ISE14/20-21

• The advancement of technology over the past decade or so has facilitated the development of telehealth services globally.^{1Legend symbol denoting The term "telehealth" has been used interchangeably with other terms such as "eHealth" and "telemedicine" by healthcare authorities around the world. These terms may have similar or slightly different definitions depending on the applications of ICT in the healthcare sector and scope of services offered in the respective places. For simplicity, the term "telehealth" is used throughout this Essentials.} Telehealth refers to the remote delivery and facilitation of health and health-related services, including medical care, provider and patient education, health information services and self-care, through information and communications technologies ("ICT").^{2Legend symbol denoting See NEJM Catalyst (2018).}
• The recent outbreak of the Coronavirus Disease 2019 ("COVID-19") pandemic has provided the catalyst for the take-up and/or expansion of telehealth services usage around the world. Telehealth can help avoid direct physical contact with the patients and minimize the risk of COVID-19 transmission. Medical practitioners can also make use of telehealth to identify and take care of home quarantined COVID-19 patients remotely.
• In Hong Kong, the development of telehealth services has been slow until recently in light of the easy and high accessibility to in-person healthcare services in the public and private sectors. While the usage of telehealth services has picked up after the outbreak of the COVID-19 pandemic, the sustainable development of telehealth services is dependent on the support of the Government and widespread adoption by the healthcare service providers and patients.^{3Legend symbol denoting See Health Advances (2020).}
• This issue of Essentials begins with an overview of telehealth services in terms of its scope and benefits and the global development trend. It is followed by a discussion of the development of telehealth services in Hong Kong and the issues affecting its development. The relevant experience in Singapore is also studied for reference, as the country has been proactive in driving the development of telehealth services over recent years.

Overview of telehealth services

• While the scope of telehealth services varies among different places, it generally comprises elements such as (a) telemedicine/teleconsultation - remote consultations between patients and medical professionals and/or peer-to-peer support between medical professionals; (b) telemonitoring - remote monitoring of patients' clinical data to provide opportunity for feedback and intervention; and (c) tele-support - the use of online services for provision of advice or information to support patients and/or carers.
• Telehealth services enable improvements in the access to, and quality, efficiency and cost-effectiveness of, healthcare services and medical information/education delivered to patients, particularly those living in remote areas and belonging to vulnerable groups. Besides, the use of telehealth services helps patients build their self-care competence and empowers patients and carers by providing them with accessible health education and decision-making options.^{4Legend symbol denoting See World Health Organization (2016).} The application of telehealth services is also regarded as the strategic solution for relieving the burden on the healthcare sector amidst ageing of the population.^{5Legend symbol denoting See Hong Kong Economic Journal (2020).}
• In light of the above potential benefits, many places started to put in place a dedicated policy or plan in the 2010s for the development and delivery of telehealth services. According to the latest survey conducted by the World Health Organization in 2015, 58% of the responding member countries indicated that they had devised a policy or strategy on eHealth/telehealth.^{6Legend symbol denoting See World Health Organization (2016).} For example, Singapore, being an early adopter of telehealth services in Asia, has guided the development of telehealth services by providing guidelines and refining the regulatory regime since the mid-2010s.^{7Legend symbol denoting See Health Advances (2020).} The Australian government launched the Telehealth Pilots Programme in 2012 to subsidize selected telehealth services projects for identifying opportunities for extending the application of telehealth services.^{8Legend symbol denoting See Australian Government Department of Health (2014).} The National Health Service of England has devised a Technology Enabled Care Services programme in 2015 to support and encourage the innovative use of technology to improve health outcomes for patients.^{9Legend symbol denoting See NHS (undated)., 10Legend symbol denoting Places around the world have achieved varying levels of success in telehealth services development. Some are lagging behind due to limitations such as a lack of funding support and trained workforce, and inadequacies of the ICT infrastructure and the regulatory framework to facilitate telehealth services development. See World Health Organization (2016).}

Development in Hong Kong

• As early as in 1998, the Hospital Authority ("HA") started to make use of teleconsultations via video-conferencing to replace conventional geriatric outreach or clinic-based services in the delivery of healthcare services, mainly for some patients living in Residential Care Homes for the Elderly. While HA's teleconsultation services programme brings with it benefits like reducing healthcare costs, improving access to services and reducing visits to the emergency department, application of the services has until most recently been very limited.^{11Legend symbol denoting Some academic research studies showed minimal experience of using the services by the patients studied. These patients were willing to accept the services to improve accessibility to healthcare if their concerns towards safety, security and communication were addressed. See Hui, E. (2008) and Kung, K. et al. (2016).}
• Amidst the outbreak of the COVID-19 pandemic, HA has expanded the application of teleconsultation services to some other patients such as psychiatric patients or patients requiring follow-up consultations. Allied health staff have also been using videoconferencing to follow-up on treatment or supporting rehabilitation of patients through HA's mobile application "HA Go".^{12Legend symbol denoting See Food and Health Bureau (2020).} Besides, usage of teleconsultation services has reportedly been growing in the private sector with some private hospitals or clinics providing such services to existing patients, particularly those with common ailments, as an option to lower the risk of COVID-19 infection.^{13Legend symbol denoting See Hong Kong Economic Journal (2020) and South China Morning Post (2020c).}
• The potential for using teleconsultation services in Hong Kong can be reflected by a survey conducted in May 2020 on the perception of senior citizens towards the COVID-19 outbreak and telemedicine services.^{14Legend symbol denoting See Lingnan University (2020).} Among the 638 respondents aged 55 years or above surveyed, 61.3% were willing or very willing to try teleconsultations when the relevant technology was fully developed. A higher percentage was observed for those respondents with tertiary or above education level (70.6%), as compared with those with secondary or below education level (55.2%). The fairly high receptiveness of teleconsultation services among the senior citizens suggests that the new service model might be a viable option for treating older patients amidst the COVID-19 pandemic in order to lower their risk of infection.
• In order to provide guidance to doctors who wish to engage in telehealth, the Hong Kong Medical Council laid down the "Ethical Guidelines on Practice of Telemedicine" in December 2019.^{15Legend symbol denoting "Telemedicine" in the context of the "Ethical Guidelines on Practice of Telemedicine" refers to a wide spectrum of telehealth services including teleconsultation, telemonitoring, and disseminating service information and/or health education to the public through telecommunication systems. See The Medical Council of Hong Kong (2019).} The Guidelines sets out some generic principles for medical practitioners who substitute telehealth for traditional modes of delivery of medical care and/or advice. In the Guidelines, medical practitioners are reminded to remain fully responsible for determining the appropriateness of using telehealth services for their patients. This, coupled with the hitherto lack of specific details and standards on practicing telehealth services, has rendered many private medical practitioners to be cautious in adopting telehealth services. As such, there have been suggestions for the Government to clearly define the specific types of cases or conditions where teleconsultation services can be applied.^{16Legend symbol denoting See Hong Kong Trade Development Council (2020), Mayer Brown (2020) and South China Morning Post (2020a).} The Government has yet to respond to such calls.
• Nonetheless, the Government has recently set out the policy direction to encourage application of innovation and technology in the healthcare sector. Related initiatives include: (a) exploring the broader application of telehealth services in patient care through developing the mobile application "HA Go"; (b) developing smart hospital initiatives to optimize the patient journey, such as the plan to set up smart wards with real time data collected by mobile and Internet of Things technologies; and (c) making available the big data analytics platform in December 2019 to support healthcare related research projects.^{17Legend symbol denoting See Food and Health Bureau (2019) and GovHK (2020).}
• All in all, there are views that Hong Kong has been lagging behind in telehealth services development with respect to areas such as the regulatory framework governing the use of new technology for healthcare services, and the openness of healthcare service providers to adopt medical innovations for patient care. As such, there have been voices calling for the Government and relevant healthcare authorities to take the lead in planning and supporting the development of telehealth services in Hong Kong.^{18Legend symbol denoting See Health Advances (2020), Hong Kong Trade Development Council (2020) and South China Morning Post (2020b).}

Development in Singapore

• In Singapore, the government has taken the lead in guiding the development of telehealth services since the mid-2010s. It aims to improve the access to and quality of healthcare services amid the challenges brought by an ageing population and increasing burden of non-communicable diseases. Following a holistic and coordinated approach, the Singaporean government has enhanced the regulatory framework of the healthcare sector to cover telehealth services and facilitate the development of innovative telehealth solutions. It has also put in place facilitation measures to boost the adoption of telehealth services among healthcare professionals and patients.

Regulatory framework

• In January 2015, the Ministry of Health ("MOH") issued the National Telemedicine Guidelines to provide non-legal binding guidance on the best practices of telehealth services in four areas. These comprise: (a) clinical standards and outcomes; (b) human resources; (c) organization of service providers; and (d) technology and equipment, for guiding healthcare service providers to develop and deliver safe and high quality telehealth services.^{19Legend symbol denoting The Guidelines categorize telehealth services into four domains, namely: (a) tele-collaboration of on-site and remote healthcare professionals; (b) tele-treatment involving interactions of remote healthcare professionals with patients or carers; (c) tele-monitoring of biomedical and other data of patients; and (d) tele-support of patients or carers through online services. The Guidelines mainly govern the first three domains of telehealth services that involve clinical applications of ICT. See Ministry of Health (2015).}
• MOH went further ahead in 2018 with the launch of a regulatory sandbox initiative,^{20Legend symbol denoting A regulatory sandbox is a framework set up by the regulatory authority of a specific sector to allow small scale, live testing of innovations by private firms in a controlled environment (e.g. operating under a special exemption or other limited, time-bound exceptions). The concept has first been applied in the financial sector for encouraging development of innovative financial services using new technology. See CGAP (2017).} the Licensing Experimentation and Adaptation Programme ("LEAP"), aiming to promote development of innovative medical services in a safe and controlled environment before introducing the regulatory scheme for the telehealth service providers. Under LEAP, MOH has worked with service providers to experiment with different telehealth services and business models to (a) better understand the risks involved; and (b) plan for the appropriate mitigation measures to safeguard the interests of the patients. Participating service providers also benefit from the programme as they will be in a better position to transit seamlessly into the eventual regulatory scheme and meet patient safety requirements.
• It was reported that around 11 service providers had participated in LEAP, including some major teleconsultation platforms which had experienced increase in usage during the COVID-19 pandemic.^{21Legend symbol denoting See Frontiers (2020).} MOH has planned to introduce a licensing scheme for telehealth service providers under the new Healthcare Services Act by the end of 2022.^{22Legend symbol denoting The Healthcare Services Act, to be put into effect in 2021, adopts a service-based licensing approach in regulating healthcare service providers in contrast to the existing premises-based licensing approach to cater for emergence of new and innovative services such as telehealth services in the healthcare sector.}
• To enhance protection of patients' safety and interests, the Health Sciences Authority, the regulatory authority of medicines and medical devices in Singapore, published the Regulatory Guideline for Telehealth Products in 2019. The Guideline is to clarify the types of telehealth products that are regulated as medical devices and the relevant regulatory approach and requirements to be adopted. Under the Guideline, regulated telehealth products include hardware devices, and software and mobile applications that are intended for medical purposes such as detection, diagnosis, monitoring and treatment of any medical conditions.

Free e-training course

• MOH has introduced a free e-training course for medical professionals to guide them on designing and delivering telehealth services so as to ensure patient safety and welfare. As at April 2020, 955 medical professionals had reportedly completed the course.^{23Legend symbol denoting See The Straits Times (2020).}

Facilitation measures during the COVID-19 pandemic

• MOH has made use of telehealth services during the COVID-19 pandemic to help patients avoid physical visits at the clinics. Since April 2020, patients are allowed, on a time-limited basis, to use their Community Health Assist Scheme subsidies^{24Legend symbol denoting Under the Community Health Assist Scheme, all Singapore citizens are provided with subsidies for medical and/or dental care at participating general practitioner and dental clinics. The amount of subsidy provided is tiered according to the household income of the citizens or the estimated annual rent of their home for households with no income.} and MediSave savings^{25Legend symbol denoting The MediSave scheme is a national medical savings scheme which helps members of the Central Provident Fund scheme put aside part of their income to meet the future medical expenses of themselves and their dependents.} to cover regular follow-up of 20 specified chronic conditions through teleconsultations provided by approved private healthcare service providers. On the other hand, small and medium-sized enterprises in the healthcare sector also get help from the government in delivering their services remotely amid the pandemic. Since May 2020, MOH has provided eligible healthcare service providers with subsidies to acquire specified pre-approved teleconsultation solutions.

Concluding remarks

• Telehealth services offer the potential benefits of enhancing the access to and quality, efficiency and cost-effectiveness of healthcare services. They also serve as a plausible solution for easing the growing demand for healthcare services brought by population ageing and disease outbreaks. The development of telehealth services in Hong Kong has been slow before the outbreak of the COVID-19 pandemic.
• Despite the recent growth in usage of teleconsultations amidst the pandemic, the long-term development of telehealth services may require the Government to step up efforts on various fronts. These include laying down a clearer regulatory framework and guidelines on the applications of technology in the healthcare sector, encouraging service providers to develop innovative solutions, and boosting adoption of the solutions among healthcare professionals and patients.
• In comparison, Singapore has been progressive in leading the development of telehealth services since the mid-2010s Guided by a clear direction and comprehensive regulatory framework, the government has set out clear guidelines on the appropriate delivery of telehealth services, made use of regulatory sandbox for testing innovative service solutions, and refined the regulatory regime of the healthcare sector to cover telehealth services. Furthermore, the government has provided incentives to the healthcare service providers and patients for adopting new telehealth services.

Prepared by Ivy CHENG
Research Office
Information Services Division
Legislative Council Secretariat
21 January 2021