"Which doctor is right?"
At the beginning of this year, Xia Liang, who lives in Changde, Hunan Province, was troubled by oral ulcers for a period of time. "There were a lot of white skin in the mouth, and it hurt to drink water." Affected by the epidemic at that time, he decided to find the cause and resolve the pain through online consultation.
However, several doctors he consulted gave several completely different diagnostic results, which confused Xia Liang and also raised questions about the accuracy of online consultation.
’s experience is not unique. According to the 49th "Statistical Report on China's Internet Development Status " released this year by the China Internet Network Information Center, as of December 2021, the number of online medical users in my country reached 298 million, a year-on-year increase of 38.7%. With the rapid development of Internet diagnosis and treatment, chaos such as misdiagnosis and white diagnosis, medicine first, AI prescription, and diagnosis and treatment accidents have also occurred one after another, becoming a "hidden mine" buried in the industry.
In response to the above problems, regulatory measures to plug leakage and demining continue to advance. From the 2018 National Health Commission and State Administration of Traditional Chinese Medicine promulgated the "Internet Diagnosis and Treatment Management Measures (Trial)", which clearly stipulates that medical institutions conduct follow-up consultations online, to the recently announced "Internet Diagnosis and Treatment Supervision Rules (Trial)" To ensure the transparency and standardization of "air-based" diagnosis and treatment, the network that guarantees the quality of Internet diagnosis and treatment becomes denser and denser.
Online consultations often lead to misdiagnoses.
Diagnostic results vary. After showing the other party a self-portrait photo of his mouth and describing the related symptoms in text, the doctor diagnosed it as "oral ulcer caused by internal heat" and said, "Take some anti-inflammatory medicine, drink more water, and have a good rest and everything will be fine." Then he prescribed anti-inflammatory medicine. He received a prescription and asked him to purchase the medicine offline.
After taking anti-inflammatory drugs for three days as prescribed by the doctor, Xia Liang did not see any improvement, so Xia Liang chose three doctors for consultation on two other platforms. The pictures and texts provided were the same as before, but different diagnosis results were obtained: some doctors thought it was " glossitis causing oral ulcers", some doctors diagnosed it as "oral inflammation", and another doctor said it was "candida infection".
The three doctors all prescribed different medicines for him, which made Xia Liang confused.
He didn’t dare to take medicine easily anymore, so he went to an offline hospital in the city for treatment and was diagnosed with candida infection caused by antibiotics. The condition was relieved after taking appropriate medicine.
A senior doctor at a Beijing dental hospital told reporters that Candida infection is actually not difficult for dental doctors to judge. The main reason why "the same picture and text, but the diagnosis results are inconsistent" is due to online Limitations of consultation.
"During offline consultations, stomatologists not only observe the oral cavity and ask about the condition, but also press and touch to make comprehensive judgments to get the results. However, doctors who consult online can only rely on pictures and texts, so it is difficult to make accurate judgments, let alone A prescription was issued,” the doctor explained. In his view, patients can upload films taken by offline hospitals, issue pathology reports, etc. for review, re-examination or consultation during online consultation, but they cannot receive first-time consultation.
In recent years, " Internet + medical health" has developed rapidly. From Internet hospitals to identifying patients with common and chronic diseases who can be reimbursed by medical insurance for Internet consultation, from online drug sales to core diagnosis and treatment to Internet medical insurance, various localities have introduced plans to actively support the comprehensive development of online medical care and have laid a solid foundation for the growth of online medical user scale.
At the same time, it is not uncommon for people like Xia Liang to consult multiple doctors online about the same disease, but get a variety of diagnostic results.
Zhang Xingze, a third-year student at a university in Beijing, calls himself a "person who loves to get sick." In recent years, he has often used online consultation platforms and has mixed feelings about using them - it is very convenient but unreliable.
The most impressive time was when some small red spots appeared on his skin, which were extremely itchy. In order to quickly solve the problem, he opened an online consultation app and chose a doctor in the dermatology department who was "professional in reading labels". I paid 109 yuan for a picture and text consultation.As a result, the doctor told him that he might have a skin disease and suggested that he buy corresponding drugs for treatment. Later, he went to an offline hospital for a detailed examination, and it turned out that he was allergic to pineapples.
"Online consultation is convenient, but descriptions of symptoms are generally limited to text and pictures, which can easily lead to misdiagnosis or white-knuckle diagnosis." Zhang Xingze said. Many industry insiders interviewed by
agreed that “air-based” diagnosis and treatment is not suitable for all patients. Follow-up diagnosis of common diseases and chronic diseases has been the positioning of Internet diagnosis and treatment for a long time. However, there has been a lack of specific standards in the industry for what constitutes a follow-up visit, resulting in some regulatory vacuums.
Choose medicine first and then write a prescription
AI Prescribe and buy medicine for patients
In addition to consultation, purchasing prescription medicine is another convenient feature of "Internet + medical health". However, during the investigation, the reporter found that some Internet medical platforms adopt the operation method of "first purchasing the medicine, then adjusting the medicine formula, and even automatically generating the prescription by artificial intelligence software".
Xie Li, who lives in Huaihua, Hunan, bought Pudilan Anti-inflammatory Oral Liquid for her 4-year-old child from an offline hospital in early 2020. The doctor prescribed it at the time. In March this year, because her child had similar symptoms again, she tried to buy this medicine on an online drug purchasing platform, and soon she was transferred to the "online consultation" section by the platform. After she uploaded the prescription from two years ago, the "doctor" immediately sent her a purchase link. After a reporter from
recently placed an order for the prescription drug levofloxacin capsules on a drug purchasing platform, the platform prompted "Please select an offline confirmed disease." The reporter randomly checked several items in the "Disease Column", left the "Prescription/Medical Records/Examination Report Column" empty, and confirmed that "this disease has been diagnosed and the drug has been used, and there is no history of allergies, related contraindications and adverse reactions." "The verification was quickly passed. After submitting the list, the system jumped to the consultation section.
A few seconds later, a "doctor" received the treatment and sent several messages in succession. The first one emphasized that " Internet medical only provides medical services to users who return for follow-up visits." The subsequent messages were all to confirm whether there was a history of allergies. Or in a special period. After the reporter replied "none", in less than 2 seconds, the other party sent a prescription form and purchase link.
Yang Mu, a Beijing resident, also had such an experience. He doubted whether the doctor behind the screen was a real practicing doctor: “When I buy prescription drugs on the ×× platform, I feel that the other person is no different from a robot. As long as I type, the other person will be there.” He agreed quickly within 10 seconds without giving any professional advice at all. "Once, he deliberately tried to describe some conditions that were not suitable for the medicine he wanted to buy, but the other party still quickly prescribed it without saying anything.
Some tips from people in the Internet medical industry: If it is a regular Internet hospital, the electronic prescription issued by a qualified doctor should have the doctor's signature and the Internet hospital's electronic seal. "It is not ruled out that some small Internet medical platforms still use artificial intelligence, robots and other tools to automatically generate prescriptions. Some large platforms will use AI to assist doctors in consultation, such as asking how old the patient is, what is wrong, etc. However, the prescription must be requested by the doctor. "Come and prescribe."
Deng Yong, a professor at the Department of Law at Beijing University of Chinese Medicine, told reporters that in order to ensure the safety of patients' medication, my country's "Prescription Management Measures" and "Medical Institutions' Prescription Review Standards" have clearly stipulated that doctors must be included in their diagnosis and treatment activities. After prescribing a prescription for a patient, the pharmacist must review it, but the relevant regulations do not explicitly prohibit the behavior of "automatically generating prescriptions".
"You can do whatever is not prohibited by law. If the regulations are not clearly formulated, local practice will be chaotic. In reality, some platforms choose the model of 'AI prescribes and customers directly take the medicine', skipping the traditional prescription issuance and review process. , turning prescribing directly into 'selling medicine'. This kind of behavior seriously violates my country's drug management system and also creates hidden risks for patients' medication safety," Deng Yong said.
Is the huge number of consultations real?
Who will supervise the online doctors?
For online consultations, how many times a doctor answers is considered a complete consultation. Is the number of doctor consultations displayed on the platform false? Is the content of the patient's diagnosis returned? Real replies from doctors... The reporter randomly interviewed more than 10 people in Beijing, Tianjin, Hunan and other places and found that these are also the main problems that trouble them.
Hao Yingrui, a sophomore at a university in Beijing, knows this very well. She often uses online consultations, but she still doesn’t know how many questions the doctor needs to answer to meet the charging standard. "In the beginning, several questions count as free consultations, but as long as you speak, it counts as one question, such as saying thank you or hello. After the free times are used up, the doctor has just entered the topic. In order to learn more, you You can only pay to become a member. After paying, the doctor will ask for information such as test results. Sometimes, after a while, you will be asked to go to an offline hospital for consultation. "
Before consulting online, you can go to the platform. See which doctor has the most consultations before deciding which doctor to consult. This is a habitual practice of Zhang Daodao, a resident of Qufu, Shandong, because in her opinion, a doctor's high number of consultations means that he has good medical skills. Very popular with patients. However, she noticed that the number of doctor consultations listed on some online consultation platforms was often as high as tens of thousands or even hundreds of thousands, and she couldn't help but question whether these data were true. A reporter from
searched for dermatologists on an online consultation platform and found that the dermatologist with the largest number of online consultations on the platform had 250,000 consultations. Assume that the average online consultation time per person is 10 minutes, and the online consultation time is about 41,667 hours. If there is no holiday throughout the year, and 10 years is 3,650 days, then the average online consultation time per day in these 10 years is about 11.4 hours Hour.
Regarding these issues, a person in charge of the platform told reporters that they have actually been exploring "quality control" in recent years, "For example, how many times a doctor answers counts as a complete consultation; how to copy and paste the searched content to The patient's doctor will supervise; how to ensure that the number of consultations is true; who will be responsible for misdiagnosis or wrong prescription of medicine, etc."
"The core issue is who is responsible for the diagnosis made by doctors online. Doctors in offline hospitals are supervised by local health commissions, and hospitals and departments will also carry out standardized management; while online doctors are relatively independent. " said the aforementioned senior doctor from a dental hospital in Beijing.
Regulatory policies have been implemented one after another
to better ensure the quality of diagnosis and treatment
The large-scale growth of Internet diagnosis and treatment began in 2018. In this year, the General Office of the State Council issued the "Opinions on Promoting the Development of "Internet + Medical Health"", aiming to improve medical care The level of modern health management. As of the end of 2021, there are more than 1,700 Internet hospitals across the country.
Over the years, in order to regulate Internet diagnosis and treatment, normative documents such as the "Internet Diagnosis and Treatment Management Measures (Trial)", "Internet Hospital Management Measures (Trial)", "Telemedicine Service Management Standards (Trial)" have been issued one after another, regulating Internet diagnosis and treatment services. Requirements are put forward for the qualifications of medical institutions involved, qualifications of employees, equipment and facility guarantees, and service process specifications. Especially after the release of the "Internet Diagnosis and Treatment Supervision Rules (Trial)" jointly formulated by the National Health Commission and the State Administration of Traditional Chinese Medicine in June this year, it has attracted much public anticipation.
The rules provide detailed provisions on social concerns such as prescription review, privacy protection, and quality control of diagnosis and treatment in Internet diagnosis and treatment.
As for what diseases can be seen online, the detailed rules require that the conditions for follow-up visits must be met: patients should provide medical records with clear diagnoses when seeking medical treatment, such as outpatient medical records, inpatient medical records, discharge summaries, diagnosis certificates, etc., and the receiving physician will retain relevant information and Determine whether you meet the conditions for follow-up examination. When the patient's condition changes, the doctor determines that this visit is the first visit, or there are other circumstances that are not suitable for Internet diagnosis and treatment, the treating physician should immediately terminate the Internet diagnosis and treatment activities and guide the patient to a physical medical institution for treatment.
Deng Yong believes that these standards are more operable, give doctors more professional authority, further clarify service boundaries and regulatory boundaries, and are conducive to the standardization and standardization of Internet diagnosis and treatment services.
Regarding whether the quality supervision of online diagnosis and treatment is consistent with that of offline diagnosis and treatment, the detailed rules give a positive answer: it requires relying on physical medical institutions to incorporate Internet diagnosis and treatment into the overall medical service supervision system.
For prescription drugs that can be bought without a prescription, the rules strictly prohibit "medication first, then medicine later": prescriptions must be issued by the treating physician himself, and the use of artificial intelligence and other methods to automatically generate prescriptions is strictly prohibited. Prescription drugs should be sold, dispensed and used based on a physician's prescription. It is strictly prohibited to provide medicines to patients before a prescription has been issued.
In Deng Yong’s view, this point is particularly worthy of recognition. “It is in line with the current main theme of Internet diagnosis and treatment of ‘returning to serious medical care’, and will help bring the development of the industry back to the right track of ‘protecting people’s health and well-being’”.
He also pointed out that in order to implement the regulations that "strictly prohibit the use of artificial intelligence and other automatic prescriptions" to be implemented, multiple factors must be considered. For example, the status of artificial intelligence and other subjects should be clarified. "Although we call it artificial intelligence, it Like some assistant physicians, they are all subjects who do not have the right to prescribe. There are still deficiencies in the current "Prescription Management Measures" and "Medical Institution Management Regulations", and the targets of punishment are limited to "personnel". Artificial intelligence should be taken into account in subsequent revisions. Due to the particularity of such subjects, if prescriptions are automatically generated only by artificial intelligence, etc., medical institutions should be directly held accountable in the same way as 'using non-health technical personnel'."
Deng Yong believes that the rules for assuming responsibilities should also be clarified. "At present, in the process of Internet diagnosis and treatment, the rights and responsibilities between medical institutions and doctors are still adjusted through contracts, and there are no clear legal provisions. For doctors who practice in multiple locations, medical institutions are often in an advantageous position during the contract signing process. If the contract stipulates that "if the damage caused by improper prescription issuance shall be mainly borne by the doctor after compensation by the medical institution," then the medical institution has essentially avoided the risk of compensation for damage liability, which violates the principle of equality of rights and responsibilities."
It is also indispensable to improve the drug traceability system. Deng Yong proposed that relevant departments should increase the review of the authenticity of prescription sources, establish a strict review system for prescription sources, and improve laws and regulations on prescription sources. Take advantage of the Internet and make full use of the QR code recognition function to review online prescriptions. At the same time, transaction records and transaction evidence are completely retained to ensure that supervision can trace the source.
(All online interviewees in this article are pseudonyms)
(Rule of Law Daily)
