Despite the bad rap, telemedicine is the future of healthcare

For the past 14 months, the telemedicine hotline operated by Mr Sivachandran Murugasu’s company has been getting 60 to 90 calls daily.
But despite the impressive volume of calls, his team of doctors could only agree to consult with a grand total of three patients in that period.
“The first thing most callers ask for is a medical certificate (MC), so we immediately decline and turn them away,” said Mr Sivachandran, a veteran nurse whose company received its licence to provide telemedicine services in September 2023.
He and his team of nurses at Abella Agency, which also provides 24-hour emergency ambulance services, triage patients over the phone for free — advising them on whether a teleconsultation or hospital is more appropriate for their ailments.
Patients are only charged a fee if they consult with their doctors.
“We genuinely want to help patients — we’re not (just) trying to make money out of this,” he said.
Telemedicine services — lauded for their time and cost savings — have come under the microscope recently after the authorities found MaNaDr Clinic, a telemedicine provider, to be lacking “clinical and ethical standards” in their operations.
Many cases seen by the clinic’s doctors involved video calls lasting less than a minute, but concluded with prescriptions for medications and issuances of MCs, investigations by the Ministry of Health (MOH) revealed.
MOH has said that it intends to strip MaNaDr Clinic of its licence to provide all outpatient services, with 41 doctors who provided teleconsultations for the clinic to be referred to the Singapore Medical Council (SMC) for potential professional misconduct.
The MaNaDr saga has sparked much discussion on what can be done to prevent people from abusing telemedicine services to obtain MCs they are not entitled to.
But this is not the first time that a telemedicine service has attracted MOH’s attention for suspicions of unethical activity.
In February, Medstar Medical Clinic & Surgery was investigated for issuing MCs without any audio or video consultation on its telemedicine website, PocketCare. The website was also found to have featured claims that patients could “Get Your MC or Get a Refund”.
In response to CNA TODAY’s queries, MOH said that the clinic was suspended from providing telemedicine services from February to May 2024. 
They added that Medstar had since rectified their lapses and were given permission to recommence their telemedicine services in June 2024 after completing a three month suspension.
These unsavoury practices have drawn condemnation from healthcare practitioners like Mr Sivachandran, who feel that such actions undermine the integrity of the profession.
“The more patients they (telemedicine providers) see, the more they earn… If you’re just giving MC without a proper diagnosis, that is totally wrong,” he said.
The spotlight on telemedicine comes at a time when some experts in the healthcare sector have warned of a shift in priority towards profit over patients as more investment funds pour into private healthcare in Singapore.
Some medical experts have even described the MaNaDr case as “a huge disappointment to healthcare professionals in the digital health ecosystem”.
But despite telemedicine’s current limitations and potential for abuse, doctors here are confident that a few bad apples will not spoil the whole barrel.
They noted that telemedicine brings with it a host of benefits across the entire spectrum of care, from the managing of chronic conditions to physiotherapy and mental health.
Its use will only continue to multiply in the coming years amid a growing greying population and physical and manpower constraints in Singapore, the doctors said.
Some telemedicine players themselves believe the MaNaDr saga serves as a good wake-up call for the industry, too.
Dr Shravan Verma, the co-founder of Speedoc, said: “While unfortunate, it has spurred a positive push towards higher standards, more transparent practices and safeguards to maintain public confidence.
“Such scrutiny benefits the entire industry by reinforcing reliable, quality care.”
In light of the MC controversy, what does the future hold for telemedicine and what role will it play in Singapore’s healthcare ecosystem?
CNA TODAY places its stethoscope to the pulse of this rapidly growing practice.
For all the trials and tribulations that the COVID-19 pandemic brought to the nation’s healthcare system, one silver lining that emerged was the rapid adoption of telemedicine – the remote diagnosis and treatment of patients using telecommunications.
This was largely due to the need for social distancing and to free up space in the accident and emergency (A&E) departments of hospitals across the island.
In 2021, several hospitals here implemented a “virtual ward” system to care for less severe COVID-19 patients remotely.
In this system, doctors and nurses monitor patients’ every one to two days over video or audio, or through wearable devices that measure one’s vitals and send alerts to hospital staff if they indicate ill health.
These virtual wards assisted more than 700 patients and saved hospitals more than 5,000 bed days, freeing up precious capacity and manpower for other patients requiring hospitalisation.
Post-pandemic, telemedicine has remained a viable avenue of clinical care for a good portion of the population.
According to MOH, there are currently around 3,500 outpatient medical services that are licensed with approval under the Healthcare Services Act (HCSA) to provide services remotely. 
The National University Health System (NUHS) said in response to queries that it conducts over 80,000 teleconsultations each year across its cluster of healthcare institutions since it launched its service in 2020.
As for SingHealth’s Acute-On-Demand TeleHealth (AODTH) service, launched in January last year, close to 35,000 video consultations have been conducted as of October 2024.
A recent survey by Bain & Company of 2,300 consumers in the Asia-Pacific region found that 43 per cent of Singapore’s respondents had used telemedicine in the last 12 months.
This is more than double the 16 per cent figure recorded in a previous iteration of the same survey in 2019, and nine percentage points higher than the 34 per cent recorded in 2021.
Dr Marcus Lee, the medical director for clinical quality governance at Fullerton Health, said that there has “definitely been an upward trend” in the usage of telemedicine services over the years.
The healthcare provider’s telemedicine doctors currently see about 600 patients a day.
Dr Verma of Speedoc also observed a “significant rise” in patients driven by the pandemic since the company was founded in 2018, though he added that the trend has steadied in recent years.
The meteoric growth of telemedicine isn’t limited to Singapore either. The same Bain survey found that telemedicine adoption doubled across all Asian-Pacific countries during the pandemic except in Australia, where its adoption increased ninefold.
Although uptake in the region has slowed since then, telemedicine has remained popular even after patients began to see their doctors in person again.
Bain’s estimates suggest that more than half of the people in Indonesia, India, China and Australia used some form of telemedicine in the past year.
While COVID-19 undoubtedly provided the springboard for telemedicine in Singapore, its continued growth has been sustained by its effectiveness in complementing the nation’s healthcare system even after the pandemic.
While most people might think of telemedicine simply as a means to remotely consult with general practitioners (GPs) for common ailments, it actually has many applications beyond that. 
Chronic conditions such as diabetes or high-blood pressure can be monitored without cumbersome trips to the clinic, using equipment that can send data to healthcare professionals. Patients who require regular outpatient care for their mental health can also talk their psychologists over the phone.
Specialist doctors have also jumped on the bandwagon offering platforms for specific types of healthcare. One such platform, Quinn, which provides discreet help for men and women with sexual health issues, said it serves about 15 to 20 new patients each month.
At the National Skin Centre, more than 2,000 patients have benefited from its teleconsultation service since the facility began offering it in April 2020.
Unfortunately, as the MaNaDr controversy has highlighted, any system – however beneficial – tends to have a downside.
While “dubious MCs” may currently be the most notable concern over telemedicine, apprehension about the sector extends beyond just that.
For one thing, doctors CNA TODAY spoke to unanimously pointed to telemedicine’s diagnostic limitations: Some conditions can be difficult to pick up over a video call.
Dr Samuel Lua, the founder of Belief Family Clinic in Lavender, noted that telemedicine providers must strive to deliver the same quality and standard of care as in-person services, in line with the Singapore Medical Council’s (SMC) ethical guidelines.
“However, without the ability to perform a physical exam, such as listening to a patient’s lungs or palpating the abdomen, certain conditions can be difficult to diagnose accurately,” he said.
Mr Sivachandran of Abella Agency, who has been a nurse for 18 years, concurred that nothing can quite replace being in the same room with a patient.
“If you have a prolonged headache, you might think it’s only a headache, but it might be a sign of hypertension or even a tumour,” he said, so necessary follow-up tests should be done in-person.
He added that even a smell can help to identify a problem, such as a fruity scent on a patient’s breath, which may be an indication of diabetic ketoacidosis.
There are also concerns that telemedicine makes it easy for patients to misrepresent their symptoms in order to obtain specific medications.
One 28-year-old patient, who spoke on condition of anonymity, told CNA TODAY that she has used a telehealth service to consult a doctor regarding her struggle with weight-loss.
While the doctor had asked for her Body Mass Index (BMI) information, he did not require her to show proof.
“You’re only supposed to be able to get these prescriptions if you’re above a certain BMI, which I was, but I realised it can be very easy to lie about it,” the patient said.
“And who knows what side effects there are if you’re too underweight to use the (prescribed medicines).”
For such reasons, doctors said telemedicine should not be seen as a substitute for in-person visits.
It is on the whole, however, a valuable tool for supporting clinical care and is best suited for follow-up appointments, allowing patients to consult with their regular doctor after an initial in-person consultation, they said.
Mr Ruch de Silva, senior director of DKSH Patient Solutions, said integrating telehealth with in-person care enables continuity and familiarity in the patient-provider relationship.
“This hybrid approach ensures that doctors have a more comprehensive understanding of their patients’ medical history, behaviours and needs, allowing for better, more personalised care and minimising the risk of missed signs or misuse of the system,” he said.
Indeed, Dr Tan Wei Jie, a general practitioner at DTAP Clinic’s Orchard branch, said telemedicine is “especially important” for his clinic’s patients who have difficulty making it to the physical clinic either because of mobility issues, busy work schedules, or because they live overseas.
For Dr Lua, he primarily uses telemedicine to care for his regular patients with chronic conditions, enabling him to adjust their medications and provide ongoing support between physical visits.
Migrant workers have also increasingly been using telemedicine services in the past two years, CNA reported last month. This ensures that those who work shifts or who live far away from healthcare facilities are able to seek timely medical attention.
Some parents told CNA TODAY that telemedicine is a great option for those who need assurance and advice from doctors for common ailments that their young children experience, while simultaneously allowing them to rest at home.
And so on balance, healthcare professionals believe the pros of telemedicine outweigh its cons.
The gaps in the telemedicine sector could be addressed through either government regulations or internal checks and audits, said doctors and telemedicine players.
Dr Lua, for instance, said it may be beneficial for the authorities to set a minimum clinical experience requirement for telemedicine providers.
“Experienced clinicians are better equipped to interpret subtle visual cues and provide safe, effective care remotely,” he said.
Presently, MOH requires doctors to undergo mandatory telemedicine e-training in order to deliver these services, which according to some doctors can be completed over a few days.
Dr Lua believes this is a good move that can be further improved with regular re-accreditation exercises, so doctors remain familiar with the appropriate protocols.
Dr Tan of DTAP Clinic also suggested putting a limit on the number of teleconsultations a patient can book within a certain timeframe to prevent patients from using it to obtain MCs.
However, in response to parliamentary questions on Monday (Nov 11), Health Minister Ong Ye Kung said he doesn’t think there is a need to review guidelines to specifically address concerns that may arise from telemedicine.
Current standards remain valid and enforcement has been effective, he said.
Mr Ong added that there tends to be a “temptation” to step up audits, enforcement and regulation, but such a response might prevent the nation from being able to seize the opportunities that new technologies can present.
He also pointed out that regulatory frameworks “cannot eradicate offences”.
In response to CNA TODAY’s queries on how telemedicine providers are licensed under the Healthcare Services Act (HCSA), MOH said that they are required to put in place clinical protocols to determine the medical conditions or medications that could be safely managed or prescribed via telemedicine. 
The ministry added that it conducts periodic audits for each clinic, and “investigates complaints promptly and takes offenders to task”.
Meanwhile, some telemedicine players told CNA TODAY that they have already implemented measures to prevent abuse of the system.
Telemedicine providers Doctor Anywhere and Fullerton Health, for instance, have in place vetting processes for their doctors. They are required to declare their telemedicine experience and show proof that they have completed the mandatory MOH telemedicine e-training.
Doctor Anywhere’s director of medical affairs Andrew Fang said its clinic’s approved doctors then undergo a structured onboarding programme that includes mandatory face-to-face training, followed by a probation period and regular training to reinforce ethical and clinical guidelines.
Senior medical director of WhiteCoat Global, Dr Tan Ming Wei, said its platforms include a “tech-driven red flags system” where patients with a history of trying to obtain MCs over a short span of time are flagged to doctors’ attention. 
Ultimately, some doctors like Dr Jonathan Ti, the principal medical advisor for sexual telehealth platform Quinn, believe that the buck stops with healthcare professionals themselves when it comes to preventing the abuse of telemedicine services.
“The greatest safeguard against the shortcomings of teleconsultation services would be having well-trained, ethically sound doctors who can provide reasoned and appropriate assessment and management,” he said.
While the MaNaDr episode may create a sense of doubt and public distrust for some of these private telemedicine services, it is not all bad news, said Mr de Silva of DKSH.
“Through this incident, the Singapore government has shown that they are playing an active role in mitigating the prevention of such incidents from repeating itself.”
At present, telemedicine often feels no different from a simple phone call to a friend.
However, advancements in technology are set to push telemedicine beyond its current limits, even bringing it closer to the realm of science fiction.
In October 2023, clinician-scientists from National University Hospital (NUH) and the Yong Loo Lin School of Medicine at the National University of Singapore (NUS Medicine) conducted a trial to perform a gastrectomy, or stomach surgery, remotely.
While the simulated organ was located in Nagoya, Japan, the surgeons who performed the operation did so from a “surgical cockpit” at the Advanced Surgery Training Centre at NUH.
Instead of the surgeon’s hands, a pair of robotic arms performed the procedure, cutting and executing intricate incisions and excisions.
This was made possible via a dedicated international fibre-optic network that transmitted, directed and replicated the movements of the surgeons in Singapore.
One of the gastric surgeons leading the demonstration in Singapore was Professor Jimmy So from the department of surgery in NUS Medicine. He is also a consultant in the surgery department of NUH.
According to Prof So, the initial results from the trial were encouraging, proving that robotic tele-surgeries across borders and large distances are feasible.
The time lag arising from the trial was minimal and within the acceptable industry benchmarks, he said, and the trial proceeded smoothly with safe outcomes.
Prof So told CNA TODAY that the one of the potential applications of telesurgery may come in the form of aid to war-torn regions that are too dangerous for surgeons to travel to. 
Nonetheless, he noted that it could take anywhere from five to 10 years before robotic telesurgery is deemed safe and ready to be used on live patients from a legal and regulatory standpoint. 
But even before society gets to that point, various diagnostic limitations are already being overcome with the aid of technology in Singapore’s public healthcare system.
An example of this is the Primary Tech-Enhanced Care ​(PTEC) project introduced in all polyclinics here.
The PTEC helps patients manage chronic conditions from the comfort of their own home with simple-to-use kits, and currently covers the monitoring of blood pressure and diabetes.
In the future, artificial intelligence (AI) technology will likely be layered on to telemedicine diagnostics, meaning camera images and videos alone could be sufficient to make accurate diagnoses, said Assistant Professor Ian Ang of NUS’ Saw Swee Hock School of Public Health.
He is also the co-director of the university’s Centre for Health Intervention and Policy Evaluation Research.
Asst Prof Ang added that the tracking input from monitoring devices and wearables would also become more refined as software and hardware technologies progress further and its usage becomes more ubiquitous.
On the government’s end, it has previously committed resources to expand the capabilities of telemedicine here in Singapore.
It was reported in September 2023 that national healthcare group SingHealth will be setting up a centralised telehealth hub at Eunos Polyclinic as part of efforts to bolster its telemedicine services.
It will bring together clinical and administrative staff involved in telehealth under one roof, and be equipped with soundproof pods for consultations.
SingHealth also recently added two new telemedicine services at the KK Women’s and Children’s Hospital and Singapore General Hospital. 
Telemedicine services at the latter, launched in June 2024 in collaboration with Minmed Group, aimed to tackle the long wait times and resource strain at the Emergency Department by diverting non-emergency cases to telehealth consultations, and has benefitted 280 patients as of October this year. 
SingHealth’s TeleHealth Service for Seniors also helps seniors who are less tech-savvy or unable to afford digital and health monitoring devices.
They can access telehealth kiosks set up at various Active Ageing Centres for video consultations on their chronic conditions with doctors from the Bedok, Marine Parade, Eunos, Tampines, Outram and Sengkang Polyclinics.
A pilot for virtual wards, titled Mobile Inpatient Care at Home (MIC@Home), was also expanded last year to include four more public healthcare institutions.
The programme allows patients with a wider range of conditions to receive round-the-clock access to care, delivered by a team of healthcare professionals via teleconsultations and home visits until they are fit for discharge.
Like it or not, telemedicine will become an integral part of Singapore’s healthcare landscape, even if it cannot entirely replace in-person consultations, healthcare professionals told CNA TODAY.
“There will always be situations where a physical examination is essential, and responsible use of telemedicine means recognising these limitations,” said Dr Lua.
“By approaching telemedicine with caution and a commitment to high standards, we can maximise its benefits while safeguarding patient well-being.
“Telemedicine is here to stay.”