Clinical Cases in Correctional Telemedicine. Elizabeth

Elizabeth A. Krupinski, PhDArizona Telemedicine Program

Reception center staff evaluates each inmate on substance abuse, education, mental health, and medical. Initial classification for placement in state institution conducted and finalized prior to movement.

Inmate may be held at reception center for > 10 days if inmate has special medical needs or other special circumstances such as pending extradition.

1 to 5 scoring system. Most important factors that determine final score & placement are public risk, institutional risk & medical needs.

Scores establish custody level & need for specific services such as medical, mental health, substance abuse or sex offense treatment, and program needs including education, vocation training & work skills.

Relocation based on bed availability in appropriate custody level & medical rating of inmate and facility.

Comprehensive medical, dental, & mental health services considered medically necessary.

Ongoing treatment by licensed professional (physicians, PAs, NPs) plus nurses, lab technicians, pharmacists, radiology techs. All phases dentistry including oral surg & restorative. Mental health assessment, crisis management, & therapy.

Emergencies facilitated through area hospitals. Specialty services provided through contracts with Board eligible or Board certified specialists in community by direct contact or video conferencing & telemedicine.

If inmate requests medical attention may submit written Health Needs Request (HNR) to Medical Unit. Request reviewed & inmate scheduled if necessary. If request urgent or life threatening, inmate seen immediately.

All medical information is considered privileged and highly confidential.

Health care recommended & provided at local facility level by local providers. If specialty services/consultation recommended, request forwarded to Health Services Central Office.

Only procedures/treatments considered absolutely medically necessary considered for approval. Cosmetic or elective in nature will not be approved. Final determination for any treatment plan decision of AZ DoC medical staff.

Charge up to $5.00 when scheduled after submitting HNR, or on emergency basis. Appointments requested by a health care provider there is no charge. Chronic serious medical conditions (diabetes or hypertension) followed on routine schedule without HNR & no charge.

Prescription medications supplied as necessary. Certain OTC medications (ibuprofen or multi-vitamins) available at inmate store.

Carondelet Health Network Southern AZ’s oldest & largest non-profit HC provider.

◦ Heart and Vascular◦ Neurology and Neurosurgery◦ Women’s Care Services◦ Orthopedics and Rehabilitation◦ Burn and Wound◦ American Diabetes Association Recognized Diabetes

Care Centers◦ Hospice and Palliative Care◦ Diagnostic and Surgical Services◦ Outpatient Services◦ Lifeline Emergency Response Helicopter Program◦ Contracted Services for Correctional Care◦ Long-term Care Facility in Nogales, Arizona

March 1998 ATP provided TM services◦ Continues to present (~ 120 consultations)

St. Mary’s started March 2000◦ Main referring site both IP & TM

SF = 649 RT = 12,847 Total = 13,496 Mental Health services not included (>

7000) Tandberg Healthcare System 3 codec 5000 Transitioning to Second Opinion

Type & # Type & # Type & #

Orthopedics = 2830 Neurology = 289 Plastic Surg = 47

Renal = 1868 Oral Surgery = 287 Nephrology = 32

GI = 1419 Internal Med = 231 Physical Therapy = 19

Urology = 1351 Dermatology = 183 Dental Surgery = 6

Cardiology = 1219 Pulmonology = 170 Oral = 5

Surgery = 1083 Hand Th/Surg = 155

Podiatry = 5

Hem/Onc = 1007 Rheumatology = 115

Cardiac Surgery = 3

ENT = 621 Infec Dis = 94 Speech Therapy = 3

Neurosurgery = 403

Vascular Surgery = 49

Thoracic Surgery = 2

Scenario #1 - Medical Center VisitScenario #1 - Medical Center VisitAverage cost per case

$849.90

Scenario #2 - Telemedicine VisitScenario #2 - Telemedicine VisitAverage cost per case

$467.25

Savings per caseSavings per case$382.65

US Department of Justice 2002 Implementing Telemedicine in

Correctional Facilities www.ncjrs.gov/pdffiles1/nij/190310.pdf

◦ Executive Summary◦ Introduction◦ Implementation Decision & Planning◦ Technology Evaluation◦ Cost Estimation Model◦ 8 Appendices with worksheets

Site/ Program Site/Program Site/Program

California Johns Hopkins (MD) Kentucky

Georgia Carolinas (NC) Louisiana State

Northwest TH (Wash.) UC Davis (CA) Iowa

NSW TH (Sydney) Mountaineer (WV) Western Australia

Virginia Commonwlth UTMB (TX) TX Tech

Maine Crozer (PA) University VA

Wisconsin ECU (NC) University AZ

SUNY Buffalo (NY) FFACTS (TX)

Specialty Specialty Specialty Specialty

Derm = 16 Ortho = 7 Oncol = 4 Burn = 2

Infec Dis = 14 Nephrol = 7 Wound = 3 Dental = 2

MH = 14 HH = 6 Renal = 3 Anesth = 2

Neuro = 12 Radiol = 6 Spch th = 3 Hand Surg = 1

Card = 10 Surg = 6 Pulm = 3 Forensic = 1

Peds = 8 Rheum = 6 Urol = 3 Audiol = 1

Gastro = 8 Pain = 5 Path = 2 ALS = 1

Int Med = 8 ObGyn = 5 Nutrit = 2 Post Surg = 1

ER = 7 Rehab = 5 Pub Hlth = 2 Plastic Surg = 1

Endoc = 7 Primary = 5 Anesth = 2 Pharm = 1

Ophthal = 7 ENT = 4 Podiatry = 2 Vasc Surg = 1

6% incarcerated women are pregnant Often at high risk (drugs, alcohol,

smoking) 1.4 Mbit T1 with 512 Kb video

capability Multi-disciplinary

◦ Generalist Ob/Gyn◦ Maternal-Fetal Medicine Specialist◦ Genetic Counselor◦ Sub-Specialists (radiology)◦ Labor & deliveryGordon Low “Pregnant & Incarcerated” ATA 2008

High patient & clinician satisfaction 41 pregnant patients served 224 patient visits 20 deliveries 56 triage calls 14 transport calls

Gordon Low “Pregnant & Incarcerated” ATA 2008

Video based consulting 2002 – 2005 668 DoC consultations

◦78% new 244 Community based consultations

◦59% new

Most common diagnoses both groups◦ Acne◦ Psoriasis◦ Dermatitis

Next most common non-TM services◦ Basal Cell Carcinoma◦ Actinic Keratoses

Only 0.4% for TM groups

 Prior Diagnosis

Change Diagnosis

Prior Treatment

Change Treatment

Corr 48% 20% 74% 83%

Comm 66% 7% 73% 67%

TM has clear & significant role in corrections Likely are programs without documented

descriptions or outcomes Numerous clinical specialties can be covered

◦ Clearly some more common than others Cost-benefit analyses generally show savings

◦ Mainly due to reduced transportation costs◦ Secondarily to reduced physician travel costs

Outcomes data are scarce but likely positive

THANK YOU!