Chapter 2 Preparing International Travelers
WHAT IS TELEMEDICINE?
Telemedicine is commonly referred to as providing diagnostics and therapeutic services via information and communication technologies. Telemedicine interventions can be as simple as 2 doctors discussing a case over the phone to decide on an intervention or as complex as real-time monitoring of astronauts at the International Space Station.
Benefits of telemedicine include reducing cost and time associated with unnecessary transportation of patients, quicker access to care with minimized waiting time, access to subspecialty care, and maintaining patients in familiar environments. Telemedicine has benefits in both rural and urban areas, but it is not always a viable option. In remote rural areas, there may not be the bandwidth and connectivity capable of supporting the communication technologies. In the urban setting, users may contend with internal firewalls and security settings.
Telemedicine can serve as an alternative to a pretravel clinical visit. It can be used directly with patients when traveling to answer questions or provide guidance to distant clinicians in case of emergencies, which can help maintain continuity of care. In addition, it may be used to assist clinicians with posttravel evaluations when there are unusual clinical findings and subspecialty assistance is needed.
CONDUCTING A REMOTE PRETRAVEL CONSULTATION
Telemedicine enables a convenient method to deliver pretravel consultations with the same elements as in an in-person visit. Providers should continue to follow the professional standards as with in-person consultations, including the same code of ethics, security and privacy practices, and adherence to clinical guidelines. What can and can’t be done in a remote consultation varies by state, so providers will need to check with their state medical boards about any restrictions. A valuable resource on telemedicine, including requirements by state, is available at https://prognocis.com/wp-content/uploads/2017/01/Telemedicine-Whitepaper.pdf.
Practices should provide patients with a resource that outlines the expectations and outcomes of telemedicine before they schedule the consultation, including the limitations of a remote consultation. Intake information, including medical history, prior medical records, or diagnostic information, may be requested of the patient and made available to the provider in advance. Patients are encouraged to set up in advance and test their connections to the telemedicine software or equipment.
At the time of the consultation, it is important to establish informed consent with the patient and ensure that the patient is in an appropriate care setting (for example, depending on the state, the patient may need to physically be in a location where the provider is licensed to practice medicine at the time of the consultation). Depending on the circumstances, a telepresenter (such as another health care provider or even a translator) may need to be present with the patient to assist with the intake and exam.
PRESCRIPTION MEDICATIONS AND VACCINES
Medications and vaccinations can be prescribed during a telemedicine encounter. Remote vaccine prescriptions are allowed in several states. Pharmacies receive the prescription electronically or over the phone, and the pharmacist may be able to administer any injectable vaccines (see www.pharmacist.com/article/pharmacist-administered-immunizations-what-does-your-state-allow). Yellow fever vaccine can only be administered at specially registered clinics, so a traveler may need a separate clinic visit to receive this vaccine. For medications and vaccines that may not be routinely stocked in a traveler’s local pharmacy, such as malaria prophylaxis, the traveler should allow time for the pharmacy to order them.
WHEN A TRAVELER IS OVERSEAS
A travel medicine provider may be called on to provide a consultation for a traveler overseas for any number of reasons. The provider’s willingness and ability to provide a remote overseas consultation will vary with type of question or the nature of the problem, willingness to work pro bono (or ability to charge for services), and perhaps the time of day, but it is important to remember that the same security and privacy practices apply as in a domestic consultation. In the case of lost medication, CDC does not endorse procuring medication or filling prescriptions overseas because of the risk of counterfeit drugs. However, in an emergency, such as with lost or stolen antimalarial drugs, a provider may be able to help a traveler locate a reputable source for replacing them.
When communicating with patients abroad, legal obligations under the Health Insurance Portability and Accountability Act (“HIPAA”) remain relevant. Providers must also ensure that the chosen technology to conduct telemedicine encounters, whether store-and-forward or live-video, is HIPAA compliant. Although encryption is not specifically addressed under HIPAA, it would be best to ensure technology is encrypted because of requirements to safeguard patient health information.
Providers must also consider bandwidth and connectivity. In the United States today, connectivity in some rural communities is often inadequate, and accessing websites is often difficult because of internal firewalls. Mobile hotspots may be used in some situations in lieu of dial-up or Ethernet connections.
Certain telemedicine vendors have optimized software to work in a low-bandwidth setting, while others have focused on targeted, established markets. Discuss needs with telemedicine vendors to understand the minimum bandwidth at which their software will meet expectations.
The Health Insurance Portability and Accountability Act (HIPAA) must be taken into account in discussions about patient data in health care today, and conversations around telemedicine will certainly include HIPAA compliance. When beginning to provide remote pretravel consultations, providers should use video software that already is HIPAA compliant. Providers should investigate specific legal requirements of the country where the traveler is located, as well as maintain compliance with federal and state privacy and security laws. In the United States, each state medical board has its own telemedicine regulations. Some states do not permit providers to practice telemedicine across state lines; some do not permit the prescribing of certain medications. It is critical that the travel clinic carefully read these medical board regulations before embarking on telemedicine consults.
In addition, particularly if providers are not part of a larger system or they are sole practitioners, they should explore whether or not there is a need for a business associate agreement or business associate contract.
When working with international partners, such as companies based outside the country in which the provider practices, additional legal issues may arise and should be considered.
Much like reimbursement for face-to-face encounters, providers need to ensure that the clinic meets certain legal requirements and payer guidelines. In the United States, the pretravel consultation is generally not reimbursed by health insurance companies, so a telemedicine practice may be primarily fee-for-service. If corporate personnel are traveling and their companies are paying for the service, it is wise to make sure the company is willing to permit their employees to engage in telemedicine and that they will reimburse for this service.
For during- and posttravel consults, issues such as eligibility for payment and licensure may surface. The provider’s medical board and the traveler’s payer may have to be queried as to whether teleconsultation is permissible, and which current procedural terminology (CPT) codes are usable.
Additional information relating to telemedicine standards, guidelines, and practice may be available through the following resources:
- American Telemedicine Association, Practice Guidelines and Resources: http://thesource.americantelemed.org/resources/telemedicine-practice-guidelines#
- American Telemedicine Association, Glossary of Terms: http://thesource.americantelemed.org/resources/telemedicine-glossary
- American Medical Association: www.ama-assn.org/delivering-care/telemedicine-mobile-apps
- Center for Connected Health Policy: www.telehealthpolicy.us/resources
- Centers for Medicare & Medicaid Services: www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/TelehealthSrvcsfctsht.pdf; www.cms.gov/Medicare/Medicare-General-Information/Telehealth
- Federation of State Medical Boards: www.fsmb.org/Media/Default/PDF/FSMB/Advocacy/FSMB_Telemedicine_Policy.pdf
- Health Insurance Portability and Accountability Act (HIPAA): www.hhs.gov/hipaa/index.html
- Institute of Medicine: www.nationalacademies.org/hmd/Reports/2012/The-Role-of-Telehealth-in-an-Evolving-Health-Care-Environment.aspx
- Strengths and Limitations of Telemedicine: https://academic.oup.com/jtm/article/23/5/taw048/2579370 ; www.ncbi.nlm.nih.gov/pmc/articles/PMC4895094 ; www.acha.org/documents/Programs_Services/webhandouts_2016/WE1-146_Neighbor.pdf