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By Kwok Siew Keong & Kimberley Leow
Executive Committee, Podiatry Association Singapore
Following the nation’s Circuit Breaker implementation since 7th April, ‘non-essential’ services were required to shut its physical operations and may continue of via telecommuting and electronic means. Regretfully, Podiatry was listed as a ‘non-essential’ service from 7 to 28 April. With the collective efforts of our colleagues’ advocacy and appeals, patients’ feedback and the authorities’ reconsideration, measures have since been relaxed for allied health and Podiatry.
Think of a pressure spot that can potentially lead to ulceration and infection, or a recalcitrant ingrown toenail that leads to bad infection, or perhaps a diabetic foot that can further complicate into an amputation if timely care is not provided. The list goes on. The feet are a vulnerable part of the body as it is bears up to 3 times our body weight when walking and more than 10 times when we jump. Furthermore, it is the body part that is furthest away from the heart and hence is the first to be affected (eg. turn gangrenous) when there is very poor blood circulation.
Podiatry services are crucial in the entire healthcare ecosystem, especially in the maintenance and prevention of foot infection and amputation. In critical times such as COVID-19 pandemic, much of the healthcare resources are channeled to fighting the outbreak, podiatrists are ever more crucial in keeping patients well so that they do not deteriorate and further strain the healthcare system.
In this unprecedented season globally, everyone is subjected to new situations that are beyond our control and we must adapt and adjust to our environment to come through this global pandemic. Telehealth is one of the new areas that needed our adoption overnight. Let’s see how our podiatrists rose to the occasion.
What is Telehealth
According to the MOH’s National Telemedicine Guidelines 2015, telehealth is a systematic provision of healthcare services over physically separate environments via information and communications technology. In a nutshell, that means using a phone or video call to do a Podiatry consultation service without being physically together in a clinic. Physical distancing, check. Don’t go out of the house unnecessarily, check.
What are the potentials
Some research have explained that the force behind telehealth emergence is the need to increase access to medical services when patients have difficulty accessing them physically. Telehealth can thus provide some form of quality local care and patient satisfaction as it allows them to see a healthcare professional in their home or local communities without huge expenses on travel costs and time consumed, and given the current situation, reduce the risk of community spread of Covid-19.
A Podiatry telehealth study done in a Hong Kong nursing home found that the use of telehealth was a good tool to triage cases and facilitated early identification, and therefore intervention for urgent Podiatric problems. These urgent cases include leg ulcerations due to peripheral vascular disease, diabetic neuropathy, venous insufficiency, gout, trauma and pressure. Among them, many residents found that telehealth Podiatry services was a good alternative to an on-site Podiatry service. 87% of this group of elderly population also preferred a telehealth consultation over a physical visit to the hospital for their Podiatric needs. In particular, Podiatry telehealth service was found to be particularly effective in the follow-up for active wounds as pictures of previous wounds can be compared easily. Their study also found that a telehealth consultation was faster, taking an average of 8.4min as compared to 30mins for an on-site visit.
Some podiatrists we have spoken with shared a few things they have tried to do with a telehealth service. Ms Dorcas Sholanke from UrbanRehab has utilized telehealth to monitor wounds and ingrown toenail progression. Ms Helen Crawford from Osteopathy and Podiatry Centre suggested the use of telehealth in the rehabilitation management of conditions like ankle sprains while Mr Supapong Supantamart from Physio and Sole Clinic sees the potential in using telehealth to follow-up with patients and ensure they are performing rehabilitation exercises appropriately. Other podiatrists also report monitoring wounds and ingrown toenails via telehealth. In fact, exercises can still be tailored to each patient’s needs, giving patients “access to a tailored programme to follow from home,” Ms Dorcas Sholanke added.
Telehealth can also be used as a triage modality – to assess the severity of their feet problems and decide if the patients require urgent medical care. Although much of what a podiatrist typically does is hands-on, we can still offer invaluable advice during teleconsultations. Ms Dorcas Sholanke further adds that “it has been extremely helpful for some of my long-term patients with underlying health issues such as diabetes. I have been able to give them advice and reassurances so that they can stay home and stay safe.”
What are the downsides
Telehealth is not without its limitations. 21% of podiatrists involved in the Hong Kong study reports encountering difficulty arriving at an accurate diagnosis and management plan without an on-site visit. Some Podiatrists in Singapore have also shared their concerns and difficulties. Ms Helen Crawford from Osteopathy and Podiatry Centre explains that most of a Podiatrist’s work is very much hands-on and a telehealth service limits our ability to be of help.
Ms Lynn Toh from Physio and Sole Clinic added that over a telehealth service, she is unable to provide any manual therapy or treatment, like treating an ingrown toenail, which a patient hopes to seek relief from when visiting a Podiatrist. A telehealth service also becomes a challenge if the patient is not tech savvy and if the internet connection is poor.
While IT is here to make our lives better, it also has its drawbacks. Problems that could affect our telehealth consultation includes video camera not being able to focus on fine skin lesions to give a clear view, the patient is unable to keep still, poor connectivity affecting image and sound quality, and many other “what-can-go-wrong-will-go-wrong” situations. Not forgetting, the patient may not be not well-versed in the use of technological devices!
To enhance his telehealth consultation, Mr Mathew Herd from MyFootDr Singapore also provides resources like videos and pictures to support his patients. However, as this is a fairly new service area, it is unsure if insurances will cover telehealth services. Undoubtedly, telehealth service can create value for patients but will the cost incurred be adequately recovered?
Things to Caution
“We must be mindful of professional liability issues if we cannot provide treatment after a diagnosis,” cautioned Mr Tay Kai Ming from Physio and Sole Clinic.
In the Telehealth Recommendations to Podiatrist 2020 released by the Podiatry Association (Singapore), Podiatrists could consider building up their telehealth services by defining clearly the type of services they are able to offer across an electronic platform given the physical and technological limitations. In so doing, we need to identify what is a reasonable and fair standard of care to be maintained and how we can obtain consent and ensure patient data protection and privacy over a virtual consultation. As clinicians, we must also identify the right group of patients who will benefit from the use of telehealth services and how we can properly document the online consultation and track appropriate outcome measures to ensure an effective Podiatry care for our patients.
Telehealth services in Podiatry definitely have its merits and can provide patients with some early forms of management during this Covid-19 period, but it will still not be able to replace the physical biomechanical assessment and wound assessment Podiatrists do. Not forgetting, the debridement of painful hyperkeratosis and treatment of ingrown toenail and the adjustment of orthoses that can only happen in a physical consultation room.
As Ms Lynn Toh puts it so candidly, “I think (having the option of) telehealth is still better than (having) nothing!”
With the resources and experience we have under our belt, we endeavour to continue to provide quality foot health services for our patients, rain or shine!