Before Malaysia can be serious about telemedicine, basic medical and health needs of the people must be met so that hospitals stop playing the Russian roulette with the lives of seriously ill when doctors have to juggle intensive care beds and critical facilities because of acute shortage

Speech - Telemedicine Bill 1997
by Lim Kit Siang

(Dewan Rakyat, Wednesday): The virtual hospital has arrived and been introduced in over 20 states in the United States where without leaving their own community, patients can consult some of the country's top specialists. The virtual hospitals rely on a multitude of high-tech communication devices, such as video cameras that can zoom in on miscroscopic as minute skin melanomas, electronic stethoscopes that magnify a heartbeat and transmit it hundreds or thousands of miles away through phone or cable lines, virtually instantaneous computer access to a patient's medical charts, large-screen TVs that permit doctors to see and chat with patients and other medical professionals.

Telemedicine applications have been evolving for 30 years in the United States and other developed countries, and it is no more technoligically impossible to have such virtual hospitals in Malaysia as well. In fact, I would like to ask the Deputy Health Minister how far the government has gone in its plans to build precisely such a "virtual hospital" in Selayang, with the latest state-of-the art telemedicine technology, where there would be a computer terminal to every bed. I would ask the Deputy Health Minister to inform Parliament and the country of the detailed plans for the Selayang Hospital, the nature of the latest state-of-the-art technology that would be installed in the Selayang Hospital, how much such a hospital would cost, how far tender processes for various phases of the project and the target dates for the completion of the various phases.

The real question Malaysians must ask is whether at this stage of our development, Malaysia can afford "virtual hospitals" or telemedicine with the latest state-of-the-art technologies, when ordinary Malaysians virtually canít fulfil their basic medical and health needs.

Telemedicine is basically an excellent concept to improve the quality of delivery of health care but basic medical and health infrastructures to meet the basic medical and health needs of the people should first be given the highest priority.

I have a friend Vincent, who was recently admitted to the Kuala Lumpur General Hospital for some serious ailment and who was placed in the third class ward as the first and the second class wards were full. Not that the third class ward was not full. In fact, the third class ward was so completely congested that it was no different from a market-place, with additional canvas beds placed all over the ward. This shock therapy half-cured Vincent, who quickly decided to go home despite his ailment!

In the Klang Valley, with a growing population, everything in terms of basic medical and health needs, such as hospitals and wards, are grossly insufficient to cater to demands from the public, particularly from the poorer sectors of our society.

For instance in the emergency department of Kuala Lumpur General Hospital, the acute bays are too few when compared to the catchment area it has to serve, and worse, when it also serves as a referral centre from all over the country.

The position for the intensive care beds are no better either as they are never enough to accommodate all the ill cases which require acute high-level care not available in the general ward. There are not enough ventilators and equipment for haemodynamic monitoring (i.e. monitoring blood pressure, pulses and heart rhythm), forcing doctors to juggle patients around to share these limited intensive care beds, ventilators and haemodynamic equipment by making decisions as to which patients have to make room for others, not because they no more require intensive care, but because other cases require even more urgent intensive care! This is like playing Russian roulette with the lives of the seriously ill in our hospitals.

There is not only shortage of intensive care beds, but also beds in medical wards. For instance, with a sixty-bed capacity per ward for the medical section, the Kuala Lumpur General Hospital often cannot accommodate the high volume of admissions on admission days with more than 60 patients having to be accommodated to a ward.

As a result, patients have to sleep on canvas beds in between hospital beds and it is not unusual for wards to have 20 to 30 extra patients than beds available - forcing the medical and nursing staff to cope with the extra workload without the necessary complementary facilities. Even other departments, like the laboratories, are placed are under severe strain close to breaking point with the large volume of ill patients.

The Kuala Lumpur General Hospital had often prided itself as the largest sprawling hospital in the world. As a result, the X-Ray Department is situated in a separate building from the wards. Medical attendants have to place patients on trolleys to push them up a slope from the wards to the X-ray departments, often dodging cars imperilling the lives of both the patients and themselves. It is worse when there is heavy rain, for it is just not possible for medical attendants to put patients requiring urgent X-Rays on a trolley and push them up a slope to the X-ray department - as the patients and attendants would not only be all wet, but run the risk of exposing patients to even worse accidents, as it will then not be difficult to envisage terrible scenarios of run-away trolleys which have gone out of control of the attendants, careening the critically-ill patient all wet on the trolley to kingdom-come!

Although the conditions in the Kuala Lumpur General Hospital are so unsatisfactory, the conditions in the other hospitals and especially those in outlying areas are even worse. The outpatient departments in most hospitals are not only an eye-sore but most scandalous, with patients having to queue up sometimes for more than half a day to get access to the doctor and medication. It is not unusual, for instance, for an outpatient doctor to have to see some 80 patients for the morning clinic - which would work out to seeing 80 patients in say, 270 minutes, which would work out to less than four minutes per patient! Is it any wonder that the poor regard outpatient departments with such dread, but yet have no choice because they cannot afford to seek medical help in the private sector?

This is why when Parliament is debating the Telemedicine Bill, MPs should ask themselves whether Malaysia can be serious about telemedicine when hospitals are playing Russian roulette with the lives of seriously ill as when doctors have to juggle beds for the critically ill because of shortage of intensive care beds.

The first paramount question we must address is whether telemedicine provides cost-effective medical services within the reach of ordinary Malaysians and whether it is a viable health care delivery option for Malaysia at this stage of our development. This takes us to the second important question whether Malaysia should take to telemedicine in a big way or whether the country should be focussing on ensuring that all Malaysians, including those in the remotest rural areas, can have access to the most basic health and medical needs.

Nobody opposes the introduction of telemedicine or even "virtual hospitals" in Malaysia, as there is no reason why Malaysia should be left out by the latest advances in information and communications technologies. The question is one of social policy: whether telemedicine or "virtual hospitals" deserves to rank high as a national priority because three considerations:

In the Information Age, the information superhighway will not only provide new healthcare services such as remote diagnosis and the "on-line doctor", the new will also challenge the traditional medical model.

This is why Alvin Toffler in his 1990 book Power Shift describes the end of "God-In-A-White Coat", which he describes at the end of the traditional role of doctors because of the advent of information and the technology to disseminate it.

Toffler states:

We must note that Toffler wrote Power Shift in 1990, before Internet emerged from the cocoon of scientists and academics, well before it became a world-wide phenomenon, as until 1991, United States government policy barred use of the Internet by for-profit businesses for commercial purposes.

The point made by Toffler should concern Parliament when we are debating Telemedicine Bill, for it can be argued that rather than benefitting society by spreading medical information around, the dissemination of healthcare information has simply flooded the market with too much technical material that needs explanation and that the availability of the information may be dangerous to untrained readers who may take their interpretations of problems as the appropriate treatment when they should still consult a physician.

I shall leave this important subject to other MPs as I would like to touch on the bigger social policy question about the relevance of telemedicine to Malaysians at this stage of our national development.

During the debate on the Telemedicine Bill, we hear the constant refrain about the two great goods of telemedicine:

I challenge the validity of these two rationales for the introduction of telemedicine in terms of the latest state-of-the-art technology such as telediagnosis, telemonitoring and tele-surgery, in a big way at this stage of our national development.

Let me first dispel certain misconceptions, that we are among the first countries to introduce telemedicine, or at least the first country to have telemedicine legislation.

Telemedicine dates back four decades and in New Zealand the first telemedicine system was established way back in 1959. Secondly, telemedicine legislation in other countries is quite commonplace. It is worth noting that a Study Group of the International Telecommunication Union on Telemedicine has prepared a draft report provisionally entitled "Telemedicine and Health Care in Developing Countries", which is about 200 pages long, which contains a survey of telemedicine in 60 countries, half of which are from the third world.

The report asks what are telemedicine and telehealth, examines types of telemedicine services, the technologies for diffusion of telemedicine, the costs and benefits of different solutions, the prospects for global standards and provides guidelines and recommendations to developing countries.

From the research done so far, it is apparent that the conception of what is telemedicine is very different in the developing countries compared to that in the developed world. While practitioners in Europe, America and Japan talk about megabits per second, asynchronous transfer mode and how high the resolution must be for an image to be of true diagnostic quality, most developing countries do not even have ISDN lines. Talk about transmission rates above 9.6 kilobits per second does not comply with the reality of the networks found there. In Africa, many clinics and hospitals in remote and rural areas do not have any communications, let alone the sophistication needed for video-conferencing.

This raises the question whether telemedicine is a toy that developing countries can ill afford -- at least at the moment.

Malaysia of course cannot be compared to the poor nations of Africa, but this does not mean that we have reached the sophistication of the developed nations in terms of the sophistication and reach of our telecommunications and development infrastructures that we can ignore the larger social policy question as to how telemedicine should fit into our order of national priorities.

Nobody should be opposed to telemedicine but we must be prudent as to what type of telemedicine is suitable and appropriate for Malaysia at this stage of our development.

There are many different types of telemedicine service, the three main categories being audio, visual (image transfer) and data, and several sub-categories within each. Thus, the telephone can enable consultation between a health care professional in a rural clinic and a specialist hundreds of kilometres away in an urban hospital. This tele-consultation is a form of telemedicine, just as are the experiments in virtual reality in Europe or America.

Even the United States cannot be unmindful of this social policy question. This is why the Telemedicine Report of the United Statesí Federal Communication Commissionís Telecommunications and Health Care Advisory Committee in October 1996 made the following findings:

Like the use of computers in other areas, information technology and information superhighway applications in medicine can go in one or two directions. They can be used to strengthen traditional ways of doing things by simply automating current procedures and tasks, or they can break through old barriers to create new and better ways of accomplishing goals

It is rather unfortunate that we are not making full use of the former possibility, while we are quite lost as what we should be doing with the latter.

Take one example. Doctors are increasingly pressured to increase the number of patients they see each day, leaving patients irritated at not receiving enough time with their doctor. The result is long lead-times for appointments, long waits in the office before being seen, and a general feeling of dissatisfaction for both doctor and patient.

One factor that contributes to the time deficit is patient information (or the lack of it). Today, doctors cannot easily access information about their patients; most is stored in handwritten paper archives. So doctors (or their office assistants or nurses) must not only find the paper files, they must also decipher the handwriting of whomever attended to the patient in the past. Gaps must be filled in by the patient's verbal account and memory of previous clinical visits. If they have seen a specialist for a condition, that specialist will often not be available quickly for consultation on the results of the visit, and the records kept by the specialist are not usually available to the primary-care physician. All of this results in doctors treating patients without proper information, or in someone spending time to find and reconstruct the patient's records.

In the United States, which also apply to Malaysia, prior to the mid-1980s, the healthcare industry suffered from a limited perspective of how to manage treatment for patients. The system was based solely on what services the patient required. The more services needed, the highest the cost of treatment, and the greater the payback for participating medical professionals and institutions. This led to a focus on performing tests, treatments, and therapies at ever-increasing costs with little regard for the overall health and satisfaction of the patient. There was no sense of value for services rendered.

In the United States, this began changing in the 1980s when companies providing medical benefits wanted to control rising healthcare costs and the healthcare community began slowly to move along a path for patient treatment that will be greatly enhanced by Information Technology developments.

This path involves focussing treatment around the patient as a whole person. The diagnosis, treatment and recuperation for medical problems will be based on the person's total needs - his or her emotional and environmental well-being as well as the immediate health problem.

The key to this new form of treatment will be information. Doctors will need all the information they can get about their patient's past, present, and future physical and emotional states, as well as background about the environment he or she is in. They will also need quick, reliable access to the records and diagnoses of other medical providers and specialists who worked directly with the patient, or who could lend useful information based on similar cases.

These information resources are available now through old techniques and technology. Paper files, stand-alone computer systems, telephones, and x-rays provide a great deal of information. Although it is theoretically possible to construct the complete patient profile and related information using these techniques, this is a practical impossibility in view of the lack of support staff to accomplish this task. Networked computer systems could accomplish the task easily, bringing together the required information extremely fast. Not only could the physician then access information from a number of different areas - hospital records, clinical databases and demographic profiles, but also the information recorded about the patient a week, a year or five years ago would be accurate and available, thus allowing continuing of care rather than an isolated reaction to the presenting problem.

But is this being done in Malaysia so that we can take advantage of the IT developments instead of just focussing on the esoteric subjects of tele-consultation or telesurgery?

In the United States, it was recently demonstrated that telemedicine could allow doctors separated by 50 miles to simultaneously view and discuss an ultrasound image of a childís heart. Does Malaysia need such a level of telemedicine in Malaysia?

The President of the Malaysian Medical Association, Datuk Dr. Abdul Hamid, who was invited to be a panellist at the Parliamentary Cyberbill Forum organised by the Parliamentary IT Committee on 25th April 1997 had clearly expressed the reservations of the MMA as with regard to telemedicine development in Malaysia - in particular with regard to its relevance to meet the medical and health needs of Malaysians.

As he said at the Cyberbill Forum, the Minister for Health and other top Health Ministry officials are fond of saying that Malaysiaís medical and health developments are so advanced that within five kilometres in any part of the country, there is a health centre or a doctor. I do not know whether this applies to Sabah and Sarawak, but be that as it may, even if it applies only to the Peninsula, the question that must be answered is the need for telemedicine for remote rural areas - where there are not even phones or power lines!

Malaysian doctors and medical professionals are also rightly concerned whether untrammelled development of telemedicine, depending on foreign experts, would stifle the development of home-grown world-class medical expertise in all fields.

As for the second argument for telemedicine, that telemedicine will drive down costs and make healthcare more cheaper and more affordable to the people at large, I do not believe that this is achievable in the first ten or twenty years - at any event, meaningful enough to ordinary people.

However, I want to ask the Deputy Health Minister whether the Ministry had commissioned any study on this aspect and if so, to reveal the studies and findings on this matter.

In the United States, a 1992 study by one of the largest management consulting and reserach firms, Arthur D. Little, estimated that telemedicine applications could reduce the cost of healthcare by US$36 billion nationally. Efficiency achieved through electronic exchange of patient information will be responsible for the bulk of the savings.

What is the position in Malaysia or are we just plunging into telemedicine without having to commission any students about the local conditions in Malaysia?

We must also address the various technical, legal and medical issues of telemedicine including those of patient safety, quality of services and malpractice liability.

Telemedicine and medical responsibility: Dealing with telemedicine including telediagnosis and teleassistance, how do we assess the legal and ethical components of medical liability. With medical telediagnosis, the dispersion of medical liabilities is the main risk: how can we ensure a clear identification of the medical liabilities involved in case of damage?

From a legal point of view, the Telemedicine Bill does not provide for a dispersion of the liabilities. How do we ensure that the use of telediagnosis would be condition conditions of total transparence?

Even in the United States, there is no method at present to establish a separate amount for a medical act based on the cost of the image records and the cost of image interpretation. The only way is to establish a contract, and the most convenient is a contract similar to the usual contract between laboratories which implies that the liability belongs to the practitioner who has received the sample. Is this the model we want to follow?

In the future, other legal obligations may appear when telediagnosis develops. As a result of the increase in reliability due to telediagnosis, would there be a medical obligation to use the latest technology? On the opposite, the excessive use of teleassistance, when there is neither emergency nor medical isolation, is dangerous because it affects the integrity and quality.

Other legal issues that will be posed by telemedicine with regard to malpractice liability involving major problems in the legal conceptualization of telemedicine are: Where is the patient? Where is the doctor? If a telemedicine doctor in one country treats a patient in another country, in which country is the transaction occurring? Which country's court will have jurisdiction in the case of a lawsuit? What controls are there for securing medical accountability for out-of-country physicians wanting to practice telemedicine from another country (country)?

Another question is how the government can enforce liability obligations on foreign consultants who practise telemedicine from outside the country and never steps on Malaysian soil? Can Malaysians choose to sue, say an American consultant for telemedicine negligence, in the American courts and avail themselves of the legal system which is prone to award huge compensations for negligence suits as compared to courts based on the British system?

The biggest legal issue of all, of course, is how the government is going to enforce the provisions of the Telemedicine Act to make foreign consultants liable for any malpractice or negligence? Will the government enter into special treaties with other agreements to bring foreign consultants and medical practising telemedicine in Malaysia within the jurisdiction of the Malaysian courts, although they are physically outside the country?

Medical Records Privacy Protection Act

During the debate on the Computer Crimes Bill, I had stressed the importance of a Data Protection Act in the Information Age and my disappointment that this had not been included in the first batch of cyberlaws for the country.

I am also disapointed with the reply by the Minister for Energy, Telecommunications and Posts, Datuk Leo Moggie, who said that the government had to consider the need for a Data Protection Act - when such a consideration should have been given before the first batch of cyberbills are presented to the House.

I had intimated that I propose to present a draft of a Data Protection Bill to the Cabinet before the next Parliamentary meeting in July.

With telemedicine, the need for data privacy and protection becomes even more urgent. Computerizing medical records may improve and streamline the health-care delivery system, but it threatens to make private information less private.

With the possible realization of such innovations as home telemonitoring, teleconsultation and the interlinking of doctors and hospitals, a flood of medical information over the "cyberwaves" would be sure to follow.

I call on the Government to introduce a Medical Records Privacy Protection Act apart from a general Data Protection Act.

Parliament must be mindful of three issues about privacy of medical records in other countries:

The Medical Records Privacy Protection Act is therefore urgently needed in Malaysia to serve the three-fold purpose to:

Probably, the multi-party Parliamentary IT Committee should organise a national conference on Data Protection which should also deal with the issue of medical records privacy protection. If such a conference comes about, I hope it could have the co-operation from all quarters, including the Attorney-Generalís Chambers, all relevant government agencies, NGOs and members of the public.

The Telemedicine Bill suffers the same defects as the first two cyberbills which Parliament had enacted, the Computer Crimes Bill and the Digital Signature Bill: - having been drafted without the benefit of public consultation and input (in this case, even without consulting the Malaysian Medical Association); the low priority given to consumer or user perspective; the "all-knowing" attitude of the Attorney-Generalís Chambers and the usurpation of the "policy" role and responsibility by the civil servants.

Unlike the Digital Signature Bill, I am more concerned about the social policy questions of the Telemedicine Bill rather than the drafting language. I must express my great disappointment however at the failure of the Deputy Minister for Energy, Telecommunications and Posts to give a satisfactory reply to all the points I had raised during the debate on the Digital Signature Bill.

Ministers and Deputy Ministers must not abdicate from their policy role and responsibilities to government officers, whether from the Attorney-Generalís Chambers or their Ministries, as civil servants are executors of policy and should not decide on policy. In Parliament, the practice where Ministers and Deputy Ministers are just "parrots" of the government officials, saying what they are told to say by government officials through chits of paper, must end.

We want Ministers and Deputy Ministers who are not only knowledgeable and have a mastery of the subjects they are responsible in Parliament, but could engage in an intelligent debate as to whether certain proposals or amendments to Bills are good and acceptable and to decide in the House itself, without having to look for instructions from government officials sitting behind them!

Let us make a new start where Ministers and Deputy Ministers are the masters of policy and the government officials mere executors of policy, especially in the new era of Information Age.

I understand the fourth cyberbill, Copyright Amendment Bill, would be presented by the Parliamentary Secretary to the Ministry of Domestic Trade and Consumer Affairs, Tan Chai Ho. This is a disaster for the Parliamentary Secretary would not know the difference between "copyright" and "copywrong".

Although there is now no Minister for Domestic Trade and Consumer Affairs, as Datuk Abu Hassan had to resign to become Selangor Mentri Besar as there is not a single Selangor UMNO Exco member or Assemblyman who is "clean and capable" enough to take over the Selangor State Government, the Acting Minister for Domestic Trade should master the subject before the Copyright Amendment Bill is introduced in the House.


*Lim Kit Siang - Malaysian Parliamentary Opposition Leader, Democratic Action Party Secretary-General & Member of Parliament for Tanjong