Telemedicine
Kenneth Lyen
INTRODUCTION
The COVID-19 pandemic has been a boon for telemedicine. According to Singapore public healthcare institutions, between 2017 and the beginning of 2020, there were only 1,947 patients using telemedicine. The number of patients employing this service blossomed to 24,227 by October 2020, and in March 2021, it increased further to 36,000. In early 2020, there were only 53 listed telemedicine providers, and this number has expanded to over 600 in early 2021.
The reason for this explosion of telemedicine utilisation is due to several factors. One of them is the introduction of the circuit breaker measures in early 2020 that deterred patients leaving home, restricted travel and the number of people allowed to gather in any one place. Although visiting doctors was permitted, unnecessary consultations for minor complaints were discouraged. There was also some public reluctance to go near hospitals and clinics for fear of catching COVID-19. On the positive side, telemedicine meant that there was no need to sit for long periods waiting to be seen by the doctor. It was far easier to talk to the doctor via handphones and computers. Patients could even opt to have medicines delivered directly to their homes, and some public institutions waived the delivery fees.
DEFINITION
Wikipedia defines telemedicine as “the use of telecommunication and information technology to provide clinical health care from a distance.” It is particularly effective in helping those patients who have difficulty physically accessing direct medical contact, such as in rural communities. Prompt advice in the management of accidents and emergencies in remote areas has saved lives.
A BRIEF HISTORY OF TELEMEDICINE
You could say that telemedicine started with the invention of the telephone and one could consult a doctor by a mere phone call. Some of you might remember carrying a pager which sent you a phone number, and you had to scramble around looking for a land line to return the call. All this changed with the invention of the mobile phone, but the earlier models could only communicate voice messages. Later phones could transmit text messages and photographs. As the speed and volume of transmissible information increased, you could send larger files which carried greater clarity and even allowed you to send videos and do video conference calls. Then came cloud storage, enabling everybody to store and simultaneously view and alter the materials sent into the cloud.
TECHNIQUES OF TELEMEDICINE
Telemedicine is generally practised from a hub, where a distant practitioner delivers service and advice through a telecommunications system. Current communication devices include handphones, computers, and teleconferencing webcams. Nowadays, nearly all medical specialties, nursing and allied health professionals, are incorporating telemedicine into their operations.
The mobile phone using wireless networking (Wi-Fi) is probably the most popular data transmission system used in telemedicine. Sensing devices can emit signals that can be transmitted to the handphone and in turn sent to distant healthcare facilities. These sensing devices are increasing the range of parameters measured, as well as in their sophistication. The more popular sensing devices in medical use include those that measure the electrocardiogram (Holter ECG), blood pressure, oxygen saturation, temperature, noninvasive skin glucose monitoring, global positioning sensors (for Alzheimer patients), activity trackers that can sense how many steps you have walked, and sensors embedded into pills that can check if you are adhering to the medication. I am intrigued by a new wearable device that can sense psychological depression (Takeda and Cognition Kit) which is currently on trial. If this works, it might cut down the rates of suicide. This list lengthens every year.
WHAT ARE THE BENFITS OF TELEMEDICINE?
The march of technology is unrelenting and, like it or not, we are powerless to resist or ignore it. On the positive side, the improved communication between doctor and patient can benefit patients, especially those who live in remote areas, and those who have difficulty with mobility, such as the elderly and the disabled.
1. No Cross-Infection
During the current COVID-19 pandemic, Singapore reported over 60,000 cases and 30 deaths. If patients do not visit clinics or hospitals, then there is no cross-infection. Clinics also limit the number of patients visiting by insisting on booking appointments, and social distancing them by separating the seating in the waiting room.
2. No Traveling
Presently, telemedicine is used for patients who have already been receiving treatment by a doctor, either a recently discharged in-patient or a regular out-patient with a chronic disease like diabetes or hypertension. As mentioned above, monitoring blood pressure, ECG, oxygen saturation, blood glucose skin patch, etc can be done at home, and medical consultation can be carried out by video-conferencing, preferably on a secure network. Follow-ups done at home saves the patient making extra trips to the clinic or hospital. Overseas patients unable to travel to Singapore have no choice but to use telemedicine for consultations. However, new patients or patients with a new complaint might still be required to physically travel to consult a doctor in person. Appointments booked online enable clinic staff to access patients’ information more readily and has reduced clinic waiting time.
3. Initial Management of Emergencies
Some acute emergencies require prompt management, and the rescue service may be taking too long to arrive. Video-conferencing to instruct the patient or bystanders to initiate first aid or some other action, might make a difference between life and death.
4. Subspecialty Opinions
Telemedicine can be used to manage unusual disorders especially if the pertinent subspecialists are not available. These include rare dysmorphic or genetic disorders, certain congenital heart diseases, atypical skin conditions, and unusual movement disorders, etc.
A wide variety of conditions, some common, some rare, can be managed by telemedicine. For example, I occasionally receive a phonecall, a photo or video sent to me by an old patient who is traveling in a country that does not have good medical services, and I am asked to give an opinion. I always preface my remarks by saying that looking at a photograph or a video is never as good as seeing the patient in the flesh, and therefore my diagnosis may be subject to a degree of error. I must admit that I am worried about the medical-legal implications of telephone diagnoses.
Another scenario that I have encountered is when I have a patient with a difficult diagnosis or management issues. I will discuss the problem (without divulging the patient’s identity) over the handphone or computer with a close colleague who I know has the appropriate specialist knowledge. This is an extension of the old hospital corridor consultation, except now it is a more distant consultation.
5. Medical Education
Several medical schools, including Yong Loo Lin and Lee Kong Chian Schools of Medicine, videotape their lectures and allow students to watch the lessons using mobile phones or computer tablets. These schools also conduct assessments and tests online. Medical books can be downloaded for reading on tablets and mobile phones, and the YouTube is a great resource for video instructions on medical topics and surgical procedures. Students find these additional sources of information extremely useful, and some have stopped attending lectures and watch the recorded videos at home. Even interviews for some medical school admissions have sometimes been conducted via videotelephony.
SUMMARY
In summary, telemedicine has many benefits, including avoidance of spreading infectious diseases, reduced doctor visits, reduced clinic waiting time, accessing subspecialist opinions, home monitoring of several medical parameters, and enhanced online learning at home. The bottom line is that there is overall improved quality of healthcare and medical education, and ultimately it has reduced overall costs of healthcare.
WHAT ARE THE PROBLEMS AND LIMITATIONS OF TELEMEDICINE?
Something is seriously missing when doctors and patients do not meet face to face.
a) By the way, there’s another problem…
Let me illustrate this with a personal example. A mother brought her 3-year-old son to see me because of a slight cough and runny nose. There was no fever and thorough physical examination was normal. I then asked the mother if there was anything else on her mind. She then told me about her worries about his development, that he was only saying a few single words, and that he was not playing with the other children in the playgroup. The boy turned out to be on the autistic spectrum, and that was the main reason why the mother brought her to see me. But the trigger for the consultation was the cough and runny nose. Quite often the ostensible reason for consulting a doctor may not be the real reason. It is only with direct contact that the real reason for the consultation surfaces.
b) Overlooked Diagnoses
Once, I saw a 1-year-old baby boy because of diarrhea, but while examining the child I noticed that there were squint eyes and an undescended testis. Both of these conditions would have been missed if mother had only communicated with me on the phone or via the internet. The consequences of missing these diagnoses include amblyopia with loss of visual acuity, and a risk of future testicular cancer, respectively. Direct human contact may be vital in medical diagnosis.
c) Clinical Judgement
Another reason why direct contact with patients can be extremely important is in the evaluation of the severity and urgency of a condition. Assessment of pain is a good example. I have had patients who are extremely sensitive to what I consider to be mild pain, and I have also seen the opposite, where a rather stoic patient can withstand severe pain without batting an eyelid. The art of medicine is the art of judgement. This includes this ability to judge the gravity of an illness, and to discern a “phoney” patient looking for a medical certificate, from the genuine patient. A balanced judgement assessing what is the optimum management strategy is best made by direct interaction with the patient.
d) Bad News
One of the grave duties that we have to perform as a clinician is the breaking of bad news. This is a serious moment when a great deal of sensitivity is called for. We need to assess whether or not the person to whom we are breaking the news fully understands the gravity of the information. There may be denial, guilt, anger, tears, depression, and one needs to deal with each of these reactions delicately and diplomatically. The road to acceptance may take a long time and sometimes more than one session. By listening and talking, we try our best to help the patient or relatives weather the sadness. I think this is where the personal touch of face-to-face interaction transcends remote telemedicine.
e) Medical-Legal Issues
Distance diagnoses using mobile phones or the internet is not the same as face-to-face evaluation of a disease. Of course both modes of consultation can have potential errors in diagnosis and treatment. Who is to blame if things go wrong with telemedicine? What if the doctor and patient are residing in different countries, how does international law view legal disputes? What if the overseas doctor consulted has a medical degree not recognized by the country from which the patient is seeking advice?
It is often claimed that a patient’s privacy is secure, but the recent hacking of hospital medical records reveals that there is no such thing as absolute security in computer technology. Who takes the blame for the breach of the patient’s confidentiality?
While it is inevitable that telemedicine will continue its march into the healthcare domain, I think it is important to remember its limitations. Perceiving a patient’s worries, unraveling the secondary fears not initially expressed, are reasons why we cannot abandon personal doctor-patient contact. While technology allows you to do distance monitoring of blood pressure, ECG, oxygen saturation, etc, there are still areas that humans can do better. These include palpating for swellings and lumps, examining a crying baby, and the early detection of subtle signs. Medicine must address not just the physical, but also the emotional aspects disease. We must not forget that we also have a duty to be healers of the mind.
WHAT IF A TELEMEDICINE COMPANY FAILS?
New startups often fail. What happens to the patients' data? Who owns the information? How can we maintain patient confidentiality if one company buys up another?
FUTURE OF TELEMEDICINE
1. Increasingly large percentage of a doctor's practice will be conducted via telemedicine. The personal touch will be reduced, while medical mistakes and conditions overlooked will increase. The cost of medical consultation will decrease.
2. Artificial Intelligence
The future of telemedicine is already here. Some of my patients try self-diagnosis on the internet. There are several online self-diagnosis programs, including the Mayo Clinic Symptom Checker, the American WebMD website, the Isabel Symptom Checker, Symptomate, and many others. By running several of these programs, patients cut down on the rate of wrong diagnoses.
Some skin conditions, like differentiating between benign and malignant melanomas, are currently more often correctly recognized by computers than human dermatologists.
3. Robotic Surgery
The advent of robotic surgery opens another door for telemedicine. A surgeon need not be operating in the same hospital, and not even in the same country.
CONCLUSIONS
Telemedicine is rapidly increasing its foothold on all aspects of medical practice and medical education. No choice, we have to embrace it, especially during the COVID-19 pandemic. But we do not wish to displace the human interaction baby by filling the bathwater with high tech. The evolution of medicine obligates us to use telemedicine and technology with intelligence and wisdom.
REFERENCES
Joyce Teo: Public healthcare institutions step up as use of telemedicine grows. Straits Times 19 April 2021.
Ministry of Health: Voluntary Listing of Direct Telemedicine Service Providers 12 April 2021
Jipson Quah: Telemedicine: Medical goldmine or minefield? SMA News. 2020; 52: 16-17.
https://www.sma.org.sg/UploadedImg/files/Publications%20-%20SMA%20News/5201/Opinion%203.pdf
Lyen Kenneth: Telemedicine: Benefits and drawbacks. SMA News: 2019: 51: 5-7
https://www.sma.org.sg/UploadedImg/files/Publications%20-%20SMA%20News/5101/Feature.pdf
Alexis S Gilroy and Catherine Barrett: What is… telemedicine? American Bar Association: 2016.
Andrea Kamenca: Telemedicine: A Practical Guide for Professionals. Mindview Press: 2017.
Eric Topol: The Patient Will See You Now: Basic Books: 2016.
Matusitz, Jonathan; Breen, Gerald-Mark (2007). "Telemedicine: Its Effects on Health Communication". Health Communication. 21 (1): 73–83.
Berman, Matthew; Fenaughty, Andrea (June 2005). "Technology and managed care: patient benefits of telemedicine in a rural health care network". Health Economics. Wiley. 14 (6): 559–573.
Four Ways Telemedicine is Changing Healthcare: https://www.healthleadersmedia.com/innovation/4-ways-telemedicine-changing-healthcare
What is Telemedicine? https://vsee.com/what-is-telemedicine/
Telemedicine (Wikipedia): https://en.wikipedia.org/wiki/Telemedicine
The surgeon who operates 400 km away: http://www.bbc.com/future/story/20140516-i-operate-on-people-400km-away
Regulating Telehealth: The New Frontier in Healthcare: https://lawgazette.com.sg/feature/regulating-telehealth-new-frontier-healthcare/
Legal issues confronting 21st century telehealth: https://www.bcmj.org/articles/legal-issues-confronting-21st-century-telehealth
Takeda and Cognition Kit for depression: https://www.takeda.com/en-us/newsroom/news-releases/2017/takeda-and-cognition-kit-present-results-from-digital-wearable-technology-study-in-patients-with-major-depressive-disorder-mdd/
ACKNOWLEDGEMENTS
I thank Dr Oliver Chen of Telemedicare, and Dr Robert Kwok of Radiologic Clinic Mt Elizabeth Hospital for valuable discussions and providing insights into current advances in telemedicine.
Written by Kenneth Lyen
Original published in Singapore Medical Association News 2019; 51: 5-7
Revised 21 April 2021
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