Background

WorldClinic was founded in 1998 by distance-medicine pioneer Dr. Daniel J. Carlin, who uses telecommunications to bring routine and emergency medical care to patients all over the world. Prior to founding WorldClinic, Dr. Carlin served as a medical officer on a US Navy nuclear cruiser and went on to practice emergency medicine as a volunteer in the Afghan refugee camps of Northwestern Pakistan. In 1995, he established Voyager Medicine, a medical practice for ocean sailors and remote expeditions. In 1998, Dr. Carlin moved to New England Medical Center in Boston to establish the first "virtual ER," a 24/7 doctor-staffed telemedical center working in support of a large-scale construction project (2000 workers) in Ghana, West Africa. This treatment model resulted in improved health and safety for the workers, a $2.5 million operational cost savings, and a reduction in lost time from 27% to 4%. Encouraged by those findings and excited by the experience, Dr. Carlin founded WorldClinic, a private telemedical practice headquartered at the Lahey Clinic in Burlington, Massachusetts, to expand services to global employee travelers and expatriates.

Who are the Patients?

It has been reported that there are more than 2.8 million American expatriates living and working abroad. In addition, ten million Americans travel internationally for business purposes and another 23 million Americans travel abroad for leisure trips each year. In a survey of international business travelers commissioned by WorldClinic and an independent agency in 2000, more than 80% of respondents expressed concern for their health and wellness when traveling abroad. Dr. Carlin states "among expatriates undertaking overseas assignment, the number one reason cited in terminating an assignment prematurely was concern over local medical care and personal health issues." This is an acute issue for older employees according to Carlin. "The number one cause of death for Americans overseas of all ages is motor vehicle accidents, but if you select out those older than 40, the number one cause of death by far is cardiovascular disease. Expatriates and overseas staff really suffer the loss of good primary care to identify risk factors like hypertension and cholesterol early."

The services of WorldClinic are designed primarily for these international business travelers as well as workers stationed at isolated worksites and company populations working abroad. The program also serves individuals and families, students, expeditions, tour groups, and those who travel frequently for pleasure.

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Worldwide Telemedical Consultation Services

WorldClinic also provides consultation services to physicians abroad and in the US with referrals to the available specialties at the Lahey Clinic. Dr. Carlin explains, "This was originally not a regular aspect of our care model, but grew out of a request for these services. There are many areas in the world that have a hospital but do not have access to specialists such as a pediatric cardiologist or neurologist." The WorldClinic web site provides an exclusive on-line consultation interface which collects information in a highly confidential, secure manner. Each patient is given a case number to use for all e-mail correspondence. Supporting data, such as EKGs, images, lab data, etc. can be sent by e-mail, fax, or regular mail. Rapid turn-around is the goal, but response time depends on the complexity of the case.

The model for care, Distance Care™, utilizes the latest communications technology to deliver, oversee, coordinate, and manage all aspects of patients’ care until their return home.

Core Traveler Service

• 24/7 immediate access via telecommunication to US doctors for attention on any medical concern arising during domestic or international travel
• Facilitated access to the highest-quality, locally-available physicians and facilities worldwide
• Quick access to over 300 subspecialist physicians at the Lahey Clinic
• Ongoing case oversight and coordination in an emergency
• Conversion of personal medical records into an electronic medical record for quick access when contacting WorldClinic
• WorldClinic wallet card with emergency contact information and summarized medical history, medications, allergies, and most current EKG
• Guaranty of payment for foreign hospitalization and emergency medical care
• Optional health and/or evacuation insurance

Comprehensive Traveler Service—includes benefits of the Core Traveler Service plus:

• Real time telecommunication diagnosis and guided treatment of medical problems by WorldClinic
• Custom-assembled personal prescription medical kit
• No-cost emergency medical evacuation from any location worldwide to the patient’s home hospital in the USA
• Payment of up to $50,000 for foreign hospitalization and emergency care with no deductibles or co-pays

Comprehensive Expatriate Service—includes benefits of the Comprehensive Traveler Service plus:

• Pre-travel consultation
• Family and individual pricing
• Custom prescription medical kit with augmented medical supplies for prolonged periods of assignment as well as age-appropriate pediatric meds for families with children
• Care for children of subscribing expatriates at no additional cost
• Assistance with finding primary care and specialist doctors for family members with pre-existing medical problems

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Providing Care Worldwide

The majority of WorldClinic patients are referred by their employer. When a company is in need of international healthcare services, Dr. Carlin usually meets with company representatives such as the medical officer or occupational health nurse and human resources representative to do an initial assessment. His concerns are centered on what countries will be visited, the ages of the travelers, and the length of the assignments. Based on the aggregate information, Dr. Carlin recommends the type of service that will create the greatest value for the company. For example, if the majority of the travelers are in their twenties, the Core Program is most likely to be the appropriate choice. Following this meeting, WorldClinic generates a custom proposal that incorporates final recommendations. Dr. Carlin states, "Currently about 55% of the patients have the Comprehensive Package. This is based on the fact that the majority of our executive travelers is over forty years old or is traveling frequently to less developed countries."

All patients enrolled in WorldClinic complete an extensive medical history including emergency and physician contact names and phone numbers, both in the USA and abroad. A separate signed release to request and transfer medical information is filled out and mailed in by the client. As many executives leave on short notice, the release may be faxed or completed on-line. Following review of the medical history, a physician from WorldClinic contacts the patient for clarification or preventive health recommendations as indicated. The patient is assigned a case number to use in communications and a medical passport that contains emergency contact information and medical information. This information is stored, along with pertinent data from prior medical records, in the electronic medical record maintained at WorldClinic. If the patient has signed up for a comprehensive package, a custom medication kit is prescribed and delivered to the patient along with the wallet card and a guarantee-of-payment letter.

The WorldClinic database includes information about locations and resources around the globe, such as hospitals, physicians, suggested immunizations, and any pertinent medical risks or cultural risks that may impact the health and safety of a traveler. The database is continually updated. When a patient contacts WorldClinic for care, an encounter form is opened and the patient’s electronic medical history is accessed. After discussion, medication may be prescribed from the medication kit, if one is available. When necessary, a prescription is faxed to a local pharmacy or the patient is referred to a nearby physician that has been screened for reliability and competence. If further care is recommended, the physician accesses the WorldClinic global hospital database and makes an appropriate referral. Dr. Carlin reports that 70% of follow-up contacts are conducted by e-mail and progress or resolution of the condition documented. Absolute confidentiality is maintained throughout the encounter.

Actual Cases

How does all of this translate into care for an overseas traveler? The care can vary from minor illness to emergency care. An engineering senior executive developed a sinus infection at the start of a five-country trip to Southeast Asia. He was provided with guided care and daily monitoring that allowed him to continue working, and he didn’t lose any time due to the illness.

Emergency care was required for a worker in West Africa who suffered second degree steam burns. His company wanted to fly him back to the United States for treatment, but knowing that air travel could endanger his life, the doctors at WorldClinic intervened and sent him to a pre-certified hospital in West Africa. A burn-treatment protocol was sent from the leading burn center in Ireland, his home country, to the designated local hospital. Two days later the man was flown to the burn center in Ireland, and the patient made a full recovery.

Emergency care was also required for an American businessman who awakened with severe chest pain at 2:00 AM in a hotel in Beijing. He called the doctors at WorldClinic, who started him on emergency medication from his personal medical kit and directed his transfer and hospitalization. Having prior knowledge of the area hospitals and the services they offered, the doctors were able to select an appropriate hospital where the patient underwent an emergency angioplasty by 4:30 AM. The procedure was successful.

Dr. Carlin received worldwide media coverage when he e-mailed a procedure to a lone Russian sailor aboard a yacht in a long-distance international yacht race. The sailor successfully opened and drained an abscess on his arm, using tools from his medical kit, and made a complete recovery.

Summary

When asked to describe Distance Medicine Dr. Carlin replied "We are similar to other medical practices, but for our patients we are really low tech and user friendly. There are ten physicians who cover the call center and much of the communication is by phone and email. We are there for our patients twenty-four hours a day, seven days a week and encourage them to contact us early with any concerns. We strive to get our patients to follow-up on any health prevention recommendations, particularly in regard to cardio-vascular disease."

For international travelers in need of medical care, either routine or urgent, access to Distance Medicine from WorldClinic goes a long way to reduce stress while on foreign soil.