CDC Yellow Book 2024Preparing International Travelers
Telemedicine means “practicing medicine at a distance,” but in common usage it refers to providing diagnostic and therapeutic services via electronic transfer of medical information. Telemedicine encounters can be as simple as patients asking providers health-related questions via the telephone or secure email or as complex as real-time monitoring of the health of astronauts at the International Space Station.
Many analyses of telemedicine programs focus on cost savings for medical organizations or on the benefits provided to distinct population subsets such as underserved urban populations or populations for whom transportation is difficult (e.g., patients in nursing homes, correctional facilities, remote areas). Few analyses have looked at total costs across the entire health care system.
Benefits of Telemedicine
Benefits of telemedicine include expanding access to specialty care, expediting delivery of care (minimizing wait times), and providing opportunities to confirm or obviate the need for someone to see a provider in person—an advantage for individuals or populations for whom an in-person visit is impractical, inconvenient, arduous, or costly.
Telemedicine has several unique uses for the practice of travel medicine. For instance, telemedicine can be used as an alternative to the in-person pretravel consultation. Moreover, travelers can use telemedicine to maintain continuity of care for existing conditions, enabling them to travel farther and longer by extending the interval between in-person visits. Notably, travelers who develop acute illnesses or injuries, have exacerbations of existing conditions, experience high-risk exposures, or need to seek medical advice while abroad can use telemedicine platforms to discuss issues with a trusted provider.
Travel health providers also benefit from using telemedicine. When a traveler seeks medical care in the country they are visiting, the local provider can use telemedicine to obtain additional information from the patient’s regular providers or health records. Clinicians who conduct posttravel evaluations can obtain prompt consultative support when travelers present with unusual clinical findings.
Conducting a Remote Pretravel Consultation
Telemedicine provides a convenient way to deliver pretravel consultations with the same elements as an in-person visit. Providers should continue to follow the same professional standards used during in-person consultations, including adherence to a code of ethics, security and privacy practices, and clinical guidelines. What can and cannot be done in a remote consultation varies by state; clinicians should check with their state’s medical board about any restrictions. Furthermore, the policies and practices of telehealth programs underwent major changes during the coronavirus disease 2019 (COVID-19) pandemic and will continue to change; providers will need to remain current with what is and is not permissible. A valuable resource on telemedicine, including requirements by state, is prognoCIS[PDF], and many additional online resources related to telemedicine standards, guidelines, and practice are available (Table 2-14).
Medical practices should provide patients with a resource that outlines the expectations and outcomes of telemedicine before they schedule a consultation, including the limitations of a remote consultation. For example, the ability to conduct a complete physical examination is limited, but current technology can help replicate a near in-person quality of inspection, auscultation, palpation, and various other core elements of a physical examination. Intake information, including medical history, prior medical records, and diagnostic information can all be requested from patients and made available to providers in advance of the consultation. Encourage patients to set up and test their connections to the telemedicine software or equipment before the encounter.
At the time of the consultation, establish informed consent with the patient and ensure that the patient is in an appropriate care setting. Depending on state regulations, a patient might need to be in a location where the provider is licensed to practice medicine at the time of the consultation (see Legal Issues: Privacy & Security, later in this chapter). Depending on circumstances, a telepresenter (e.g., another health care provider or translator) might need to be with the patient to assist with the intake and exam.
Table 2-14 Online telemedicine resources
|ORGANIZATION OR SOURCE||RESOURCE|
American Medical Association
American Telemedicine Association
Center for Connected Health Policy
Federation of State Medical Boards
The Appropriate Use of Telemedicine Technologies in the Practice of Medicine (2022) [PDF]
The National Academy of Medicine
The Role of Telehealth in an Evolving Health Care Environment (Workshop Summary, 2012)
US Department of Health and Human Services: Centers for Medicare & Medicaid Services
COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers [PDF]
Medicare Learning Network Fact Sheet: Telehealth Services [PDF]
US Department of Health and Human Services: Health Resources & Services Administration
US Department of Health and Human Services: Office for Civil Rights
World Health Organization: Pan American Health Organization
Prescribing Medications & Vaccines
Depending on state and country-specific regulations, medications and vaccines can be prescribed during a telemedicine encounter. Where applicable, pharmacies or other allied health care providers can receive certain prescriptions electronically or over the phone, and eligible providers can dispense the medications or administer vaccines.
Yellow fever vaccine is available only at designated yellow fever vaccine clinics, and travelers might need to schedule a separate visit to receive it. For medications (e.g., malaria prophylaxis) and vaccines not routinely stocked at a local pharmacy, the traveler should allow time for the pharmacy to order them.
When a Traveler is Abroad
US-based health care providers, regardless of their level of expertise in travel medicine, might be asked to provide a consultation for someone traveling outside the United States. The provider’s willingness, comfort, and ability to provide a remote consultation under these circumstances will vary with the type of question or nature of the problem, their ability to charge for services, the technical quality of the communication, and perhaps the time of day. Providers must remember that the same security and privacy practices apply during a telemedicine consult as in a conventional, in-person, domestic consultation.
The Centers for Disease Control and Prevention (CDC) does not endorse procuring medication or filling prescriptions abroad because of the risk for counterfeit drugs (see Sec. 6, Ch. 3, . . .perspectives: Avoiding Poorly Regulated Medicines & Medical Products During Travel). In an emergency, however, such as when a traveler’s medication is lost or stolen, a provider might be able to help locate local, reputable sources for replacement.
Legal Issues: Privacy & Security
US Federal Law & International Law
Telemedicine consultations must comply with state and federal privacy and security laws, including the Health Insurance Portability and Accountability Act (HIPAA). In addition, providers should investigate specific legal requirements of the country where the traveler is located; some countries have strict requirements related to the transfer of personal health data, and even a patient’s written consent might not be sufficient to allow this.
Communicating with patients abroad deserves a careful assessment of data and protection laws relative to the originating (i.e., overseas) location, type of service, and means of electronic transmission. Providers must ensure that the technology and video software chosen to conduct remote pretravel consultations and telemedicine encounters, whether store-and-forward (asynchronous) or live interactive video (synchronous), is HIPAA-compliant and meets the privacy and data security requirements of the countries involved. Although encryption is not specifically addressed under HIPAA, ensuring technology is encrypted will help providers safeguard patient health information.
Providers should communicate with at-home patients via an established patient portal or other HIPAA-compliant method. In urgent or unexpected situations, however, patients often will communicate via their personal email accounts, many of which are not encrypted. Remember that no data storage system or transmission of data over the internet, or any other public network, is guaranteed to be secure.
US State Laws & Regulations
In the United States, each state has its own telemedicine laws and regulations, most of which address reimbursement issues (e.g., informing providers and insurance carriers which telemedicine services are reimbursed) but not the practice of telemedicine. Therefore, providers must perform due diligence to ensure that they conduct telemedicine encounters in accordance with the laws and regulations applicable in their local jurisdiction.
In response to the COVID-19 pandemic, some states modified licensure requirements to support cross-state telemedicine. Providers should check with the Federation of State Medical Boards to ensure they are following all state and federal policies (see Table 2-14). Without appropriate licensing, some states do not permit providers to practice telemedicine or to prescribe certain medications across state lines. Therefore, travel medicine clinics and providers must carefully read medical board regulations before embarking on telemedicine consults across state lines. No state prohibits the practice of telemedicine across state lines, but many do require providers to have required licensure. For example, a provider living in State A conducting a telemedicine encounter with a patient in State B would need to be licensed in both states. The standards for maintaining privacy and security during an international telemedicine consult are the same as for domestic consults.
In addition, providers—particularly solo practitioners or those not part of a larger health care network or system—should explore whether a business associate agreement or contract is needed. When working with international partners (e.g., companies based outside the country in which the provider practices), additional legal issues can arise and should be considered.
Providers should consider the bandwidth and connectivity needed for live interactive video telemedicine encounters. Connectivity can be inadequate in some places, and website accessibility can be made difficult because of internal firewalls. Mobile hotspots can be used in some situations in lieu of dial-up or Ethernet connections.
Some telemedicine vendors have optimized software to work in low-bandwidth settings; others have focused on markets where high-bandwidth networks are more widely available. Providers should have their technology vendor provide information about minimum bandwidth requirements that they can review with patients to ensure a seamless telemedicine encounter. Although not required, providers also should recommend that patients use private, secure connections and avoid using public Wi-Fi such as that available in hotels, internet cafes, and airports, because these connections can pose privacy and security risks.
Much like reimbursement for face-to-face encounters, providers need to ensure that their clinic meets certain legal requirements and payer guidelines. In the United States, the pretravel consultation might not be reimbursed by health insurance companies, so a telemedicine practice might be primarily fee-for-service. If corporate personnel are traveling for work and their companies are paying for the associated health care they receive, providers should make certain the company permits their employees to engage in telemedicine and will reimburse for this service.
Box 2-16 Photographs in telemedicine: advice for travelers
One of the most common ways that travelers use telemedicine is by sending photographs of travel-associated rashes and minor injuries to their home providers with implicit requests for a diagnosis and for treatment recommendations. Nowadays, most such photos are digital images taken with smart phones. Although the cameras on smart phones are seemingly simple to use, travel medicine providers often find these photographs blurry (due to poor focusing, motion artifact, or improper depth of field), poorly lit, or marred by distracting objects in the foreground or background. Even with well-focused, well-lit photographs, discerning which body part is being shown or which lesion is the one in question can be difficult. The following recommendations can help travelers take more useful, information-laden photographs.
Pictures Should Show
- Distribution (i.e., the parts of the body that are involved)
- Configuration and arrangement of lesions with respect to one another (grouping)
- A primary lesion (e.g., an undamaged blister)
- Lesions with secondary changes (e.g., an open or eroded blister)
Mark The Lesion
- If several lesions are present, or if the lesion is subtle, indicate the specific lesion using a marking pen or (for digital images) editing software.
Use Good Lighting
- Take pictures in a well-lit room, or outdoors in a shaded area.
Take Several Pictures
- An orientation view should show the entire body or affected body part; the location of the lesion should be obvious in the picture.
- A mid-distance view should center on the lesion and show an anatomical landmark (e.g., belly button, armpit) for orientation and size.
- A close-up view can be physically close (under 18”) using the camera’s macro function or from farther away if using a zoom lens.
- Take pictures both straight-on and from different angles.
- Make sure the lesion is in the center of the picture; the lesion should fill most of frame but also include some normal skin around it.
- Include a scale/size comparison in the picture (use either a ruler or measuring tape or a standard object like a pencil, paper clip, or US coin).
- Show the normal opposite side for comparison (e.g., a swollen elbow and the uninvolved elbow).
- For lesions on the head, neck, and face, remove jewelry; and for hair problems, focus on scalp.
- Take as many pictures as necessary; send sharply focused, well-lit photos only; blurry pictures are not helpful, even if they are 5MB.
The following authors contributed to the previous version of this chapter: Taylan Bozkurt, Jose F. Flórez-Arango, Matt Levi
Kennedy KM, Flaherty GT. Medico-legal risk, clinical negligence and the practice of travel medicine. J Travel Med. 2016;23(5).
Rokosh RS, Lewis II WC, Chaikof EL, Kavraki LE. 2021. How should we prepare for the post-pandemic world of telehealth and digital medicine? NAM Perspect. Washington, DC: National Academy of Medicine; 2021. Available from: https://nam.edu/how-should-we-prepare-for-the-post-pandemic-world-of-telehealth-and-digital-medicine/.