Starting a Telemedicine Practice: Legal Considerations
Amidst the tumult and noise of the Covid era, telemedicine quietly found its place within our nation. Birthed in 2017, and blossomed throughout 2020 during early lockdown phases, Singapore has licensed Telemedicine under the Health Services Act (HSA) since mid-2022. To put its growth into perspective, there were only 1,947 telemedicine users from 2017 to the start of 2020. But by January 2021, telemedicine providers in Singapore had amassed 36,000 users.
As a result of its growing popularity, many in the medical scene have expressed interest in running a telemedicine practice, though some may be unsure how to get started. This article will explain the legal considerations of starting a telemedicine practice in Singapore, including whether you need to get a licence and so on.
In this article, we will cover:
What is Telemedicine?
Telemedicine refers to an online doctor service that allows prospective patients to consult a Singapore-licensed doctor, without having to make the physical trip down to their clinic, for examination, diagnosis, and medicinal prescriptions with just a mobile phone/laptop.
Beyond these services, telemedicine services may also be able to facilitate specialist referrals, medicine refills, travel medication advice, laboratory and health screening results reviews. The process is meant to be generally straightforward. Doctors will ask questions pertaining to symptoms, and discuss the diagnosis and/or prognosis with patients. Medication, along with a medical certificate, may be prescribed and delivered to the patients’ homes if needed.
Pilots during the early stages of this process only covered the review of stable consultations which did not require physical checks/tests (i.e., mental health). It has now evolved into providing treatment for a wide range of non-emergency medical conditions with mild-moderate symptoms, as well as follow-ups on chronic conditions. Examples include:
- Acute illnesses: Common cold, fever, sore throat, cough, diarrhoea, constipation, rashes, red eye, and headaches.
- Chronic conditions: Hypertension, high cholesterol, diabetes, and gout.
Severe conditions such as choking, trauma with open wounds, burns, shortness of breath, fever for more than 3 days, etc. that may require urgent medical attention are excluded from the general scope of service provided. Patients experiencing these symptoms are advised to visit the A&E department instead, or dial 995 for an ambulance.
It is worth noting that beyond the traditional scope of services provided by general practitioners, there has been an increased focus on dermatology services, Men/Women’s Health, and Mental Health. Examples include:
- TWL Specialist Skin & Laser Centre which first offered teleconsultation for its dermatological services in February 2020. While not all conditions are suitable for teledermatology, there are many which can be treated, e.g. acne/eczema/perioral dermatitis etc.
- Noah, a men’s health service platform which offers a range of treatments and provides advice, consultation, and MOH-approved products and supplements. Mental health assistance is also provided for suitable patients, including seniors, with existing mental health conditions at Public Healthcare Institutions.
- IMH offers phone and video consultations with a healthcare provider (i.e., doctor, psychologist, etc.) via phone or a secured video conferencing platform (video consultation) to patients if they require regular specialist outpatient care. Telemedicine also extends to online counselling and psychotherapy where needed.
Hospitals, polyclinics, and private clinics are some of the healthcare institutions that may provide telemedicine services in Singapore. Examples include Tan Tock Seng Hospital, National Skin Centre, and Pinnacle Family Clinic.
Is There a Legal Framework Governing Telemedicine Services in Singapore Currently?
Yes. The National Telemedicine Guidelines serve as a general direction for providers, subject to their unique conditions in applying the sections within. Essential sections, amongst others, include:
- Duty of Care:
- Healthcare professionals must establish clear responsibilities for both patient/ caregiver and other healthcare professionals (e.g., who to deliver which aspect of care, to ensure follow-ups, to keep patient’s notes, etc.).
- Standards of Clinical Care:
- Healthcare professionals must provide services as part of a structured and well-organised system. If face-to-face consultations are reasonably practicable, the delivery of care via telemedicine must not be inferior compared to the former.
- Before providing services to a patient, the provider must deem them suitable based on factors such as clinical context, objectives, compatibility of technology, literacy, and availability of satisfactory alternatives.
- Privacy and Patient Confidentiality:
- A confidentiality policy that complies with applicable existing legislations (e.g., the Personal Data Protection Act, SMC Ethical Code and Ethical Guidelines) must be in place to safeguard patient information and records.
- Licensing & Credentialing:
- Healthcare professionals from or within Singapore must be registered and licensed with the respective regulatory and licensing bodies. There is no additional/different privilege for providing service through telemedicine.
These guidelines are designed to be complementary with the HCSA, which is effective, in conjunction with other various disparate laws. For example, common law would still apply to certain aspects/activities of telemedicine (i.e., contract disputes between service provider and patient). Other examples include the tort of negligence which will continue to apply in the event of any misdiagnosis, advice or treatment by a doctor, and a breach of laws under the Personal Data Protection Act in the event of any data breach. Legislative pieces such as The Health Products Act also regulate telehealth products (e.g., supplements, medical devices) that may be used in the provision of such services.
The HCSA has discontinued a Voluntary List containing direct telemedicine service providers, as they seek to regulate and streamline the processes. The licensees’ information (e.g., operating hours, contact details), are now listed on HealthHub. Prospective telemedicine providers should note that this is an evolving area that is subject to future change/revisions, and you should remain abreast with these developments.
Do I Need to Apply for a Licence to Provide Telemedicine Services?
Yes. As per the MOH, you need to apply for special licences under the HCSA, subject to certain fees depending on the licence. The licence you apply for depends on the services provided. Examples include:
- Outpatient Medical and Dental Services: $360 – $720;
- Assisted Reproduction Service Licences: $1,900;
- Emergency Ambulance Service: $1,000 – $1,300; and
- Outpatient Renal Dialysis Service: $850.
This is in conjunction with a non-refundable application fee of $100 per service licence which will be retained despite withdrawal/ rejection. There are also late fees, and amendment fee charges, amounting to 20% of their full licence fees, and $100 respectively.
To apply for a licence (Phase 1/2 licensable healthcare service), you will need to:
- Login to the Healthcare Application and Licensing Portal (HALP) using SingPass or CorpPass.
- Receive confirmation on inspection date.
- Receive email notification on application status after all licensing requirements have been met.
- View e-licence on HALP upon approval.
- Update on HALP if there are any changes to your licence.
If you need technical assistance, you can contact (via phone or email), a helpdesk available from Mon-Fri, 8am-8pm, excluding Public Holidays, at 6768 9796 or firstname.lastname@example.org.
The good news is that most licensees will see no change/reduction in their licence fees, unless you provide certain additional services. This is thanks to regulatory fee bundles, and a gradual fee increase mechanism. Please visit here for more information.
What are My Duties as a Telemedicine Provider?
It is of paramount importance that doctors offering telemedicine services have a valid medical licence to practise – and the provider may need to ensure that the doctors are not under suspension/investigation by the Singapore Medical Council (SMC).
Beyond the foremost qualification of the above factors, you will also have duties of:
- Reasonable standard of care. According to the National Telemedicine Guidelines released by the MOH, doctors who offer telemedicine services must ensure a reasonable standard of care for patients. This is determined by their medical condition, purpose of seeing the doctor, and whether the care needed can be met by the doctor. Doctors are also expected to follow existing Clinical Practice Guidelines (CPGs), and the Ethical Code and Ethical Guidelines provided by SMC to ensure patient safety and standard of care. In essence, doctors have a duty to provide competent, compassionate, and appropriate care to patients, and to do no harm. Despite the absence of physical interaction, medical negligence/malpractice can still occur via such platforms. This happens when a healthcare professional fails to exercise an accepted standard of care in medical professional skills/knowledge, resulting in injury, damage, or loss. For instance, you can be negligent if you do not refer a patient for an in-person consultation despite symptoms of a worsening condition which reflect an obvious need for physical consultation and treatment as soon as possible, especially if the matter is time-sensitive. As a telemedicine provider, you must be aware of the potential consequences for a breach in standard of care; from mediation to out-of-court settlements or legal action taken against you.
- Proper disclosure and standards of confidentiality. First, you must clearly indicate the limitations of your services at the start of the consultation, provide sufficient information about the service provided, and refer the patient to an in-person consultation if need be. Next, you must take reasonable care to ensure patient confidentiality and comply with existing laws governing the sharing and use of personal data (i.e., adopt state-of-the-art security controls, encrypted and stored in enterprise-grade cloud solutions).
Please refer to our other article for more information on the duties of a doctor providing telemedicine services.
Regarding medical indemnity, it is important for you to remain informed on the risks associated with the practice as the landscape is still evolving and maturing, and because you are still providing medical services. You should remain up to date with your continuing medical professional development obligations, relevant training etc. to remain updated on the best clinical practices, including the realm of telemedicine.
Can I Subcontract My Telemedicine Services? How Might This be Done?
Yes, you can subcontract telemedicine services. According to the MOH, both “independent doctors/dentists offering teleconsultations themselves, OR organisations who hire or engage doctors and/or dentists to provide teleconsultations as part of the organisation’s services”, are permitted.
For example, if the new start-up/ business wishes to create an online platform, and subsequently engage medical professionals to provide approved services, it is permissible to do so pending the fulfilment of licensing requirements of the respective medical professionals:
- They must hold an Outpatient Medical Service/Outpatient Dental Service licence; and
- Obtain approval for the remote mode of service delivery (MOSD).
This is dual-pronged, and provision of telemedicine services without meeting these requirements, will constitute a breach under section 8 of the HCSA. You will be liable to a fine of up to $100,000 ($200,000 if you have a previous qualifying conviction) and/or imprisonment of up to 2 years.
The smoothness of such an arrangement also depends on the clarity of terms within a contract (i.e., identification, job scope, qualifying criteria, duty of care to patients). To gain further clarity on who you can subcontract it to, and what the criteria lays out, please visit here.
How Do I Ensure I Protect Doctor-Patient Confidentiality?
It is important to protect doctor-patient confidentiality so that patients can be treated and advised appropriately. If confidentiality is breached, patients may be reluctant to divulge information and be transparent with their doctors in the future, thus affecting their treatment. Beyond that, breaches of confidentiality have legal implications and it is ironclad that practices have a legal obligation to maintain it.
Call from private settings
The basic requirement would be that you call from a private setting such as your office/appointment room. You should also remind your client to be in a private and safe location, where he/she feels comfortable to openly discuss their health concerns. You can also use a privacy screen to prevent others from viewing patient information over your shoulder as a further precaution.
Call via safe platforms/approved applications
Whilst certain providers have specific apps that have video consultation capabilities, an example of a publicly accessible, and generally safe platform, would be Zoom. It is recommended by the National University Hospital, the Singapore General Hospital, and used by many other medical bodies in Singapore.
Have systems in place that protect patients’ personal data
Holistically clear and organised infrastructures/systems are required. You should ensure that there are proper Identity and Access Management mechanisms in place to prevent unauthorised access to the platform/patient records, whilst also preventing identity impersonation where possible.
You should also try to ensure that there is impermeable/updated software (strong authentication/encryption/enterprise-grade cloud solutions). There should be regular training, and audits to ensure that the processes in place are up to date, and that all staff are aware of good practices/ habits.
Familiarise yourself with the relevant laws and ensure compliance
You should be well versed with the requirements for protecting personal data under the Personal Data Protection Act (i.e., ensuring you have patients’ consent prior to collection/usage/disclosure of data, etc.).
Compliance with the relevant laws/regulations is also key, and it is important for doctors to remain updated and cognizant of the changes in any of their governing legislation.
Given the still-evolving scene of telemedicine, you must remain vigilant and reactive to a wide range of updates/revisions in legislations/guidelines/other relevant authorities. This concerns not just the intangible requirements to set up your business, but also the tangible bodily well-being and health of actual patients.
There is no denying that telemedicine is an innovative way to provide healthcare services, however, you must not lose sight of the duties and responsibilities that every doctor must uphold and abide by.
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