This article first appeared in Forum, The Edge Malaysia Weekly on August 28, 2023 - September 3, 2023

The Covid-19 pandemic has accelerated the use of telehealth in care delivery to patients, such as delivering consultations, diagnoses and even treatment through the use of technology, digital devices and the internet. In 2021, McKinsey estimated that telehealth use stabilised at levels 38 times higher than before the pandemic started.

As we move towards a post-pandemic world, telehealth will become even more vital in healthcare delivery. However, to ensure safe and effective telehealth services, we argue that it is essential to establish even stronger standards and guidelines. In this op-ed, we discuss the current scenario with existing standards, international best practices of telehealth training and our efforts towards a telehealth training programme, as well as propose the next steps for Malaysia.

Telehealth has existed for many years, but its adoption was slow due to various factors, including regulatory barriers, reimbursement issues, resistance from healthcare providers and a relative lack of trust or familiarity with a new tool. Prior to the pandemic, telehealth was applied in limited circumstances, such as connecting rural doctors and patients.

During Covid, countries such as Australia, Belgium, Canada and the US reported a significant increase in virtual care delivery. This expansion in telehealth has positively impacted many aspects of healthcare system performance, including equity, efficiency, access, cost effectiveness and quality.

While telehealth used in the right context has many benefits, it also poses some challenges. One challenge is the early stages of standards and guidelines due to the early stages of telehealth in Malaysia. Early standards are helpful, but may not support effective integration of telehealth into routine clinical care. Strong and future-proof standards are essential to provide transparency and foster collaboration among various health professions. Strong standards will ensure consistent care quality, address patient safety concerns and build trust, and support moves towards reimbursing telehealth. In a progressive move, Malaysia has taken early steps to address this issue in the form of setting up the Online Health Service (OHS) Regulatory Sandbox in 2022.

Several countries have established training for standards and guidelines for telehealth, which can serve as best practices for Malaysia. For example, the US has established the Center for Connected Health Policy, which provides guidance on telehealth policies and regulations. The UK has established the National Health Service Digital Academy, which provides training and education for healthcare providers on digital health. Australia, meanwhile, has established the Australian Digital Health Agency, which provides guidance on digital health policies and standards.

Closer to home, Singapore established the Licensing Experimentation and Adaptation Program (LEAP), a regulatory sandbox under the Ministry of Health (MOH) that allows licensing for healthcare providers delivering telehealth. The LEAP sandbox allows companies to test innovative healthcare solutions, including telehealth, in a controlled environment. These examples illustrate the importance of establishing standards and guidelines for telehealth and then training these standards.

LEAP culminated in a licensing framework for telemedicine under the Healthcare Services (Amendment) Act in March 2023. As part of the licensing requirements, doctors are required to undergo a telemedicine e-training provided by the MOH. Doctors can only perform telemedicine consultations after successful completion of the training. Another major part of this Act is the move from premise-based licensing to service-based licensing, which will be discussed in a future article.

Recognising the need for training and guidance for current and future telehealth providers, our organisations have jointly developed a telehealth micro-credentialing programme that provides healthcare providers with the knowledge and skills they need to deliver safe and effective telehealth services. The programme covers areas such as regulations, governance and legal considerations, patient physical examination, etiquette and data security.

This effort is congruent with the global telehealth education landscape as virtual care evolves into an integral mode of healthcare delivery. We are seeing rapid expansion in the areas of faculty development in telehealth teaching and assessment of telehealth competencies. For example, in 2021, the Association of American Medical Colleges (AAMC) developed six comprehensive telehealth competencies for medical school graduates, residency graduates and experienced physicians.

Similarly, in the same year, the Accreditation Council for Graduate Medical Education’s (ACGME) milestones for internal medicine was updated to include a specific milestone for digital health. Milestones are competency-based developmental outcomes related to telehealth that describe the knowledge, skills, attitudes and other attributes expected from novices (recent graduates) to those in the advanced practitioner level (consultants).

First, it is essential to strengthen national standards and guidelines for telehealth in Malaysia. These standards should cover areas such as patient safety, data security, quality of care, integration with in-person care, and collaborative care. The standards should be developed across health professions (not just doctors, but also nurses, pharmacists and other professions), with patients, payers and other stakeholders to ensure that they are relevant and effective. The standards must also be regularly reviewed, for example, every three years, to account for rapidly changing technologies.

Second, we must move to incorporate telehealth into the curricula of undergraduate, postgraduate and lifelong education programmes. In the undergraduate curriculum, the integration should focus on imparting a comprehensive understanding of telehealth fundamentals, encompassing its benefits, limitations, and legal and ethical considerations. Additionally, undergraduate students should be offered opportunities to engage in telehealth sessions during clinical rotations.

For postgraduate students, training should delve into the more advanced aspects of telehealth, data security, and effective physical examinations in virtual patient interactions. Integrating case studies and simulated telehealth consultations can hone diagnostic skills and adapt clinical assessment to virtual settings. More innovatively, we may need to consider “telehealth examination” as one additional method to assess if a postgraduate student is allowed to pass their specialist exams.

For practising healthcare professionals, continuous professional development or short courses should be made available, focusing on the evolving landscape of telemedicine. Interprofessional workshops that bring together healthcare professionals, digital health start-ups and administrators can foster effective collaboration.

One main benefit of stronger standards and better training is improved trust. Currently, one limiting factor for telehealth is that patients and payers may not fully trust that the standards are strong and doctors are trained. To fully maximise the benefits of telehealth, all stakeholders must build trust among patients and payers that telehealth is safe and effective. And trust can be built only with years of hard work by all stakeholders, with the two main thrusts of “clear standards” and “proper training”.

To achieve the above, the leadership responsibility should be collectively shared among different stakeholders. For example, the government, through the Ministry of Health and Malaysian Medical Council, should lead the strengthening of regulatory frameworks to prioritise patient safety, data security and ethical standards in telehealth. Medical schools play a pivotal role in preparing the next generation of healthcare professionals by incorporating telehealth training into their curricula. Professional organisations and societies (for example, the Malaysian Medical Association and Academy of Medicine) should systematically include telehealth training requirements in their undergraduate, postgraduate and lifelong learning programmes.

Hospitals and clinics delivering telehealth should offer resources, training and necessary infrastructure for their doctors and other healthcare professionals. The recent designation of five hospitals as Health Technology Hubs of the National Technology and Innovation Sandbox (NTIS) in Malaysia in September 2022 is also a step in the right direction. All five sites, leveraging on 4G/5G facilities, will be used for the testing of robotics, the Internet of Medical Things (IOMT) and other digital health and telehealth tools. Finally, collaborative efforts between digital health companies and healthcare stakeholders are important to create user-friendly and secure telehealth platforms that align with clinical needs.

Telehealth is here to stay, and its importance will only grow. To ensure safe and effective telehealth services, it is essential to strengthen standards and guidelines and to systematically train doctors and healthcare providers. Malaysia has taken early steps to address this issue, and more can be done to maximise the benefits and reach of telehealth in Malaysia.

Dr Na Wei Lun is a general practitioner and Dr Roslina Abdul Manap is a chest physician — both are co-leads of Angsana Academy. Dr Vishna Devi Nadarajah is pro vice-chancellor (institutional development and international) at the International Medical University. Dr Khor Swee Kheng is CEO of Angsana Health.

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