Telemedicine Rules in South Africa: What the HPCSA Allows

Can doctors consult online in South Africa?

Yes. Virtual consultations are lawful and regulated. The governing document is Booklet 10 of the HPCSA's ethical guidelines, revised in December 2021. The council previously called these the telemedicine guidelines; it resolved that the wider term telehealth be used going forward, as a term that accommodates all the registered professions, from telemedicine to telepsychology and telepsychiatry.

Booklet 10 defines telehealth as the application of electronic telecommunications, information technology or other electronic means to deliver healthcare services between two geographically separated locations, and treats it as a blanket term for all components of healthcare conducted through telecommunications technology. The guidelines are clear that when telehealth is used, all principles of good practice on patient consent, confidentiality and record keeping still apply, and that Booklet 10 must be read together with the HPCSA's other ethical booklets and the National Health Act 61 of 2003.

Who may practise telehealth

Registration comes first. Booklet 10 restates the rule in the Health Professions Act 56 of 1974: registration is a prerequisite for practising a registrable health profession for gain within South Africa. Only practitioners who have been deemed competent and are registered in their respective professions are authorised to take part in telehealth practice in South Africa, whether as the practitioner in charge of the patient or as the consulting practitioner.

The standard does not drop because the consultation is remote. Practitioners engaging in telehealth are held to the same standards of professional practice as practitioners who consult face to face. The guidelines also close the fully-remote loophole: no practitioner may render professional services exclusively through telehealth.

Cross-border practice is addressed directly. A practitioner outside South Africa who serves South African patients should be registered both with the regulator in their own country and with the HPCSA.

Is a prior face-to-face relationship required?

For years the practical answer was yes: before the pandemic, the HPCSA expected telehealth to happen within an already established practitioner-patient relationship. COVID-19 forced the question. On 26 March 2020 the council issued special guidance on applying the telemedicine guidelines during the pandemic, and on 3 April 2020 it amended that notice: telehealth should preferably be practised where an established relationship exists, but where it does not, practitioners may still consult remotely provided the consultation is in the best clinical interest of the patient.

The December 2021 revision of Booklet 10 settled the position permanently. An established professional relationship is desirable before telehealth services are considered, but it is not a compulsory requirement. The relationship itself is established when the practitioner agrees to treat the patient and the patient provides informed consent to be treated.

For routine telehealth, the guidelines keep the same formulation: preferably within an existing practitioner-patient relationship, and where none exists, only where the consultation is done in the best clinical interest of the patient.

When a virtual consultation is not appropriate

Booklet 10 states that telehealth is intended to replicate a physical consultation as far as possible, but not to serve as a substitute for one. Routine telehealth is an adjunct to normal medical practice and only replaces face-to-face services where the quality and safety of patient care are not compromised.

The decision to consult remotely rather than in person, other than in an emergency, must always take defined factors into account:

• The need for review, or to assess the severity of physical and psychological symptoms
• Previous knowledge of the patient, and of the family and wider situation where appropriate, alongside access to the clinical records
• Any need to physically examine the patient
• A previous medical history that may trigger a need to see the patient face to face
• Social or clinical circumstances that would require seeing the patient in person

Consent, confidentiality and records

A telehealth consultation needs informed consent twice over: for the treatment itself and for the use of the telehealth technology. Booklet 10 states that a practitioner should not give medical advice or provide treatment through telehealth without obtaining proper informed consent, which may be given in writing or recorded orally. This part of the guidelines must be read with the HPCSA's informed consent guidance in Booklet 4 and the provisions of the National Health Act. Where the practitioner and patient do not agree on whether the condition suits a telehealth consultation, the guidelines require that a face-to-face consultation be conducted. Consent documentation for telehealth should record, among other elements, the identities of the patient and the practitioner, the practice number, the types of transmissions consented to, the security measures in use, any material risks to confidentiality, and the secure, encrypted storage of consultation recordings.

Confidentiality and record keeping carry over unchanged. Policies and records for telehealth consultations must be maintained at the same standard of care as face-to-face consultations, and patient information must be handled in line with the Constitution, the National Health Act, the Promotion of Access to Information Act and POPIA. Social media is ruled out as a consulting channel: Booklet 10 calls the use of social media platforms for telehealth undesirable and advises practitioners not to interact with patients on them. Its definition of social media names Facebook, Twitter, WhatsApp, TikTok, LinkedIn, YouTube and Instagram.

Prescribing after a virtual consultation

A prescription may follow a telehealth consultation, but not a shortcut. Booklet 10 requires a documented medical evaluation, together with the relevant clinical history needed to diagnose the underlying condition and identify any contra-indications, before treatment is provided, including issuing a prescription electronically or otherwise.

The guidelines then draw a hard line: treatment, including issuing a prescription, based solely on an online questionnaire does not constitute an acceptable standard of care. When prescribing through telehealth, express informed consent must meet the same standard applied to face-to-face prescribing.

Practitioners may charge consultation fees for services delivered through telehealth platforms. The HPCSA pairs that permission with a strong caution against practices that may amount to over-servicing and perverse incentives.

What getting it wrong costs

Practising a registrable health profession without registration is a criminal offence under the Health Professions Act, punishable on conviction by a fine or imprisonment for up to 12 months, or both. That applies with full force to a purely online practice, and to a practitioner abroad who consults South African patients without HPCSA registration.

For registered practitioners, telehealth failures are professional conduct matters. Prescribing off the back of a questionnaire, skipping consent for the technology or the treatment, consulting patients over social media, or running an exclusively virtual practice can each found a complaint of unprofessional conduct, and the penalties available after an HPCSA conduct inquiry range from a caution or reprimand and fines to suspension from practice or removal from the register.

The record is the defence. A telehealth consultation documented to the same standard as an in-room visit, with consent captured and the clinical evaluation on file, is what answers a complaint months later. Sphygmos keeps that documentation on the patient record as a matter of course.

How Sphygmos helps

Sphygmos keeps virtual and in-room consultations on the same patient record, so a telehealth visit is documented to the same standard as a visit to the rooms. Recording is consent-led, the consultation note is drafted with full provenance, and nothing is issued until the doctor reviews and signs it off. The doctor is always the final gate.

See Sphygmos, the clinical operating system for South African doctors

Frequently asked questions

Sources

• HPCSA Booklet 10: General Ethical Guidelines for Good Practice in Telehealth (revised December 2021)
• HPCSA: Ethics guidance for registered practitioners
• National Health Act 61 of 2003 (South African Government)

This guide is general information for healthcare practitioners, not legal advice. Verify current legislation and HPCSA guidance before relying on any detail.

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