Singapore is renowned for its high standards of healthcare, consistently ranking among the best in the world for patient outcomes, medical innovation and accessibility. Our healthcare system is built on a strong foundation of well-trained medical professionals, rigorous regulatory frameworks, and investment in medical technology and innovation.
Public and private healthcare institutions work in tandem to provide comprehensive, evidence-based care, ensuring that patients receive timely and effective treatment. With initiatives such as Healthier SG and the integration of electronic records, Singapore continues to enhance its healthcare ecosystem while maintaining strict clinical governance and patient safety standards. This commitment to excellence is critical to fostering public trust and confidence that our healthcare system is able to deliver high quality healthcare that is safe and reliable.
Benefits of telemedicine
The adoption of telemedicine over the past few years has made healthcare even more accessible in Singapore. National health initiatives, such as Healthier SG, allow for teleconsultation to serve as a follow-up option for patients with chronic conditions. With virtual consultations, patients can seek medical advice without the need for commuting or waiting in crowded clinics. This convenience is especially beneficial for certain populations such as elderly individuals and those with mobility issues, as they can receive medical attention from the comfort of their own homes.
Beyond accessibility, telemedicine offers time and cost savings for both patients and healthcare providers. Telemedicine platforms operate with low overheads and some do not even have physical clinics, which means that these cost savings can potentially be passed on to patients. For healthcare providers, telemedicine helps to optimise clinic workflows, enabling them to manage their daily caseloads more efficiently. Multi- doctor practices can utilise telemedicine to share the workload between branches during peak periods. These efficiencies also extend to medication delivery, as prescriptions can be issued electronically and sent directly to online pharmacies.
The widespread adoption of telemedicine during the COVID-19 pandemic cemented its role in primary care as it enabled safe and effective medical consultations while minimising the risk of virus transmission. Chronic disease management also benefited from virtual follow-ups, as physicians were able to monitor conditions such as diabetes and hypertension remotely during periods of lockdown. With digital medical records and remote monitoring tools, patients can actively participate in their own healthcare, fostering better long-term health outcomes.
Quality of care
Despite its advantages, telemedicine comes with some inherent limitations, particularly regarding the quality and safety of care provided. The absence of physical examinations can sometimes result in missed diagnoses, especially for conditions that require in-person assessment, such as abdominal pain, respiratory distress or injuries. While telemedicine is suitable for minor ailments and chronic disease follow-ups, many medical conditions necessitate face-to-face consultations to ensure accurate diagnosis and appropriate treatment. Moreover, as different telemedicine platforms vary in their service quality, concerns have arisen about the consistency of care across these providers.
Expected standard of care when conducting teleconsultations
The National Telemedicine Guidelines issued in 2015 states the following in Section 1.2(a): "Any Telemedicine service must be provided as part of a structured and well-organised system and the overall standard of care delivered by the system must not be any less compared to a service not involving Telemedicine. ... Where face-to-face consultations are reasonably practical, the delivery of care via Telemedicine must not compromise the overall quality of care provided as compared with non-Telemedicine care delivery."
Similarly, the Singapore Medical Council (SMC) Ethical Code and Ethical Guidelines (ECEG) 2016 states in Section A6(1): "If you engage in telemedicine, you must endeavour to provide the same quality and standard of care as in-person medical care." It is therefore very clear and explicit that the standard of care for telemedicine is expected to be on par with, if not equivalent to, that of in-person consultations.
Telemedicine providers must meet the same clinical and ethical standards as all other healthcare services. Such key principles include accurate diagnosis, patient safety, informed consent and proper documentation. Telemedicine consultations must be conducted by Singapore-registered medical practitioners, and doctors are expected to exercise sound clinical judgement in determining whether a patient's condition is suitable for remote video assessment or requires escalation to an in-person visit. Additionally, all telemedicine platforms must ensure data security, confidentiality and proper medication management.
Doctors must always uphold the same duty of care as in face-to-face consultations, act in the best interests of their patients, and maintain the high standards expected as part of the medical profession.
The problem with ultra-short consultations
Not all patients require a long and tedious consultation at every visit, as many patients present with straightforward medical conditions that do not require too much time to assess. However, the principles and practice of family medicine require a family physician to make full use of each consultation to explore other areas beyond the primary complaint, such as chronic conditions, opportunistic health screening, lifestyle issues and modifying health-seeking behaviours. A consultation that is brief and concluded within a few seconds or minutes is a wasted opportunity and is not consistent with good clinical practice.
Moreover, a teleconsultation that lasts only a few seconds raises serious concerns about the provided quality of care, as doctors are required to conduct thorough clinical assessments regardless of whether a consultation is in person or virtual. A proper medical review involves taking the patient's history, assessing symptoms and making an informed diagnosis before recommending treatment. If a doctor rushes through this process, he/she risks misdiagnosing or overlooking serious conditions, which could compromise patient safety.
The SMC ECEG emphasises that doctors must provide competent, compassionate and appropriate care, and failing to do so breaches professional and ethical standards. Beyond clinical inadequacy, ultra-short consultations violate key ethical principles such as beneficence (acting in the patient's best interest) and proper patient communication. Doctors are expected to explain diagnoses, discuss treatment options and obtain informed consent, ensuring that patients understand their condition and care plan. If a consultation is too brief, patients do not have the opportunity to ask important questions, and necessary precautions – such as reviewing pre-existing conditions or potential drug interactions – may be missed. This lack of due diligence can lead to inappropriate prescriptions or unsafe medical advice, further endangering the patient.
Medical records
The SMC ECEG states in Section B3(1) that: "You must maintain clear, legible, accurate and contemporaneous medical records of sufficient detail to enable a high quality of continuing care." Ultrashort consultations are incompatible with good clinical care, and the medical records would likewise reflect the brevity of the encounter. Short consultations are incompatible with keeping good medical records.
Conversely, if the records entered are found to be incongruous, and turns out to be too detailed and comprehensive despite an ultra-short consultation, it would cast doubt on the integrity of the doctor who entered the records. Entering information into the medical records that did not take place is a form of falsification and is a significant breach of the SMC ECEG. These actions reflect dishonesty, violating the ethical standards expected of medical practitioners.
SMC emphasises that doctors must act with integrity and honesty in all professional interactions. Falsification of records not only breaches this trust but also jeopardises the credibility of the medical profession.
MC issuance
Regarding medical certificates (MCs), the SMC ECEG states in Section B4(1) that: "MCs must be issued to patients only on proper medical grounds arrived at through good clinical assessment." A doctor who conducts ultra-short consultations and engages in poor record-keeping breaches the SMC ECEG by failing to ensure that MCs are issued only on proper medical grounds based on a thorough clinical assessment.
The SMC ECEG clearly states that an MC should be granted only after a doctor has properly evaluated a patient's condition to determine whether he/she is medically unfit for work or daily activities. If a consultation lasts only a few seconds, it is highly unlikely that the doctor conducted an adequate assessment, raising serious concerns about the validity of the MC issued. Furthermore, poor record-keeping compounds the breach, as medical records must accurately reflect the consultation, including the history taken, clinical findings, diagnosis and justification for issuing an MC. This not only violates the duty of care owed to the patient but also undermines the public and employers' trust in the integrity of MCs, potentially leading to misuse and abuse of the system.
Patients who take multiple MCs in a short duration of time or on multiple occasions should be flagged for concern, and the reasons for the frequent sickness and work or school absence explored. Chronic absenteeism from work or school may indicate stress, mental health concerns, workplace bullying or academic struggles, rather than a purely medical condition. The doctor should explore whether the patient is facing such personal, social or psychological issues, and consider referring the patient to an appropriate specialist or counsellor. Telemedicine platforms that enable cheap and easy access to obtaining MCs feed the cycle of MC abuse and undermine public trust in the medical profession.
The Ministry of Health (MOH), Health Sciences Authority (HSA) and SMC issued the Joint MOH-HSA-SMC Circular on Regulations and Professional Standards for Telemedicine Services and Advertisements on 22 November 2024, providing additional regulatory requirements for telemedicine providers. Regarding the issuance of MCs, licensees are advised to perform regular documented reviews of the telemedicine services provided by their medical practitioners, and it is noted that medications and MCs are to be prescribed and issued with appropriate clinical assessment and on proper medical grounds. In addition, the circular stipulates that "Cases with short consultations and multiple issuances of MCs over a short period of time to the same patient (eg, three or more MCs within a 30-day period) are (to be) escalated and reviewed internally."
Final notes
Below are some other important points to note from the Joint MOH-HSA-SMC Circular on the ethical and professional standards of care expected of every medical practitioner during teleconsultation:
- That practitioners should practise within the limits of their own competence, and to refer cases to specialists where appropriate.
- That practitioners have to ascertain that telemedicine is the appropriate mode of service delivery for each case, and that there is a need to inform the patient of the limitations of teleconsultation.
- That practitioners should be aware of the professional standards and regulatory restrictions which need to be adhered to when prescribing medications with high risk of addiction, such as controlled drugs, codeine-containing products, opioids, benzodiazepines and hypnotics.
- That MCs and medications are only issued based on adequate clinical assessment.
In conclusion, telemedicine is an emerging field and is still at a nascent stage. The practice of telemedicine is likely to evolve over time and adopt newer methods or technologies. Doctors are advised to keep abreast of these changes and consider undergoing appropriate training before embarking on being a provider of telemedicine services.
SMA and the SMA Centre for Medical Ethics and Professionalism supports lifelong learning in the areas of medical ethics and professionalism. To find out more about the courses and events we conduct, visit the SMA Courses and Events page at https://www.sma.org.sg/courses-&-events.