South African healthcare is undergoing a significant digital transformation, with paper files being replaced by electronic health records and consultations taking place over secure video platforms. According to Dr Petrus van Niekerk, founder and CEO of Udok, this shift towards digital healthcare has been accelerated by greater connectivity and the normalisation of telehealth.
The shift to digital healthcare has significant benefits, including the ability to share information efficiently between healthcare providers. However, it also changes the nature of the clinical record, and the need for trust and accountability remains. A handwritten signature provides a familiar link between a practitioner and a document, but in a digital environment, this link needs to be established through technology that can verify the practitioner’s identity and protect the integrity of the document.
Digital Transformation in Healthcare
Digitising healthcare is about more than removing paper, says Van Niekerk. It’s about creating a digital chain of information that can be trusted and relied upon. A remote consultation, for example, can generate an entirely digital chain of information, including the patient’s details, consent, clinical notes, prescription, referral, and billing information.
This digital chain of information creates significant benefits, but it also raises important issues about trust and accountability. The issue is not simply whether a document is electronic, but whether you can trust that document, establish who signed it, demonstrate that the practitioner authorised it, and tell if the document has been changed since it was signed.
An advanced electronic signature (AES) uses a digital certificate and defined identity verification and security processes to create a stronger association between the signatory and the document. This provides specific legal and evidentiary benefits, particularly in healthcare where clinical documentation has implications for patient care, professional accountability, and future legal disputes.
The Importance of Advanced Electronic Signatures
An AES is designed to address three fundamental issues: Who signed the document? Did they authorise it? And has the document changed since it was signed? Its digital certificate links the signature to a verified identity, while the signature is bound to the document so that subsequent alterations can be detected.
According to Van Niekerk, the value of an AES is that the signature becomes part of the document’s digital integrity. It isn’t just an image of a signature placed on a PDF, but a technological and legal framework that helps establish the identity of the signer and the integrity of what they signed.
In telehealth, for example, a practitioner conducting a remote consultation may never meet the patient face to face. The consultation, clinical assessment, prescription, and related documentation can all be generated electronically, and the AES forms an important part of that chain by establishing the practitioner’s relationship with the electronic document.
The AES provides a mechanism for dealing with one specific but critical part of digital healthcare: attribution and document integrity. When a digital record becomes evidence, the importance of a trusted digital signature becomes particularly clear. A properly implemented AES can provide evidence connecting the document to the verified practitioner and enabling the integrity of the signed document to be checked.
Section 13(4) of the Electronic Communications and Transactions Act also provides an evidentiary presumption in relation to an AES, subject to the requirements of the Act. As Van Niekerk notes, in healthcare, you have to think beyond the moment the document is created, and a record may need to stand up to scrutiny long after the consultation has ended.
The security of an AES depends on more than the technology used to apply it. The practitioner’s identity must be properly established, the digital certificate securely managed, and signing credentials kept under the practitioner’s control. Multi-factor authentication and appropriate credential-management processes can provide additional protection.
For healthcare organisations, this makes certificate and identity management an operational consideration, not simply an IT issue. The signing credential effectively becomes part of a practitioner’s professional identity in the digital environment, and it needs to be protected with the same seriousness that a practitioner would apply to any other professional credential.
As Van Niekerk concludes, the move to digital healthcare should not be viewed as simply replacing a paper process with a digital one. The opportunity is to build processes where trust, accountability, and security are designed into the way information is created and shared. The AES is an important part of making that possible, and its use is becoming increasingly important as healthcare moves further into the digital age.
The Electronic Communications and Transactions Act 25 of 2002 provides the legal framework for electronic signatures in South Africa, and the AES is a critical component of this framework. As healthcare organisations work through the complexities of digital healthcare, the AES will play a vital role in establishing trust and accountability in the digital environment.
Implementing AES in Healthcare Organisations
The Electronic Communications and Transactions Act 25 of 2002 provides the legal framework for electronic signatures in South Africa, and healthcare organisations should ensure that their AES solutions comply with the requirements of the Act. Additionally, the Protection of Personal Information Act (POPIA) requires healthcare organisations to implement appropriate safeguards to protect sensitive patient information, and the AES may play a critical role in ensuring the integrity and confidentiality of this information.