Important note: Information in this article was accurate in May 2000. The state of the art may have changed since the publication date. | The online version of HEPP News displays the main article only, to view the entire newsletter download the following PDF:
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Telemedicine was introduced in the U.S. in the late 1950s when the Bureau of Indian Affairs used telephone and video programs to train paramedics who resided on indian reservations 1. Despite technological advances that have greatly expanded the potential applications of telecommunication, telemedicine has developed slowly in the U.S. where issues such as physician acceptance, federal regulation of Medicare/Medicaid reimbursement, other third party reimbursement, and state regulation of medical licensure have impeded widespread adoption 2. Two recent reviews of the use of telemedicine in the U.S. suggest that only 50 - 80 telemedicine programs conduct interactive consultation 1, 2. Radiology, Cardiology, Dermatology, and Psychiatry are the specialties that have used telemedicine most extensively 2.
Telemedicine has been incorporated into various correctional healthcare systems and appears to meet with physician and patient satisfaction and to reduce costs that are associated with travel and security for inmate healthcare. Although a comprehensive review of the literature is beyond the scope of this article, selected published information regarding the use of telemedicine in prisons has been reviewed and summarized. In addition, this article will highlight the development of a telemedicine clinic for HIV care in the Texas Department of Criminal Justice.
The experience of seven correctional jurisdictions' use of telemedicine for inmate healthcare has been reported. Most of these reports describe a pilot or feasibility study in which telemedicine was incorporated into the existing correctional healthcare system. Since primary medical care is provided at the correctional unit, telemedicine has been used for specialty or subspecialty consultation. In most cases, telemedicine has replaced specialty/subspecialty care that had been provided at a distant location, most commonly at a university medical center. None of the reports compare specific health outcomes of care delivered in a traditional clinic visit versus care delivered via telemedicine. In general, patients and prov-iders have been satisfied with their respective telemedicine experiences. According to the reports, six out of seven systems indicated that reductions in travel and security for inmate healthcare costs have had a positive financial impact. See Heppigram on page 6 for details of each correctional jurisdiction's experience with telemedicine.
In 1997 there were approximately 2,000 identified HIV+ inmates in the TDCJ. Most were housed in the eastern sector of the state. University of Texas Medical Branch Galveston has a managed healthcare contract to provide both primary and specialty care to inmates who are housed in the eastern sector of the state. This area covers 134,000 square miles (approximately half the area of the state) and contains 69 correctional facilities. Prior to the introduction of telemedicine for HIV healthcare, inmates traveled to UTMB Galveston for HIV clinic which is conducted one day per week in the TDCJ Inpatient/Outpatient Hospital located on the UTMB campus. Because of the distances involved, inmate travel can take up to a week each way and involves nightly stays at several transfer units along the way. Like the other systems that delivered specialty care at a central location, the cost of transportation and associated security for healthcare-related travel was enormous.
Since time and space in the Galveston Inpatient/Outpatient Prison Hospital facility are limited, only one day per week could be assigned for HIV care. An average of 100 inmates were seen weekly, and due to a limited number of medical providers, the clinic day often stretched to 10 - 12 hours, which incurred additional operation costs for overtime for clinic staff and ancillary healthcare providers. By the end of the day, morale among providers, support staff, and patients was low.
Inmates also had valid concerns related to their healthcare. When they are away from their unit of assignment overnight, they risk losing their cell or dormitory bed. Their possessions (which are often numerous for those with long sentences) have to be turned over to security for safekeeping during their absence, nonetheless; many inmates report that possessions are lost on their return. While provisions have been made to stock transfer units with all antiretroviral medications, the truth is that doses of medications are often missed during stays at transfer units. For all of these reasons, some inmates refused to travel for HIV-related healthcare or refused to return to clinic as frequently as the providers felt was necessary.
UTMB Correctional Managed Care made a commitment in the early 1990s to develop telemedicine for correctional healthcare. A large telecommunication network that links 12 remote sites with the primary site for specialty healthcare in Galveston was installed. The 12 remote sites are hubs that are in proximity to surrounding correctional units so that telemedicine may still involve inmate travel, but travel back and forth to each of the hubs takes less than a day altogether. In 1997, subspecialty services were mandated to develop telemedicine clinics.
During planning for the HIV telemedicine clinic, the following provider issues were raised:
The patient-provider issue had to wait until telemedicine encounters commenced for resolution. In regard to the other issues, it was determined that confidentiality remained the responsibility of healthcare providers and ancillary support staff used to conduct telemedicine [for a review of telehealth confidentiality issues, see Stone, 1999] 12. UTMB Managed Care also recognized that not all health issues could be addressed using telemedicine, so there was no issue with precertification for onsite visits following a telemedicine encounter that was deemed inadequate for effective healthcare.
One system issue related to unit level laboratory capabilities also had to be addressed. At most TDCJ correctional units, blood specimens for laboratory tests are collected and processed at the units and then transported by an established courier system to UTMB Galveston where the tests are performed. Prior to 1997, inmates had to travel to Galveston for viral load testing since laboratory personnel were not trained to process viral load specimens and courier vans did not have the equipment to properly store specimens during transport to Galveston. This was addressed by training unit level laboratory personnel to process viral load specimens and by purchasing temperature controlled transport units for the courier vans.
Tasks necessary to conduct telemedicine clinics efficiently were identified and assigned to specialists and to unit providers. HIV specialists designed data collection forms that would capture all of the clinical and laboratory data necessary to make HIV-related medical decisions. Unit providers would collect available data prior to the telemedicine encounter and fax this information to the Galveston site prior to the encounter. Galveston HIV specialists were responsible for initiating and changing antiretroviral therapy and were available for telephone consultation as necessary by the unit providers. Unit providers were responsible for monitoring ongoing antiretroviral therapy for adherence, toxicity, and efficacy and to make indicated interventions to improve adherence or treat side effects. Since unit providers were being asked to actively participate in HIV care, a three-day "HIV Minifellowship for Correctional Care Providers" was developed and is conducted two to three times per year. Course faculty are the UTMB HIV specialists who take advantage of the opportunity to establish a professional working relationship as well as to provide education.
HIV telemedicine clinics are conducted once per week and are staffed at the primary site in Galveston by a physician, physician assistant, two clerical staff, a clinical pharmacist to help review compliance and other drug-related issues, and a research nurse who may verbally screen appropriate patients for participation in clinical trials. The remote site is staffed by the presenter (usually an R.N.) with appropriate clerical and security support. Equipment at both sites includes video and sound equipment, a FAX machine, and computers which are used to access electronic data that both systems share (primarily laboratory data and healthcare appointment data). Completed medical data forms are faxed from the remote site to Galveston prior to the encounter. The patient encounter occurs, and the specialist writes a clinic note with recommendations which is faxed to the remote site for inclusion in the medical record. Follow up appointments are requested at intervals deemed appropriate by the HIV Specialist.
Experience has shown that patient-provider relationships can be established and maintained with telemedicine. My personal observation is that close-up video shots of both the patient and the provider are effective in creating a sense of intimacy that is lacking when long shots are used. The use of auxiliary cameras, for example a document camera, can be used to present visual educational information such as pill charts and viral replication cycles. This information can then be faxed to the inmate. Formal provider and patient satisfaction surveys have not been completed, but the two physicians and one physician assistant who conduct telemedicine clinic feel it is effective in treating HIV and more efficient from a time standpoint than specialty care delivered onsite at Galveston.
The first year of the Texas telemedicine experience was reported and reviewed above 11. Cost savings due to a reduction in travel and security for inmate healthcare were directly related to the total number of telemedicine encounters. Comparison of specific medical outcomes (i.e. number of patients achieving nondetectable viral loads) between telemedicine and onsite HIV care have not been conducted, but the telemedicine providers who also staff onsite HIV clinic have not noted major differences in progress between the two populations. In 1995, the number of deaths in HIV-positive inmates peaked and then began to decline in parallel with national trends in HIV-related deaths. This trend has been attributed to combination chemotherapy with protease inhibitors and/or efavirenz. This trend has continued through 1999, therefore; the introduction of telemedicine did not affect this gross measure of overall HIV care.
In 1999, a "teleconsult" clinic for HIV care was established. In this clinic, unit providers perform patient encounters and collect clinical and laboratory data that is necessary for medical decision making on forms that were designed by the HIV specialists. This information is faxed to the specialist prior to teleconsult clinic. During the clinic, the specialist and the unit provider use telecommunication equipment to develop a plan for HIV care. Both providers have the patient's medical chart for review of information that is pertinent, but not easily summarized on data collection forms. This method of healthcare delivery works best when unit providers are highly motivated to participate and have attended the "HIV Minifellowship for Correctional Healthcare Providers" so that minimal baseline HIV knowledge has been established.
A potentially promising expansion of telemedicine in correctional settings would be to use it for discharge planning and linkage to community-based services. For example, telemedicine could be used for inmates to "meet" and establish rapport with community-based providers prior to being released, thereby increasing the likelihood that releasees would actually obtain needed services in the community.
At the TDCJ, telemedicine allowed a notable reduction in overall healthcare costs. Since its establishment last year, the Teleconsult Health Clinic at TDCJ appears to be delivering effective HIV healthcare. Anecdotally, providers and patients seem to be satisfied with telemedicine encounters and medical outcomes between the clinics appear to be similar.
*Speaker's Bureau: Roche Pharmaceuticals
1. F Buckner, M.D., J.D., F.A.C.O.G., F.C.L.M., " Telemedicine: The State of the Art and Current Issues." Journal of Medical Practice Management, 1998 Nov-Dec;14(3):145-9
2. J Grigsby, PhD., and JH Sanders, M.D., "Telemedicine: Where It Is and Where It's Going." Annals of Internal Medicine 1998 Jul 15;129(2):123-7
**References 3-12 will only be found in the PDF version of this issue. Please click 
here to view PDF version and associated references. Scroll to Page 6 to view Heppigram.
3. E Rosen," Managing Anger and Disease Behind Bars", Telemedicine Today, 1999 Aug;7(4):12-3, 36.
4. G Hastings, M.D., M.Ed., Primary Nurse Practitioners and Telemedicine in Prison Care: An Evaluation, in: Zoog S, Yarnall S, ed. The changing health care team. Seattle, MCSA, 1976, pp. 54-9.
5. LN Adams and RK Grigsby, DSW, The Georgia State Telemedicine Program: Initiation, Design, and Plans, Medical College of Georgia Telemedicine Center, Augusta, GA.
6. CM Phillips, M.D., R Murphy, M.S., WA Burke, M.D., VB Laing, M.D., BE.Jones, M.D., D Balch, and S Gustke, M.D., "Dermatology Teleconsultations to Central Prison: Experience at East Carolina University." Telemedicine Journal 1996 Summer;2(2):139-43
7. LH Zincone, Jr., B.A., Ph.D., E Doty, B.A., M.B.A., Ph.D., and DC Balch, B.A., M.A., "Financial Analysis of Telemedicine in a Prison System", Telemedicine Journal, 1997 Winter;3(4):247-55.
8. J Mekhjian, M.D., J Warisse, M.A., M Gailiun, M.A., M.S.W., and T McCain, Ph.D., "An Ohio Telemedicine System for Prison Inmates: A Case Report". Telemedicine Journal 1996 Spring;2(1):17-24.
9. H Mekhjian, JW Turner, m Gailiun and TA McCain, "Patient Satisfaction with Telemedicine in a Prison Environment." Journal of Telemedicine and Telecare, 1999;5(1):55-61.
10. MJ McCue, D.B.A., PE Mazmanian, Ph.D., C Hampton, M.M.S., TK Marks, R.N., B.A., E Fisher, M.D., F Parpart, R.N., M.S., and RS Krick, M.S. "The Case of Powhatan Correctional Center/Virginia Department of Corrections and Virginia Commonwealth University/Medical College of Virginia." Telemedicine Journal, 1997 Spring;3(1):11-7.
11. RM Brecht, Ph.D., CL Gray, M.P.H., C Peterson, and B Youngblood, "The University of Texas Medical Branch-Texas Department of Criminal Justice Telemedicine Project: Findings from the First Year of Operation." Telemedicine Journal 1996 Spring;2(1):25-35.
12. TH Stone, JD, LLM, "Patient Health Information Confidentiality in Telehealth Applications", Journal of Healthcare Information Management, 1999 Winter;13(4):79-88.
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©1997,1998,1999,2000. The recently formed HIV Education Prison Project (HEPP) is a medical education program that targets a growing population, inmates in correctional facilities, that has been underserved in HIV care. It is part of the Brown University AIDS Program. Permission to use and reproduce portions of this newsletter is hereby granted provided that author and publication are fully credited and both copyright and permission notice appear with reprinted material. Inquiries may be directed to heppnews@brown.edu. Website: HIV Education Prison Project.
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