Telemedicine is defined as the investigation, monitoring, and management of patients as well as patients and staff are able to use systems which allow ready access to expert advice and patient information no matter where the patient or relevant information is located. In short, telemedicine enables medical related information to be exchanged from one site to another through electronic communications. Telemedicine amounts to all health aspects of practicing medicine at a distance. Practicing medicine includes diagnosing and treating patients, physician education, patient education, administrative functions, video conferencing, and continuing medical education. Therefore, telemedicine can be described, broadly, as the use of telecommunication technology to deliver medical services .
In Malaysia, telemedicine is governed by the Telemedicine Act 1997. Section 2 of the Telemedicine Act 1997 defines telemedicine as the means of practising medicine using audio, visual and data communications.
There are several advantages of telemedicine. One of the advantages is cost saving. The Rural Broadband Association in their 2017 report finds that United States national average hospital cost savings per medical facility is estimated at $20,841. For example, the annual hospital cost savings in California is $104,564 per facility and New York saves $54,937. Another way how telemedicine is cost saving is that, a telehealth appointment can determine if a patient’s visit is guaranteed. In many cases, telehealth provides a platform for a cost-efficient way to provide an equivalent service. According to The Wall Street Journal, telehealth appointments for non emergency reasons typically cost approximately $45, contrary to a personal visit to a doctor’s office which costs $100 or $160 at an urgent-care clinic. Remote analysis and monitoring services reduce healthcare service costs and also reduce unnecessary non-urgent Emergency Room (ER) visits and eliminate transportation expenses for regular checkups.
Secondly, telemedicine provides extended specialist and physician access. Telemedicine benefits patients who live in remote or rural areas where there are relatively few doctors. In the United States, for every 100,000 rural patients, there are only 43 specialists available. These patients endure longer appointment commutes and have trouble accessing lifesaving consultations for specific diseases or chronic care plans. Telemedicine also benefits patients in the case of emergencies in remote environments such as on ships, in aeroplanes or even on ships. For instance, telemedicine can provide nuclear medicine to rural hospitals with no physician dedicated to nuclear medicine. Telemedicine also offers better access to more specialists such as being able to refer patients to the specific physicians they need no matter where they are located at.
Thirdly, the professional standards are maintained. According to Section 3 of the Telemedicine Act 1997, the person who may practise telemedicine are medical practitioners who hold a valid practising certificate. This means that all healthcare professionals must possess the required qualifications along with being registered with the appropriate authorities and are qualified by their respective professional bodies in order to provide telehealth services. The healthcare professionals’ conduct are also regulated by this Act. By virtue of Section 5 of the Telemedicine Act, if a medical practitioner practises telemedicine on patients without first obtaining their written consent, he is guilty of an offence and will be subjected to a fine not exceeding RM 100,00.00 or imprisonment for a term not exceeding two years or to both.
Fourthly, telemedicine provides better patient care quality. This means that patients can refer to doctors regarding their health issue with real-time urgent care consultations and get notified of the most suitable treatment for them within minutes. A new study conducted by Reena, L, et al (2015) shows that telemedicine patients score lower for depression, anxiety, and stress, and have 38% fewer hospital admissions. Apart from that, telemedicine in nursing will be more economic in terms of the use of time and resources. By using interactive telemedicine equipment at the health centre, a home health nurse can monitor pregnant women, the elderly and the sick without being always physically present.
Fifthly, telemedicine is more convenient and accessible. According to a Cisco global survey, 74% of patients prefer easy access to healthcare services than having to interact face to face. Telemedicine will also benefit patients who live in rural areas or those who can’t take off time from work as they can access care virtually. Doctors can connect with patients through Skype, video conferencing, smartphone apps, and online management systems. For instance, RelyMD is a website which is one of the platforms for telemedicine which provides virtual medical solution for the ongoing care of the patients.
Next, telemedicine increases patient engagement. Ernst & Young Senior Advisory Services Manager Jan Oldenburg said that “the high cost of disengaged consumers affects everybody.” Therefore, telemedicine which is proven to be cost saving will attract patient to engage and consult the doctors regarding their health issues. Patients can engage with doctors virtually and this helps them to maintain appointments and care schedules. Only 50% of patients who suffer from common diseases such as tobacco related diseases and obesity was recommended to exercise more. Therefore, increased engagement initiatives can also curb obesity rates and tobacco use by helping the doctor to encourage their patients’ to change their lifestyle choices. Virtual visits reassure patients that their doctors are available and much more involved in their care and it makes it easier for the patients to ask questions, report early warning signs, and make a follow-up appointment to make sure they are healthy. Frequent check-ups improves the patient’s engagement with the doctors as they will put the doctor’s advice into action and thereby preventing readmissions.
In the present case, Sara has telemedicine membership which benefits her. Instead of turning back to get her medication refill, she had a quick 5-minute consultation with a physician over the phone who helped her to get an emergency refill nearby. Therefore, she would not miss her flight. Apart from that, telemedicine is cost saving as Sara saved RM 375 which she would have spent if she made an appointment with a local doctor. This is because the physician who Sara consulted through the phone was able to write her prescription immediately.
However, despite the numerous number of benefits that one can obtain in telemedicine, this advance service also have its downside.
Firstly, to make this system works, there will be a need to restructure the IT staff responsibilities and purchasing equipment takes time and costs money. Training is very important in order to build an effective telemedicine program. Medical staff such as doctors and nurses need to be trained on the new systems to ensure that the patient will get the best service out of it.
In situations where patients are utilizing on-request telemedicine service that link them with unfamiliar healthcare platform, there will be the issue of inconsistency because a patient's essential care supplier might not have previous records from those different visits and wind up with a fragmented history for the patient. It will also increase the tendency to misdiagnose as a doctor is not disclose to a patient's history. To overcome this limitation, the telemedicine providers must apply top-notch solutions to maintain adequate and accessible patient records.
We should be aware that even though the technology is advancing day by day, there are hiccups especially regarding internet access in rural areas. Many doctors and other medical practitioners worry about technical problems associated with telemedicine. Arun Ravi, Senior Healthcare Group Consultant told Becker’s Hospital Review that poor broadband connections could lead to “possible patient mismanagement.” Telemedicine might take longer time for the difficulties in connecting virtual communication due to low internet speed or server problem. Moreover, this system cannot provide immediate treatment, such as, antibiotics.
When associating with telemedicine, the subscribers will be exposed to tricky policies and reimbursement rules. While significant advancements have been made to telehealth repayment over the past couple of years, despite everything it still remains a complication for providers who are interested in telemedicine.
In telemedicine, there is absolutely no physical touch. For palpation and auscultation (the action of listening to sounds from the heart, lungs, or other organs, typically with a stethoscope, as a part of medical diagnosis) , the remote specialist usually has to rely on an amanuensis, a literary or artistic assistant, in particular one who takes dictation or copies manuscripts. Virtual clinical treatment decreases human interaction among the healthcare professionals and patients that increases the risk of error in clinical services, if the service is delivered by inexperienced professional. Moreover, confidential medical information can be leaked through faulty electronic system. Low quality of health informatics records, like, X-ray or other images and clinical progress reports run the risk of faulty clinical treatment.
Other than that, we should also address on the issue of privacy concerns. There is the potential for invasion of privacy. Once hackers are exposed to the unsecure service of a telemedicine provider, they can easily extract out the information needed especially for personal advantage.
Though successful telemedicine requires enthusiastic practitioners, no one should pretend that distance medicine is equivalent to the face-to-face model. The art of successful telemedicine lies in identifying the circumstances in which its disadvantages are outweighed by the benefits. Fear of malpractice suits and litigation may prevent some people from implementing telemedicine. However, clinical risk management is designed to reduce these threats. Health care providers must adopt clinical standards and protocols agreed by practitioners and suitable indemnity cover for potential failures such as misdiagnosis should be arranged.
Once telemedicine boom in the market, it might promote less people to go to actual diagnosis such as to the hospital or clinic. It may reduce in-person interactions with doctors because online interactions are impersonal, and physical exams are often necessary to make a full diagnosis. If more patients are resorting to online interactions in place of in-person visits, there will be surplus especially to the employment sector.
Besides, if the telemedicine provider is found to be effective, there will be no doubt that the costs of membership is cheap. Not everyone can afford the packages offered and sometimes, the customers only pay for unnecessary hidden charge. This can challenge the proficiency of doctors and other medical practitioners.
Regarding legal issues, according to Section 3 of the Telemedicine Act 1997, it was stated that only certified medical practitioners can practice telemedicine. However, we need to bear in mind that there could be some irresponsible parties who poses as someone who had the necessary certification and this will lead to fraud. It will have detrimental effect especially to the patients as they are engaging with fake doctors due to the reason such as to opt for cheaper alternatives.
In Section 5 of the Telemedicine Act 1997, it is regarding the patient’s consent. As we all know, consent need to be real, the patient need to have capacity and the consent must be voluntary. All of this requirement can be fulfilled when it is a one-to-one consultation between a doctor and a patient. In the context of telemedicine, there will be a conflicting issue of consent as by using this medium, it raises a question on how to determine whether the consent is real or did the patient has proportionate capacity to consent.
In Teladoc, Inc. v. Texas Medical Board , the issue is whether the Texas Medical Board has demonstrated immunity from federal antitrust laws. The Court of Appeals is being asked to determine whether the Board may be held liable under the antitrust laws for its rule requiring a “defined physician-patient relationship to exist before a physician may prescribe dangerous or addictive medications. The necessary relationship is defined as established through either an in-person examination or an examination by electronic means with a health care professional present with the patient.
Based on the judgment by the Court of Appeal, it will expose to floodgates as there will be many telemedicine provider who are expected to request for the same immunity as Teladoc, Inc. Teladoc, which uses telecommunications to connect patients and physicians, provides services in a way that would allow physicians to prescribe medications without the establishment of the required patient-physician relationship .
Moreover, telemedicine may also give rise to constitutional issues. In many countries, health services are regulated on a state level, while telecommunications and cross-state-border trade is regulated on a federal level. So telemedicine fits into both regulatory schemes. Telemedicine is also one part of a health service that involves both telemedicine and traditional medicine. It is clear that both the state governments and the federal government may claim a right to regulate the activity .
To apply in the question, the action of Sara resorted to telemedicine is a not a good alternative especially when one is travelling across countries and did not have sufficient time to actually visit healthcare centre in order to get proper prescription. The medications provided by the telemedicine provider may not match with the healthcare centre especially when travelling outside of home country. The medicines might be different so it will cause conflicting issue on the suitableness and tolerance of a patient towards the medication. Besides, if a situation such as the doctor on-the-line was negligent in prescribing the right prescription, the patient will have confusion in deciding to charge liability to which doctor. Telemedicine may be a good alternative to cater those who in same situation as Sara and telemedicine should not be the primary choice to all patients as one-to-one consultation is always better and more precise to address proper disease and to issue correct prescription.
Despite the benefits and the downsides of the telemedicine practice, the Telemedicine Act 1997 has some implications on the practice in Malaysia.
In Malaysia, although a medical professional resides outside of Malaysia, he can still provide telemedicine service through a registered medical professional in Malaysia. This is provided in section 3 of Telemedicine Act 1997 where a medical practitioner who is registered or licensed outside of Malaysia may offer telemedicine services in Malaysia if he is certified by Malaysian Medical Council (MMC) to practice telemedicine . From this section, there will be no issue regarding the service of telemedicine across national borders because only registered medical professional will remain primarily responsible to the patient.
However, in this act, it does not provide a clear guidance to address the issue on the liability of the practitioner or the healthcare provider on any malpractice of telemedicine. Whether there is a doctor-patient relationship established during the consultation and what is the liability of the practitioner when there is a misdiagnosis due to technological error? Associate Professor Dr Puteri Nemie Jahn Kassim in her article stated this issue comes to the concern of the healthcare provider on how the use of the internet may affect their liability as the negligence only exists if the defendant owes the plaintiff a legal duty of care. Therefore, this raise the issue of the appropriate standard of care for telemedicine that is not provided by the act or any other legal precedents .
The implication from this issue is, there might be any malpractice among the practitioner and the professional in telemedicine which can cause injustice to the aggrieved party as no clear regulations can be used or referred to in order to solve the problem.
As for the time being, we can refer to the cases in the United States for a preliminary guide to address the issues as no medical malpractice involving telemedicine has been decided by Malaysian courts.
In the case of Wheeler v Yettie Kersting Memorial , an on-call physician received information through the telephone from a nurse at the hospital regarding the status of a woman in labour. The on-call physician used the information to determine that the patient could be sent to a hospital over 90 miles away. Less than an hour into the journey, the patient began delivering a breech position baby, which died when her cervix clamped shut around the baby’s neck and suffocating him. The court held that the physician-patient relationship was established when the on-call physician received the information from the nurse because he had evaluated the status of the patient and gave approval for the transfer even though he had no prior contact with the patient other than one phone call from the nurse.
Another case to be referred is the case of Kenneth Newborn v US where a medical officer at the Walter Reed Army Health Centre, Washington D.C., had consulted a patient via email and telephone with the supervision of an army hospital in German. The court held that there was no physician-patient relationship as there was no direct control of the doctor in consulting the patient which is required by the law to prove the duty of care. The court decided on the principle that duty of care of the second physician contravenes with the general policy as it can cause difficulties to obtain the expert’s advice in medical terms due to their refusal to confront the legal liability on any malpractice or negligence.
In this act, section 5 provides that a medical practitioner who practice telemedicine must first obtain the consent from the patient or the family or close friends on behalf of the patient if the patient is someone who is incapable. The written consent must be given by indicating his sign provided that the patient has been informed and understands the information of the content, the risks, consequences, benefits and the privacy policy of the service .
This section however does not mention about the mandatory obligation to do health screening or check up between the physician and the patients. For example, in South Africa, the Health Profession Council of South Africa (HPCSA) has regulated a guideline where telemedicine must be conducted when there has been a previous relationship and face to face consultation between the patient and the practitioner have taken place . This is the way for HPCSA to monitor the telemedicine practitioners and protect the patients from any possible mismanagement or medical malpractice by the telemedicine practitioners.
This regulation should be enacted in the act to ensure the rights of the patients and also the physician. The rationale for the mandatory health screening or check up is to ensure that the physician is familiar with the patient’s condition and also medical history. In any emergency case, if the patient is not on the state and the doctor on-call is in need of medical condition and history of the patient, the current physician whom the patient has contacted in telemedicine can provide him such information in order to give a physical or suitable treatment to the patient. This move can prevent any negative implication of this practice in Malaysia.
In this section, it also provides that the patient should be told about the privacy policy where all the confidentiality of information obtained or disclosed during the telemedicine interaction is protected under this act and no information during the interaction, for whatever purpose, can be disseminated to anyone without the consent of the patient although it is arguably that the data or information of the patient’s health can be used in certain cases provided that the personal identification is stripped out.
However, in Malaysia, the Constitution of Malaysia does not specifically recognize the right to privacy. Referring again to the disadvantages of telemedicine where there could be invasion of privacy by hackers, the absent of the provision specifically guarding the privacy and confidentiality of the medical information of the patient can give a negative implication on the practice of telemedicine in Malaysia. The leaked confidential information about the patient can be misused by evil party for their personal advantage.
This issue is then being addressed by the Malaysian Ministry of Energy, Communications and Multimedia (MECM) by drafting a new personal data protection bill in order to provide protection to health consumers regarding their right to access their health records including electronic health records. The aim of this bill as stated in the article written by Associate Professor Dr Puteri Nemie Jahn Kassim, is to establish a guideline on the handling and treatment of personal data by any person or organisation which includes the collection, possession, processing and use of the personal data.
In the light of global access to information over the internet, this effort is important as it will encourage the service provider to establish and provide a highly secured platform to the users or the patients of telemedicine.
In conclusion, access to healthcare service has always been an important concern in the world. The practice of telemedicine is an innovative movement in providing health service especially for those who are not in accessible mode to go to the hospital or clinics to get treatment. The role of this service has given a big implication to the society. It gives a lot of benefits to the people although there are still some downsides of this practice regarding few matters including the concern on issue of privacy. The development and improvement on the legal perspective of practicing telemedicine in Malaysia should be looked at by the authority to ensure the integration and growth of this practice will achieve a premium standard of healthcare service along with the advancement of technologies.