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Telemedicine Behind Bars

The National Commission on Correctional Health Care (NCCHC), which provides accreditation for medical services in prisons, jails and other correctional facilities, held its national conference in Nashville, Tennessee from October 28 to 30, 2013.

PLN managing editor Alex Friedmann attended the conference and sat in on several presentations that addressed the issue of telemedicine in the correctional setting. Telemedicine involves medical consultations over a remote connection, typically with a patient speaking with a physician or other medical practitioner on a video screen.

The first NCCHC conference session on telemedicine was conducted by Lawrence Mendel, a physician and acting medical director at the Leavenworth Detention Center, a facility operated by Corrections Corporation of America.

According to Mendel, the first prison telemedicine program began in 1978 at the South Florida Reception Center in conjunction with Jackson Memorial Hospital. The use of telemedicine expanded during the 1990s and it is now used in a variety of settings to provide long-distance medical evaluations and diagnoses.

One advantage of telemedicine in prisons and jails, according to Dr. Mendel, is the ability to provide specialty medical services at facilities located in rural areas where specialists may not be available locally. Additionally, telemedicine can result in a reduction in scheduling delays since medical practitioners don’t have to travel to distant facilities to see prisoner-patients.

And, of course, telemedicine can cut costs – particularly staff-related expenses (including overtime) incurred when prisoners are transported to medical appointments. Further, it can provide an alternative to local providers who order expensive tests and treatment for prisoners. Telemedicine thus “has the potential to become cost effective with relatively little use,” Mendel stated, and is the “only security measure that can pay for itself.”

Based on transportation costs alone, he estimated that around 16 telemedicine sessions per month result in break-even costs. The cost of telemedicine equipment has dropped over time and is currently around $6,600 per video conferencing unit.

Mendel also noted that most prisoners prefer telemedicine, as it means they don’t have to endure being shackled and transported to off-site medical appointments.

Friedmann posed the following questions: “The vast majority of medical consults outside the prison setting are face to face, in-person examinations. If that is the community standard of care, to what extent does telemedicine applied specifically to prisoners represent a deviation from the standard of care? Also, if the emphasis on telemedicine is to cut costs and ensure the system pays for itself, does that emphasis on cost cutting come at the expense of quality of care?”

Mendel responded that since prisoners can refuse telemedicine visits there is no difference in the standard of care; i.e., they can demand in-person medical examinations and consultations. With respect to cost savings, he said “no one does telemedicine to save money” but rather to solve a problem – despite the repeated references to reducing costs during his presentation.

The second NCCHC conference session on telemedicine was presented by Dr. Rebekah Haggard, employed with Corizon, a for-profit prison medical company, who spoke on the topic of leveraging telemedicine to achieve the “Triple Aim.” The Triple Aim is a framework developed by the Institute for Healthcare Improvement that describes an approach to optimizing health system performance which emphasizes 1) better care, 2) better health and 3) better affordability – that is, lower costs.

Haggard noted that most medical mistakes are due to diagnostic errors and said telemedicine can reduce such errors by forcing the practitioner to focus on the patient’s complaints, since the primary interaction – via video – is with the patient. “Listen to the patient,” she said. “They will tell you their diagnosis.”

She argued that telemedicine minimizes cognitive bias and mistakes in diagnoses. Also, practitioners have more time to spend with patients through telemedicine, as they don’t have to factor in travel time to correctional facilities.

In 2012, Corizon conducted more than 20,000 audio-visual medical visits at 150 sites in over 20 states; those visits included consultations and examinations for both medical and mental health care.

Like Mendel, Dr. Haggard repeatedly cited the cost savings that can be achieved through telemedicine. In one state prison system (which she declined to identify when asked), she referenced $2.9 million in reduced staffing costs and overtime by using telemedicine.

Haggard also said there were improved outcomes in terms of cancer death rates and HIV treatment through telemedicine, but did not cite any sources. She acknowledged that prisoners may refuse telemedicine visits – though it was unclear whether prisoners are informed they have the option to decline.

Friedmann asked if she would advocate telemedicine even if the cost was equal to or greater than traditional, in-person medical visits. She said she would, as she felt that telemedicine provided better patient care.

Neither Dr. Haggard nor Dr. Mendel indicated whether they or their families use telemedicine rather than in-person visits for their own medical care.

Sources: NCCHC conference sessions, www.ihi.org