Telemedicine (TM) is not a new concept, but its journey is only beginning and there is an urgent need to address the challenges practitioners may face. Recognising that, SMA held a webinar with close to 1,800 participants over Zoom on 13 June 2020. The webinar brought the practice of TM to the forefront with insights from several speakers, including the Director of Medical Services A/Prof Kenneth Mak and Group Director of the Ministry of Health's (MOH) Health Regulation Group Adj A/Prof Raymond Chua.
The rise of telemedicine
In his opening address, A/Prof Mak addressed the disruption COVID-19 has had on Singapore, remarking that it has "significantly changed the way care is delivered to patients". TM options used to be limited to phone calls for follow up or non-urgent queries, but advances in technology have allowed innovations in TM to make leaps and bounds. He further commented that though in-person care remains the best way to treat patients, TM can act as a valuable adjunct, especially in this era of safe distancing.
In SMA Council member Adj Prof Tan Sze Wee's introduction to TM, he also noted that there has been a steady increase in volume of TM consults both locally and internationally, especially due to COVID-19. As such, he found that it is "inevitable" for TM to be incorporated into local clinical practice.
Throughout the webinar, Adj Prof Tan conducted multiple polls aimed at getting a feel of the participants' understanding of TM, gauging their interest in starting a TM service and their main concerns with adopting TM. The results showed that most participants had not tried TM, but were interested in trying it out. This was also reflected in the live question and answer, where participants took the opportunity to raise relevant questions for the experts' clarification. One of the polls also addressed the question of charges for TM consultations, which is an area the representatives from SMA TM Workgroup, MOH and other professional bodies will look into.
Regulating telemedicine
The usage of TM is growing, and it is imperative to ensure that it is safe for both doctors and patients. Adj A/Prof Chua took the mic with his segment focusing on regulations, concerns of the quality of care from TM, medico-legal issues and medicine delivery, among others.
Adj A/Prof Chua then addressed concerns surrounding TM, from clinical red flags to modality, legal concerns to misuse of e-prescriptions, and said that upcoming new regulations and guidelines would clarify these concerns. Patient data security was also brought up, which Adj A/Prof Chua said falls on the provider to ensure patient privacy is well protected.
He also encouraged doctors interested in setting up their own TM services to undergo the LEAP Regulatory Sandbox and Telemedicine Training to better understand how to safely and properly provide a TM service. More than 2,500 doctors have completed it since it launched in March 2020.
Concluding thoughts
This era of rapidly advancing technology is ripe for TM consultations. COVID-19 has highlighted the benefits of conducting consultations remotely. Though the barrier of entry to TM is high, this is due to the need to ensure the highest standards of care can be provided without an in-person consultation. With 146 TM services in hospitals and over 20 clinics offering the service as well, the full potential of TM is still to be realised. As more doctors explore the use of TM in their practices, SMA hopes to provide guidance and education to ensure that TM is adopted safely and judiciously with a high standard of patient care. For more information on the webinar, visit https://bit.ly/SMATelemedicine.
Telemedicine in practice – speakers share
Dr Elaine Chua, Family Physician, Bedok Medical Centre
Dr Chua shared case studies of TM consultations to show when they were appropriate and not. She also outlined a non-exhaustive list of conditions that are not suitable for teleconsultations.
"Main points of consideration for teleconsultation include patient selection, disease/symptom selection and follow up care."
Dr David Ng, Family Physician, National Healthcare Group Polyclinics
Dr Ng related his experience with TM, highlighting its increased use during the circuit breaker, its operational challenges and potential use in other specialties.
"Survey results from patients suggest that perhaps education and age may not be as significant a barrier of technology adoption."
Dr Lim Kwang Hsien, Paediatrician, Mount Alvernia Hospital
Dr Lim elaborated on how TM has reduced clinic dwelling time, as well as how it has established potential connectivity between patient, doctor, and hospital.
"Telemedicine adoption is currently in its infancy phase but like all our patients, we see its growth potential."
A/Prof Yeo Khung Keong, Cardiologist, National Heart Centre Singapore (NHCS)
A/Prof Yeo shared the NHCS' teleconsultation pilot, which focused on follow-up cases with low cardiac risk not requiring physical examinations.
"In terms of consent for teleconsultations, regulations suggest that implied consent from patients is acceptable."
Mr Steven Phua, Enterprise Singapore
Mr Kevin Tan, Singapore Manufacturing Federation
Mr Phua and Mr Tan shared standards on appropriate medicine packaging and delivery to comply with existing guidelines, as well as a major concern – verification of identity and traceability of deliveries.
"Standards complement regulations by filling in the gaps." – Steven Phua
Burning questions
On understanding the risk of misdiagnoses and risk liability
Adj A/Prof Chua emphasised that it was important that the standard of care provided via TM must be the same as that of an in-person consultation, and that learning points from experience are important to ensure that error rates are reduced as much as possible.
On savings for care providers and patients
Most of the panellists agreed that cost savings and increased convenience were more apparent for patients, especially those with young children or who are bed-bound. However, A/Prof Yeo also highlighted that the TM landscape continues to evolve, and it will take time to determine where the cost savings lie.
On indemnity and insurance
SMA President Dr Tan Yia Swam acknowledged that there is no common standard from SMA's preferred indemnity providers. SMA is actively consolidating all concerns to the providers and asks for patience while they come up with a formal statement regarding their specific terms of coverage for TM in a local context. More information on indemnity will be addressed in a seminar on 5 September hosted by SMA, with a highlight on TM coverage and TM case studies.
On medicine delivery and service providers
Mr Tan clarified that the SS644 standards would allow more service providers to engage in medicine delivery. Additionally, participants are advised that there are grants available to support clinics in setting up the needful.