The doctor is online: why telemedicine apps need to tread with caution

Telemedicine startups are pushing for a brave new frontier in healthcare. But innovators and investors need to tread cautiously in a landscape full of legal and ethical challenges.

GENERAL practitioner (GP) Dr Jipson Quah sees patients not just at his Woodlands clinic, but on his smartphone as well. When setting up his clinic three months ago, Dr Quah, 31, decided to try out an app that would let patients consult him through video-conferencing or messaging. But the MaNaDr app, built by a local startup, has its limits, Dr Quah emphasises. In fact, he has told some 30 per cent to 40 per cent of patients who consulted him on the app to see him in person instead, because of the difficulty of remote diagnosis. "For example, you may tell me that you just need painkillers. But in person, a doctor can use his clinical acumen to determine that you are dehydrated or suffering from anemia. Connecting on a face-to-face level gives us a lot more information to act on. On the app, you are limited to how articulate the patient can be," he says.

A handful of what are referred to as "doctor apps", like MaNaDr, have emerged in Singapore, allowing patients to remotely consult a doctor via text, phone call or video-conferencing. Six of these startups operate in a regulatory sandbox overseen by the Ministry of Health, where they work with the MOH on clinical and data governance (see table).

According to data from analytics firm Tracxn, funding into Asian telemedicine startups has risen since 2010 (see chart), peaking at US$934 million across 56 funding rounds in 2016, mainly due to the US$500 million raised by China's Ping An Good Doctor that year.

Sentiment has since cooled somewhat. Investor giant Softbank's Vision Fund, which backed Ping An Good Doctor, is said to have held discussions about investing in other telemedicine businesses, but decided against it, according to people familiar with the matter, the Financial Times reported in January.

Yet interest in South-east Asia is brewing. Earlier this year, Indonesia's Halodoc raised US$65 million from backers including Singapore's UOB Venture Management and Singtel's venture arm Innov8.

According to a report by Frost and Sullivan, the Asia-Pacific telehealth market could hit US$1.79 billion by 2020, with an annual growth rate of 12 per cent.

Elsewhere, startups developing medical applications such as remote consultations have taken off, in markets with strong government support.

The United Kingdom's National Health Service (NHS) in January announced a long-term plan lauded as radical, paving the way for digital consultations for all British citizens. The NHS also put in place plans to trial remote monitoring devices, the use of artificial intelligence (AI) to interpret scans, even a genome-sequencing project, and earlier this week, announced it had joined hands with Amazon's Alexa to dispense medical advice activated by voice.

UK-based Babylon Health, which partnered the NHS to provide video consultations, has raised US$85 million. The startup has more than 52,000 listed patients in London, and last month started rolling out service in Birmingham. Ping An Good Doctor, which raised US$1.1 billion via a Hong Kong listing, boasts 265 million registered users, while WeDoctor, which tied up with insurer AIA, raised US$500 million at a valuation of US$5.5 billion in 2018.

Clearly, doctor apps could greatly aid more efficient healthcare delivery, perhaps even alleviating Singapore's stubbornly high medical costs. But as telemedicine startups emerge in Singapore, medical practitioners like Dr Quah caution that entrepreneurs and investors alike must acknowledge the limits of these technologies, even if it means lowering their revenue expectations.

Beyond the question of accurate diagnosis and financial viability, lies a whole minefield of ethical and medico-legal issues that digital medicine will need to address.

First, do no (digital) harm

The rise of telemedicine comes against the backdrop of favourable macro factors. For one, Singapore faces an ageing population. Older patients with limited mobility could have better access to primary care with telemedicine apps. The apps could also enable follow-up consultations for patients recently discharged from the hospital.

These platforms could "facilitate more efficient doctor-patient interactions in the same way that the sharing economy has made food and transport more accessible", says Dr Daniel Tan, deputy medical director and head of radiation oncology at Concord International Hospital, a local private hospital.

"Telemedicine platforms play a role in providing early diagnosis and intervention of certain conditions. This could contribute to better outcomes, cost savings and productivity gains such as reducing unnecessary onsite clinic or hospital visits," he adds.

The growing use of smartphones across South-east Asia, coupled with the low penetration of primary healthcare networks in rural communities, also points to a market ripe with potential.

"If you look at all the South-east Asia digital health deals in 2018, 9 per cent of these deals were in telemedicine. So investors are still looking here," says Julien de Salaberry, chief executive of healthtech consultancy Galen Growth Asia. "What you're seeing is a very natural phenomenon. It's a young ecosystem that's in full growth with a lot of innovators and aiming to scale."

Australian accelerator BlueChilli, which launched a healthtech accelerator in Singapore in May, is bullish about the rise of the online physician. "As platforms thrive on the demand economies of scale, it's possible we'll see the growth of innovative players with more dominant market share than even traditional businesses," says Seow Hui Hong, programme director at BlueChilli.

But take a closer look, and there are clear limits to applying online tools for an ageing population. One issue is the challenge of accurately diagnosing an elderly person remotely, given the higher risk of complications compared to a young patient. Telemedicine may not be suitable for the elderly without adequate safeguards, says Dr Quah.

"I generally accept younger patients (on telemedicine apps), because the likelihood of them having an underlying treatable condition that I could miss is lower. (For patients) beyond the age of 40, I would be a lot more careful... If you ask an elderly patient whether they've taken their medicine, they will say yes; but when you actually count the pills, you realise they have not," he adds.

Under the Singapore Medical Council's 2016 ethical code and ethical guidelines, doctors must also ensure patients "understand any limitations of telemedicine that may affect the quality of their care".

This is a challenge if patients are not tech-savvy.

More broadly, medical liability is another big minefield in what could develop into medicine's Wild West. Complicating matters is how many of these platforms do not employ their own doctors, but tap "freelance" doctors who have their own medical practices. This is roughly similar to how ride-hailing firms like Uber use freelance drivers.

"This places a huge burden on the platform and the gig doctor to ensure that the patient's background is sufficiently known - for example, if the patient has any allergies or has some relevant medical history which the gig doctor should learn about, before prescribing medicine," says Adrian Tan, partner at law firm TSMP.

In the event of malpractice or negligence, who takes the blame?

"In general, where liability will fall will most likely depend on the contractual relationship between the healthtech platform and the freelance doctor. The court will likely look at the facts to determine whether the person is an employee or an independent contractor," says KK Lim, head of cybersecurity, privacy and data protection at law firm Eversheds Harry Elias.

There has not been a case in Singapore involving telemedicine negligence, but players acknowledge that even one case could have a chilling effect on the whole industry. The startups tell The Business Times that they are working closely with MOH to ensure patient safety.

Dr Siaw Tung Yeng, CEO and founder of MaNaDr, which has over 600 doctors listed on its platform, says: "We regularly review every telemedicine consultation to identify potential risks to doctors and patients as well as submit quarterly reports to MOH and attend meetings with MOH to discuss potential problems and iron out practical solutions."

Dr Yii Hee Seng, executive chairman of doctor app WhiteCoat, says that the startup mitigates the risks by employing its own physicians, all of whom maintain requisite medical malpractice insurance.

HiDoc, an app catered mainly for specialist consultations, comes with a transparent fee structure to ensure doctors are not negatively incentivised, says CEO Dr Christina Low. HiDoc charges patients a flat fee of S$120 for the first consultation with a specialist and S$80 for follow-ups.

"Our doctors practise medicine for its own sake. Their fee is not determined by providers, and so it doesn't incentivise them at all... Even for medication, there's no extra fee given as an incentive for the doctor to recommend beyond what the patient needs," she says.

Oh, the places data could go

Beyond the quality of care, doctors who spoke to BT flagged data protection as another major concern when it comes to telemedicine services.

For GP Dr Jeremy Chan, the privacy of a consultation - which should be sacrosanct in a doctor-patient relationship - could be compromised if a telemedicine app is not properly safeguarded.

"Depending on how the camera is angled, you would not know whether a person is hidden. On the doctor's end, you are not able to assess whether the symptoms are really true, unless the signs are there," he notes.

Confidential patient data could also be left in limbo if the startup collapses, notes gastroenterologist Dr Desmond Wai. There needs to be more clarity on how such data should be protected before the medical community can be confident about telemedicine providers.

"My understanding is that out of 10 startups, maybe one survives. When the rest close down, who will be keeping the patient records? If they leak it, and the company has already been liquidated, who is responsible? In my clinic, I am responsible for the data. With these startups, I wonder who is responsible," he says.

While medical professionals are bound by privacy laws, it is "not entirely clear" how the platforms are regulated, says Dr Tan of Concord. "In addition, it is possible for some of these platforms to classify their platforms as technology instead of medical providers.

"Users need to exercise care in the same way as they would handle their personal information on other platforms... Platforms need to be forthcoming in addressing these issues when users sign up for their services and place strict data management systems as a priority," he says.

For their part, the startups say that they have sufficient safeguards and are working closely with the regulators. "We ensure that all patient data is securely encrypted and stored using enterprise-grade cloud solutions... In addition, to safeguard the confidentiality of patients and their medical records, we have adopted both extensive IT security controls," says WhiteCoat's Dr Yii.

"We have a very qualified CTO (to) manage our handling and storage of patient data and on top of that, we hired an external consultant to go through our data handling and storage processes. We believe that this will give the doctors and patients the assurance that every possible effort has been made to secure their data," says Dr Siaw of MaNaDr.

Bracing for the new wave

The concerns raised by doctors over existing healthtech platforms could potentially be addressed in the near future, with telemedicine services to be licensed under the upcoming Healthcare Services Act. But with the emerging crop of providers tapping cutting-edge technologies, regulators will need to be nimble, according to TSMP's Mr Tan.

"Startups can think of one crazy idea and have it up and running in a short time, without any thought about safeguards. Legislators cannot possibly foresee all the ways the world is changing... Lawyers will always be playing catch-up with entrepreneurs," he says.

In fact, the next generation of telemedicine is enabled by AI, says healthcare investor Tony Estrella. "Now, more transformative solutions are being developed, including the use of AI to create new uses for telemedicine between patients and virtual clinicians... These opportunities are attracting the interest of investors, clinicians, and commercial partners," he adds.

Several healthcare incumbents, such as SATA CommHealth and Parkway Shenton, have signalled their openness to new technology by offering telemedicine services under the MOH sandbox. It remains to be seen if more practitioners will embrace the doctor apps.

While flagging concerns, Dr Quah is no Luddite. Telemedicine startups can be beneficial, as long as they bear in mind the unique ethical and legal responsibilities of the medical profession, he points out.

But ultimately, Dr Quah feels that a strong red line should be drawn at completely doing away with the doctor-patient relationship. "I don't want to see the day of that happening, really. Because it would relegate patients to numbers. You would just become your name, NRIC, phone number, address and your medical history details. You would become depersonalised and your doctor also becomes depersonalised. That's not quality care," he adds.


Telemedicine has regional potential, but navigating regulations is key

SINGAPORE may be ideal as a testbed, for telemedicine startups, but is "too limited" a market for players to thrive, reckons healthcare consultant Dr Vincent Chia, director of Asian Healthcare Solutions.

The social impact is greater if the platform steps out of Singapore, adds Chik Wai Chiew, chief executive of venture firm Heritas Capital Management. Heritas has not invested in a telemedicine startup, but Mr Chik is watching those with regional potential closely.

"From an impact standpoint, we would like to see solutions that can help people who otherwise find it very difficult to speak to a doctor; that is what we would like to back first and foremost. Commercially it makes sense too... it's a high-volume market that is served," he says.

Therein also lies the difficulty of scaling regionally: in bringing telemedicine to rural communities, the platforms will also need to be clear about which jurisdictions they are operating in, and ensure compliance with all the relevant regulations.

Tricky questions

Going cross-border could raise some tricky legal and ethical questions, as highlighted by KK Lim, head of cybersecurity, privacy and data protection of Eversheds Harry Elias.

"If there is a malpractice or negligence suit, where would be the proper jurisdiction to hear the case, in the event that the freelance doctor is in one country, and the patient in another country?

"Different jurisdictions have different approaches in dealing with the area of medical negligence; will that encourage forum shopping by parties involved?" he notes.

There could also be uncertainties when a telemedicine platform links up patients in one country with doctors in another. This can be observed in the case of Practo, an India-based healthtech platform, which allows patients to chat with doctors, among other functions.

When using the Practo online consultation service for a skin condition, this writer was connected to a doctor in Pune, India. During the consultation, which was done via online messaging, the doctor requested personal information including age, gender and photos of the affected skin. The doctor then provided a signed prescription for a list of drugs including topical creams and allergy tablets.

The fact that a Singapore-based individual can get an online consultation with a doctor in India involving no physical examination, coupled with the sharing of personal information, raises some questions from a legal standpoint.

"Based on the Question and Answer (section) provided on Practo, the doctors are not only verifiable but qualified. But the issue is whether these doctors are registered with the Singapore Medical Council. If they are not, the platform may be prosecuted for providing medical advice by doctors not registered with the Singapore Medical Council," says Mr Lim of Eversheds Harry Elias.

In addition, there are also issues surrounding the collection of data, Mr Lim adds. "Even if the provision of medical advice is legally permissible, the issue is whether the platform is able to collect Singapore-based personal data and export it out to an apparent India-located server.

"The PDPA (Personal Data Protection Act) prohibits the export of data from Singapore to another country without the equivalent protection unless exempted by the Personal Data Protection Commission," he says.

The Ministry of Health and Practo did not respond by press time on whether this service is allowed and how it is regulated.

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