Doctors, patients must see and hear each other during teleconsults; MOH studying potential lapses

11/30/2024 10:30:00 PM | The Straits Times

The article is contributed/written by

Under the Healthcare Services Act, teleconsultations must be “conducted using two-way, interactive, audio-visual communications in real time”. ST ILLUSTRATION LEE YU HUI

SINGAPORE - The Ministry of Health is looking into potential lapses by telehealth platforms in the provision of online consultations.

This comes after The Straits Times consulted seven platforms that offered popular weight-loss drugs in July, and found two instances where cameras were not turned on.

Asked about this, MOH said cameras are necessary to establish a proper doctor-patient relationship, and to provide similar quality and standard of care as in-person medical care.

“We would have to look into these breaches, why they happened and if there were any mitigating factors,” said a spokesman.

Under the Healthcare Services Act, teleconsultations must be “conducted using two-way, interactive, audio-visual communications in real time”.

The operators in question told ST that they are reviewing the instances flagged.

Despite the lapses, the ministry pointed out that telemedicine promises a more efficient way to ensure healthcare becomes accessible and affordable.

“As with any new business model or technology, there will be lapses, even abuse, but we should still embrace it, regulate it, and make it work for the benefit of the public we serve.”

The telehealth industry has been in the spotlight, with the authorities clamping down on clinically and ethically inappropriate practices by MaNaDr Clinic. Lapses include teleconsultations that lasted one minute or less.

Separately, MOH and the Health Sciences Authority also sent a joint circular to medical providers on Nov 22 reminding them of the need to comply with telemedicine guidelines.

MOH and HSA said in a joint reply to ST that the licensees and clinical governance officers of telehealth services must establish and implement formal protocols and processes for teleconsultations.

The operators also have to ensure that all medical practitioners providing care through the teleconsultation service comply with them.

How the teleconsults were done

ST’s reporter signed up for weight-loss teleconsultations with Doctor Anywhere, Elevate, MaNaDr, Novi Health, Ova, Siena Health, and Zoey in July. Some of these telemedicine providers had started out in areas such as reproductive health, sexual health and hair loss.

There were weight-loss teleconsultations for only six platforms, as Doctor Anywhere referred the reporter to an in-person consultation for the first-time prescription of glucagon-like peptide-1 (GLP-1) drugs.

All seven operators required the reporter to fill in a questionnaire about her medical history, with some asking for details on previous attempts to lose weight, and lifestyle habits such as diet, exercise frequency and sleep.

She was then able to book a date and time for the consultations, which she started with her camera turned off.

During the teleconsultations, which lasted between 5½ minutes and 46½ minutes, doctors verbally confirmed her height and weight, but did not ask for further verification.

On at least five platforms, doctors discussed the possibility of prescribing GLP-1 drugs to her for weight loss, though her body mass index (BMI) of 28 without pre-existing conditions puts her outside the standard criteria for such treatment.

Only Ova, which is run by Ora Group, required the reporter to have blood tests for liver and kidney function to assess if she was suitable for weight-loss drugs.

Two platforms – Zoey and Elevate – allowed the reporter’s camera to remain off during the teleconsultation.

In the case of Zoey, the doctor’s camera was also off during the entire consultation. Nonetheless, ST was able to obtain a one-month prescription of Saxenda from the platform.

ST approached all seven operators for comment.

Four of the operators said they have various methods to verify if a patient has accurately declared their height, weight and medical history. They may ask for photos and live weight measurements, lab reports, or arrange for in-person appointments if discrepancies are suspected.

Dr Sue-Anne Toh, co-founder of Novi Health, said that video consultations are important as doctors can identify potential discrepancies with the patient’s declared information through observing their appearance.

“If we highly suspect that something is off, then we would find some way of communicating it sensitively,” said Dr Toh, who is also an endocrinologist.

Siena Health and MaNaDr did not respond to queries.

Some operators said they had encountered instances where some users may have misrepresented their information in order to get GLP-1 drugs.

The firms also emphasised that a consultation does not guarantee a prescription for GLP-1 drugs.

Ordinary Folk, which runs platforms Zoey and Noah, said one in five prescription requests was denied between November 2023 and August 2024. Some patients did not meet the prescription criteria based on the information they declared, while others did not provide additional information requested by the doctor, among other reasons.

Ora Group, which operates telehealth platforms andSons and Ova, said up to 40 per cent of its consultations do not lead to GLP-1 prescriptions.

With Doctor Anywhere, the reporter was asked to go for an in-person consultation.

Dr Andrew Fang, the company’s director of medical affairs, said this facilitates detailed counselling on the proper use of weight-loss medication. “This approach helps maintain the integrity of the treatment and ensures the safety and effectiveness of the care provided.”

He added that consultations for GLP-1 weight-loss drugs have increased more than fivefold since they were introduced on the platform in August 2022.

The operators of the two platforms that allowed the reporter to proceed without her camera on said they are investigating the matter.

Ordinary Folk founder Sean Low said the company will proceed with corrective actions if any wrongdoings are found regarding the consultation on Zoey.

Elevate co-chief executive Rio Hoe said a support team in the virtual waiting room monitors the pre-consultation process to ensure that patients and doctors both have their cameras on before the consultation begins.

“We will review this specific case with the doctor promptly to ensure our policies continue to be followed as intended. Our goal is always to provide secure, compliant and effective care for our patients,” he said.

“We will need some time to gather all the facts and conduct this review, and therefore it would be premature to comment on any potential actions at this point in time.”

The weight-loss drugs

Many telehealth platforms have added GLP-1 drugs to their inventory in the past year amid increased interest in the new class of weight-loss drugs.

ST’s reporter signed up for the weight-loss teleconsultations to find out how easy it would be to obtain them, and uncovered varying consultation standards and protocols among the providers.

GLP-1 drugs for weight loss are currently approved for individuals who meet specific BMI and health criteria. Details such as weight and height, which are used to calculate BMI, are self-declared by patients in the case of weight-loss teleconsultations.

GLP-1 drugs were originally developed to treat diabetes, but received widespread attention after they were found effective for losing weight.

Eight GLP-1 drugs are currently approved for use in Singapore, with two approved for weight loss – Wegovy and Saxenda. Wegovy is not available in Singapore yet because of supply issues.

Saxenda is approved for patients who have a BMI of 30 or more, and for those with a BMI of 27 or more but who also have co-existing weight-related medical problems such as hypertension or obstructive sleep apnoea.

But doctors can opt to prescribe such medications for those who fall short of approved BMI ranges – an off-label practice that is allowed here, with caveats.

Doctors can also opt to prescribe GLP-1 drugs approved for diabetes for weight loss, such as Rybelsus, a pill taken once a day. It is often prescribed off-label due to its effectiveness in reducing body weight and ease of use.

Doctors are permitted to use an approved drug in a setting for which it has not received regulatory approval, based on their clinical discretion. They are accountable for this decision.

MOH and the Health Sciences Authority said doctors must first conduct “an adequate assessment”, and determine if it is “in the best interest of their patient to be provided the treatment after considering the benefits and risks”.

Doctors must ensure that the benefits of using the drug outweigh the risks, that there is a justifiable medical indication, and that patients are properly informed.

Saxenda, a daily injectable and the main GLP-1 drug offered by telehealth platforms, was suggested as an option to the reporter during consultations with at least three platforms.

Rybelsus was also suggested as an option to the reporter by three platforms.

ST asked for a prescription from Zoey, which was the only platform where both cameras were turned off, and succeeded.

ST asked the platform’s operator, Ordinary Folk, why it prescribed Saxenda to the reporter despite her not meeting the approved guidelines.

Ordinary Folk said that its doctors apply “evidence-based medical judgment” to offer personalised care.

“Our doctors are also informed by real-world evidence and insights from professional bodies. For instance, a South Korean study demonstrated that liraglutide (the active ingredient in Saxenda) is effective for patients with a BMI of 27 and above, showing significant weight-loss benefits,” said Ordinary Folk’s medical doctor, Dr Colin Lai.

The firm’s founder, Mr Low, added that ST’s consultation is being reviewed to confirm compliance. “Should any areas for improvement be identified, we will take immediate corrective measures, including strengthened review and oversight procedures,” he added.

Novi Health is also offering GLP-1 drugs on an off-label basis.

Its screening criteria for its weight-loss management programme for Asians are either a BMI of more than 27.5, or more than 23 if the patient has a weight-related chronic condition.

Explaining the company’s policy, Dr Toh said: “It is well known that metabolic complications associated with excess weight occur at lower BMI thresholds in Asian populations than Western populations. For example, countries like Japan and Korea define obesity at BMI cut-offs of 25, while Singapore defines it at 27.5.”

Dr Toh said the company prescribes drugs off-label responsibly by having an informed discussion with patients about the benefits and risks.

Side effects of GLP-1 drugs

GLP-1 drugs work by mimicking a gut hormone that reduces appetite and increases feelings of satiety. The drugs also slow down the emptying of the stomach, which prolongs the feeling of fullness after eating and helps reduce overall food intake.

Common side effects include nausea, vomiting, diarrhoea, constipation and upper abdominal pain or discomfort.

Dr Ravishankar Asokkumar, a senior consultant at the department of gastroenterology and hepatology at Singapore General Hospital (SGH), said side effects occur in nearly 40 per cent to 60 per cent of patients on GLP-1 drugs, and most of them are mild to moderate.

Patients who take these medications for weight loss are more prone to having side effects because of the higher dose of drugs used as compared with diabetes treatment, he added.

Dr Lee Phong Ching, director of SGH’s obesity centre, warned that GLP-1 drugs “should not be abused by those who do not have obesity but just want to lose some weight”.

He said these medications are intended for and have been studied in people with obesity and related metabolic conditions such as diabetes. “For individuals with a healthy weight, this may result in malnutrition and loss of lean muscle mass.”

Dr Chan Soo Ling, a consultant with Ng Teng Fong General Hospital’s division of endocrinology, said that if such drugs are used without medical supervision and healthy lifestyle and diet changes, people can regain the weight they lost after coming off the medication.

“This leads to yo-yo weight cycling which is associated with impaired metabolism rates and disruption of hormones that regulate hunger and satiety, making it harder to lose weight in the future,” she said.

How the seven teleconsultations stacked up

Platform: Doctor Anywhere

Two-way audiovisual consultation conducted: Yes
What was discussed: The doctor explained why there is a need for in-person consultation for first-time patients
Teleconsultation duration: About two minutes
Outcome: Referred for in-person consultation for first-time prescription of GLP-1 drugs

Platform: Elevate

Two-way audiovisual consultation conducted: No, patient’s camera was off
Teleconsultation duration: Nearly 14 minutes
What was discussed: Whether the patient had taken weight-loss medication previously, or done previous blood checks or tests to look for reasons why she was overweight. Potential side effects were discussed, as well as diet advice.
Outcome: Saxenda and Rybelsus suggested as potential options. Patient did not proceed further.

Platform: MaNaDr

Two-way audiovisual consultation conducted: Yes
Teleconsultation duration: Nearly 14 minutes
What was discussed: The patient’s current diet and exercise routine, and side effects of GLP-1 drugs. The doctor encouraged the patient to try engaging a dietitian before considering medication.
Outcome: Doctor advised the patient to let the platform know if she still wants weight-loss medication. The platform offers Saxenda, and other non-GLP-1 drugs. Patient did not proceed further.

Platform: Novi Health

Two-way audiovisual consultation conducted: Yes
Teleconsultation duration: About 46½ minutes
What was discussed: The patient’s medical history, including family history and drug allergies. The doctor also asked for details of her daily activities, types of workout done, and the types of meals and snacks she would typically eat. The doctor discussed how GLP-1 drugs work, and what to expect when taking the drugs for the first time. The platform’s GLP-1 weight management programme also includes sessions with a health coach.
Outcome: Rybelsus suggested as a potential option. Patient did not proceed further.

Platform: Ova

Two-way audiovisual consultation conducted: Yes
Teleconsultation duration: About 17 minutes
What was discussed: Doctor emphasised the importance of diet in weight management, and discussed what makes a healthy meal. Encouraged the patient to do moderate-intensity exercise for 150 minutes a week, along with strength training. Side effects of medication are also discussed.
Outcome: Required to get a blood test to check liver and kidney function before evaluating suitability for GLP-1 prescription. Patient did not proceed further.

Platform: Siena Health

Two-way audiovisual consultation conducted: Yes
Teleconsultation duration: 11 minutes
What was discussed: The efficacy of different GLP-1 drugs, and how diet and exercise are important components of weight management. Side effects to look out for were also discussed.
Outcome: Saxenda and Rybelsus suggested as potential options. Patient did not proceed further.

Platform: Zoey

Two-way audiovisual consultation conducted: No, both doctor and patient’s cameras were off.
Teleconsultation duration: About 5½ minutes
What was discussed: After verbal confirmation of the patient’s height and weight, and whether she had taken any weight-loss medications previously or had any long-term medical problems, the doctor asked if she preferred taking tablets or injections. Potential side effects were also discussed.
Outcome: Patient received a one-month prescription for Saxenda. After receiving the medication, patient attended a nine-minute teleconsultation with Zoey’s pharmacist to learn how to administer Saxenda safely.