INTRODUCTION Telemedicine has emerged as a mode of care that aligns with pandemic control measures during the coronavirus disease 2019 (COVID-19) pandemic.1 In Singapore, the Ministry of Health (MOH) envisages telemedicine to be a key feature of the local healthcare landscape.2 Telemedicine services across various medical subspecialities have taken off during this pandemic. Many public institutions have set targets for a percentage of outpatient consultations to be done via telemedicine. MOH has also launched a course to guide doctors on the provision of telemedicine services.2 Subsidies for telemedicine have been expanded to include all chronic conditions under the Chronic Disease Management Programme.3 In serving children with developmental disabilities such as autism spectrum disorder (ASD) and attention deficit hyperactivity disorder (ADHD), telemedicine has been established as a mode of care in countries where access to specialist inputs may be limited due to large distances.4,5 However, many low- to middle-income countries have reported difficulties with establishing telemedicine due to healthcare access disparities and technological limitations.6,7 Concurrently, providers including physicians, psychologists and early interventionists often face barriers in adopting telemedicine due to lack of adequate training and local guidelines.7 Telemedicine practice is novel in the field of developmental and behavioural paediatrics (DBP) in Singapore. The Singapore MOH had previously approved telemedicine for limited use only. The clinical evaluation and management of children with developmental disabilities rely heavily on direct observation of and interaction with the child, building trust and rapport with the family over time.8 Our institution is a tertiary centre serving children with conditions such as ASD, ADHD, speech and language delays, and other developmental, behavioural and psychological conditions. In our practice, in-person consultations are highly valued by most caregivers, even though many can access telemedicine.9 In April 2020, as part of COVID-19-related measures, Singapore implemented a nation-wide ‘circuit breaker’, akin to a lockdown,10 resulting in cessation of non-essential services, including our DBP service. We responded to this change by offering telemedicine for continuity of patient care.11 In this article, we report the telemedicine experience of caregivers and providers during the lockdown. The primary aim of our study was to determine the ease, acceptability and efficacy of teleconsultation for caregivers and providers in the current health climate. We hypothesised that teleconsultation would be an acceptable alternative to physical consultation without compromising the quality of care. METHODS This is a cross-sectional study of caregivers and providers who participated in a telemedicine visit. Ethical approval for the study was obtained from the National Healthcare Group Domain Specific Research Board as per the institutional policy. Teleconsultations were offered to patients who (a) were existing patients at our clinic (i.e. not visiting the clinic for the first time); (b) had developmental diagnoses with no diagnostic uncertainty; and (c) were not expected to require an in-person developmental assessment. Telephone-based consults were used for the majority of patients due to limitations in the infrastructure available to provide videoconferencing for all patients. Video consultations were prioritised for patients accessing therapy services and for those whose appointments were to discuss results of diagnostic assessments (e.g., following cognitive or psychological testing). The patient service associate would call patients to offer teleconsultations, as per the eligibility criteria. The teleconsultations were conducted either in English or in the caregiver’s mother tongue if the healthcare provider had similar fluency. Telephone or video consultation charges were the same as in-person consultations, as per the hospital billing guidelines. Time allocation for teleconsultation slots was also identical to in-person consultations. Consent for teleconsultation was sought verbally at the beginning of the session and documented clearly in the clinical notes, with all providers following clear guidelines on verification of identity, explanation of costs, duration of consultation and documentation. Caregivers were sent a web link after their first telemedicine visit between 8 April 2020 and 14 May 2020, a 5-week period coinciding with the circuit breaker in Singapore. The study measure was a voluntary, anonymous questionnaire in English, with questions regarding the telemedicine-based encounter, including satisfaction, perceived benefits and limitations, in comparison to previous face-to-face consultation(s) at our clinic. Providers included physicians, speech therapists, occupational therapists, psychologists, learning support educators and social workers. Providers were sent a web-based questionnaire at the end of the study period to rate their telemedicine encounters in comparison to previous in-person consultations. Data was analysed using the IBM SPSS Statistics version 25.0 for Windows (IBM Corp, Armonk, NY, USA). Descriptive statistics were used to look at the demographic variables of data, and responses by caregivers and providers. Chi-square tests were used to determine if there were any differences in caregiver perceptions of teleconsultations, depending on the medium used for teleconsultation (video vs. telephone). RESULTS Around half of the patients (n = 216, 47.3%) who were offered teleconsultation accepted it. Of these, 105 (48.6%) caregivers completed the study questionnaire. Table 1 shows the demographic variables of the children whose caregivers participated in the survey. The mean age of the children was 5.9 (standard deviation SD 2.4) years. The mean duration of follow-up before teleconsultation was 2.3 (SD 1.7) years. The most common diagnoses were ASD (33.3%), language delay (28.6%) and ADHD (12.4%). Almost two-thirds (59.0%) of these patients were accessing early intervention.Table 1: Demographics of children whose caregivers participated in teleconsultations.Majority of the telemedicine encounters were telephone based (80.0%). Most (95.2%) caregiver respondents rated connectivity and call quality as good or excellent Table 2. Almost all (98.1%) the caregivers felt that their concerns were well addressed during the teleconsultations. There were no significant differences between caregivers who received telephone-based versus video-based consultations in terms of concerns being addressed. About two-thirds of caregivers (61.0%) found it was ‘easy’ or ‘very easy’ to prepare for the teleconsultation. Nearly half of the caregivers (44.8%) reported ease of following up with management plans after the teleconsultation Table 2. Similarly, 47.6% of the caregivers rated that they felt safer with a telemedicine-based encounter, as they could avoid travelling to the clinic in the midst of the pandemic, while a quarter (24.8%) felt that the main benefit was not having to take time off work. Most caregivers (68.6%) did not report any difficulties with respect to the telemedicine encounter; however, nearly one-fifth of the caregivers (17.1%) felt that the consultation was incomplete without face-to-face assessment of their child. Overall, 63.8% of the respondents were open to continuing telemedicine-based encounters for their child even after the pandemic.Table 2: Caregiver responses on their telemedicine experience.Caregivers who had video-based teleconsultations were more likely to have difficulties with preparation for the consultations, as compared to those who had telephone-based consultations (52.3% vs. 27.4%, P = 0.03). These caregivers had difficulties remembering and following up with the plans discussed, compared to those who had a telephone-based consultation (52.3% vs. 25.0%, P = 0.02). There was no difference between the two groups in terms of concerns being addressed or perceived benefits. The patients’ diagnoses, therapy received (or lack thereof) and duration of follow-up at our clinic had no impact on the caregivers’ perceived benefits or difficulties of teleconsultations. Twenty-five providers participated (response rate 96.2%) in the study. The three main provider subgroups were psychologists (32.0%), physicians (28.0%) and speech therapists (20.0%). Half (52.0%) were as satisfied with telemedicine-based consultations as with face-to-face consultations; while 40.0% were neutral about this. About one-third (28.0%) of providers felt that infrastructure and technological support were good or excellent Table 3. The majority of providers (88.0%) cited at least one difficulty with using telemedicine. The most frequent difficulty reported (32.0%) was the inability to directly observe and interact with the child. Other difficulties cited were challenges in communicating with caregivers without in-person contact, connectivity and call quality, and not being able to provide patients with resources in person. Main perceived benefits by providers included feeling safer as they were able to minimise physical interaction with patients (92.0%) and being able to provide similar quality of care as a routine consult with less inconvenience to patients (64.0%). Fifty-six percent of providers would like to continue telemedicine services for patients even after the pandemic.Table 3: Provider responses on their telemedicine experience.Among providers, paediatricians were more likely to continue teleconsultation services after the lockdown, compared to the rest (100% vs. 38.9%, P = 0.008). Paediatricians were more satisfied with teleconsultations, compared to other providers, although this was not statistically significant (85.7% vs. 38.9%, P = 0.073). Non-physician providers reported poorer satisfaction with the hospital’s technological infrastructure support compared to paediatricians, with a trend towards statistical difference (83.3% vs. 42.9%, P = 0.066). DISCUSSION There have been limited studies describing the caregiver and provider experience of telemedicine in a DBP service in Singapore and Asia, where face-to-face visits are traditionally valued.12 One of the key findings of our study was that almost all caregivers reported that their concerns were well addressed via telemedicine. This was the case even with the majority of the clinical encounters being conducted via a telephone rather than by videoconferencing-based methods. This is relevant, especially in reaching out to families that do not have access to videoconferencing either due to financial limitations or due to limited technological literacy. In addition, the use of telephones as the primary mode of telemedicine would be much more feasible in communities with limited technological infrastructure.13 Lastly, telephone-based services can be set up in a much shorter time and can act as an interim measure while establishing infrastructure for videoconferencing. Indeed, given that currently several barriers exist in the adoption of telemedicine in especially vulnerable communities such as those in developing countries,14 these findings support that telemedicine can be adopted quickly and is acceptable to caregivers. Healthcare facilities can thus establish some degree of continuity of care for families of children with developmental disabilities. Providers were comparatively less satisfied with teleconsultations. The greatest challenge reported was their inability to interact directly with the child. Previous studies have similarly reported that healthcare professionals were reluctant to accept telemedicine due to lack of in-person contact, perceived complexity and lack of training.15,16,17 Establishing local guidelines with respect to the use of telemedicine and telemedicine training for providers would help their acceptance of this service. Our finding that paediatricians were more likely to continue practising telemedicine after restrictions were lifted in comparison to non-physician providers was interesting. A possible explanation for this is that the physician’s role in telemedicine was anticipatory guidance and management planning as, by the inclusion criteria, the diagnosis was certain and there was no need for in-person developmental assessment. However, the therapists’ sessions encompassed demonstration of intervention/recommendations to the caregivers, which would have been challenging without the child in person. Technological and infrastructure support for teleconsultations was a significant issue for providers, thus contributing to the lower overall satisfaction. Improved IT infrastructure and support would help to improve the end-user experiences of telemedicine (see below). Caregivers understandably had more difficulties in preparing for video-based teleconsultations compared to telephone-based consultations as the former required caregivers to access a secure online platform, coordinate with the clinic reception staff and have technological literacy; it also required reliable internet and access to an electronic device. In contrast, telephone-based consultations only required a phone line. Similarly, caregivers who had video-based teleconsultations were more likely to have difficulties in remembering and following up with recommendations after the consultation. By our clinic telemedicine criteria, video-based teleconsultations were more likely to have been used for intervention sessions by therapists or for sharing results of diagnostic assessments, and hence, it could have conceivably been more difficult for caregivers to follow-up with recommendations. In contrast, a phone consultation session would more likely have been with a paediatrician discussing management plans and checking in with the family. This could also reflect a suboptimal teleconsultation experience possibly due to connectivity issues, or that caregivers of children with more complex issues opted for video-based teleconsultations. These findings are in line with existing literature suggesting that video-based teleconsultations come with more complexities and should be used to supplement rather than replace telephone consultations.18,19 Video-based teleconsultations better serve a select group of caregivers who are experienced in video calls and have the required technology infrastructure. Given the above reasons, and as hospitals adopt telemedicine more widely, our experience helps to refine the subgroup of patients most likely to successfully accept and benefit from video consultations. Patients with more complex conditions may also require more post-consultation support with a follow-up telephone call or e-mail to ensure that the caregivers are clear on the plans discussed. For providers, the infrastructure within the clinic and training on the use of video-based teleconsultations can be improved to help improve acceptance in the use of telemedicine. When embarking on providing telemedicine, clinics should also be prepared to dedicate more administrative support towards the preparatory and follow-up work surrounding a teleconsultation. This study has several limitations. Firstly, we did not obtain demographic data on caregivers who participated and those who declined a teleconsultation. A selection bias could have stemmed from caregivers of different age groups, educational status and income groups being more or less likely to have opted for a teleconsultation. Participant demographics could have impacted on satisfaction ratings found in the survey; this would be important to include in any follow-up studies. Secondly, we did not ask if the cost of a teleconsultation or perceived ‘lack of value’ without an in-person visit could have motivated caregivers to decline a teleconsultation. Thirdly, as this was a cross-sectional survey conducted during the peak of the COVID-19 pandemic, respondents might have overrated the telemedicine experience due to their relief at being able to access specialist health care without the risk of exposure to infection. Despite these limitations, strengths of this study include timely information on the caregiver and provider experiences of a novel teleconsultation service in a DBP clinic within the ongoing COVID-19 pandemic. The data allowed for a rapid evaluation of the efficacy of telemedicine during an unprecedented time, which enabled us to understand caregiver needs and be affirmed to provide telemedicine-based services to as many patients as possible. Given that this pandemic will be prolonged, we believe that the data will have relevance to similar services in the country and region now and post-pandemic as well. Over the past year, as the pandemic continued and video-based teleconsultation became the new norm with expanded IT support in healthcare settings, a follow-up study to evaluate the telemedicine experience including via videoconferencing would be helpful to inform continued adaptation of services. In conclusion, this study provided insights on the caregiver and provider experiences of a novel telemedicine service in a DBP clinic during a period of ‘lockdown’ in the ongoing COVID-19 pandemic. Families who already have a relationship with their DBP provider find that telemedicine is an acceptable form of consultation, and that their concerns are well addressed. The use of telemedicine in serving children in a DBP practice is a viable option in a pandemic situation and beyond. Furthermore, using telephones as the primary modality for telemedicine can be a sustainable method for patients with stable diagnoses. Given that telemedicine is set to be a constant fixture amidst this ongoing pandemic, these findings can be considered when redesigning DBP clinical services across the region. Acknowledgement We would like to acknowledge the caregivers and providers who participated in this study and Dr Dimple Rajgor for her help in editing and formatting the manuscript. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.
Tan et al. (Thu,) studied this question.