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Health Practicioner on his computer reviewing Telemedicine Guidelines

Summary of International Telemedicine Guidelines

In January 2019, the International Society for Telemedicine & eHealth published an article by Nathaniel Lacktman, Esq. and Dr. Neil Nerwich entitled, “Teleconsultation Services for the Mobile Workforce- Considerations and Guidelines for the Provision of Global Services in Compliance with Regulations and Best Practice Clinical Standards of Care.”  The International Society for Telemedicine & EHealth (ISfTeH), founded in 2011, is a “nongovernmental and not-for-profit society that services primarily as the umbrella association for national Telemedicine and eHealth organizations,” advising on international standards and best practices for telemedicine.  

ISfTeH defines telehealth as, “the provision of healthcare at a distance using communications technology,” which “is rapidly becoming an established model of domestic healthcare delivery in many markets around the is not a medical specialty, but rather a tool- a technological conduit - through which medical care is provided.”  The article focuses on “legal and regulatory compliance across multiple international jurisdictions” for direct-to-patient telehealth services (also called “direct to consumer telemedicine services” or “teleconsultations.”) in which the “physician delivers clinical services directly to the patient, often by interactive audio-video, but also interactive audio or asynchronous telemedical technologies” such as secure messaging.

The following is a summary of the three main sections of this whitepaper:

I. Teleconsultation & Licensing

Internationally, licensing rules & medical practice laws are based on the location of the patient vs/ the location of the physician, which means that “a physician licensed in the United Kingdom and providing teleconsultation services to a patient located in Chicago, Illinois, USA must hold a license issued by the Illinois state medical board (or otherwise meet a state licensure exception under Illinois law)...this licensure also applies to the ability of a physician to be able to prescribe, and have fulfilled, medicine in a certain jurisdiction.”  In the USA, “a physician delivering medical services via telemedicine must be licensed in the state where the patient is located.”  It is critically important that local medical boards have the authority to set and uphold standards of medical care for citizens within their jurisdiction, giving them oversight to ensure that clinicians are “qualified, credentialed, and adhere to best practice clinical pathways.”

The “patient-location-law” is similar to other laws surrounding internet-based services and also serves to clarify the jurisdiction/ procedure for reporting a “medical malpractice or negligence complaint against the treating physician.”

Two physicians consulting on a case are governed by “peer to peer consultation laws” which vary widely but, “the foreign physician typically must be licensed in the jurisdiction where they are located, and the local physician must be licensed in the jurisdiction where they and the patient are located.”  

II. Teleconsultation and the Standard of Care

The goal is for the standard of care in telemedicine to reflect the standard of care in face-to-face medicine; “labs, diagnostic tests, medical histories, and any other information required to be obtained in the in-person setting should be obtained when delivering care via teleconsultation,” and the physician should have “the ability to prescribe medication, or refer to inpatient or specialist care.”  According to the ISfTeH, an in-country physician in the patient’s locality is strongly preferred in order to…

Select & prescribe medication.  Selecting appropriate medications “requires broad knowledge and familiarity of local medication availability, brand names and accessibility, including differentiation between prescription and controlled medications.”

Recognize differences in diagnostic approaches & understand environmental risks within the local context.  For example, the article states that tropical diseases would be best treated by specialists in the country where they occur, as “the scope of medical practice of a physician seeing patients in New York regarding tropical diseases such as malaria or Dengue Fever will be very limited compared to a physician managing patients in Singapore. Considerations in the differential diagnosis and clinical approach...may be substantively different…(which may) be compounded for teleconsultations without diagnostic testing or in-person examinations.”

Adequately follow-up and achieve continuity of care.  Proper follow-up requires familiarity with the local healthcare system and the ability to communicate in the local language (to order diagnostic tests, make referrals to specialists, etc.) as well as to understand “the implications to the patient of the cost and payment for local medical care.”  

III. Global Best Practices

“Regardless of jurisdiction, the following best practices are nearly universal and are recommended for any global teleconsultation service” by the International Society for Telemedicine & eHealth.

  • “Physicians delivering teleconsultation services should be appropriately licensed in the patient location and working in compliance with local health regulations.”
  • “Physicians should be permitted to prescribe remotely to the patient (when clinically required), with a detailed knowledge of local drug names, availability, and prescribing regulations.”
  • “Patients should be told about the benefits and risks of services delivered via teleconsultation and give their consent to such care.”
  • “Personal health information related to the teleconsultation should be managed in accordance with relevant local data protection regulations.”
  • “The organization providing, or coordinating, the teleconsultation service should be certified to appropriate quality management standards, such as ISO/TS 13131 Telehealth Services.”
  • “The standard of care should be the same whether the patient is seen in-person, through teleconsultation, or other methods of electronically enabled health care.”
  • “If the physician cannot competently and confidently diagnose or treat the patient via teleconsultation, the physician should refer the patient to an in-person examination before rendering a diagnosis or prescribing therapeutic treatment.”
  • “The undertaking of a teleconsultation should not be considered in isolation and should include the capability of facilitating the patient’s necessary medical care and assistance requirements post-teleconsultation.”
  • “The physician should be fluent in the local language at the patient location to ensure appropriate documentation and referral pathways when necessary.”