8% taking written consent. Consent to refer patients to other healthcare providers was obtained by 67.6%, and 15% was obtained in a written format. There were 14% of nurses who did not use a computer at all.Of those who did, few used emails to send patient information, 19.1%, and less than half of those obtained informed consent to do so. The key conclusions of this study are that informed consent practices among nurses fall below legal requirements, and written consent is not routinely obtained, even for those practices that carry some element of risk, such as special investigations or transmitting health information via fax or email.