The endocrinologist of Peking Union Medical College Hospital visited the telemedicine center. Xinhua news agency
Doctors in Yuhang District, Zhejiang Province conducted consultation through remote retrieval of inspection images. Xinhua news agency
The team of experts from the First People’s Hospital of Shanghai provides online consultation services for the citizens. Xinhua news agency
Doctors from the People’s Hospital of Luanzhou City, Hebei Province consult patients together with doctors from the Luanzhou Traditional Chinese Medicine Hospital in the "Medical Community" image diagnosis and treatment center. Xinhua news agency
According to statistics, in China’s Internet medical market last year, hospitals received more than 300 million patients per month, and the number of monthly Internet users exceeded 54 million. "internet plus" medical care is gradually changing the existing medical service model and traditional medical care pattern. Faced with such a huge user scale, the state has also introduced a series of policies to regulate Internet medical care. From 2018, the "Administrative Measures for Internet Diagnosis and Treatment (Trial)" and other documents were issued, to the release of the "Hospital Intelligent Service Grading Evaluation Standard System (Trial)", and then to the "loosening" of the medical insurance policy, the policy norms were orderly and coherent. However, Internet hospitals still have regulatory loopholes due to the numerous sub-sectors, especially online consultation, medical e-commerce, etc., exposing some problems and causing heated discussion on the Internet. The reporter selected representative examples and interviewed relevant experts to discuss the blind spots and boundaries of Internet hospital supervision.
Lack of supervision, vague scope of diagnosis and treatment, and unclear medical responsibility.
Operation and management standards are not unified.
Internet hospital is not a simple "1+1" of Internet platform and medical diagnosis and treatment, but a breakthrough innovation of medical service in management mode, service scope and service content through Internet technology. However, at present, Internet hospitals are faced with multiple levels of regulatory problems, including the whole process supervision, the scope of diagnosis and treatment, and the determination of rights and responsibilities.
Netizen "Zi Fei fish silently said": "Micro-doctor" said that he could consult 24 hours a day, but what’s the use of doctors not replying? After reading it, the rash on my face became more and more serious. Now I don’t reply to questions at all. I want to see another doctor, and I always prevaricate when I ask customer service.
Many people said that they were afraid to try online medical treatment because they were worried about regulatory loopholes in online consultation, electronic prescription and drug review and distribution processes in Internet hospitals. Internet hospitals are still new things, and industry norms and industry supervision need to be improved.
Liao Zangyi, a researcher at the Medical Insurance and Medical Reform Research Center of the Chinese Academy of Labor and Social Security, Ministry of Human Resources and Social Security:At present, the supervision of Internet hospitals is lagging behind, the industry access standards and hardware facilities standards are not perfect, and there are loopholes in ensuring information security on the platform. However, the Internet can rely on big data to provide regulatory possibilities for risk early warning, process traceability and timely disposal of online services. Strengthen the audit by weaving the cage beforehand; It is necessary to ensure medical safety, accessibility of services and compliance of behaviors, and strengthen the supervision of compliance in service content, consultation process and doctor’s prescription, so that the drug distribution process can be traced back; In the post-event stage, strengthen the monitoring of electronic medical records, medical quality, cost control, decomposition services, patient satisfaction and other service results.
Netizen "Xiaomeizi": Recently, rhinitis is more serious. After the previous medication was finished, I thought it would be more convenient to make a follow-up visit online. As a result, the doctor assigned me to three different departments and said that I would not receive treatment.
National Health Commission requires that Internet hospitals can make follow-up visits to some common diseases and chronic diseases, but the first visit is not allowed. In practice, is the first visit based on the patient’s self-report or the records of previous hospital visits? What common diseases and chronic diseases can be followed up?
Zhou Qiru, head of the Internet Medical Center of the Second People’s Hospital of Guangdong Province:As long as it is diagnosed in a physical hospital for the first time, it is a follow-up visit to an Internet hospital. As long as the diagnosis is clear and there is clinical evidence, we all recognize it. For the follow-up cases, if it is clinical consultation, it is equivalent to helping patients to make reasonable triage, or giving professional advice, recommending corresponding medical institutions, departments and even doctors according to the patient’s situation, so that patients can avoid detours; If the patient is a common disease or chronic disease that has not reached the critical value, we will consult online according to the condition and issue an electronic prescription according to the prescription management regulations. Generally speaking, chronic diseases can be diagnosed and treated online, but each chronic disease has a critical value, such as hypertension. If systolic blood pressure reaches 180mmHg and diastolic blood pressure exceeds 100mmHg, patients with dizziness, dizziness, palpitation and other symptoms and signs can’t be seen online, so they need to be guided and triaged to an offline specialist. Online and offline diagnosis and treatment must be carried out in accordance with the rules and regulations and clinical diagnosis and treatment guidelines.
Netizen "Mr. Lei, a citizen of Chongqing": The child caught a cold and coughed. According to the advice of the online doctor, he gave the child cold medicine and antibiotics for two days, but the symptoms did not ease but worsened. After that, I quickly took my child to the hospital, and it was diagnosed as pneumonia.
Doctors in Internet hospitals mostly take part-time jobs in their spare time. Patients choose doctors through Internet hospitals. If medical disputes or even medical accidents are caused by diagnostic errors, should doctors, platforms or hospitals be responsible?
Zhou Qiru:When a physical hospital applies for an Internet hospital, it must be responsible for its management and diagnosis and treatment, and standardize, train and manage doctors. Once there are any diagnosis and treatment problems online, the physical hospitals and doctors are responsible. Before conducting online diagnosis and treatment, doctors must be registered in medical institutions that have obtained Internet medical licenses (they can practice more), and practicing doctors should also have more than 3 years of clinical experience in related professions. The platform company is only a technical support, responsible for data security, and unable to undertake medical risks and disputes. At present, all online consultation platforms are basically affiliated with medical institutions, otherwise it is impossible to carry out diagnosis and treatment activities, otherwise it will violate the rules. Physical hospitals will also sign a cooperation agreement with the platform to clarify their respective obligations and responsibilities. If there is a problem of excessive publicity or excessive medical treatment, it is necessary to agree on responsibility sharing.
Misdiagnosis, missed diagnosis, doctors’ qualifications are mixed, and prescription drugs are prescribed at will.
The behavior and quality of diagnosis and treatment need to be standardized and improved.
How to effectively supervise the quality and behavior of diagnosis and treatment in Internet hospitals is the biggest bottleneck for the development of Internet hospitals. At present, the quality control behavior management of Internet hospitals needs the entity hospitals that Internet hospitals rely on to regulate themselves, and there is no corresponding regulatory regulation on the quality and behavior of Internet hospitals at the national level.
Netizen "Tea Tea": I went to see a doctor on the Good Doctor App. The doctor read my lab report and said it should be leukemia. I said I didn’t have any symptoms, and there was no problem with blood routine. He said that if I didn’t, there would be blood diseases. Let me have a bone marrow puncture. As a result, I went to the hospital and the doctor said that I was not sick at all.
At present, Internet hospitals have problems such as misdiagnosis and wrong diagnosis to varying degrees. The essence of the Internet platform is to re-match patients’ medical needs and doctors’ effective time in a larger virtual space-time. Under such a mechanism, how to ensure the quality of doctors’ online services and achieve the same online and offline quality?
Jin Peisheng, Executive Vice President of Affiliated Hospital of Xuzhou Medical University:The essence of Internet medical treatment is still medical treatment, but the space and carrier of medical service have changed. Therefore, the quality control of online diagnosis and treatment should still comply with the relevant offline regulations, and improve the management system related to Internet diagnosis and treatment on the basis of offline measures to ensure medical quality and safety. According to the actual situation of their respective hospitals, each medical institution implements normal management for the quality of medical services, improves the efficiency of information services, and effectively connects hospital-related prescription automatic screening system, electronic medical record system, intelligent medical safety monitoring platform and Internet drug distribution platform to assist doctors in diagnosis and treatment.
Netizen "sole sunny": When I asked my family, the platform marked the doctor as a doctor in a third-class hospital. I called the hospital to verify, and the result was that there was no such person. The platform replied that the doctor was a doctor in a county hospital. He was transferred back to the top three hospitals before, and the information was not updated in time.
Without effective supervision of online doctors’ qualifications, Internet medical care will not only be mixed, but even have the problem of "bad money driving out good money", which will seriously affect patients’ trust in Internet hospitals.
Person in charge of Ping An Health:The Internet medical platform must ensure the safety of Internet medical services. Take Ping An Health App as an example. After a doctor registers an account, he/she must enter the ID number, and then upload the doctor’s practice certificate, the doctor’s qualification certificate or the doctor’s photo with his/her work card. Only through manual examination and certification can he/she conduct medical treatment and other activities, and rely on technologies such as face recognition to assist in identity authentication. If a doctor wants to prescribe, he must also submit information such as ID card, medical practitioner qualification certificate, medical practitioner registration certificate, professional and technical qualification certificate and so on for review to obtain the right to prescribe.
Netizen "white porridge": My throat was uncomfortable before. The doctor simply asked me a few symptoms online, whether I was allergic to penicillin, and whether I had used cephalosporin before. Although it was suggested that I had to go through the process of "providing a prescription", I actually only needed to click "no allergic history". In less than two minutes, an "electronic prescription" was opened.
In the interview, the reporter found that in the process of online diagnosis and treatment, some commercial Internet hospitals with drug sales business encouraged doctors to prescribe more drugs for patients, and even colluded with pharmaceutical companies to promote excessive drug use and boost online drug sales; Problems such as the lack of online prescription review and supervision on some platforms and the lack of management against excessive drug use are gradually exposed.
Jin Peisheng:In order to prevent Internet hospitals from prescribing drugs indiscriminately, we should focus on the following aspects: First, we should embed a pre-prescription review system in the online system of Internet hospitals, so that when doctors prescribe drugs, the reviewing pharmacists will review the prescriptions online, and only after they are qualified can they be issued; Second, strengthen training, and train doctors who have obtained the prescription right of Internet hospitals on rational drug use and medical insurance policies, so as to strengthen the importance of rational drug use; Third, clinical pharmacists should shoulder the responsibility of guiding patients to use drugs safely and rationally. Internet hospital system can set up face-to-face communication channels between pharmacists and patients, and pharmacists can directly participate in patients’ medication guidance and education; The fourth is to strengthen supervision and management. The hospital has established an Internet hospital quality management department, which is consistent with the management objectives of the entity hospital. Full-time departments and full-time personnel are responsible for rational drug use supervision, accepting complaints from patients about unreasonable prescriptions, and linking doctors’ practice behavior on the Internet with performance, evaluation first, and promotion of professional titles.
Obstacles in medical insurance payment coexist with abuse, and patients’ information is sensitive and easy to leak.
There are hidden dangers in medical insurance payment policy and user information security.
In different regions, the conditions and standards of medical insurance payment are not uniform, and there are still cases of excessive medical insurance and abuse of medical insurance in some regions. Due to the special properties of Internet hospitals, it is convenient for storage and circulation, but also increases the possibility of patient privacy disclosure.
Netizen "walked through the zebra crossing": Concord Hospital has my commonly used medicine, but it is hard to find the No.1 Concord Hospital. It was very troublesome to prescribe medicine every time before. I thought it was convenient to go back to the Internet Hospital after it went online, but I couldn’t take medical insurance.
Most of the Internet hospitals seek medical treatment in different places. China’s medical insurance adopts a county-level or municipal-level overall planning system, and the insurance policies vary from place to place, with certain differences in reimbursement ratio and scope of treatment. The problems are mainly manifested in which treatment items and drugs can be reimbursed, the deductible line, the capping line and the self-payment ratio of insurance.
Liao Zangyi:There are differences in the medical insurance payment policies of Internet hospitals in different places, and the medical insurance services of Internet hospitals will certainly keep up in the future. However, at present, the implementation of medical insurance policies in various places still needs institutional preparation. Since ordinary people have this demand, medical security services should be more precise and targeted, and the medical insurance system should be adjusted accordingly, including the medical insurance payment system, payment methods and pricing standards, which should be improved in combination with the forms and characteristics of Internet hospitals. However, we should be cautious to avoid the problem of excessive medical insurance. On the one hand, we should strictly rely on the entity, implement the mode of combining offline and online, and refer to the existing pricing standards to improve the medical insurance payment method of Internet hospitals as soon as possible.
Netizen "Tang Yuaner loves learning": Asking questions on the platform is completely different from asking questions in reality. Who knows if the person who asks questions is really sick or has other intentions? It is no longer an insider that offline pharmacies are "linked" with online platforms to prescribe drugs. If they abuse medical insurance payment, wouldn’t it be unfair!
At present, eligible Internet medical services are supporting medical insurance payment policies according to the principle of online and offline fairness. If medical insurance pays for online medical services according to items or service units, it will easily lead to the abuse of medical insurance resources and fund management risks in the absence of supervision.
Liao Zangyi:We can combine the service characteristics of Internet hospitals, explore the incentive payment mechanism of value-oriented medical care, change from quantity payment to quality and value payment, and reward the diagnosis and treatment process and the diagnosis and treatment results. It is suggested that the service package value of designated medical institutions with different levels of Internet medical insurance services should be calculated in the form of disease or head package, taking into account factors such as clinical pathway, price level, medical insurance payment ability and patient experience, and the package payment of disease or head should be implemented on the basis of reasonable total budget, so as to reduce medical costs and unreasonable visits and prevent the abuse of medical insurance resources.
Netizen "virtual front seat ticket": I wanted to check my illness online a few days ago. After entering an Internet hospital, I first need to register, but I have to fill in a lot of personal privacy information, including my name, phone number, medical history and so on. I am still willing to communicate with the doctor face to face.
According to the analysis of Tencent Smart Security Threat Intelligence Center, there are serious logical loopholes in the third-party medical service platform accessed by many domestic 3A hospitals, which may lead to the leakage of patient information and medical diagnosis data on the platform.
Person in charge of Ping An Health:Medical institutions providing diagnosis and treatment services must first improve the complete guarantee system of relevant diagnosis and treatment information, and start with its website, App and other links to prevent information leakage at the root; Secondly, we should strengthen the awareness of privacy protection of medical staff, and adopt "one person, one number" real-name registration system for medical treatment, so that when information leakage happens, we can find out the leaked staff at the first time and make remedies. From the perspective of administrative departments, we should strengthen the supervision of the Internet medical industry, improve relevant laws and regulations, establish an accountability system for those who leak information, and use mandatory provisions to protect information security. From the patient’s point of view, when using Internet medical websites and APPs, it is necessary to carefully choose a formal platform to avoid revealing their own information.