TELEMEDICINE has its attractions in that the use of telecommunications technology enables doctors to overcome the barrier of distance to diagnose and treat patients, even those in rural areas.
But, as the telemedicine scene grows in Singapore, health professionals and industry players are increasingly confronting fundamental questions about the limits and ethical obligations of the new technology.
Gastroenterologist Tan Chi Chiu said it may be risky, for example, for a doctor to treat a stomachache remotely through a video consultation.
"Without examing the patient and determining where the exact point of maximum pain is, how would you know that you haven't missed a cue for appendicitis, as opposed to mild gastritis?" he asked.
Several telemedicine players told The Business Times that their workaround is to maintain a low threshold for redirecting patients to brick-and-mortar clinics, and to undertake consultation by video only in specialised circumstances.
The number of telemedicine startups in Singapore has grown in recent years. Of the nine such providers in the Ministry of Health's regulatory sandbox, six are startups: WhiteCoat, MyDoc, Doctor Anywhere, MaNaDr, Doctor World and HiDoc.
The newest players come with the blessings of healthcare incumbents: HiDoc is backed by the Singapore Medical Group (SMG), while Doctor World counts Raffles Medical Group as a partner.
Meanwhile, older players have rapidly scaled up their capabilities. MyDoc, founded in 2012, has a client base of more than 200 companies and insurers, the employees and policyholders of which are served by its network of doctors. The startup has trained over 100 doctors, the majority general practitioners (GPs). It declined to say how many are actively rostered.
MaNaDr, started by general practitioner Siaw Tung Yeng in 2016, has more than 600 local doctors on its platform; seven in 10 are GPs, and the remainder, specialists.
With scale, controlling the risk of misdiagnosis is more challenging. MaNaDr and MyDoc said they address this through stringent selection of doctors and do not hesitate to refer patients to physical clinics where warranted.
MaNaDr said it brings only experienced doctors on board. Dr Siaw said most of them on the platform have 10 to 20 years experience and run their own clinics. And many users of the platform are long-time patients of these doctors.
"Misdiagnosis should not even happen in telemedicine because ... we tell the doctors, don't be so gung ho. Certain things, if you cannot use telemedicine, please don't use it," he said, citing gastric conditions and persistent fever as examples.
About 10 per cent of MaNaDr's patients are redirected to physical clinics because a doctor is unable to make a diagnosis through a tele-consult, he said.
Over at MyDoc, the proportion of referrals to physical clinics is 27 per cent. "What we train our physicians on is that they should never compromise patient safety. If there's a grey area, then you refer it out," said its chief executive Snehal Patel.
Doctor Anywhere, founded in 2015, has about 50 GPs on board. Its chief operating officer Kevin Kok (see amendment) said that with the lack of a physical exam, its doctors take a more conservative approach. There is a lower threshold to refer patients out. Up to about 5 per cent of Doctor Anywhere's patients are advised to go for physical consultations because tele-consultations are unsuitable for them.
Like ride-hailing and other gig economy services, many telemedicine startups adopt the asset-light model of not employing the doctors.
WhiteCoat, however, has employed six full-time doctors in a physical clinic it owns. Its CEO Bryan Koh said: "We prefer to house them together so that they can compare case notes and discuss more difficult cases." This means higher costs, but he said it also ensures better quality.
"They have fortnightly doctor meetings where, together with our medical advisor... they go through their cases and constantly look at refining our protocols," he added. About 3 per cent of the company's telemedicine cases are referred out to WhiteCoat's own clinic or other GP clinics.
Ultimately, the startups stress that with acute ailments, they do not pressure doctors into making diagnoses they are uncomfortable with.
In order to grow, these players are looking to expand their proportion of chronic patients and specialist doctors.
WhiteCoat's Mr Koh said: "About 11 per cent of our patients are chronic patients, but I would like to see this number higher, because there is so much potential. There are also quite a few specialities that are suited for telemedicine. One that comes to mind is mental wellness and psychiatry... and dermatology."
Doctor Anywhere plans to launch a specialist module on its app. Its CEO Dr Kok said: "As the practice becomes more mature, our patients who come in for acute issues will come in for chronic issues like diabetes and high blood pressure medication. We see this as the next phase of our growth and one of the main revenue drivers for our business."
Interestingly, SMG-backed HiDoc is starting from the opposite end: Its platform admits only specialists on board, but plans to include GPs on board in future. Its CEO Christina Low said: "We will still be managing chronic cases, not acute cases like cough and colds ... This will be more for follow-up care after the patient has seen a specialist."
The challenge is not a static one. Dr Jeremy Lim, partner for health and life sciences at global management consulting firm Oliver Wyman, for instance, said the limitations of telemedicine today may not exist in future. Remote physical examinations can be enabled with technologies such as digital stethoscopes and pulse oximeters, which can be connected via smartphones.
"Hence, the list of conditions amenable to telemedicine models of care will grow over time... We should also be open to hybrid models, in which lesser-skilled or qualified health care professionals support (telemedicine) doctors by being (with patients) in person."
Dr Tan the gastroenterologist supports the rise of telemedicine; he had helped draft the professional and ethical aspects of the 2015 National Telemedicine Guidelines. He said he has not taken part in telemedicine platforms, but this comes from a lack of demand from his patients and time constraints.
Whatever the future holds, operators must be honest and realistic about the benefits and limits of their platforms, he said: "I would hate to see a situation where patients have unrealistic expectations of telemedicine and on the other hand, doctors face lots of pressure to deliver telemedicine without admitting they can't make a proper diagnosis or offer a management plan which they are confident about."
Amendment note: Due to an editing error, an earlier version of this story incorrectly referred to Dr Kevin Kok as chief executive officer of Doctor Anywhere. He is in fact its chief operating officer. The article above has been revised to reflect this.