Joint CFPS and SMA Advisory on participation in Telemedicine and Online issuance of Medical Certificates

26 January 2018

Dear Members of CFPS and SMA,

Joint CFPS and SMA Advisory on participation in Telemedicine and Online issuance of Medical Certificates

It has come to our attention that medical companies are offering online medical certificates (MCs) or e-MCs. This service was highlighted in recent media reports (ChannelNewsAsia: Medical apps providing virtual consultations, e-MCs on the rise dated 7 September 2017, and Today Online: Seeing the doc online? Some physicians advise caution dated 16 September 2017).

These medical services providers promote telemedicine with the use of technology that connects the patient with the doctor online. They have also advertised to the public that their doctors are able to issue patients with e-MCs.

The CFPS and SMA Councils view this development with concern.

Some of the business entities are not registered medical establishments and not operated by physicians. Therefore, they are not regulated by the Ministry of Health (MOH) and their directors are not answerable to the Singapore Medical Council (SMC). These businesses are on the look-out to sign on registered doctors to be on their panels to provide telemedicine and issue e-MCs.

We wish to caution our members regarding the potential pitfalls of telemedicine, as well as highlight that doctors are ultimately responsible for any clinical decisions made and will be accountable if clinical standards are not upheld.

In particular, we wish to remind doctors of the following paragraphs in the 2016 edition of the SMC Ethical Code and Ethical Guidelines (2016 SMC ECEG) as well as the MOH National Telemedicine Guidelines issued in 2015:

1) 2016 SMC ECEG
Section A6: "Telemedicine can improve patient access to medical care. Yet, it is not equal to conventional in-person care and has to be provided in a responsible manner.
Providing telemedicine responsibly means:
(1)If you engage in telemedicine, you must endeavour to provide the same quality and standard of care as in-person medical care."

2) 2015 MOH National Telemedicine Guidelines
Section 1.2: "The lack of face-to-face contact raises the important question of whether Telemedicine allows health care providers to reasonably meet the standard of care where a direct analogue to the traditional mode of health care delivery may not exist....
a) Any Telemedicine service must be provided as part of a structured and well organized system and the overall standard of care delivered by the system must not be any less compared to a service not involving Telemedicine.
i. Where a face-to-face consult is not reasonably practical, it is permitted to deliver care exclusively via Telemedicine as this is better than not having any access to care at all.
ii. Where face-to-face consultations are reasonably practical, the delivery of care via Telemedicine must not compromise the overall quality of care provided as compared with non-Telemedicine care delivery."

Bearing these in mind, we are of the opinion that the current telemedicine technology is unable to replace a face-to-face consultation, which typically includes a physical examination, except for the most minor of conditions. For example, it is not possible for a doctor practising telemedicine to assess a patient with asthma or exclude red flags in a patient with gastroenteritis.

Therefore, doctors who sign on to businesses offering telemedicine need to be aware that their clinical decisions must always be justifiable and defensible.

A medical certificate is a medical opinion given by a doctor after careful and adequate assessment, and is a responsibility that cannot be taken lightly.

Dr Tan Tze Lee
College of Family Physicians Singapore

Dr Wong Tien Hua
Singapore Medical Association