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Cross-border telemedicine and remote second opinion services provided by U.S. hospitals

Article-Cross-border telemedicine and remote second opinion services provided by U.S. hospitals

Overview and GCC case study.

Since the start of the COVID-19 pandemic, U.S. hospitals and health systems have continued to scale up their telemedicine and remote second opinion (RSO) programs for both domestic and international patients. The U.S. Cooperative for International Patient Programs (USCIPP) – a program of the National Center for Healthcare Leadership (NCHL), an American 501(c)(3) nonprofit organization – conducts an annual survey of U.S. hospitals and health systems with international services divisions. The most recent survey collected data from the period between July 2019 to June 2020, and 54 American hospitals and health systems responded to the survey in total.

Some key findings from the July 2019–June 2020 survey follow. (Figure 1 contains USCIPP’s standard definitions for both “telemedicine and “RSO” as well as further subclassifications for both.)

  • Seventy-four percent (74%) of the US hospitals surveyed indicated that they provide RSO services to international patients.
  • Of those hospitals offering RSO services to international patients, written RSOs were the most common format. The median number of written, international RSO encounters was 35 across the 28 hospitals reporting at least 1 encounter.
  • Sixty-three percent (63%) indicated that they provide telemedicine services to international patients.
  • Of those hospitals offering telemedicine services to international patients, real-time telemedicine was the most common format. The median number of real-time, international telemedicine encounters was 17.5 across the 22 hospitals reporting at least 1 encounter.

Figure 1-min-min (1).jpg

Figure 1. USCIPP standard definitions for telemedicine and remote second opinions

In speaking with U.S. hospitals and health systems that currently offer cross-border digital health services, the broad sentiment in late 2021 is, unquestionably, that the ability to offer international telemedicine and RSO services is an increasingly important component of U.S. providers’ broader relationships with their global partners. These partnerships may include clinical collaborations with public and private healthcare facilities abroad, relationships with international ministries or departments of health, collaborations with international information technology companies, and more.

Providing international telemedicine and RSOs in the GCC

American hospitals and health systems continue to care for significant numbers of international patients who travel to the U.S. from the GCC. Cases referred to American providers from the region are often quite complex; anecdotally, U.S. providers report that this has been particularly true since the start of the COVID-19 pandemic. Increasingly, international telemedicine and RSO services can be used as a tool to help patients and in-country physicians decide if travelling abroad for care would be in a patient’s best interests. Cross-border digital health services can be used both for pre-arrival screening as well as for follow-up care once patients return home from receiving care in the U.S.

Across the Gulf, the laws regulating the cross-border delivery of telemedicine and RSO services continue to evolve. The USCIPP program has worked closely with its member hospitals and international law firm Hogan Lovells to monitor relevant regulatory updates and changes. Some highlights from the current regulatory environments in four Gulf countries – Kuwait, Qatar, Saudi Arabia, and the United Arab Emirates (UAE) – follow below.


  • In general, physicians who are not licensed to practice medicine in Kuwait are not permitted to provide remote, virtual care to patients in Kuwait. However, there may be some exceptions to this rule, particularly for follow-up care for patients who were previously treated abroad or those who are preparing to travel abroad to receive care.
  • Physicians must be licensed in Kuwait to provide written RSOs directly to patients for the purpose of being used for the treatment of the patient in Kuwait. However, there may be exceptions to this if the purpose of the written RSO is for the treatment of the patient outside Kuwait.
  • Physician-to-physician services are generally permitted.


  • Currently, there are no specific laws relating to telemedicine in Qatar. However, in general, foreign doctors who are not licensed and registered in Qatar may not deliver virtual care directly to Qatari patients. However, foreign doctors may be permitted to provide preliminary assistance or follow-up care from outside the country if they advise the patient to seek care locally afterwards. 
  • Foreign physicians who are not licensed or registered in Qatar can continue to provide routine follow-up care to established/existing patients (i.e., patients who previously received in-person care from the non-Qatari physician outside Qatar and now have returned to Qatar).
  • Foreign doctors who are not licensed or registered in Qatar may engage in a virtual consultation with Qatari doctors, and Qatari patients may be present during such consultations. At the time of publication, written RSOs directed to Qatari patients are not regulated.

Saudi Arabia

  • Virtual, cross-border, direct-to-patient telemedicine services remain prohibited. The exception to this is if both the physician is licensed in Saudi Arabia, and a Telemedicine and Telehealth Centre oversees the activity.
  • Physician-to-physician services are now permitted. There is no explicit requirement for non-Saudi physicians to be licensed in Saudi Arabia to provide these services. Foreign physicians also can provide peer-to-peer RSOs to Saudi physicians.


  • As a general requirement, all physicians practising in and from the UAE must be licensed by the regulatory authority in the emirate in which they practice. Where the physician is providing the services in and from the UAE, there are no exceptions to this requirement. Physicians providing services from a location outside of the UAE to individuals based in the UAE are not covered by this and as such would not require licensing/registration by UAE authorities.
  • Under the Federal Telehealth Regulations, there are “general controls” for the provision of all remote health services and “specific controls” for certain services, including “remote medical consultation.” The definition of “remote medical consultation” includes both peer-to-peer consultations/RSO and physician-to-patient consultations in which the two individuals are not in the same place (this would cover interactive video consults with patients).
  • For “remote medical consultation,” specific controls may be imposed by the emirate-level health authorities. These controls cover matters surrounding the types of medical issues for which “remote medical consultation” could be offered.

Looking forward

U.S. providers that offer digital health services to patients and partner organizations located in the GCC should expect countries’ telemedicine laws to continue to mature as time goes on. Future changes could affect how American providers are able to engage with prospective patients who may need to travel to the U.S. for care and how American providers can collaborate with the governmental bodies responsible for administering the treatment abroad programs for those patients. Additionally, future changes to telemedicine laws may affect how international digital health services fit into the broader framework of U.S. providers’ clinical partnerships with both public- and private-sector hospitals across the GCC.  

This article appears in the latest issue of Omnia Health Magazine. Read the full issue online today.

TAGS: Telemedicine
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