While the novelty of asserting that the global pandemic has rapidly accelerated the uptake of telemedicine and remote second opinion services has by now worn off, insights into the current state of cross-border distance health services remain much less common. As of October 2020, the U.S. continues to maintain entry restrictions for foreign nationals who are traveling from certain countries – regardless of visa status – and routine visa services are still suspended at many American consular posts worldwide. Prospective international patients wishing to receive care at American hospitals may face significant administrative hurdles when trying to obtain a visa or when attempting to travel to the U.S. As such, U.S. hospitals with international programs have recognized both the need to scale up their international digital health offerings as well as the importance of working with their global partners when travel to the U.S. may not be possible.
The US Cooperative for International Patient Programs (USCIPP) – a program of the National Center for Healthcare Leadership, a Chicago-based 501(c)(3) nonprofit organization – recently conducted a survey of 40 U.S. hospitals and health systems with international services divisions to find out more about their international telemedicine and remote second opinion (RSO) programs. Figure 1 contains USCIPP’s standard definitions for both telemedicine and remote second opinions as well as further subclassifications for both telemedicine and remote second opinions.
According to the survey, the top specialties for international telemedicine or RSO services provided by U.S. hospitals in 2020 were oncology, neurology, and cardiology. These results are unsurprising and mirror the hospitals’ top service lines for international patient care delivered in person. Moreover, numerous American hospitals also reported that they regularly receive requests for cross-border distance health services involving multidisciplinary team case review.
When comparing the period from January–July 2020 to the same period in 2019, the survey results showed that nearly all types of international telemedicine and RSO services increased, with the total volume of real-time telemedicine encounters ballooning by 636%.
UAE case study
According to USCIPP’s proprietary research and its cross-border collaborations dashboard, the UAE ranks as the country with the second greatest total number of international healthcare collaborations (after China). There are at least 100 documented collaborations in the UAE. (Note that the dashboard typically does not include collaborations involving tech companies, insurance providers, NGOs, medical facilitators, or two governmental entities)
Of the 100 Emirati collaborations known to USCIPP, some 62 are between American hospitals and Emirati organizations in both the public and private sectors. Indeed, the UAE is one of the most important partner countries for U.S. hospitals, both for international patient care – the UAE consistently ranks as one of the top countries of home origin for medical travelers receiving treatment in the U.S. – and in terms of cross-border education and training programs, management services agreements, advisory and consulting services, joint ventures, distance health services agreements, etc.
During the pandemic, U.S. hospitals and health systems have continued to work closely with their Emirati colleagues, including the International Patient Care (IPC) division at the Department of Health – Abu Dhabi (DOH). DOH formally halted IPC services in March 2020 due to the pandemic; as of August 2020, IPC services remain suspended, “with the exception of urgent cases whose treatment is not available in the UAE”. Given the restrictions, several U.S. hospitals have reported that they are working with DOH and Emirati providers to offer telemedicine and RSO services to Emirati patients.
The UAE regulatory framework in relation to telemedicine has broadened in recent years, as technology advances and healthcare providers and consumers respectively seek more convenient ways to provide and access treatment. Regulations surrounding telemedicine naturally fall into two areas: 1) regulating the provision of care and 2) regulating the protection of data. The UAE is keen to promote the option of accessing care remotely to patients, a trend which has only become more apparent and important during the current pandemic. In 2019, the UAE Cabinet issued a set of Controls and Conditions of Providing Remote Health Services as part of Resolution 40 of 2019 on Medical Liability, a federal ruling largely tracked DOH’s recent release of its Standards on Tele-Medicine and the Dubai Health Authority’s Standards for Telehealth Services. Facilities wishing to offer telemedicine must be licensed, with the DOH offering six distinct new activities, including Tele-Prescription, Tele-Medical Interventions, Tele-Counselling, and Tele-Consultation. Practitioners will not require any additional licensing beyond their current DOH accreditation.
While the regulations and directions regarding the provision of care might appear to signal opportunities for U.S.-based providers to offer telemedicine to UAE-based consumers, the data protection framework gives cause for caution.
The DOH Standard on Patient Healthcare Data Privacy states that “entities shall perform a privacy risk assessment to understand and implement the controls as appropriate”, while also stating that “no entity is permitted to store, develop, or transfer [patient health information] outside the UAE that is related to health services provided within Abu Dhabi”.
This directly reflects UAE Federal Law No. 2 of 2019 on the Use of the Information and Communication Technology in Health Fields. The law provides that the regulatory authorities may give permission for the transfer or processing of health data outside of the UAE, but as of yet the authorities have not publicly issued any guidance on how to obtain this permission or what might be required to do so.
Given this absence of an authorization mechanism, the absolute prescription on the international transfer of health data by UAE entities stands, making it theoretically prohibited for UAE-based physicians to share information in order for professionals elsewhere to provide second opinions or even for UAE healthcare providers to store patient data on company servers based outside of the UAE. Notwithstanding this, IPC services are conducted in conjunction with the DOH, and the US hospitals working with DOH to provide services to Emiratis who would otherwise seek permission to travel for non-urgent treatment will have structured the patient care in such a way as to be in compliance with the law or will have been granted the proper approvals to carry out this work.
The UAE healthcare market is an attractive one to international providers, with a working-age population, compulsory private health cover, and relative affluence among a large proportion of locals and expats. Those providers that wish to access the market but don’t benefit from an IPC agreement with the DOH and/or other facilities may find that the best course of action is to establish a local entity with UAE-based professionals and, crucially, UAE-based record-management systems or to market themselves so as to reach residents and citizens without needing to establish a domestic presence.