No one goes on a cruise with the intention of falling ill, but bad things happen even to fun-seeking people.

Since the average age of a cruise ship passenger is 46, and an estimated 14.3 million people—the populations of the Los Angeles and Milwaukee metro areas combined—sauntered up the gang planks of 220 North American cruise ships last year, based on cruise industry data, sick passengers are a mathematical certainty.

And when cruise ship passengers become ill, healthcare information technology is beginning to emerge in the cruise ship industry as part of the arsenal of care.

Sickness aboard ship occasionally makes the headlines, particularly when there is an infectious-disease outbreak. In 2010, according to the Centers for Disease Control and Prevention, more than 2,600 passengers and 230 crew members were stricken with gastrointestinal disorders in 14 cruise ship incidents severe enough to require reporting under U.S. law. But these serious bouts of the bug are an aberration.

What are far more common are the gamut of injuries and illnesses one would expect from such a sizable population of travelers, says Dr. Carter Hill, an emergency physician and a 22-year veteran of the cruise ship business who serves as chief medical officer of the Seattle-based Holland America cruise line.

Hill says Holland America has 15 ships sailing 51 weeks a year on about 450 voyages a year and combined, its medical facilities “probably have 100,000 visits a year.”

Holland America is one of the 11 cruise ship companies owned by Carnival Corp. and Carnival PLC, based in Miami and Southampton, U.K., respectively. Taken together, the Carnival companies, the largest cruise operation in the world, own 96 ships.

Shipboard medical facilities are called infirmaries or clinics, Hill says, but they look very much like a hospital emergency room. And sometimes, there is just as much medical drama on board as there is in a land-based ER.

“We have ICU beds,” Hill says. “We have capabilities to do all of the cardiac enzymes and tests you need in heart conditions. But it's still not home.” When you're in the ocean between Hawaii and San Diego, moving at 20 to 22 knots, or upwards of 25 mph, it takes 4½ to 5 days to reach port, but not nearly that long to get outside of helicopter range, according to Hill.

“We've had a situation where we're a day and a half out of Hawaii (and) somebody cuts loose with massive GI bleeding,” Hill says. “We can transfuse their blood (several crew members are designated universal donors, but the ship doesn't carry its own blood bank). We get a call saying we have this massive bleeding, here's the clinical situation. We can speed it up, or we can turn around and go back to Hawaii and they can meet us with a helicopter in maybe a day.”

Just such a turnaround will make the ship at least two and sometimes three days late reaching the West Coast, and the delay will cost the line “maybe between $2 million or $3 million” in hotel accommodations and other make-good payments to passengers, Hill says. “But, if that's what you do, that's what you do. That really happens.”

According to Hill, who still pulls midnight shifts in the ER at 160-bed Highline Medical Center in Burien, Wash., a Seattle suburb, emergency physicians are the doctors of choice to staff shipboard clinics and infirmaries, because even in the age of jet travel and rescue helicopters, the world remains a very large place when you're sick and aboard a ship far out at sea.

“I'm still working full time in emergency medicine and those are the docs that we hire,” Hill says. “The skills of the people we have are quite good. They know how to do the routine procedures they used to do in emergency rooms.”

Improved telehealth communications between shipboard healthcare providers and specialists as well as information service providers “have dramatically changed the practice,” Hill says. “We used to just send people out there,” he says. If there was a serious illness or injury, “we would just get a message through to them and tell them, ‘Do the best you can.' ”

“Now, we can help them, because there is access to good communication,” he says. “I would not consider it high-speed Internet connectivity like we are used to” on land. “But it's still pretty good. All of our X-rays are done digitally, and we send those to the University of Texas and in 24 hours get overreads. They read all the X-rays for us. We get specialty consults with those folks as well. If you have a skin rash, I can get a jpeg and get a consult and practice pretty good medicine. But we can't get them to operate, we can't get CAT scans, but still, having access to that sort of information is still extremely helpful.”

Shipboard physicians also have access to mobile healthcare applications such as Epocrates and UpToDate that provide prescription drug, diagnostic, case management and therapy information.

And while his ships don't yet have electronic health-record systems, across Carnival “there is a commitment to do it, brandwide,” Hill says.

Dr. Anne Burdick is a professor of dermatology and associate dean of telehealth and clinical outreach at the University of Miami Miller School of Medicine, which recently contracted with Miami-based Royal Caribbean Cruises and its affiliates to provide telehealth services to its 20,000 employees on 33 ships around the world. The scarcity of practitioners in dermatology, and not specific medical conditions inherent to the cruise ship environment, is what prompted the company to contract for her services, Burdick says.

Under the program, the cruise line has armed each of its shipboard infirmaries with $300 off-the-shelf digital cameras and the dermatology version of MedWeb, a Web-based clinical documentation system, with some modifications Burdick specified to its documentation templates. She oversaw training on appropriate use of the camera, the Web-based system, and a clinical “refresher” on dermatology, either in person when the medical crew was in port, or via an online lecture Burdick gave and had posted on the university's website.

The requests by shipboard clinicians for evaluation of a photograph are triaged and tagged when entered into the system as either routine or urgent. Burdick says the protocol is to read and return routine consults within 72 hours, and urgent cases within 24, but most often, the turnaround time is a lot quicker than that, she says.

“I check them in the queue, I see urgent, and I'm on it right away, even if I'm in the middle of seeing a patient,” she says. A clinical telehealth coordinator aids in monitoring and managing Web traffic. Director of Telehealth Dr. Scott Simmons rounds out the program.

Burdick says she averages about 10 consults a week from the cruise line. Cases have ranged from common dermatological problems such as acne and eczema to far more serious cases with more weighty circumstances.

Burdick recalls one consult to back up the onboard clinic's decision to medically evacuate a cellulitis patient—at considerable expense to the cruise line. “I received multiple images and a detailed history from the ship doctor,” Burdick said. “The consideration was a medical evacuation, and do you agree? They were in an area in the Mediterranean Ocean that was a day out of port. Yes, I confirmed the need for evacuation and yes, it did occur.”

One of the treatment rooms aboard the cruise ship Crystal Symphony. The ship’s EHR went live in April. Photo credit: Charlie Kesinger

Perhaps the earliest EHR vendor to recognize the market opportunity in the cruise ship industry is Arlington, Texas-based Emergisoft, a 21-year-old developer of clinical documentations systems for ERs. Two years ago, the company began meeting with members of the marine division of the American College of Emergency Physicians, with the aim of designing from scratch an EHR system tailored to the industry's needs, according to Charlie Kesinger, the company's chief operating officer. In December, it announced its first deal with a cruise line, the two-ship, Los Angeles-based Crystal Cruises.

Kesinger says their developers sat down with Crystal and representatives from some other lines that he declined to name “and mapped out their workflow and developed a maritime-specific information product.”

Kesinger says he was aboard the Crystal Symphony for the April 18 go-live on a cruise from Victoria, British Columbia, to Los Angeles.

“I personally was the one who did the install,” he says. Later this month, the line's second ship, Serenity, is scheduled for its EHR installation while it's in Germany, he says.

“The real power of our system is in the analytics. Now that we are associating the diagnosis or the stated complaint through specifics of point-and-click, it allows a finite way of putting the data in.” The system helps the medical staff prepare reports as mandated by law, including the GI reports for the CDC and a new set of records required under the 2010 Cruise Vessel Security and Safety Act legislation sponsored by Rep. Doris Matsui (D-Calif.) and Sen. John Kerry (D-Mass.).

But Emergisoft soon could have more competition in the shipboard EHR market, according to Kimberly Alise, executive director of Pro-Med Clinical Systems, Plantation, Fla., which has been offering EHRs for ERs since 1993.

“This is something we're definitely interested in pursuing,” Alise says. The needs of shipboard clinicians who provide care for transient passengers as well as crew members, who might remain with a ship for as much as six months at a time, creates a challenge for software developers, according to Alise. “Plus, these infirmaries “are tiny, tiny, tiny,” noting that there's little room for a lot of IT hardware.

“It's a bit of a different model” than a standard hospital ER implementation, she says. “We just brought our Web-based product to market this month. It's something we're definitely going to be looking at.”