Cross Border Telemedicine: A How To Guide

Cross Border Telemedicine: A How To Guide

I received an intriguing email from a colleague the other day.

We're in different fields of medicine, but we both made the transition from brick and mortar clinics to virtual clinics about a year ago.  That said, we were generally living similar lives to many of our friends who are not in medicine, with our trip to our clinics now replaced with a trip to converted home offices. Although we had encountered colleagues who utilized telemedicine to drastically reimagine how they wanted to work and live, our last year had ended up a bit more mundane.

Until I read this simple email from him...

The subject line read: Can I do telepsychiatry from abroad?

These six simple words sent me down a rabbit hole on Google and Wikipedia for several hours looking up information on international telehealth laws and regulations. 

Types of Telemedicine 

For one, if we're talking about what is possible in cross border telemedicine, we have to be a bit more careful about our terms and the types of telemedicine we're discussing.

1.) Asynchronous Telemedicine: Sometimes referred to as "store and forward" telemedicine. This can take several forms and some forms are commonly being used internationally today. For example, some hospitals utilize teleradiology services to provide late night reads of MRI scans/CT scans/teleretinal photos. These services are occasionally provided by international groups and are generally considered acceptable.

The VA administration has been conducting screening teleretinal exams asynchronously for years that an article in JAMA Ophthalmology describes as "an effective method to screen patients for sight-threatening conditions." 

In the academic world, a study of Stanford University's teledermatology clinic has revealed that Dermatologists were able to asynchronously diagnose a patient accurately in 36 out of 38 cases.

2.) Teleconsultation: The standard direct, synchronous audiovisual visit between patient's and providers. This proves tricky, if you're treating patients from another country you do need to be licensed in that country. Additionally, if you're providing care for patients for the US, CMS generally requires physicians to be in their office and the patient's to generally be at a clinic. During the COVID-19 pandemic there has been some flexibility provided in which patient's can be in the comfort of their own home. The location of the physician is a bit murky, but the verbage in the current guidelines states that if the provider is making a "good faith effort" to provide care during the emergency, that CMS will not be digging too deeply. That said, CMS has generally previously frowned on providers being across state lines or in other locations. There are some companies that will allow their providers to be abroad but they don't make a habit of advertising this.

3.) Peer to peer consultation: Also known as tele-expertise. This is a form of telemedicine in which a provider in one country discusses a patient's case with a provider in another country. Given that they will not be providing direct medical care to a patient abroad this is generally considered far more acceptable. They are simply providing medical knowledge to another provider.

4.) Remote patient monitoring: If you have a diabetic patient that has continuous glucose monitoring that goes abroad, you are still having the patient upload their own data. This data by it's very nature is collected by patients outside a hospital/clinical setting and is used to alert patient's provider to their blood sugar values. If you contact a patient and make adjustments through your EMR generally remote patient monitoring does not require a report of the provider or the patient's location.

Telemedicine for International Patients 

If you are an international patient seeking the opinion of US based doctors, the situation is challenging. Providing international, cross border telemedicine is a complex regulatory challenge. Usually this requires a visit in the United States and then follow-up care can at least conceivably be done internationally if you dial in to a hospitals telemedicine app.

Otherwise, international asynchronous telemedicine or peer to peer consultation from your physician to a US based physician may be possible, albeit limited option. 

Aside from that, current global health regulations to not generally allow for a US based physician to provide a synchronous telehealth consultation for a patient living in another country without that physician having a license in said country.

Telehealth Providers Abroad

If however, you are a telehealth provider looking to practice US based telemedicine WHILE abroad, the choices to appear to be a little bit wider. As stated earlier, CMS rules do not generally allow a US based physician to be abroad while providing telehealth using conventional Medicare/Medicaid CPT codes. again, most of this verbage is suspended during the course of the COVID-19 pandemic but it's not something we would advise pushing your luck with. 

However, many US based telemedicine companies do not actually use CPT billing codes and are instead cash based businesses.

If you wanted to work for any number of these companies, you could in essence, live out your digital nomad provider fantasy from any number of tropical islands of your choosing while providing virtual care. As is the case in most areas of tech, international telehealth laws have not quite caught up to reality, so regulators have so far not objected (or really commented on) this practice.

As a guiding principle in medicine and in telehealth, always strive to replicate the quality and experience of a patient actually coming to see you in clinic in person as closely as possible. 

Also, if living abroad while providing medicine seems like too much of a stretch but you still want to do telehealth while traveling, consider moving to one of these top 5 telehealth friendly cities in the United States. It's never a bad idea to start your next telehealth adventure a little closer to home!

So to answer my colleague's question, yes, it is possible to be a traveling, international rockstar of a provider, it simply depends on the company you're looking for.

But if you're an international patient looking for the opinion of a US physician, you may have to wait a few years until telemedicine across international borders develops laws and regulations that meet the demands of a more interconnected world.