The Green Report analyses the initiatives, trends and politics in e-health care in South Africa. With its finger on the pulse of developments in the industry the Report brings you timely information and analysis to assist you in your business life.

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This month's stories:
The Ministry of Health and Information Technology - The Interview
Hypertension Compliance Service
Codes of ethics for health sites - do they work?
Online prescription and dispensing of medicines

The Ministry of Health and Information Technology - The Interview
The Green Report (TGR) persisted in its efforts to contact the Minister of Health and can now bring you the interview. The questions to Minister Manto Tshabalala-Msimang hinged around e-health and the Ministry's plans (if any) in this regard. The Ministry feels that they are involved in a "progression" or journey to fully integrated e-health systems. While all nine provinces have the implementation of e-health as an objective, some parts of the health system have access to e-mail only and others are already moving towards doing transactions on the World Wide Web.

In response to the question "In the context of the poor infrastructure available to most South Africans is the Internet relevant, in the short term, for health care delivery?" the Ministry responded that, although service delivery is the Department's main objective, "managing the +\- 40 million South African's that use our facilities comprehensively without the aid of information systems is an impossibility. The only qualification is the degree and speed with which Health is able to implement these systems"

The development of an e-strategy for the government is in the hands of the National Health Information Systems of South Africa (NHIS/SA) Committee. Unfortunately this committee's site has not been updated since 25 March 1999. Is this an indication that the Web is not a priority for this committee?

The Ministry places emphasis on Telemedicine as a major focus area for development. Exciting initiatives are underway in this regard. The most recent is a Telemedicine project in, rural KwaZulu-Natal (reported by SAPA on 22 March 2001). The promise of Telemedicine is that people will be able to be cared for closer to their homes at lower overall cost to the health system. The KwaZulu-Natal project seems to be achieving just that with 12 Ante-Natal cases not being referred (that would otherwise have been referred) to the more expensive tertiary facility after having their Ultra-sound scans assessed via Telemedicine.

There is a saying amongst geeks that goes "The Network is the computer". By this is meant that a computer on its own used to administer a hospital is useful, but it is really useful (and only really a computer) when it is networked with other computers. The largest (and most useful) network to connect to at the moment is the Internet. Health is not making adequate use of this network. TGR feels that it is hard, if not impossible for Government to exploit the Internet. This is simply because governments are inflexible and bureaucratic in nature. Committees, lengthy processes and political agendas don't gel with the culture of the Internet. While the Government understands what is required, this is one area that would be doing much better with a public private partnership.

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Hypertension Compliance Service
Compliance with prescribed anti-hypertensive medication is a perennial problem. Every GP in practice knows that many, if not most of their patients on medication for hypertension are not taking the medication as prescribed, or even close to as prescribed. Some of the more pessimistic estimates suggest that about 40% of prescribed and dispensed anti-hypertensives are not taken.

A new service, aimed at improving compliance amongst hypertensives has been launched. This service sends registered hypertensives a Short Message Service (SMS) message each morning reminding them to take their medication. The message is different each morning and has been well received by patients in pilot studies. You can sign-up your hypertensive patients at The Hypertension Site or they can sign-up themselves.

The service is sponsored by Healthbridge who provide a real-time patient validation and claims submission system. Healthbridge allows practitioners direct access to the processing systems of the medical aids with an immediate response, resulting in faster payment (14 days from date of service to date of payment) a reduction in bad debt, and reduced administration. For many practitioners the benefit of this has been most apparent during the recent postal strike - paper based claims were simply not getting to the schemes so payment processing could not begin, whilst HealthBridge claims (and payments) kept on rolling.

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Codes of ethics for health sites - do they work?
Anybody, whether qualified or not, can put up a web site giving health advice. Many people do, giving, at times, pretty dangerous advice (http://www.trepan.com). This has worried people who are serious about providing high quality health information online for some time. Whilst the trepan example is pretty obvious, often health information is such that the consumers of that information may not know that they are getting bad advice. In order to help consumers discern good from bad information online a number of initiatives have been set up. The oldest, and perhaps best known of these is the Health On the Net (HON) Foundation. If web sites are compliant with the HON Code they can apply to the HON to carry the HON "seal of approval". Another, more recent, such initiative is the Hi-Ethics initiative launched by a number of web sites mainly in the USA.

The problem is that health sites carry these seals but do not comply with the rules for carrying the seals. The Detwiler Group recently published the results of a survey in which they tracked the inclusion of new pharmaceutical information onto a range of sites. The fact that this information did not make it onto the sites as part of their drug databases for many months (the Web is meant to increase the distribution of information - right?) is one issue. A more serious issue, in the opinion of The Green Report (TGR), is the fact that information contained on the sites was not dated or acknowledged to source. Knowing who wrote the health information and knowing when it was published is key information in determining its appropriateness and quality.

The sites are all heavyweights in online health. Amongst them are WebMD (a founder of the Hi-Ethics initiative), MD Consult and Intellihealth. If you can't get the big, well resourced sites to comply with the codes, how are the small niche sites, focussing on rare diseases and driven by passion and not much else going to do it? What health information out there can be trusted? It seems to TGR that the traditional sources of health information (the family practitioner) should be involved here somehow.

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Online prescription and dispensing of medicines
We all know that "consulting" and prescribing via a web site is going to leave the patient short changed. It is obvious, the patient cannot be examined in person, so a proper diagnosis cannot be made. In the absence of an established therapeutic relationship the web can only really be used to convey general health information. Not so fast - a paper published in the Journal of Internet Research, in which a "Cyberdoctor" who prescribes sildenafil (Viagra) online, collected data from over 2000 patients and compared the data to a similar number of patients from a traditional bricks and mortar clinic. His conclusions? "The Internet-based prescribing physician has more, not less, clinically relevant and useful information than was typically obtained and utilized in a specific hospital clinic setting". There is also no evidence to suggest that his patients were harmed.

There are a number of other issues not raised in this paper but it does cause us to pause and think again. Perhaps more research is required.

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