The Florida Senate. Issue Brief September 2011 USE OF TELEMEDICINE IN INMATE HEALTH CARE. Statement of the Issue.

Transcription

1 Cmmittee n Criminal Justice Statement f the Issue The Flrida Senate Issue Brief September 2011 USE OF TELEMEDICINE IN INMATE HEALTH CARE The Department f Crrectins (department) is respnsible fr prviding health care services fr Flrida inmates. Crrectinal health care includes physical, dental, mental health, and pharmacy services. Health care staff at each majr institutin prvide primary health care services t inmates. Inmates wh require cnsultatins with medical specialists are transprted t cmmunity physicians fr treatment unless the department has cntracted fr the specialist t prvide services within the facility. In Fiscal Year , the department spent mre than $400 millin fr health services, almst duble the expenditure in Fiscal Year and an increase f nearly 3 percentage pints in the share f ttal department expenditures. This reflects bth rising medical csts and increasing inmate ppulatin thrughut the decade. Telemedicine has been used by sme crrectinal systems and large crpratins as a way t prvide medical services thrugh the use f cmmunicatins technlgy. Telemedicine has the ptential t save mney while preserving the quality f medical care. In the crrectinal cntext, telemedicine wuld eliminate the security risks and csts assciated with transprting inmates utside f the crrectinal facility. This issue brief will prvide an verview f telemedicine and assess the benefits and drawbacks f using it in prviding health care t Flrida inmates. Issues t be addressed include a descriptin f current uses f telemedicine in crrectinal and nn-crrectinal settings, the types f treatment fr which it is apprpriate and viable, the technlgical infrastructure needed t supprt a telemedicine system, and the ptential fr cst savings thrugh its use. Discussin The American Telemedicine Assciatin defines telemedicine as: the use f medical infrmatin exchanged frm ne site t anther via electrnic cmmunicatins t imprve patients health status. 1 Senate Bill 1882, intrduced by Senatr Garcia in the 2011 Legislative Sessin, included a mre detailed definitin f telemedicine as interactive audi, vide, r ther electrnic media used fr the purpse f diagnsis, cnsultatin, r treatment, including hme health vide cnferencing and remte patient mnitring. Three types f telemedicine are described belw: 1. Real-time interactin between a dctr and patient that is equivalent t a clinical visit when bth participants are in the same place. This is the frm f telemedicine that is mst cmmnly thught f and is the type fcused n in this discussin f crrectinal telemedicine. Telemedicine can be used fr live clinical cnsults in almst any medical field, but is used mst ften fr psychiatry and dermatlgy. This is because these specialties d nt require high definitin vide f patient mvements t be effective and thus can be used when high data transmissin speeds are nt available. 2. Stre-and-frward f patient data such as radilgy and labratry results. This simply means that clinical infrmatin is btained at ne site and upladed and stred n a remte server until dwnladed fr review by a specialist at anther lcatin. The Veteran s Health Administratin makes extensive use f stre-andfrward technlgy and has fund it t be particularly suited fr teledermatlgy, teleradilgy, and 1 American Telemedicine Assciatin, Telemedicine Defined, last viewed n September 1, at i4a/pages/index.dfm?pageid=3333.

2 Page 2 Use f Telemedicine in Inmate Health Care teleretinal imaging (analyzing the effects f diabetes n the retina). 2 crrectinal setting. This has clear applicatin in the 3. Remte mnitring f vital signs f patients. In a nn-prisn setting, this culd minimize the need fr a patient t travel t a dctr s ffice fr mnitring activities ranging frm simple bld pressure r bld glucse checks t ECG readings. Remte mnitring culd be used in assisting with mnitring the vital signs f inmates wh are inpatients in a prisn hspital, but they wuld nt be able t use testing instruments withut supervisin due t security cncerns and csts. Telemedicine in Rural Areas and the Natinal Bradband Plan Grwth f telemedicine services in the United States has been fcused n imprving the quality and availability f health care services in rural areas. Implementatin f telemedicine is ne aspect f prviding better health care t persns wh ften live far frm a majr hspital r medical specialists. The availability f remte cnsultatins between patients at rural hspitals r clinics and specialists can reduce travel time and lss f incme. Fr sme peple, the availability f specialty care near their hme may determine whether they will even seek care. One f the majr barriers t use f telemedicine in rural areas is the lack f ready and affrdable access t bradband services. 3 Mdern telemedicine delivery systems use the Internet fr transmissin f audi/vide signals and medical infrmatin. A key initiative f the Federal Cmmunicatin Cmmissin s Natinal Bradband Plan released in March 2010 is prmtin f the grwth f telemedicine (referred t as E-Care in the Plan) by expanding the availability f bradband service in rural areas. The Plan estimates that use f remte mnitring and electrnic health recrds culd create ver $700 billin in net savings ver the next 15 t 25 years. 4 Use f Telemedicine in Crrectins At least thirty-ne state crrectins departments use telemedicine fr sme facet f inmate health care. Flrida des nt, and is the nly ne f the ten largest state crrectinal systems in the United States that des nt use telemedicine in prviding health care t inmates. 5 Six f these large prisn systems partner with medical schls in their state fr telemedicine services. In Texas, the natin s largest state crrectinal system, inmate health care is prvided by the state s tw majr medical schls and telemedicine is used extensively in prviding services t remte lcatins. 6 The United States Supreme Curt has established that prisners have a cnstitutinal right t adequate medical care. The Curt determined that it is a vilatin f the Eighth Amendment prhibitin against cruel and unusual punishment fr the state t deny a prisner necessary medical care, r t display deliberate indifference t an inmate s serius medical needs. 7 Telemedicine is nt a separate medical specialty and des nt change what cnstitutes prper medical treatment and services. 8 It is a methd fr mre efficient and cst-effective delivery f medical services with quality cmparable t mre traditinal delivery methds. The Natinal Cmmissin n Crrectinal Health Care (NCCHC) adpted a psitive psitin tward telemedicine in The NCCHC s 2 VHA Office f Telehealth Services, Stre-and-Frward Telehealth, last viewed n August 25, 2011 at 3 Lack f bradband access affects crrectinal health care because crrectinal institutins are ften in rural areas. Tw ther barriers that d nt apply t crrectinal health care include restrictive Medicaid and Medicare rules regarding credentialing and insurers refusal t reimburse fr telemedicine services. Hwever, the Centers fr Medicare and Medicaid Services recently eased its credentialing rules, and there is grwing acceptance f telemedicine amng insurers. 4 Federal Cmmunicatins Cmmissin, Natinal Bradband Plan: Health Care Highlights, last viewed n August 25, 2011 at issues/healthcare.html. 5 Flrida is the third largest state crrectinal system with 102,319 inmates as f June 30, Case Study: A Texas Telemedicine Prgram Offers Lessns fr Gvernments and Care Delivery Organizatins Wrldwide, Gartner Grup (June 10, 2008), last viewed n August 29, 2011 at case_study_a_texas_telemedic_ pdf. 7 Estelle v. Gamble, 420 U.S. 97, 97 S.Ct. 285, 50 L.Ed.2d 251(1978). 8 Supra nte 1. Als see American Telemedicine Assciatin, Cre Standards fr Telemedicine Operatins (Nvember 2007), last viewed n September 1, 2011 at

3 Use f Telemedicine in Inmate Health Care Page 3 psitin statement ntes that telemedicine affrds the pprtunity fr reducing csts assciated with prviding health care, but that the basic principles gverning the physician/patient relatinship d nt change. 9 Althugh telemedicine can be used fr many different types f medical treatment, the specialties fr which telemedicine is mst cmmnly used in crrectinal health care are the same as thse in the free wrld: radilgy, dermatlgy, and psychiatry. In additin, telemedicine is particularly useful in the cntrl f infectius diseases. Benefits f Using Telemedicine in Crrectins: Benefits that have been identified as a result f using telemedicine in crrectinal health care include: Increased access t specialists and, ptentially, t mre experienced and qualified specialists. This has a clearly beneficial effect n the quality f health care fr the inmate. Eliminatin f the need t transprt the inmate utside f the crrectinal institutin. This has multiple sub-benefits, including: Cmpletely eliminating the security risk f transprting the inmate t a medical appintment. There is always the risk f an escape attempt when an inmate is being transprted r is in a nnsecure setting, and Flrida has had tragic examples f crrectinal fficers being injured and killed by inmates r their cnspiratrs. Saving n the actual csts f transprtatin and, mre significantly, the salaries f fficers wh wuld be required t accmpany the inmate. Apprximately 2000 inmates are transprted fr clinical visits (withut hspitalizatin) utside f Flrida crrectinal institutins every year. The medical directr f the Gergia crrectinal health system indicates that Gergia saves an average f $500 in fficer s salaries and transprtatin csts each time that an utside medical cnsultatin is avided. 10 Assuming that the cst per trip is similar fr Flrida and that 1000 utside trips fr medical treatment are avided each year by using telemedicine, the savings in transprtatin and salary culd be as much as $500,000 per year. Reducing the time between identifying a need fr cnsultatin and the appintment with the specialist. Withut telemedicine, an appintment fr a nn-acute cnditin may be delayed t crdinate the appintments f several inmates in rder t reduce transprtatin csts and fficer wrklad. Eliminating the extra discmfrt and reducing the recvery time f ill inmates that can be caused by travel r by waiting fr ther inmates t finish their appintments. This is nt nly beneficial t the inmate, but als may reduce inmate grievances. A ptential decrease in the time between indentifying a need fr cnsultatin and the appintment date frm the standpint f the specialist s schedule and availability. Apart frm the ptential benefits f treating the patient earlier, frm the dctr s perspective telemedicine can be beneficial because it allws either: Treatment f the inmate patient frm their ffice and avidance f travel t the crrectinal facility; r Avidance f having inmates in their clinic, which culd cause apprehensin fr ther patients r require treating the inmate patient after hurs. 9 Natinal Cmmissin n Crrectinal Health Care, Psitin Statement n Use f Telemedicine Technlgy in Crrectinal Facilities, last viewed n August 25, 2011 at 10 New Yrk Times, The Dctr Will See Yu Nw. Please Lg On. May 29, 2010, last viewed n August 26, 2011 at

4 Page 4 Use f Telemedicine in Inmate Health Care Cncerns with Using Telemedicine in Crrectins: The primary cncerns with the use f telemedicine center arund whether the data transfer speeds required fr audi/visual cnferences and recrds and imaging transfer are attainable at the lcatin; the csts f bradband access, necessary equipment, and any required infrastructure imprvements; and the quality f the clinical experience. As previusly nted, the lack f high-speed internet access is the mst significant barrier t use f telemedicine. Flrida s majr crrectinal institutins already have bradband access thrugh a T1 line. Hwever, nrmal prisn peratins use much f the bandwidth. The remaining bandwidth des nt appear t be adequate t supprt telemedicine, and may be needed in the future fr VOIP telephne systems. Acquisitin f additinal bandwidth wuld require running anther dedicated line t the facility at significant cst. Apart frm the infrastructure csts, the minimum acceptable bandwidth wuld require T1 service at a cst f apprximately $500 per mnth ($6000 per year) fr each supprted institutin. Therefre, the ttal annual cst fr bradband access fr telemedicine services t all 60 majr institutins wuld be apprximately $360,000 per year. The increasing capabilities f bradband cellular netwrks may eliminate the need fr additinal cable, but are unlikely t lwer mnthly access csts. Current 3G speeds can be adequate fr telemedicine applicatins, and the speeds attainable by 4G netwrks are mre than adequate. Hwever, mst prisns are in rural areas that already have pr cellular receptin and are well utside current 4G cverage areas. Each institutin wuld need dedicated audi/vide equipment and specialized medical instruments (such as electrnic stethscpes) t transmit infrmatin t the cnsulting physician. The middle range f cst fr equipment wuld be $30,000 - $45,000 per supprted institutin. 11 Althugh the utcmes f medical care using telemedicine are similar t utcmes using traditinal treatment methds, many physicians are ppsed t using telemedicine. 12 In mst cases, this is based upn cncern that they might miss subtle physical r emtinal signs that wuld cntribute t making a prper diagnsis. This cncern highlights the need t invest in high-quality equipment and t give careful cnsideratin t which types f services r specialties can be accmplished using telemedicine. The Rle f Telemedicine in Privatizatin The Legislature initiated tw majr prisn privatizatin effrts during the 2011 Legislative Sessin: privatizatin f 11 majr crrectinal institutins and their satellite facilities in the suthern part f the state and privatizatin f inmate health care services thrughut the state. The Requests fr Prpsals fr cmprehensive health care services included a requirement that the selected cntractr use telehealth 13 where services culd apprpriately be prvided and using telehealth results in imprving respnsiveness f care, reducing security csts, and imprving public safety. The stated gals f using telemedicine are t imprve inmate s access t primary health care services, imprve the quality and timeliness f primary, psychiatric, and specialty health services, and reduce the cst and disruptin f transprtatin Ibid. 12 New Yrk Times, Are Dctrs Ready fr Virtual Visits? January 7, 2010, last viewed n September 1, 2011 at 13 Telehealth generally refers t telemedicine and ther uses f telecmmunicatins, such as facilitating cntinuing educatin f health care persnnel. 14 All f the Requests fr Prpsal fr Cmprehensive Health Care, which were issued August 9, 2011, and subsequently cancelled, can be accessed at last viewed n August 29, 2011.

5 Use f Telemedicine in Inmate Health Care Page 5 Cnclusin Telemedicine has a grwing rle in mdern medical practice. In terms f its use in Flrida prisns, annual savings in transprtatin csts and fficers salaries that can be avided thrugh the use f telemedicine may exceed the csts f cmmunicatins access. Hwever, it appears that implementatin f telemedicine in all majr crrectinal institutins wuld currently require a significant investment in infrastructure and equipment. The need fr investment in infrastructure may be significantly reduced in the near future due t imprvements in wireless bradband technlgy and cverage. In the shrt term, an alternative t adding telemedicine capability in all majr institutins may be t prvide it in selected institutins that have a high vlume f utside medical transprts.