Telemedicine services

The Straits Times (23 February 2012)


What: Dermatologists at the National Skin Centre (NSC) check on the skin conditions of long-stay patients at the Institute of Mental Health (IMH) through teleconferencing. The pilot project was initiated by the Institute of Mental Health in 2006.

How it works: The patient shows his rash, for instance, in front of a computer linked to a webcam and a speaker - the entire set-up costs about $3,000 - and a doctor will look at it on the other end.

In the past, when IMH patients needed to see a doctor for a skin condition, it would take a nurse up to four hours to accompany them to and from the NSC.

Now, it takes just an hour for 11 patients to be checked and a nurse can make a single run to the centre to collect medication for all of them the following day.

Remote consultation is less stressful for patients, who may become agitated in a new environment. They pay the same for a remote consultation as they would a face-to-face consultation, but they save on transport cost and time spent travelling and waiting.

More than 65 patients are now on follow-up appointments using teledermatology.

In the future: The IMH is reviewing the arrangement to find out how it can be improved.

The skin centre has collected data on the efficacy of such remote consultations versus face-to-face ones and is analysing them.

So far, it has found that both types of consultations yield equally accurate diagnosis and treatment.

With better imaging technology and resources, the skin centre hopes to extend this option to other facilities.

Sources: Institute of Mental Health and Dr Mark Tang, senior consultant dermatologist at the National Skin Centre


What: Between 2005 and 2007, most polyclinics here started transmitting X-ray images electronically via a computer system to radiology centres to be interpreted.

How it works: All nine polyclinics under the National Healthcare Group (NHG) now use the services of centres here and in India.

The Singapore General Hospital (SGH) has set up satellite imaging centres at six of the nine Singapore Health Services (SingHealth) polyclinics. These polyclinics send their X-rays electronically to two centralised reporting centres for interpretation, helping to spread out the workload and reducing the turnaround time.

In the past, polyclinics would courier X-rays to radiologists and wait for the reports to be returned a few days later.

Meanwhile, polyclinic doctors would treat patients first according to their own reading of the X-rays.

Patients have to return on another day to receive their reports and find out if there should be any changes in their treatment.

With this initiative, polyclinic doctors can get the reports within an hour and treat the patients on the same day.

The SGH also uses teleradiology for urgent consultations between hospitals and specialised centres under the SingHealth group.

In the future: Under an initiative started in 2010, diabetic retinal photography images taken in three SingHealth polyclinics are now sent electronically to the Singapore Eye Research Institute for assessment.

This enables patients to receive their results within the hour.

In the past, patients had to return to the clinic on another day to review their results.

Diabetic retinal photography checks the eyes of diabetics for abnormalities that may lead to blindness.

There are plans to roll out this service to the remaining SingHealth polyclinics in the next two years.

NHG has a similar initiative between Hougang Polyclinic and the NHG Eye Institute at Tan Tock Seng Hospital. It hopes to extend this to all its polyclinics by the end of next year.

Sources: SingHealth Polyclinics, National Healthcare Group Polyclinics and Associate Professor Winston Lim, senior consultant at the department at diagnostic radiology of Singapore General Hospital


What: Doctors specialising in geriatric medicine at the Khoo Teck Puat Hospital (KTPH) follow up on frail elderly patients through teleconferencing.

A pilot project was started at the St Joseph Nursing home in 2010, while another pilot involving home-bound patients began last July. The typical patient is bedridden or wheelchair-bound but has stable chronic conditions such as stroke, diabetes, heart disease and hypertension.

How it works: Using a teleconferencing device with an attached movable camera and speaker, which is mounted on a trolley at the nursing home, doctors are able to remotely observe their elderly patients at their bedside.

For the home teleconsultation, a nurse clinician takes along a tablet device installed with a teleconferencing programme.

She is trained to do basic assessments such as a physical examination. This includes listening to the patient's heartbeat and palpating his abdomen to feel for hard masses, which she then relates to the consulting doctor through the camera.

The nurse will also check the patient's medication and make sure that he is taking them correctly.

In the past, doctors had to go to the St Joseph Nursing Home for weekly rounds. With this initiative, they need to make the trip just once a month. More than 130 consultations have been done remotely.

Similarly, home-bound patients would have to visit the hospital four times a year or have a doctor see them at home.

The new initiative has reduced this to two face-to-face visits.

There is some cost savings, as a two-way ambulance ride may cost $70, while a house call can cost more than $200.

A teleconsultation, on the other hand, costs $65. The fee will be increased next month.

The project has benefited three home-bound patients so far.

In the future: The KTPH plans to extend the projects to four more nursing homes and more home-bound patients in future.

For the latter project, it is exploring the use of software which gives better image quality and connectivity.

For the project with nursing homes, the hospital is looking into the use of digital stethoscopes, which would allow doctors to hear patients' heart and lung sounds in real time.

The hospital is exploring other types of software for better image quality and connectivity.

Sources: Dr Ang Yan Hoon, senior consultant geriatrician at Khoo Teck Puat Hospital (KTPH), and Mr Kenneth Lam, senior operations manager of geriatric medicine at KTPH


What: Eye specialists at National Healthcare Group (NHG) Eye Institute at Tan Tock Seng Hospital (TTSH) diagnose patients with chronic blurred vision at Hougang Polyclinic through scan results and teleconferencing. The service started last year after a two-year pilot run.

How it works: Optometrists from the NHG Eye Institute are stationed at the polyclinic. When a polyclinic patient is referred to them with chronic blurred vision, they take a series of high-resolution images and videos of the patient's eyes. These are similar to what the specialist will see in an actual eye examination.

The scans are then transmitted via a $300,000 system which uses portable cameras and multiple computer screens for the eye specialist to view the images, make a diagnosis and communicate in real time with the patients.

For minor conditions such as mild cataracts or dry eyes, the specialist will dispense advice and prescribe spectacles or even basic medication via the optometrist and polyclinic doctor.

But those who are diagnosed with more serious conditions, such as glaucoma, will be referred to the eye specialist clinic at TTSH for a face-to-face consultation.

In the past, doctors at NHG polyclinics would refer all those with chronic blurred vision directly to the specialist at the eye institute.

With this initiative, patients with chronic blurred vision due to minor problems, such as refractive errors or dry eyes, can be treated at the polyclinics. This saves them a trip to the specialist clinic.

It also takes the load off the specialist clinic, as chronic blurred vision - due to mild or serious eye conditions - makes up half the cases seen there.

Patients do not have to pay extra for the teleconsultation. More than 500 people have benefited from the programme. About 42 per cent were found to have minor conditions such as mild cataracts or dry eyes.

In the future: The service will be extended to all NHG polyclinics. The NHG Eye Institute is looking into using teleophthalmology to monitor patients after cataract surgery.

Source: Dr Wong Hon Tym, medical director of the National Healthcare Group Eye Institute at Tan Tock Seng Hospital

Telemedicine for stroke

What: Stroke patients who are admitted to the emergency medicine department at Changi General Hospital (CGH) are examined remotely by neurologists at National Neuroscience Institute (NNI).

The service began running round the clock at CGH in February last year, after a three-month pilot.

It has since been extended to Khoo Teck Puat Hospital.

How it works: If initial assessments of a patient point to an acute ischaemic stroke, or stroke caused by a blood clot in a blood vessel, the doctors at the emergency department will call up the NNI neurologist on duty to find out if they should administer a clot-busting medicine.

The neurologist logs on to a computer either at home or at the institute and links up to the emergency medicine specialist through video-conferencing.

The doctor at the emergency department will examine the patient by asking a series of questions, while the neurologist observes and assesses the severity of the patient's condition.

A webcam that captures the patient's movements during the questioning and a copy of his brain scan help the neurologist make the diagnosis and recommend the appropriate treatment.

In the past, emergency department doctors who suspected patients had an acute ischaemic stroke would refer them during office hours to an NNI neurologist seconded to the hospital. After office hours, the emergency doctors would contact the neurologist on call at NNI for advice.

Patients do not have to pay extra for the new service. They pay only for the clot-busting drug if it is administered.

More than 200 patients have benefited from the programme, with about 60 treated with clot-busting medicine.

Recent studies in Germany and the United States show remote assessment of stroke is as accurate as that done on site.

In the future: There may be plans to roll out the programme to more public hospitals. The NNI is studying the cost-effectiveness of such stroke teleconsultations.

Source: Dr Rajinder Singh, consultant neurologist at National Neuroscience Institute

Source: The Straits Times © Singapore Press Holdings Limited. Reproduced with permission.