Commentary: MaNaDr Clinic scrutiny is an opportunity for telemedicine to prove itself

SINGAPORE: Is it clinically and ethically sound to prescribe medication and issue medical certificates (MC) after very short teleconsultations, with video calls lasting one minute or less? The Ministry of Health (MOH) has its doubts, after investigations into MaNaDr Clinic found a “very large number” of such cases.

MOH announced on Thursday (Oct 24) its intention to revoke the clinic’s licence amid concerns over care standards and safety, and will refer 41 doctors who provided teleconsultations for MaNaDr Clinic to the Singapore Medical Council (SMC) for potential “professional misconduct”. This comes as a huge disappointment to healthcare professionals in the digital health ecosystem.

It is in the interest of the sector for the clinic and doctors to receive any appropriate regulatory actions, once the specifics of the case play out fully.

However, it is also essential to not let this incident tarnish the credibility of telemedicine and lead us to dismiss its value to the Singapore health system.

COMPLEMENT SINGAPORE’S BUSY HEALTHCARE SYSTEM

Let’s not throw the baby out with the bath water.

In consultancy Bain and Company’s 2024 Asia Pacific Frontline of Healthcare Report, over half those surveyed in Australia, China, India and Indonesia had used telemedicine in the 12 months prior. In Singapore, the equivalent percentage was 43 per cent, an almost-threefold increase to pre-pandemic numbers.

Patients with well-controlled chronic conditions, such as diabetes or high blood pressure, can have remote follow-ups substituting some of the in-person visits, saving time and increasing convenience for both doctors and patients.

And while telemedicine was invaluable during the pandemic to reduce contact and slow the spread of the coronavirus, it has also blossomed in its applications beyond as a simple “virtualisation” of a doctor’s consultation or substitution of an in-clinic attendance.

With the right configuration of remote skills, patient mix, caregiver support and potentially even medical equipment delivered to patients in their home settings, telemedicine can be a powerful complement to our very busy and strained largely in-person healthcare delivery system.

During the pandemic, National University Hospital, Singapore General Hospital and Khoo Teck Puat Hospital all implemented virtual wards systems to care for less severe COVID-19 patients remotely. This initiative has assisted more than 700 patients and saved hospitals more than 5,000 bed days, which meant freeing up precious capacity and manpower for other patients (including those with non-COVID-19 conditions) requiring hospitalisation.

There can also be other benefits from using telemedicine. The American group Kaiser Permanente reported in 2019 that having dermatologists remotely supporting primary care doctors in examining photos of skin lesions resulted in better diagnosis of skin cancers and a reduced need for patients to undergo a biopsy.

As Singapore’s population ages, the demand for healthcare will increase substantially. Plans are underway to expand physical healthcare infrastructure, but there will always be competing space demands in tiny Singapore.

RETHINKING ROLE OF TELEMEDICINE

With the spotlight on telemedicine, it would be timely to review the existing guidelines and practices to assure patients, doctors, employers and other stakeholders of the continued role telemedicine in Singapore can and needs to play as well as the governance mechanisms to ensure appropriate use.

First, telemedicine is an adjunct to traditional medical services and builds upon the established infrastructure and norms of in-person practice. The foundational tenet of “First, do no harm” has to be preserved in telemedicine and the threshold for declining to use telemedicine as a suitable consultation modality or switching to an in-person consultation should be low.

Second, the digital and remote nature of telemedicine offers opportunities to consider a more nuanced framework that considers its unique strengths and challenges.

For example, the telemedicine consult can begin even before the physician engages “live” with the patient through use of symptom questionnaires, and can extend hours or even days after the first interaction through automated follow-up queries or check-ins. Seen in this light, telemedicine can be viewed as a “video” of patients’ clinical evolution rather than just a one-off “snapshot” observation.

Would a single in-person consult be better, worse or equivalent to a telemedicine consult that involves an initial remote assessment and a half-dozen progress reviews?

The Singapore Medical Council’s Ethical Code and Ethical Guidelines (ECEG) states that doctors providing telemedicine must “endeavour to provide the same quality and standard of care as in-person medical care”. Note the ECEG does not prescribe the same steps or processes but instead focuses on quality and standard of care. This has been useful to telemedicine as overly rigid rules can stifle the growth of telemedicine and limit its ability to innovate and expand into new areas of care.

However, we as healthcare professionals can do more to delineate what is appropriate practice-articulated norms by professional societies and issuance of clinical practice guidelines. Even reports of complaints and learned peers’ opinions can be useful in establishing the parameters of what “endeavour to provide the same quality and standard” means in practice.

As the equivalent to the legal profession’s case law builds up, telemedicine’s boundaries will naturally become clearer and doctors and operators will know more specifically what would be permissible and what would be frowned upon.

POLICING SICK LEAVE

Third, we should not infer from the MaNaDr Clinic episode that consultation times and MC issuance are the metrics to determine the safety and quality of clinical care in telemedicine.

The actual time doctors interact “live” with patients may not accurately reflect the full clinical encounter. Here, the adage “a measure that becomes a target can be gamed” rings true: Unethical doctors could simply drag out the video calls without providing quality care.

The same goes for dubious issuance of MCs. This is by no means a feature unique to telemedicine.

Outcome-based metrics would be valuable in both in-person and telemedicine consultations. Perhaps a more systematic way to track health outcomes, patient satisfaction, and inappropriate diagnoses leading to delayed hospital attendance would be worth looking at.

Under the upcoming Health Information Bill, it is proposed that both public and private sector patient information including consultation dates, diagnoses and medicines prescribed be automatically entered into the central National Electronic Health Record. With consult data captured centrally for both in-person and telemedicine, much richer analyses can be conducted to compare the different modalities for patient care outcomes.

Finally, there have been calls for an honour-based sick leave system, at least for a specific number of days. In 2022, Health Minister Ong Ye Kung shared his hope that such a model becomes “a more prevalent practice”, noting also that consulting simply for MCs is “not the best use of the doctor’s precious time and resources”.

As we move forward, should doctors continue to be tasked by society to police sick leave on behalf of employers? Or are there changes in workplace culture and attitudes that could be more fruitful?

“Never waste a good crisis” as the saying goes. Singapore has the opportunity to undertake a root and branch review of telemedicine in the context of how it is today and how it should be tomorrow.

Singapore does not have geographic access issues the way that much larger countries with dispersed populations may have, and telemedicine’s use case in expanding access may be more tightly circumscribed. On the other hand, we have reliable, high speed internet access and with advancements in video analytics and artificial intelligence, perhaps coupled with smart phone-enabled diagnostics, telemedicine platforms may soon be able to assess vital signs and conduct even “physical examinations” virtually.

It would be a pity to dismiss or downplay telemedicine now, when we have an opportunity to promote it in settings of greatest value. 

Dr Jeremy Lim is a medical doctor and public health specialist. He is author of Myth or Magic - The Singapore Healthcare System. Koh Lin Pin is an incoming medical student at the Yong Loo Lin School of Medicine, National University of Singapore.