Dr Cai Glushak, International Medical Director and Chief Medical Officer of AXA Partners, notes that international prescribing of medication is still a complicated issue, due to the following factors:
• Do local regulations allow for e-prescribing and, if so, for which medications?
• Will they allow prescribing from non-local providers? In the European Union, generally a doctor can prescribe for all countries, but not all enable e-prescribing. Pharmacies may still require a physical prescription. For this reason, the role of international teleconsultation may be limited
• Some jurisdictions require the prescribing doctor to have an established relationship with the patient
• Controlled substances are usually much more restricted.
“So,” said Glushak, “be suspicious of any provider who claims to be able to prescribe anywhere. No one approach works and the best of them cobble together regional solutions.”
Ultimately, the decision an assistance company has to take regarding offering an international prescription service or admitting the patient to a hospital should come down to one thing, and one thing only, said Dr Bettina Vadera, Medical Director of AMREF Flying Doctors. “The decision of hospitalisation/length of stay in hospital should always be made on the basis of the benefit/safety of the patient, with an approach that hospitalisation should be as long as necessary/medically indicated. The decision has to be based on clinical, not financial considerations, but where hospitalisation does not provide additional value, patients should be discharged as soon as possible to avoid unnecessary costs.”
Be suspicious of any provider who claims to be able to prescribe anywhere. No one approach works and the best of them cobble together regional solutions
Dr Simon Worrell, Global Medical Director at Crisis24, and Dr Adrian Hyzler, the risk management company’s Chief Medical Officer, noted that the only situation where Crisis24 would prescribe medications ‘over the phone’ is where the patient is in a remote location and already has the medication with them, but needs the go-ahead from the medical team to use it. This can occur with clients such as film units on location or when providing assistance to staff on ships at sea.
“For example,” they said, “in a remote setting, if it is clear that an insect bite has become infected, the patient is feverish, and the cellulitis is spreading, it is important to start antibiotics as the patient begins their journey to a local clinic that may be located several hours away.”
In such a situation, they continued, a consultation would occur with the medical team, taking a complete history and ensuring important aspects such as allergies are thoroughly discussed. At the end of the consultation, a risk analysis would inform the medic about the benefit of starting medication now or the risk of withholding medication until the patient reaches a local clinic.
“In this situation, we would also be preparing for evacuation, especially if the clinical situation is concerning and the only available local clinic’s abilities are modest,” Worrell and Hyzler explained. “As we can see, in this scenario, the cost is not the consideration but the timely provision of medical assistance under challenging circumstances.”
Travellers with an already prescribed injectable medication should be trained in self-administration or have a companion that can administer it, or they will need to get it in a clinical setting
Continuity of medication has clear benefits
The safety and cost benefits of being able to continue prescribed medication are obvious. However, Glushak pointed out that when this is requested, it can be more an issue of ‘convenience’ than prevention. “This is now a commoditised offer,” he explained, “even when the practicalities make it challenging to guarantee success.”
There are, of course, logistical issues at play as well, although not all (or many) travellers and expats will be aware of them. Said Glushak: “It is impressive the increase in number of travellers and expats taking complex and costly medications who assume they can get access abroad. Many travellers are now on immunosuppressive medications such as infliximab for autoimmune disease.
They routinely get biweekly or monthly injections and are surprised to find these are not easily obtained abroad.” In such cases, as long as the assistance company knows about the illness in advance of the trip, such access can be actively researched in advance. “This is a time-intensive service, but well worth it for these vulnerable travellers,” he concluded.
Vadera believes that an important piece of advice that could and should be given to travellers is to carry sufficient supplies of their regular medication when travelling. If an unforeseen situation occurs that requires special medication that is not available locally or the traveller is running out of a medication that is not locally available, she observed: “A similar drug may be available locally that can be used to ‘bridge’ the time until the traveller can obtain his/her original medication. Or, the medication can be delivered to the patient through a reliable courier service – this is where a local partner/agent is able to assist the assistance company.” The final option is that the patient needs to be evacuated to a place where appropriate treatment/medication for their condition is available.
Worrell and Hyzler agree: “If a patient requires medication or therapy unavailable locally, we will move the patient to an equivalent treatment. In some circumstances, a locally available equivalent can be prescribed by a doctor on the ground. As long as we are confident of the authenticity of the medication, this may be a viable option with the most negligible impact on the individual.”
There are potential safety benefits in offering an international prescription service – for example, not admitting a patient to hospital in a pandemic. However, this comes down to patient safety. As Vadera said: “The question here is why a patient needs to be admitted into hospital in the first place. Is it because of surgery, an illness that requires hospital treatment or a treatment that can only be provided in a hospital setting? In each of the cases, the benefit and importance of the treatment in hospital has to be evaluated against the risk of infection during a pandemic.
As we have seen during the Covid pandemic, patients who needed elective surgery, for example, were advised to postpone it, not only because hospitals were overwhelmed, but also to be better isolated at home.”
There are many countries where remote prescribing is illegal or unavailable
On the other hand, patients who needed to continue with a specific cancer treatment in hospital, or required an important hospital-based procedure, were anxious because of the risk of infection. A delay, however, may have resulted in a deterioration of their condition. “There can be no general rule to this question, but a good case-by-case assessment and recommendation by the primary doctor (i.e. general practitioner) is important to weigh up the risk/benefit together with the patient,” concluded Vadera.
Worrell and Hyzler also noted: “The bottom line is if the patient needs admission to a hospital, they must be admitted. There are no ifs or buts with this. During the pandemic, we were often asked to provide treatment and oxygen therapy at home for sick patients with Covid. We chose each time to evacuate to hospitals, sometimes located in different countries, as the local healthcare facilities were overrun. In so doing, lives were saved.”
No admission required
Worrell and Hyzler shared their insights with ITIJ with regard to how best to manage patients who may not require admission to hospital: “If the situation is relatively simple but requires medication, we often arrange for a local doctor to consult the patient in their hotel room. This is a particularly valued service as the patient may well be sufficiently sick to make the modest journey to a clinic or hospital uncomfortable. Why travel to a hospital if it is unlikely that the patient will require admission or need hospital-based investigations?”
Sending a doctor to the patient will give the assistance company more information to support the patient, taking a conservative approach to treatment and allowing the on-site doctor to prescribe medications as needed. “If the clinical report provided by the doctor shows that the condition is evolving into something more serious, then escalation to a hospital may be appropriate. The on-site doctor will provide initial therapy and support the patient with the transfer,” they added.
We must always be aware of the risk versus benefit when managing the care of a patient and making remote decisions that are judged to be in the patient’s best interests
When is a commercial medical escort needed?
Travellers with an already prescribed injectable medication should be trained in self-administration or have a companion that can administer it, or they will need to get it in a clinical setting. “For travel, it is only after an acute illness, when the patient needs ongoing IV or injectable medication after discharge or en route home that they may need a medical escort if they cannot manage doing it themselves,”
Glushak told ITIJ. “A good example is someone newly prescribed insulin for diabetes while on a trip. This requires considerable training for the patient or caretaker and may not be practical before their travel home. Other frequent examples are ongoing antibiotics and injected anticoagulants.”
Local regulations have to be observed
Theoretically, a foreign prescriber could be in breach of local regulation as well as medical liability if they prescribe for a patient with no pre-existing medical relationship, especially where medical history is lacking. However, Glushak told ITIJ that in his practical experience, there have been virtually no adverse consequences to helping patients in need, and, he added: “We can usually defend our efforts to do so.”
There are many countries where remote prescribing is illegal or unavailable. In this situation, a local correspondent doctor is needed. Depending on the medication, many physicians will ask for adequate medical history or justification before blindly filling a prescription.
Jane Munyua of AMREF Flying Doctors made another vital point with regard to local regulations: “A last logistical issue to consider, especially if the medication required by the traveller (working as an expatriate) has to be shipped into the resident country, are the laws governing importation and clearance of the medical supplies. This can be long and tedious.”
Vadera told ITIJ: “In cases of over-the-phone or online consultations, it is advisable to state a disclaimer that waivers the liability of the advising doctor/assistance company. The patient should always be instructed that where symptoms persist or get worse, a physical medical consultation is necessary.”
As it is, she pointed out, treatment advice given remotely is usually in cases that are uncomplicated or to provide an initial first aid recommendation if it is an emergency. If there is any doubt during the medical consultation that symptoms are critical and pose an acute danger to the patient’s life, the patient needs physical examination and diagnostics anyway, i.e. needs to be referred to the nearest medical facility or evacuated.
“Where things go wrong in medicine, the risk for legal repercussions are generally high, but in my experience, if above protocols are applied and communication with the patient is good and clear, the risk for legal consequences are low,” Vadera explained to ITIJ.
Worrell and Hyzler finished with some succinct advice: “We must always be aware of the risk versus benefit when managing the care of a patient and making remote decisions that are judged to be in the patient’s best interests. Once the medical team has considered all options and determined that the patient requires intervention, we make a collaborative decision, including the patient where possible. While we act in the patient’s best interests, comprehensive medical malpractice insurance protects all parties in case of unforeseen consequences.”