A Systematic Implementation of Telemedicine in Singapore's COVID-19 Community Recovery Facilities

Abstract

Introduction:

This article describes the experience of the Singapore Armed Forces (SAF) implementing telemedicine consultations for COVID-19–positive patients recovering within community recovery facilities (CRFs) in a semi-inpatient setting.

Materials and Methods:

The SAF adopted a systematic approach to telemedicine implementation and scaling up, with Phase 1 being the deployment of medical teams operating on-site clinics daily at six CRFs and telemedicine only provided for after-hours medical consultations on an ad hoc basis. Subsequently in Phase 2, most clinical consultations in the CRFs were conducted virtually.

Results:

Phases 1 and 2 recorded 1,902 and 449 clinical consultations, respectively. The mean number of clinical encounters was 33 per 1,000 occupants per day in Phase 1, and 12 per 1,000 occupants per day in Phase 2 (p < 0.001). Acute respiratory illness (52.3% in Phase 1 and 46.7% in Phase 2) was the most common reason for consultations. With full telemedicine in Phase 2, there was reduction in the mean number of clinical encounters per 1,000 occupants per day (p = 0.001), lower man-hours in personal protective equipment (PPE) (p < 0.001), and rise in escalation of care (p < 0.001) but without adverse events reported.

Conclusions:

Telemedicine for patients was safe, improved medical manpower efficiency, and reduced man-hours in PPE. The increased escalation of care in Phase 2 due to the lack of physical examination capabilities was to be expected to ensure patients' safety. Overall, it is recommended that for stable and mild medical conditions, telemedicine is a viable, safe, and efficient health care delivery tool in crisis situations similar to COVID-19.

Introduction

COVID-19 is an infectious disease with high public health impact,¹ and escalated to become a pandemic. Back in March 2020, local cases in Singapore climbed rapidly due mainly to clusters within densely populated dormitories.² Owing to the scale and rapidness of this surge, the Multi-Ministry Taskforce devised a national strategy³ to ensure that infected individuals could receive prompt and quality medical treatment; with the scaling up of medical facilities and augmentation of the health care workforce. The implementation of a differentiated strategy to care for patients, swift contact tracing, mass testing, and isolation of close contacts was meant to break the chain of transmission.

A two-stage medical plan was devised to guide the admission of patients into the appropriate tiered facilities for medical care and support, based on research data from Singapore's National Centre for Infectious Disease.⁴ In the first stage, acutely infected but medically stable COVID-19–positive patients were admitted to community care facilities (CCFs) and received round-the-clock medical care equivalent to a tertiary hospital's general medicine ward. On completion of the first stage (fixed 14-day duration), patients were discharged to the community recovery facilities (CRFs) for another 7 days before being discharged⁵ back to the community.

This national strategy was based on early evidence that COVID-19 demonstrated highest infectivity in the initial 10 days of illness. Although complications arose mostly within 14 days of illness,⁶ there were still significant uncertainty about the infectivity and risk of spread to the community and vulnerable individuals. With this strategy, Singapore saw thousands of medically stable but potentially infectious patients housed within CRFs until they could be discharged.

The Singapore Armed Forces (SAF) was tasked to lead the effort in deploying and managing six CRFs across Singapore⁷ and developed a bespoke digital platform for telemedicine to reduce reliance on our limited medical manpower resources. Through this effort, we helped ensure the optimal deployment of medical resources to reduce the strain on Singapore's health care system. This allowed for tiered medical care and support to be provided to patients based on their needs, and differentiating between patients who were stable, with mild or no symptoms, and those who required higher levels of medical care, such as the critically ill, the elderly, and the immunocompromised.

This article describes our experiences in the rollout of the bespoke telemedicine solution, and we report the outcomes of the implementation. This study was exempted from IRB review by the DSO-SAF institutional review board.

Materials and Methods

Before the pandemic, our military health system had been working on small-scale pilot deployments for virtual care needs for minor conditions, and telemedicine was performed in controlled environments within military camps.⁸ Although our experiences were limited, the pilot deployments positioned us to quickly establish a systematic process to the wider implementation of telemedicine during the pandemic.

APPROPRIATENESS OF TELEMEDICINE SOLUTION

In the initial phase of operations, there was a lack of information on COVID-19 and the disease progression. As such, it was challenging to determine the appropriate level of medical care for the CRFs. Based on empirical data from the CCFs, we found that there was a need to cater medical care for a range of primary health care needs, including acute conditions related to respiratory illness, chronic diseases, and psychiatric issues.⁹ Given the uncertainty of COVID-19's disease progression and its complications, an effective health monitoring system was required to identify sick individuals and escalate the level of medical care appropriately.

We critically evaluated demands of medical teams in similar settings^10

–13 and assessed that a telebooth concept was most appropriate as our virtual medical clinics (VMCs). Besides providing telemedicine services, the VMCs deployed in the semi-inpatient setting would facilitate triaging, enable effective and efficient vital signs measurements, and provide a convenient location for subsequent medication collection.

BUILDING A BESPOKE TELEMEDICINE SYSTEM

After deciding on the appropriate telemedicine tool for our situation, an in-house development team was engaged to develop a bespoke telemedicine platform for our use case. Within a short span of 2 weeks, the team successfully developed a web interface for telemedicine for both the patients and the doctors (Fig. 1).

Fig. 1.

Web platform developed for telemedicine consultations for patients and doctors.

The patient portal provided a simple interface for patients to register, triage, and attend their telemedicine consultations. The doctor portal provided a dashboard to conduct, manage, and prioritize telemedicine consultations based on vital signs (temperature measured using a tympanic thermometer, heart rate and oxygen saturation measured using a pulse oximeter) and symptoms data provided by the patient.

CONCEPT OF TELEMEDICINE OPERATIONS

The concept of telemedicine operations was developed by the centralized command center overseeing the six CRFs. This included developing a standardized telemedicine consultation process across all the CRFs, determining the clinical conditions that could be seen at the VMCs and the possible outcomes of each clinical consultations, identifying the red flag scenarios that telemedicine should not be provided, and ensuring that operational and technical issues at the VMCs could be raised and resolved quickly.

TELEMEDICINE DEPLOYMENT

To ensure a smooth deployment of telemedicine at the six CRFs, a two-phase approach for the deployment of telemedicine was adopted. Phase 1 (initial 5-week period) comprised daily on-site mobile medical team and ad hoc after-hours telemedicine services, and Phase 2 (2 weeks) was the delivery of primary health care services entirely by telemedicine.

In Phase 1, our mobile medical teams operated on-site clinics for 2 h daily, with manpower comprising one doctor, one senior paramedic, and two health care assistants (HCAs). The clinic processes comprised patient registration, vital signs measurement and triaging, doctor consultation, followed by medication prescription (Fig. 2).

Fig. 2.

Mobile medical team running in-person clinics in a CRF. CRF, community recovery facility.

This model of health care delivery was replicated across all six CRFs. A total of six medical teams were required—four to operate the on-site clinics and two assigned to cover after-hours telemedicine consultations. Telemedicine was provided through virtual medical booths set up in place of the clinics during after hours (Fig. 3).

Fig. 3.

Telemedicine processes in the CRFs with corresponding screenshots from the telemedicine system used by the medical teams.

At each booth, patients were accompanied by the CRF facility operator and would self-register on a camera-enabled touch-screen laptop. They would then proceed to measure their temperature, heart rate, and oxygen saturation using the thermometer and pulse oximeter provided. They also had to indicate the type of symptoms they experienced on a web-based software platform integrated with a virtual queue management system. After symptom checking and queuing, the patients were able to conduct a telemedicine consultation with the doctor through a commercial off-the-shelf videoconferencing software of Google Meet in this case.

Although clinical consultations were conducted on the videoconferencing platform, clinical information was recorded on a separate cloud-based electronic medical records system. Three outcomes were possible from the consult: (1) conveyance to hospital as their medical condition required escalation of care, (2) on-site in-person medical review the following day by the doctor, or (3) return to CRF with medications delivered by the next day.

In Phase 2, given that most clinical conditions encountered were mild without any red flags (defined as severe symptoms such as chest pain and acute shortness of breath, oxygen saturation <95%, heart rate >100, and temperature >38.5°C), mobile medical teams ceased on-site clinic operations, and VMCs were deployed instead. The process of telemedicine services delivery was similar to Phase 1. On-site assistance for the patients attending the VMCs was facilitated by the respective facility operators and a deployed HCA.

One doctor conducted telemedicine consultations for three facilities in the western sector of Singapore and a second doctor conducted telemedicine consultations for three facilities in the eastern sector of Singapore. When there was a need for an on-site in-person medical review, the doctor would be activated to visit the patient at the CRF. Medications prescribed during the VMC were packed and delivered to the patients through the HCAs by the next day.

EVALUATION OF KEY OUTCOMES

We collected and analyzed key data points throughout the deployment of telemedicine services to ensure effective health care delivery. Data from Phases 1 and 2 were collected and compared, on the mean number of clinical encounters per day, mean number of clinical encounters per 1,000 occupants per day, mean number of after-hours telemedicine encounters, mean man-hours conducting clinics per day with and without personal protective equipment (PPE), number of individuals requiring escalation of medical care, and the number of adverse events.

IBM SPSS version 25.0 (IBM Co., Armonk, NY) was used for all the statistical analyses. A p value of <0.05 was considered significant. Data were tested for normal distribution using the D'Agostino and Pearson test. Linear variables were assessed using the paired or independent samples Student t test for parametric data or Mann–Whitney U test for nonparametric data. Differences between dichotomous data were assessed using chi-square test.

At the end of Phase 2, the rate of infections slowed significantly across Singapore, and Singapore's CRFs were subsequently repurposed as temporary housing facilities for migrant workers deemed to have recovered from COVID-19. Telemedicine support was withdrawn subsequently and routine access to primary health care services in the community was subsequently made available to all patients.

Results

In Phase 1, the mean number of clinical encounters per 1,000 occupants per day across the six CRFs was 33, with a total of 1,902 clinical encounters over the 5-week period. In Phase 2, the mean number of clinical encounters per 1,000 occupants per day across the six CRFs was 12, with a total of 449 clinical encounters over the 2-week period. The breakdown of clinical conditions seen is shown in Figure 4. The most common medical condition was acute respiratory illnesses, representing 52.3% and 46.7% of the total number of clinical conditions seen in Phases 1 and 2, respectively. In both phases, the number of clinical conditions seen was less than the total number of clinical encounters recorded as a substantial number of patients recorded multiple clinical encounters for the same clinical condition as part of follow-up reviews (Fig. 4; Table 1).

Fig. 4.

Types and number of clinical conditions seen at the CRF at the two phases.

Table 1.

Clinical Encounters, Escalation of Care, and Personal Protective Equipment Usage Comparisons Between Phases 1 and 2

VARIABLE	PHASE 1 (N = 1,902)	PHASE 2 (N = 449)	p
Mean number of occupants per day, n (SD)	2,370 (149)	3,930 (816)	<0.001^*
Mean number of clinical encounters per day, n (%)	76.1 (25.7)	44.9 (24.8)	0.027^*
Mean number of clinical encounters, n (SD), per 1,000 occupants per day	32.5 (11.0)	11.84 (7.34)	0.001^*
Mean number of after-hours telemedicine encounters, n (SD)	0.71 (0.99)	1.57 (1.34)	0.075^*
Mean man-hours per day, hours (SD)	97.6 (2.89)	85.3 (1.67)	<0.001^*
Mean man-hours in PPE per day, hours (SD)	49.6 (2.88)	24.8 (1.66)	<0.001^*
Number of escalations of care, yes:no (%)	22:1880 (1.16)	28:421 (6.23)	<0.001^†
Number of adverse events, n	0	0

Paired student t test.

†

Chi-squared test.

SD, standard deviation.

The mean man-hours per day required was 97.6 h for Phase 1 and 85.3 h for Phase 2. The mean man-hours in PPE per day was 49.6 and 24.8 h, respectively (p < 0.001). There were 22 and 28 cases required escalation of care in Phase 1 and Phase 2 respectively (p < 0.001). However, there were no adverse events reported throughout the deployment. No activations for in-person reviews by doctors were made.

Discussion

With a full telemedicine-based model of care, there was a significant reduction in mean man-hours per day both with and without PPE. This was associated with a significant decrease in the mean number of clinical encounters per 1,000 occupants per day in the CRFs. We also found that there was a higher mean number of after-hours clinical encounters in Phase 2 than in Phase 1, although this was not statistically significant. We postulated that the occupants in the CRFs were generally well, and that not having an on-site doctor shifted health-seeking behavior to the use of ad hoc telemedicine consultations instead of scheduled hours.

This supports the notion that in communal facilities housing medically stable patients, health-seeking behavior may entail an element of “supply-driven demand.”¹⁴ Although we also noticed a significant increase in the number of escalations of care (28 in Phase 2 compared with 22 in Phase 1), this was postulated to be a result of the limitations in the conduct of physical examinations by telemedicine compared with in-person consultation by the doctor. Doctors conducting telemedicine consultation also tended to err on the side of caution. Although not specifically measured in this study, it is possible that the increased escalation of care using telemedicine could potentially utilize greater emergency medical evacuation resources than having on-site medical support.

The use of telemedicine enabled the delivery of a sustainable and safe medical support to patients in the CRFs. This was demonstrated by a decreased manpower requirement in Phase 2 compared with Phase 1, despite an increase in the mean number of occupants residing in the CRFs. The optimization of medical manpower was important in ensuring long-term sustainability of the medical operations provided during the COVID-19 situation. Telemedicine was an effective force multiplier,¹⁵ enabling two doctors to effectively cover the medical support for six CRF clinics in Phase 2, compared to the need for four doctors in Phase 1. In addition, our military doctors were able to carry on with their primary roles in the military providing health care services to SAF personnel.

Telemedicine also enabled a safer delivery of health care services by limiting hazard exposures. The use of telemedicine services allowed the medical team to be housed in areas without heightened infectious disease precautions. This not only reduced the risk of health care worker-associated COVID-19 infections¹⁶ by limiting the physical exposure to high-risk infectious environments, but also significantly reduced the man hours in full PPE.

Despite experiences utilizing telemedicine in a local military setting, several challenges remain for the integration of telemedicine as part of the national public health response to COVID-19 and future outbreaks.¹⁷ In Singapore, although the National Electronic Health Record was able to provide a summary of patient health records across different health care providers,¹⁸ there was a lack of a simplified version that would work effectively in the unique operating environments of the CRFs, which were located outside traditional health care facilities. Processes such as medical triaging, telemedicine consultations, medication dispensing and delivery services, and issuance of digital medical certificates were some areas that need better integration.

This was demonstrated by our experience that health care information (such as memos, patient care records, and medication prescriptions) from upstream medical facilities (such as public hospitals and CCFs) could not be digitally transferred to efficiently transfer of patient information between facilities. We had to rely on a mix of digital and paper records. Telemedicine consultations in the scenario of health care provision for COVID-19 patients at CRFs were initially perceived to be challenging, given that the majority were migrant workers with an anticipated language barrier and relative technological naivety to the deployed systems.¹⁹ These factors are possible barriers²⁰ to the adoption of telemedicine as a default model of care.

The deployment of effective telemedicine and electronic medical records platforms required close collaboration between operations and technology development teams.^21,22 Within a short span of 2 weeks, the teams worked closely together to adapt existing systems and develop new systems that were sufficiently robust for use. Software user interfaces were customized to the demographics of the patient population, which included translations into six different languages (English, Mandarin, Malay, Tamil, Bengali, and Burmese) and creating pictorial representations of common medical conditions that the patients would present with. Waterproof laptops with touch-screen function were procured for use by gloved HCAs to enable ease of use during clinical consultations and easy disinfection (Fig. 5).

Fig. 5.

Pictorial representation of common symptoms (screenshot from telemedicine web platform).

The systematic approach toward implementation of telemedicine, enabled the team to collect data to determine the viability, safety, and efficacy of telemedicine in the semi-inpatient setting. Although the future crisis situations where telemedicine could be deployed may vary, our experience using this systematic approach had yielded positive results and could serve as a useful guide for medical teams looking to deploy telemedicine systems in the future (Fig. 6).

Fig. 6.

A systematic approach to implementing telemedicine.

LIMITATIONS

During this study, other health care-related mobile applications such as a symptom checker were also deployed—providing health care advice to patients on whether they should seek medical assistance. The effects of these health care-related mobile applications on our study outcomes measured were not evaluated. Although there were no instances of negative feedback²³ from the patients on the telemedicine services provided, formal user feedback²⁴ such as the use of validated patient satisfaction scores²⁵ was not collected in this study.

Conclusions

The deployment of telemedicine in a systematic manner to deliver health care for patients in our CRFs was proven to be effective and safe and was able to optimize medical manpower and reduce man-hours spent in PPE by medical personnel. It is recommended that telemedicine be considered as a useful health care delivery tool in crisis situations such as COVID-19.

Footnotes

Acknowledgments

The authors thank our partners from Defence Science and Technology Agency (DSTA) for supporting the team with a mobile electronic medical records system used in this field study. We also thank the Republic of Singapore Air Force's (RSAF's) SWiFT Office for developing the bespoke telemedicine platform used in this study.

Disclosure Statement

The author(s) declare(s) that there is no conflict of interest.

Funding Information

This study was conducted without receiving any funding from any institutions.

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