Telemedicine in Singapore: Doctor’s Duties and Protecting Patients

What is Telemedicine? 

Telemedicine refers to the consultation of a doctor via a mobile application or video conferencing application (instead of the usual face-to-face consultation in clinics) for the diagnosis, clinical examination and treatment of disease, which a reader like yourself may seek if you feel unwell.

The doctor-patient relationship has traditionally been something that has been built in the clinic. However, with the rise of technology, demands on patients’ time and an increasing number of patients with reduced mobility, telemedicine is crucial in enabling patients to seek help for their medical conditions as needed.

This is because, with telemedicine services, patients are able to see a doctor from their homes or workplaces without travelling to the clinic or hospital.

How Does Telemedicine Work?

Various telemedicine virtual platforms are available, some of which are launched by insurance companies and private healthcare providers. These virtual platforms are able to offer healthcare consultations and electronic Medical Certificates (MCs) to patients.

In order to gain access to telemedicine services, patients must first download the application and sign up. Patients can then answer some simple questions to be referred to the appropriate doctors who can diagnose the problem and treat the medical condition.

Should a medical certificate or referral letter be necessary, an e-copy will be sent to the patient. Medication can also be delivered to the doorstep or a prescription sent via e-copy to the patient.

The current Private Hospitals and Medical Clinics Act does not cover telemedicine services and the Ministry of Health (MOH) has said in January 2020 that it intends to license telemedicine under the future Healthcare Services Act.

This is to protect patients from doctors who are not qualified to provide such services and ensure that quality care is provided to patients who choose to see their doctor via telemedicine.

This article will discuss:

• The duties of a doctor providing telemedicine services;
• What you, as a patient, should do to protect yourself from unqualified medical professionals; and     
• The actions you can take if you believe you are a victim of medical negligence or malpractice. 

Duties of a Doctor Providing Telemedicine Services

According to the National Telemedicine Guidelines released by the MOH, doctors who offer telemedicine services must adhere to certain principles in order to ensure a minimum standard of care for patients.

Standard of care

The doctor is expected to provide a reasonable standard of care via the telemedicine platform which is determined by:

• The medical condition that a patient has;      
• The purpose of seeing the doctor; and      
• Whether the care that the patient needs can be met by the doctor.  

The medical condition that a patient has

Telemedicine may be used to treat less serious illnesses such as the common flu and cough. Based on a 2014 multi-centre study performed in the United States, chronic diseases such as congestive heart failure (CHF) and chronic obstructive pulmonary disease (COPD) can be well-monitored by telemedicine.

The purpose of seeing the doctor

If your purpose of seeing a doctor is due to a serious medical condition that you have just experienced, or because your child is very ill, the doctor will not be able to see you or your child via the telemedicine application. Instead, a face-to-face consultation is necessary.

Whether the care that the patient needs can be met by the doctor

There are limitations to the care that doctors can deliver through telemedicine. By conducting telemedicine services through the display of an electronic device, doctors are limited in their ability to diagnose and treat complicated health conditions.

This means that medical conditions such as anaemia and hyperthyroidism that require medical laboratory tests or in-patient care cannot be seen by a doctor during telemedicine consultations.

However, it is important that the doctor fulfils his or her duties nonetheless when seeing a patient via a telemedicine platform. You have a legal right to expect the doctor providing telemedicine services to provide the same quality and standard of care as in-person medical care.

Disclosure and confidentiality

Doctors who provide telemedicine services need to clearly indicate the limitations of his or her telemedicine services at the start of the consultation, and refer the patient for an in-person consultation when advisable.

Sufficient information about the medical service provided via telemedicine must also be provided to patients for them to consent to seeing the doctor via telemedicine.

Such information includes what patients can expect when they see the doctor on the telemedicine platform, the limitations of using the platform and the risks involved.

Reasonable care must also be taken to ensure the confidentiality of patient medical information and to ensure compliance with existing laws governing the sharing and use of personal data.

Such measures include adopting extensive IT security controls to ensure that all patient data is securely encrypted and stored using enterprise-grade cloud solutions.

Patient safety

The responsibility for the safety and management of patients rests with the doctor responsible for the patient.

The doctor is expected to follow existing Clinical Practice Guidelines (CPGs) when caring for patients on telemedicine platforms to ensure patient safety.

CPGs are guidance to doctors produced by workgroups appointed by the MOH comprising of experts from the Academy of Medicine Singapore, the College of Family Physicians Singapore, other professional bodies and their representatives. These CPGs ensure that patients are kept safe when they are provided with the right medical care that they require. 

For example, Hypertension CPGs released by the MOH state when patients with hypertension need to be referred to a hypertension specialist or clinic for urgent in-person treatment. In such situations, a doctor will not be able to see the patient through a telemedicine application.

Apart from CPG, the Ethical Code and Ethical Guidelines (ECEG) provided by the Singapore Medical Council (SMC) also ensures standard of care and patient safety. Doctors have a duty to provide competent, compassionate and appropriate care to patients and to do no harm.

The ECEG also states that a doctor can follow up with patients who are well-known to him via telemedicine if there is no evidence to suggest that there is serious worsening of a patient’s health, or that a new medical condition has developed.

What to Do If You Suspect that Your Doctor is Not Qualified to Provide Medical Care

To ensure patient safety, it is important to prevent patients from being misled by unqualified healthcare providers.

Telemedicine providers are legally required to ensure that healthcare professionals who provide telemedicine services are appropriately qualified and competent. This involves ensuring that these professionals have been registered with the SMC and have obtained a practising certificate.

Patients, such as yourself, also have a role to play to ensure that you are seeking help from qualified medical professionals. You can check the registers of doctors maintained by the professional boards like the SMC to ensure that the doctor you are seeing is a qualified healthcare professional.

If an unqualified medical professional were to provide healthcare services, MOH can investigate and take appropriate action. This includes referring the doctor to the SMC or professional medical body for further action.

When new laws under the Healthcare Services Act come into effect in 2022, doctors providing telemedicine services in Singapore from any country must be licensed. All foreign doctors offering such services must also be registered with SMC. The ministry can publish information of unlicensed telemedicine providers to ensure patient welfare and public interest.

What to Do If You are a Victim of Telemedicine Malpractice or Negligence?  

Medical negligence or malpractice occurs when a healthcare professional fails to exercise an accepted standard of care in medical professional skills or knowledge, resulting in injury, damage or loss.

In a telemedicine consultation, this can occur when a doctor does not refer a diabetic patient for an in-person consultation at a specialist clinic after the patient reports recent feelings of tingling, pain or numbness in his or her hands and feet.

The patient’s complaint of tingling, pain or numbness are signs of worsening diabetes and the patient must be seen by a doctor in-person as soon as possible in order to receive treatment. Failure to do so will lead to loss of limb or life as a result of the doctor providing telemedicine services not exercising an accepted standard of care.

Where such failure in medical care occurs, recourse may be sought against the allegedly errant doctor, especially when the consequences are severe.

Such measures include lodging a complaint with SMC where mediation may take place following referral by the Complaints Committee. The committee can refer the case for a formal inquiry for disciplinary action or for a health inquiry to question the doctor’s physical or mental fitness to practice.

Where the dispute arises with a healthcare institution instead of a doctor, the case can be filed with the Singapore Mediation Centre for mediation under the various mediation schemes available for differing claim amounts.

Out-of-court settlements between the victim and the errant doctor are sometimes reached to recompense the victim and minimise legal fees incurred by both sides.

Alternatively, the patient may choose to pursue legal action against the allegedly errant doctor. In cases involving medical negligence or malpractice, it is prudent for you to consult and engage a medical negligence lawyer with past experience in similar matters.

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Telemedicine is a beneficial way to deliver essential medical care to patients who may otherwise not be able to receive needed medical services. However, there are important duties that a doctor providing such services must abide by.

You have the right to seek legal assistance if you have received medical care provided by unqualified medical professionals, or if a doctor may have breached his or her duty to you as a patient while receiving medical care via telemedicine.

Where medical negligence or malpractice might have occurred, do consider seeking help from a medical negligence lawyer to decide on the best legal option available to pursue your claim.