Caring for Travelers While They are Overseas

Karl Neumann, MD, FAAP

Travel medicine and telemedicine have both come of age, and they have found each other. The two are now in the courting stage, getting to know each other better, considering each other's strengths and weaknesses. But both realize that they were made for each other; that, sooner or later, marriage is inevitable; and that the couple(ing) will mature in one form or another, and become a meaningful and ongoing relationship, beneficial for all involved.

This is the general sentiment of the sixty-five ISTM members who responded to a short questionnaire placed on the ISTM ListServ, asking them:

• Do you as a travel medicine professional have a responsibility to provide services to your clients while they travel overseas?
• What kind of services do you provide?
• Do you see a future for telemedicine in travel medicine?

Fortunately, many respondents passed up the chance of merely checking "yes" and "no" boxes on the questionnaire, and instead spent time writing well thought out paragraphs. Responses came from all over the world.

Surprisingly, the respondents were very much divided on the responsibility that travel health professionals have for their clients once they leave their offices. Also, travel medicine practitioners have widely different conceptions of the term "telemedicine." To some this means telephone and email communication with their clients overseas, while others think that it should include sophisticated monitoring of travelers who becomes ill overseas and electronic transmission of medical data back and forth.

Statements made to describe the need for better communications between travel medicine practitioners and their clients abroad include: "It is a little embarrassing that we are no further along with remote monitoring of our travelers", and "The way we care for travelers today is like surgeons performing pre- and post-operative procedures but foregoing the surgery," referring to the hiatus in care while clients are traveling. But there appears to be marked differences in how available practitioners make themselves for giving advice, and if indeed giving advice to travelers far from home is all that helpful.

For example, most of the respondents offer telephone and e-mail advice, but only about half are available 24/7.

"I only give out my daytime office number. Only a select few [travelers] get my home number and cell phone… those that are high risk for any special reason."

"I take calls but only on standard "work" days. Once I am in contact with a specific traveler who has a problem by e-mail, I will monitor e-mails several times a day, even from home over weekends and holidays. If I then go away, I'll pass the thread to another staffer. Occasionally we get phone calls, but usually from an intermediary who is in the U.S. I've actually had an email "conversation" in real time with a patient who had traveler's diarrhea, and who was e-mailing me from an internet cafe in India."

"We have 600-800 students who participate in off-campus programs overseas each year. We provide e-mail and phone contact during regular office hours."

"I give my travel patients my e-mail and a few have used it to get refills or questions answered while out of the country. A more common source is the "stateside spouse" who calls with a question or request. I have had only a few calls/e-mails each year, but my travel practice is new and small. I think it is important if we have the capabilities to handle it [telemedicine]. I prefer email due to convenience factors."

"Travelers can leave a message 24 hrs. on my direct line.  They can reach someone through our centralized HMO number (recently published to all members)."

The general feeling among a majority of respondents appears to be that it is "nice" to be available by e-mail and telephone, but that such communications "do not resolve serious medical situations and rarely, if ever, save lives."

"Telemedicine is important because it is often the only means available to triage a medical situation and see if it requires medical evacuation and immediate treatment, as well as a means of providing medical stabilization until more adequate care can be obtained. We instruct our patients to call us by telephone if needed for acute medical emergencies, and to e-mail us for less acute problems. We promise a return telephone call within one hour and a return e-mail within 24 hours. Our telephone system is set up to page the physician on call any time a message is left on the voicemail, and we monitor our e-mail 16 hours daily. With the increasing use of cellular and satellite telephones, we are seeing a steady increase in the use of these systems, plus a steady increase in the volume of e-mails."

"Our organization regularly sends staff on mission travel (35,000 to 40,000 mission days per year) throughout the world, mostly to Asia, sometimes to very remote areas with basic or non-existing medical facilities. In these conditions, the mildest pathology quickly becomes a source of anxiety and the patient needs prompt reassurance. Distrust in local facilities (however developed they might be) and/or local doctors is a common features of many expatriates and travelers.

A simple contact through phone call to their regular doctor is often sufficient for the patients to cool down and get necessary reassurance. It is of course sometimes impossible for the doctor to have a clear idea of the situation and diagnosis, but a call will at least guide the patients through the steps to follow in order to get the right medical attention. This is particularly obvious in countries and areas where few doc (tors) can speak English."

"I encourage my travelers to call me. It gives me a better picture of what goes on while they are overseas and helps me refine … my advice giving skills."

"The problem of staying in touch with travelers overseas is a HUGE pet peeve of mine. I shiver to think of how many of my colleagues try to do good by giving their patients the all clear to call/email 24/7 but know that most of them (the travel medicine professionals) cannot provide what travelers really need.  It may seem comforting to the traveler that they have our numbers/e-mails but we must ask ourselves what we will do for them at 2 AM when they have chest pain, a broken leg or a high fever. In our clinic, we council each traveler about the importance of a good medivac policy/assistance plan as a safety net. These providers are fully equipped to handle, triage, refer, monitor, evacuate 24/7. We have a listing of such vendors and encourage our travelers to do homework to find which one best meets their needs. Most of us are NOT equipped to handle this and we need to know our limits. We should not give travelers expectations of care that we cannot meet. It may be a huge potential liability for us as providers. Therefore we do not have a system for travelers to contact us. Occasionally we will get a call anyway.  If they do not have a medivac vendor we will try to get them the embassy/consulate telephone number."

In fact four responders stated that they are "hooked up" with a medivac/assistance company and that they "instruct" their clients to call the company, not them, directly, and to do so whether the issue is trivial or life threatening.

Some travel health practitioners also see telemedicine as a legal minefield:

"Horrendous potential medico-legal pitfalls. Even with electronically transmitted data, ECGs, etc., there is no substitute to having a real patient in your consulting room. The traveler should attend a doctor or hospital in the country visited, even if that means helicopter evacuation. The only role I see myself playing would be to provide information on the patient's medical history to a doctor abroad but not to take responsibility for my patient's care in a foreign country."

"While telemedicine may be important in the future, presently its availability is not spread enough for travelers to easily find a telemedicine facility in countries where they would really need it. In countries where telemedicine is widely available, it is usually easy enough to find medical facilities good enough to diagnose and treat most problems a traveler could experience and it is unlikely that they will need telemedicine."

"Telemedicine is of limited importance - many health problems that crop up may not be travel-related and may be outside the travel medicine provider's area of expertise, whereas a single call to a travel insurance help line may be a faster track to appropriate advice. Really depends on the exact nature of the problem. Also depends on the exact definition of telemedicine: are we talking primary care and advice here, or secondary referral with pictures, diagnostic images or ECGs for interpretation?"

"While I think there are obvious applications for acute diagnostic values for cardiac care or orthopedic care where timeliness is essential, providing needed care must be a companion piece to diagnostics.  Traveling involves risk; this is one of its inherent compelling characteristics."

"As there is more international travel for business and pleasure, there will inevitably be more teleservice medicine, by necessity.  The globe is shrinking.  High tech companies here are using many more workers in India, creating a new concept of ourselves as global citizens.  If people in the USA call India now for technical advice, catalogue ordering, etc. something tells me they will soon be calling India for medical advice as well.  But the step in between may involve those of us in travel health."

A few responders believe that the International Society of Travel Medicine (ISTM) may be able to play a role in telemedicine:

"Am not doing this [telemedicine] at this time because my malpractice insurance costs would be high and my current insurance doesn't cover it. Perhaps we could get a group insurance policy thru ISTM."

 "What is needed is a network of travel medicine clinics and doctors in all places mostly visited by travelers. This network could be interactive and more effective than telemedicine as it presently works. Telemedicine is probably another possible good option for the future, but it will long be limited by unavailability in remote areas, cost, and difficulties of connection."

"Let's work on a network of travel physicians with central routing (a live telephone exchange) for contact. This way there will always be a "doc on call". The cost per year to us would be minimal with 20 or more participants and the service would be extraordinary. We could even develop a link to air evac and travel insurance companies."

A large number of travel clinics are not set up for giving advice to travelers overseas:

"We are a Public Health Unit and are nurses who do pre-trip counseling and vaccinate.  We do not do post-trip follow up other than completing vaccination series."

Another frequent comment: while the technology to transfer sophisticated medical data between any two locations in the world - and to and from space - is available, making practical use of the technology is another story:

"The remote medical monitoring of clients/patients may be far more complex than many of us realize and is probably way beyond the one-on-one clinic-to-patient tracking across the planet for the foreseeable future, at least."

"I am in contact with groups that are monitoring small numbers of patients, using devices that connect to the phone lines for daily data uploads. Those experiments are facing two problems, problems which will only get worse as the number of patients on monitors increases, and as the data flows become more "real time" and less "snapshot". Problem 1 is data analysis. There are not the bodies (people) to collect and analyze the data, and costs are prohibitive. Problem 2 is that the care givers (doctors, clinics) cannot process the summary data that is fed to them on a regular basis (just too much even for a handful of patients) and are even less able to handle data that - if read - calls for immediate attention. The only solution is some sort of middleware (software sitting between the monitoring site and the decision makers) that does two things. First, it processes large and complex data flows quickly (in real time). Second, it provides output that is usable for medical decision making. Some sort of "triage" process is needed to divide clients into: no problem; on watch list; and attend to now; along with a tool - in our case a virtual construction of the patient - so that data arriving at the doctor's attention (or the patient's attention) is readily useable."

Several responders suggested that travel medicine practitioners should explore the potential of videoconferencing, a technology already widely available, and one that could be very useful to stay in touch with groups of travelers and expatriates, for example.

If you have additional comments on telemedicine, please send them to: Editor, NewsShare, at travhealth@aol.com.

(Karl is the editor of NewsShare and webmaster for the ISTM. He frequently writes about travel medicine for both health care professionals and the media.)