New normal comes with big changes: Telemedicine to the fore
Like it or not, the COVID-19 pandemic will reshape clinical practice for the foreseeable future, says a panel of experts.
The panel, chaired by infectious diseases physician and former deputy Director-General of Health Datuk Dr Christopher Lee, saw the participation of Dr Benedict Sim, consultant infectious diseases physician, Hospital Sungai Buloh; Dr Suganthy Robinson, dermatologist, Dermatology Department, Hospital Kuala Lumpur; Dr Nordiana Nordin, consultant geriatric physician, Hospital Sungai Buloh; and Dr Nazrila Hairizan Nasir, family medicine specialist, Deputy Director (Primary Care), Family Health Development Division, MOH. They were speaking at the weekly Clinical Updates on COVID-19 webinar series on 30 April organized by the Institute for Clinical Research (ICR), part of the National Institutes of Health (NIH) Malaysia.
The session saw the invited panel discuss about virtual consultation clinics in the outpatient setting. According to Nazrila, the MOH was already mulling the idea of virtual consultations in 2019. She said the existing appointment system of the Health Clinics (Klinik Kesihatan, KK) are a practical failure as it does not resolve the congestion at KKs and thereby causing access issues. Furthermore, in its current state, the healthcare delivery system does not prepare the non-specialist doctor for the digital age.
Therefore, the goal of the virtual clinic was to improve accessibility of the public to primary healthcare and reduce congestion at the KK. The initial definition of a virtual clinic was a planned contact by the healthcare professional responsible for care of a patient for the purpose of clinical consultation and treatment planning. The virtual clinic is a live interactive session held at a scheduled time. The test run involved five KK as well as selected patients who had chronic conditions and needed review or consultations for monitoring or management of their conditions, on top of usual care.
The virtual clinics can result in many benefits to the patients resulting in time and money saved due to reduction of travel and transportation costs. Also, it can bring about an increase in productivity and function as a form of empowerment to the patient, getting them to report and take charge of their condition at home. The preliminary run at five KK was a success as it was meant to be a proof of concept. Due to the COVID-19 pandemic, the virtual clinic programme was expanded with the aim of reducing patient visits to healthcare facilities and to make it easier for patients in light of the movement control order (MCO). Most importantly, the effort would help curb the spread of COVID-19.
The virtual clinic system can be considered new and some issues are still being ironed out. These include payment, ethics, and indemnity. Nazrila said there is currently no comprehensive legal framework for telehealth but there are guidelines by the Malaysian Medical Council (MMC) which encompasses virtual consultation.
Sim, too, shared his experience on running virtual clinic for his large cohort of HIV patients. The clinic is known as EZ Clinic and caters to patients who are well-informed, have access to video conferencing tools, are stable, prior patients, and usually do not require any physical examination, thus their clinical needs are usually straightforward. In the running of the clinic, Sim said there were still certain doubts and questions regarding virtual clinics. One is the conditions for which telemedicine is appropriate, second is the rules for ensuring confidentiality and security of the information exchanged, thirdly is the standards for obtaining the patient’s consent, and lastly the methods for confirming the patient’s identity and maintaining the medical records.
Just like the KK virtual clinics, the EZ Clinic also wanted to reduce congestion at the clinics and improve patient satisfaction in terms of accessibility and experience. Perhaps most importantly, Sim said they wanted to reduce the defaulter rate among stable HIV patients.
The field of dermatology, too, has seen efforts at telemedicine, said Suganthy. In dermatology, telemedicine or virtual clinic was started close to a decade ago. It was aimed at providing dermatology care to patients living in areas with no access to specialist clinics. In fact, Suganthy noted, back in 2010, Sabah had no dermatologists and a patient had to travel to Kuching or Peninsular Malaysia or wait 3 months to have the visiting dermatologist attend to them.
The teledermatology clinic was in operation on working days and was manned by a consultant or specialist with referrals to these telemedicine clinics replied within 1 hour. All referrals made after 3 pm would be attended by the next working day. The teledermatology service was not done in real time, but rather relevant information about the patient was recorded and images of the dermatology condition was uploaded and submitted. This constituted as a referral.
The attending specialist based in Hospital Kuala Lumpur who receives the alert then reviews the case and digital images, and recommends a skin biopsy if necessary. Otherwise, the specialist prescribes the necessary medication and sends the reply to the referring centre. Suganthy noted that the specialist does not see the patient at all. Due to a combination of factors, the teledermatology service was terminated in 2015.
In the geriatric setting, telehealth was mooted as a way to overcome a few challenges specific to this group of patients, said Nordiana. Firstly, it was a way to reduce the patients’ risk of contracting COVID-19. It was also a way to overcome the high default rate in this group of patients. Thirdly, telehealth would also prevent the geriatric patients from getting stopped at roadblocks during the MCO. Fourthly, telehealth would improve medication compliance and adherence.
The patients benefited from teleconsultation as it was designed to be a patient-centric approach. They also stuck to their schedule or appointment. Nordiana felt the teleconsultation avenue allows doctors to explore impending issues. The cascade effect of timely intervention and consultation is thus the avoidance of unnecessary hospital visits and hospital admissions. While it is still early days, the feedback from patients has been positive, with most of them saying that the teleconsultation was as good as a traditional visit.The MMC guidelines on virtual consultation can be accessed at: https://mmc.gov.my/wp-content/uploads/2020/04/MMC_virtualconsultationADVISORY.pdf