Is the doctor who sees 250,000 people online reliable?
Misdiagnosis, white diagnosis, AI prescribing, and other Internet diagnosis and treatment chaos are frequent, and national regulatory policies continue to tighten.
● In recent years, "Internet + medical health" has developed rapidly.
By the end of 2021, there have been more than 1,700 Internet hospitals nationwide.
What followed was misdiagnosis, white diagnosis, medicine first, AI prescribing, diagnosis and treatment accidents, etc., which became "dark thunders" buried in the industry.
● The patient "has a lot of white skin in his mouth, and it hurts to drink water". Many doctors who consulted online got different diagnosis results: some thought it was "mouth ulcers caused by glossitis", while others were diagnosed as "mouth inflammation" ", or "Candida infection"
● The number of doctors with the largest number of online consultations on a certain platform is 250,000.
Assuming that the average online consultation time per person is 10 minutes, the online consultation time is about 41,667 hours. If there is no rest all year round and 3,650 days in 10 years, then the average daily online consultation time in these 10 years is about 11.4 Hour
● Clarify the status of subjects such as artificial intelligence, and directly hold medical institutions accountable for prescriptions that are automatically generated by artificial intelligence; improve the drug traceability system, make full use of the QR code recognition function to do a good job in reviewing online prescriptions, and ensure the root cause of supervision Traceability
□ Our reporter Wen Lijuan
□ Zhang Gongye, an intern of this newspaper
"Which doctor is right?"
At the beginning of this year, Xia Liang, who lives in Changde, Hunan, suffered from oral ulcers for a period of time. "A lot of white skin appeared in the mouth, and it hurt to drink water."
Affected by the epidemic at that time, he decided to find the cause and solve the pain through online consultation.
However, several doctors he consulted gave several completely different diagnosis results, which confused Xia Liang and questioned the accuracy of the online consultation.
This experience is not unique.
According to the 49th "Statistical Report on Internet Development in China" released by the China Internet Network Information Center this year, 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, misdiagnosis, white diagnosis, first medicine, AI prescribing, diagnosis and treatment accidents and other chaos have also come one after another, which has become a "dark thunder" buried in the industry.
In response to the above problems, the regulatory measures for plugging leaks and mines have continued to advance.
From the 2018 National Health Commission and the State Administration of Traditional Chinese Medicine promulgated the "Administrative Measures for Internet Diagnosis and Treatment (Trial)", which clearly stipulated that medical institutions conduct online follow-up visits, to the recently announced "Internet Diagnosis and Treatment Supervision Regulations (Trial)" "Transparent and standardized diagnosis and treatment, a network that guarantees the quality of Internet diagnosis and treatment is becoming more and more dense.
Frequent misdiagnosis in online consultation
Diagnosis results vary
Xia Liang recalled to the "Rules of Law Daily" reporter that the first doctor he consulted online at that time was a stomatologist in a tertiary hospital.
After showing the other party a selfie photo of the oral cavity and describing the relevant symptoms in words, the doctor diagnosed it as "oral ulcer caused by getting angry", saying "take some anti-inflammatory drugs, drink more water, and have a good rest, you will be fine", and then prescribed anti-inflammatory drugs Prescription, instruct him to buy medicine offline.
After taking anti-inflammatory drugs as prescribed by the doctor for 3 days, there was no improvement. Xia Liang selected 3 doctors on the other two platforms for consultation.
The pictures and texts provided are the same as before, but different diagnosis results were obtained: some doctors thought it was "mouth ulcers caused by glossitis", some doctors diagnosed it as "oral inflammation", and some doctors said it was "candida infection".
The three doctors prescribed different medicines for him, which made Xia Liang confused.
He didn't dare to take medicine easily, and then went to an offline hospital in the city to see a doctor, and the diagnosis was: Candida infection caused by antibiotics.
After taking the right medicine, the condition was relieved.
A senior doctor at a dental hospital in Beijing told reporters that Candida infection is not difficult for stomatologists to judge. limitation.
"When a stomatologist conducts an offline consultation, in addition to observing the oral condition and asking about the condition, he also presses and touches, and comprehensively judges the result. On the other hand, online doctors can only rely on pictures and texts, and it is difficult to accurately judge, let alone prescribe. Prescribed," the doctor explained.
In his view, patients can upload videos taken by offline hospitals and issue pathology reports for review, follow-up or consultation during online consultation, but they cannot be the first consultation.
In recent years, "Internet + medical health" has developed rapidly.
From Internet hospitals to the identification of patients with common diseases and chronic diseases, they can be reimbursed by medical insurance, and from online drug sales to core diagnosis and treatment to Internet medical insurance, various regions have introduced plans to actively support the comprehensive development of online medical care, which has laid a solid foundation for the growth of online medical users.
At the same time, it is not uncommon for Xia Liang to consult multiple doctors online for the same disease, but get a variety of diagnosis results.
Zhang Xingze, a third-year student at a university in Beijing, claims to be a "sick-loving person". In recent years, he has often used an online consultation platform, and he has mixed feelings about using it - it is very convenient but not very reliable.
The most impressive one was that his skin had some red spots, which were extremely itchy. In order to solve the problem quickly, he opened an online consultation app and selected a doctor in the dermatology department who was "professional in reading labels". 109 yuan for graphic consultation.
As a result, the doctor told him that he might be suffering from a skin disease, and suggested to buy corresponding drugs for treatment.
Later, he went to the offline hospital for a detailed examination, and it turned out that he was allergic to eating pineapple.
"Online consultation is convenient, but the description of symptoms is generally limited to text and pictures, which is prone to misdiagnosis or white diagnosis." Zhang Xingze said.
Many industry insiders who were interviewed agreed that "space-to-air" diagnosis and treatment is not suitable for all patients, and that the follow-up 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, leading to some regulatory vacuums.
Choose medicine before prescribing
AI prescribes patients to buy medicine
In addition to consultation, purchasing prescription drugs is another feature of "Internet + medical health" convenience.
However, the reporter found in the investigation that some Internet medical platforms adopt the operation method of "purchasing medicines first, then formulating medicines, and even automatically generating prescriptions by artificial intelligence software".
Xie Li, who lives in Huaihua, Hunan, bought Pudilan Anti-inflammatory Oral Liquid for her 4-year-old child at an offline hospital in early 2020, and the doctor prescribed it at the time.
In March of this year, because the child had similar symptoms again, she tried to buy this drug on an online drug purchase platform, and she was soon 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 the reporter placed an order for the prescription drug levofloxacin capsules on a drug purchasing platform recently, the platform prompted "Please select an offline diagnosed disease".
The reporter randomly checked several items in the "disease column", and the "prescription/medical record/examination report column" was empty, and confirmed that "this disease has been diagnosed and the drug has been used, and there is no allergic history, no related contraindications and adverse reactions. ”, it quickly passed the verification, and after submitting the list, the system jumped to the consultation section.
A few seconds later, a "physician" received the consultation and sent several messages in succession. The first one emphasized that "Internet medical care only provides medical services to users who are returning to the clinic." period.
After the reporter replied "no", within 2 seconds, a prescription form and a purchase link were sent to the convenience.
Yang Mu, a Beijing resident, has also had such an experience. He doubts whether the person behind the screen is a real licensed doctor: "When buying prescription drugs on the XX platform, I feel that the other party is no different from a robot. Agreed quickly within seconds, without giving any professional advice at all." Once, he deliberately tried to describe some situations that were not suitable for the disease he wanted to buy, but the other party still prescribed it quickly without saying a word.
There are people in the Internet medical industry who offer advice: 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 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, and some large platforms will use AI to assist doctors in consultation, such as asking how old the patient is and where he is uncomfortable, but the prescription must require the doctor. Come on."
Deng Yong, a professor at the Law Department of Beijing University of Traditional 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 Specifications" clearly stipulate that after a doctor prescribes a prescription for a patient during diagnosis and treatment activities, the pharmacist must conduct Review, but the relevant norms do not expressly prohibit the behavior of "automatically generating prescriptions".
"It can be done without prohibitions. If the specification is not clear, local practice will be chaotic. In reality, some platforms choose the model of 'AI prescribes, and customers directly pick up the medicine', skipping the traditional prescription and review links. It has directly turned the prescription into 'selling medicine'. This kind of behavior is a serious violation of my country's drug management system, and it also lays a hidden risk for the safety of patients' medication." Deng Yong said.
Is the huge number of admissions real?
Who will supervise online doctors?
For online consultation, the doctor's answer several times is considered a complete consultation, whether the doctor's consultation volume displayed on the platform is false, and whether the patient's diagnosis content is the doctor's real reply... The reporter randomly interviewed Beijing, Tianjin and Hunan. More than 10 people in other places found that these are also the main problems that plagued them.
Hao Yingrui, a sophomore in a university in Beijing, has a deep understanding of this.
She often uses online consultations, but it is still unclear how many questions the doctor answers to meet the fee.
"In the beginning, there were a few questions that were considered free consultation, but as long as you spoke, it was considered a question, such as a thank you or hello. After the free times were used up, the doctor just entered the topic. For more information, you You can only pay to be a member. After paying the money, the doctor will ask for information such as test results. Sometimes, after a circle, you will be asked to go to an offline hospital for consultation.”
Before making an online consultation, first check on the platform which doctor has the most consultations, and then determine which doctor to consult. This is the practice of Zhang Daodao, a resident of Qufu, Shandong Province. A large amount means that its medical skills are more popular with patients.
However, she noticed that the number of doctors' consultations marked 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.
The reporter searched for dermatologists on an online consultation platform and found that the number of dermatologists with the largest number of online consultations on the platform was 250,000.
Assuming that the average online consultation time per person is 10 minutes, the online consultation time is about 41,667 hours. If there is no rest all year round and 3,650 days in 10 years, then the average daily online consultation time in these 10 years is about 11.4 Hour.
Regarding these questions, a relevant person in charge of the platform told reporters that they have been exploring "quality control" over the years, "For example, a doctor's answer several times counts as a complete consultation; how to copy and paste the searched content to patients? how to ensure that the number of consultations is real; who is responsible for misdiagnosis or prescribing the wrong 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 and health commissions, and hospitals and departments will also conduct standardized management; online doctors are relatively independent." The aforementioned senior doctor of a dental hospital in Beijing said.
Regulatory policies have been implemented one after another
Better quality of diagnosis and treatment
The large-scale growth of Internet diagnosis and treatment began in 2018, when the General Office of the State Council issued the "Opinions on Promoting the Development of "Internet + Medical Health", which aims to improve the level of modern medical and health management.
By the end of 2021, there have been more than 1,700 Internet hospitals nationwide.
Over the years, in order to standardize the behavior of Internet diagnosis and treatment, normative documents such as "Internet Diagnosis and Treatment Management Measures (Trial)", "Internet Hospital Management Measures (Trial)" and "Telemedicine Service Management Specifications (Trial)" have been successively issued. The qualifications of medical institutions, the qualifications of practitioners, the guarantee of equipment and facilities, and the specification of service procedures are required.
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 been highly anticipated by the public.
The detailed rules make detailed provisions for social concerns such as prescription review, privacy protection, and diagnosis and treatment quality control in Internet diagnosis and treatment.
Regarding what diseases can be seen online, the rules require that the conditions for follow-up visits must be met: patients should provide medical records with a clear diagnosis, such as outpatient medical records, inpatient medical records, discharge summary, diagnosis certificates, etc. meet the conditions for re-examination.
When the patient's condition changes, the doctor judges this visit as the first visit, or there are other circumstances that are not suitable for Internet diagnosis and treatment, the receiving 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, and give doctors more professional authority, and further clarify the boundaries of services and supervision, which is conducive to the standardization and standardization of Internet diagnosis and treatment services.
Whether the quality supervision of online diagnosis and treatment is consistent with offline diagnosis and treatment, the detailed rules give a positive answer: relying on physical medical institutions, Internet diagnosis and treatment are required to be included in the overall medical service supervision system.
For prescription drugs that can be bought without a prescription, the rules strictly prohibit "prescription first and then later": the prescription should be issued by the receiving doctor himself, and the use of artificial intelligence to automatically generate prescriptions is strictly prohibited.
Prescription drugs shall be sold, dispensed and used on the basis of a physician's prescription.
It is strictly prohibited to provide a drug to a patient before a prescription has been issued.
In Deng Yong's view, this is especially worthy of recognition. "It is in line with the current theme of Internet diagnosis and treatment of 'returning to serious medical care', and will help lead 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 “strictly prohibiting the use of artificial intelligence and other automatically generated prescriptions”, multiple factors must be considered, for example, the status of subjects such as artificial intelligence should be clarified. “Although we call it artificial intelligence, it is related to Like some assistant physicians, they are all subjects who have not obtained the right to prescribe. The current "Prescription Management Measures" and "Medical Institution Management Regulations" are still insufficient, and the punishment object is limited to 'personnel'. Artificial intelligence, etc. should be considered in subsequent revisions. Due to the particularity of the subject, if the prescription is automatically generated only by artificial intelligence, the responsibility of the medical institution should be directly investigated in the same way as the use of non-health technicians.”
Deng Yong believes that the rules for assuming responsibility 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 it is stipulated in the contract that 'if the damage caused by improper prescription is issued, the medical institution shall pay the compensation after compensation', then the medical institution has substantially avoided the risk of compensation for damage liability, which violates the principle that rights and responsibilities should be equal."
It is also indispensable to improve the drug traceability system.
Deng Yong proposed that relevant departments should increase the verification 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 do a good job in reviewing online prescriptions.
At the same time, the transaction records and transaction evidence are kept intact to ensure that supervision can be traced back to the source.
(All online inquirers in this article are pseudonyms)