Tele-consultations with patients comfortably participating from their homes are no longer uncommon. The use of video consultation in Singapore’s public healthcare has skyrocketed, largely accelerated by the COVID-19 pandemic. The number of monthly video consultation sessions in the sector grew by more than 26X in the last 1.5 years. In this article, we take a look at the video consultation journey.

Introduction on Telehealth

Telehealth was first introduced into Singapore’s public healthcare landscape more than a decade ago. However, video consultation, a mode of tele-consultation, only began to gain more traction in 2017 when IHiS developed the national Smart Health Video Consultation programme to pilot new video consultation use cases at Public Healthcare Institutions.

Apart from providing a stable platform with economies of scale, the Smart Health Video Consultation programme enabled sharing of learnings and best practices across Public Healthcare Institutions for use cases such as psychiatry/psychology, dermatology, cardiology, and chronic diseases. This improved the delivery of patient care.

Related article: Smart Health Video Consultation

As video consultation is mostly suitable for patients who are stable and do not require a physical examination, the Smart Health Video Consultation programme began with a few pilot use cases for evaluation. Approximately 2,000 unique patients adopted video consultation in the first three years. In the initial stage of the programme, a fair number of patients still preferred in-person consultations. In a compact city with medical services never too far away, and a prevailing culture of face-to-face interaction especially among the older generation, there was no real impetus for patients to give telehealth a shot.

All that changed when the COVID-19 pandemic hit our shores. Since then, the use of video consultation has skyrocketed, with more than 56,000 unique patients using the service in the last 1.5 years, and the number of different video consultation programmes (i.e. how video consultation is being used to care for specific patient cohorts at specific care settings) growing by 1,000%.

Twenty four, or almost all, Public Healthcare Institutions are now using video consultation (as compared to only 12 in 2019), and in May 2021 alone, there were more than 11,000 video consultation sessions. Since 2019, the overall number of institutions using video consultation, including Intermediate and Long-Term Care Services and Community Care Partners, have grown by about 140%. More tellingly, in the same period of time, the number of medical, surgical, allied health and other specialties combined has also grown significantly by 160%, with practically all specialties (60) using video consultation now.

Benefits of Telehealth Video Consultation

With video consultation, patients save on transportation costs and travelling time, while being able to keep their appointments more private. They are also potentially more motivated to see a doctor in a timelier fashion, and “turn up” for their appointment. Healthcare staff save on time too, as the no-show rate is significantly lower in teleconsultations. Community case partners supported by hospitals such as nursing homes also save on transportation costs whenever they use video consultation, as opposed to transporting a patient to and fro a hospital.

This was exemplified by the Institute of Mental Health (IMH), which was among the first to mainstream video consultation in 2020. Prior to that, nursing home and psychiatric residential home staff had to bring patients to-and-fro IMH. After video consultation was implemented, it saved staff and institutions plenty of time and money from not having to travel and charter transport. Patients’ default rate have also been reduced significantly from about 20% for traditional face-to-face consult to virtually zero for video consultation.

With prompt and regular video consults with the same designated IMH doctors, patients display better compliance to their treatment plan, which in turn reduces their risk of relapse and readmission to IMH, as well as length of stay. IMH has also extended video consultation to individual patients to allow greater accessibility to care amongst the whole IMH population, whom may have travel limitation or work commitment.

These Telehealth benefits have always been quite apparent, but they became crystal clear with the COVID-19 pandemic. With unnecessary travelling discouraged and work-from-home implemented, see-a-doctor-from-home while avoiding infection risk in a hospital or polyclinic quickly became popular; in fact, in April 2020 alone, there was an extraordinary increase of over 6,000% the usual average of medication deliveries.

Related article: Central Fill Pharmacy (CFP): How IHiS Helped NHG Deliver 60x More Medication During COVID-19

Let’s take a further look at some use cases and statistics of video consultation at various healthcare clusters.

Teleconsultation at National Skin Centre

The National Skin Centre (NSC) started providing teleconsultation services for their patients in April 2020. Their main considerations were increased convenience for their patients, as well as increased safety for them and staff due to fewer people on premise.

The teleconsultation workflow is as such:

• Suitable patients identified by the attending doctor or nursing team are shortlisted for tele-consultation. Examples of some exclusion criteria are those with complex/extensive skin conditions, or who require nurse/doctor-administered treatment in the clinic.


• Prior to tele-consultation, patients send photos of their skin condition via email, which are then uploaded into the Electronic Medical Record (EMR). 
  
  
• Mode of teleconsultation for follow-up patients may be phone or video. For new patients, video consultation is used.


• Patient is registered in the EMR on the day of teleconsultation, so that the doctor can record clinical notes and create relevant orders. 
  
  
• Post-teleconsult, the centre contacts the patient to arrange for billing, appointment scheduling for any follow-up, and medication delivery.

A pilot of 30 new patients revealed that there was a high diagnostic concordance of 86.7% between teleconsultation and face-to-face consultation. This suggests that teleconsultation can be useful for follow-up patients who bring up a new dermatological issue during the session, as well as for new patients with simple conditions.

There was also a high level of satisfaction by both doctors and patients, with more than 88% of doctors and 82% of patients surveyed in April 2020 reporting that they were satisfied/highly satisfied with the service. Based on its good outcomes, this teleconsultation use case has obtained in-principle approval for mainstreaming by the national Telehealth Implementation Workgroup, and is undergoing formal MOH approval process. Meanwhile, the patient numbers are expected to progressively go higher with more familiarity. As such, NSC intends to progressively increase its teleconsultation load by raising awareness of this service to their patients, and actively offering it as an option to suitable ones for future appointments.

Virtual Monitoring Clinic at National University Hospital, Division of Rheumatology

Apart from video consultation, phone consultation is also gaining traction with providers and patients. A team from the National University Hospital (NUH) piloted a gout Virtual Monitoring Clinic (VMC) for patients with gout in 2016, so that patients could follow up on their conditions regularly via phone consultation and in a timelier fashion with healthcare staff. NUH also collaborated with 12 polyclinics across Singapore such that gout patients can visit these nearby polyclinics for blood tests if necessary. These not only helped patients to shorten the overall treatment time, but it also saved them up to 60% of their medical expenses.

Gout VMC, which officially started in 2017, saw about 100 gout patients completing the programme in the next three years, with more than 460 physical visits saved. Clinical results were also positive, with the average time required for patients the reach back to the normal level of uric acid levels reduced from 243 days to 155 days (a reduction of 12.5 weeks).

The results for the proof-of-concept study were positive, and the team concluded that phone consultation for gout care is a safe intervention, with flares able to be managed appropriately and adverse drug reactions detected.

Healthcare staff and patients were also satisfied with the service. Based on its good outcomes, this phone consultation use case has obtained in-principle approval for mainstreaming by the national Telehealth Implementation Workgroup, and is undergoing formal MOH approval process. Meanwhile, NUH is working to expand gout VMC to other disciplines such as nephrology and general medicine.

While teleconsultation (via video or phone) is the most well-known modality of Telehealth, there are several other modalities, such as Vital Signs Monitoring (VSM). Recent examples include the massive remote VSM operations that were set up at the Community Care Facilities, and Primary Tech-Enhanced Care.

Related article: Primary Tech-Enhanced Care (PTEC): Telehealth Programme Enables Patients to Better Manage their Health Conditions from Home