Making Correctional Health Care Smarter.

Invariably, during every critical event within an organization, there comes a time when information that will solve or alleviate the situation is unknown to the people who need to make the decisions. Making health care organizations smarter is a challenge to be met by a computerized patient record (CPR). The introduction of this technology into correctional health care systems will enhance knowledge available to leaders and decision-makers.

Knowledge becomes an asset when information is put into a coherent format, such as a meeting agenda or process description. When information is captured in a way that allows it to be described, shared and exploited, and when it can be used to do something that could not be done prior to its collection, it becomes knowledge.

Packaging information into a useful format and placing it within a CPR of a care delivery organization enhances knowledge. During the past 20 years, health care has struggled with the development and advancement of CPRs and electronic medication administration records (EMAR).

Nearly every major industry relies on a system that monitors, measures and reduces the error rate of its products and services. Automobile companies, toy manufacturers and airlines are just a few of the industries that employ effective technology solutions to ensure the best and safest products and services. Yet, health care, an industry in which lives are at stake at all times, has no system of detecting and reducing defect rates in care. Consider this:

* Between 44,000 and 98,000 patients die each year in U.S. hospitals as a result of medical errors (Kohn, Corrigan and Donaldson, 2000).

* Preventable medication errors occur in 7.3 percent of hospital admissions (Bates, Boyle, Vliet, et al., 1995).

* The average cost of an inpatient adverse drug event ranges from $1,900 to $5,900 (Raschke, Gollihare, Wunderlick, et al., 1998).

Patient safety improvement is a critical initiative spreading throughout the health care industry. Numerous adverse events may occur in health care; many are hidden or unpredictable. However, many more are caused by human error not because of flawed people, but flawed processes. As the Institute of Medicine and other sources report, threats to patient safety come in many forms. The most noted is the preventable adverse drug event (ADE). But other errors can be just as injurious, such as missed medications or appointments, and wrongly identified patients.

The issue is not who to blame, rather, it is that most patient safety issues could be avoided if only better designed, technology-enabled processes were in place. When processes facilitate information and communication, streamline operations and supplement human expertise with decision support capabilities, medical errors decrease and patient outcomes improve.

Los Angeles County Sheriff's Department

Correctional health care facilities are facing significant new challenges. With an inmate population that is ever-changing, tracking medical records, administering medication and scheduling clinic visits can be difficult and time-consuming. Those difficulties are only multiplied when using a nonautomated record-keeping system.

The Los Angeles County Sheriff's Department (LASD) jail system is among the world's largest correctional facilities and with an average of 20,000 daily sentenced and pretrial inmates, it is the largest system in the United States, according to the National Institute of Corrections. Prior to the automation of its system, the work processes had been almost exclusively manual. The functions being automated include laboratory, pharmacy, radiology, care documentation, care pathways, scheduling, automated orders, medical records and materials management.

LASD has an annual inmate population of more than 165,000 inmates per year, with approximately 8,000 requiring daily medical care. On average, the Los Angeles system has about 500 inmates with AIDS and more than 3,000 with mental health conditions. Nine, facilities located in urban and rural settings in Los Angeles County provide medical care in various services with more than 50 administration areas. More than 100 prescribers and 400 nurses provide care. More than 150,000 medical charts are filed annually and more than 4,600 charts are created monthly. Requests for charts from providers and courts average 9,500 per month and that number is growing.

The strategic objectives set by LASD for the correctional facility include:

* Maximizing the efficiency of staff time associated with delivery of medical care;

* Providing full electronic access to inmate medical records from any facility;

* Receiving reimbursement for all eligible medical care, such as HIV and mental health medications;

* Integrating documents received from outside facilities and ancillary services with electronic medical records;

* Providing timely delivery medication to all inmates, regardless of transfers or location within a facility; and

* Providing a level of inmate care that is consistent with community standards.

JHIS Goals

The LASD Medical Bureau is implementing a computer-based health care system throughout the 20,000-bed Los Angeles County Jail (LACJ). The project began in 1998 and will continue through the end of this year. The Jail Health Information System (JHIS) will allow doctors, nurses and clinicians to perform patient care tasks, such as ordering clinical tests, reviewing patient results and documenting patient care via computer, streamlining many processes and eventually eliminating paper. The system's goals are to:

* Improve efficiency for the clinical and operational activities in the medical services bureau;

* Integrate with the computerized booking system, adding an electronic record with the inmate tracking system;

* Include and automate documents from outside facilities;

* Improve quality of care for all inmates and enhance clinical decisions with more complete information; and

* Streamline manual processes.

Ultimately, most care information will be maintained and managed in JHIS. Regardless of an inmate's location and when he or she was incarcerated, critical patient information will be available online through JHIS. Better, informed care decisions can be made because test results are available more quickly online. Patient care plans for many typical disease states are automated and can be managed more effectively. Redundant activities will be eliminated and the new system provides quicker and better information to the courts.

JHIS Benefits

In 1998, LASD and Cerner Corp. partnered to install a clinical information system within the department's medical and mental health facilities. This comprehensive JHIS project is one of the first in the country of this scope and magnitude. Benefits received by the LASD Medical Services Bureau from the installed Clinical Information System (CIS) include:

* Direct standard order entry and clinical documentation by a broad multidisciplinary user group, including physicians, nurses, dietitians, lab technicians, radiologists and pharmacists. The pharmacy ordering systems will process orders and provide drug interaction checks. Today, more than 500 concurrent users access the system.

* Improved clinical documentation through the automation of clinical forms, consents and pathways. The forms and consents capture approximately 90 percent of required patient information.

* Improved tracking of tests in progress and the automated printing of specimen collection labels from JHIS.

* Improved order placement efficiency, decreasing the amount of time it takes for nursing staff to place and confirm orders; decreasing the amount of time for lab and radiology personnel to answer calls and search for results. The combined reduction in time is more than 90 percent.

* Capturing discrete data-in the JHIS repository, the system will provide users with immediate access to better inmate health information and future population data and outcomes analyses, which will aid the sheriff's quality management team in its inmate population and services analyses.

* Reduction in filing and results reporting time improved lab and radiology departmental capacity for performing procedures by an average of 15 percent.

* Timely project management decisions based on issue definition and resolution work across functional areas. Integration and resolution of issues involving both process and technical aspects, such as equipment-readiness.

* Development of new process model maps showing operational changes as a process inventory and user training for those process-related changes.

* The system deployment has engaged the Medical Services Bureau and Mental Health Department staff in cross-functional dialogue resulting in improved processes and task standardization.

Clinical information systems (CIS) have evolved from nursing documentation and orders/results applications to sophisticated, multidisciplinary information systems used throughout the medical field. A CPR system requires a complex, comprehensive and robust set of health care-related applications and contains electronically maintained information about an individual's health status and focuses on tasks directly related to patient care. It must react to a wide range of other health care information systems to provide optimum support for the practice of health care. A CPR environment contains feeder and support systems covering clinical, financial and managed care functionality. Seamless integration of disparate and decentralized information systems is a goal for all care providers.

The most important attribute of seamless integration the enterprisewide integration of multiple clinical, financial and administrative applications, while maintaining patient privacy. This only is possible if the provider offers all applications on the same technology platform. If not, the applications are merely interfaced. If integrated, the applications may seamlessly share information throughout the care delivery organization (CDO). Display screen menus, system prompts and report formats are consistent across all applications for ease of use.

Once full access is achieved, the CDO can manage the quality as well as the cost of care delivery. The information forms a CPR and is stored in a clinical data repository (CDR). The system can provide clinical alerts, missed medication or clinic notification and clinical documentation to assist medical personnel at the point of care. Captured data may be used to identify clinical trends and help alleviate waste.

HIPAA: A Correctional Perspective

Discussion of the potential impact of the Health Insurance Portability and Accountability Act (HIPAA) has become overheated and largely speculative throughout the health care industry. While HIPAA will not require health care organizations to achieve levels of national classified security, it requires health care organizations to take a huge leap forward in information management. An effective and realistic approach to HIPAA compliance requires health care organizations to reach beyond technology and create a fundamental change in attitude, awareness, habits and capabilities in privacy and security.

It is difficult to determine HIPAA's legal impact on the correctional health care community, but it will be felt during the next several years. However, HIPAA's influence on the health care community at large is being debated and felt now. Generally, the act will have a measured effect on the operation and delivery of services throughout the health care community. The act requires public and private sector health care organizations to adopt the same information-handling practices that have been in effect in the federal government for years, which results in: standardized formation of data electronically exchanged between providers, and federalization of security and privacy practices within health care information management.

HIPAA derived from the Health Care Reform Act of 1993, which was rejected early in the Clinton administration. The Health Care Reform Act, which sought to guarantee comprehensive health coverage for all Americans, regardless of health or employment status, was reborn as HIPAA (Public Law 104-191) and signed into law Aug. 21, 1996. HIPAA's goals include:

* Reducing the cost of health care program administration;

* Providing standardized information exchanges between employers, providers, insurance companies and beneficiaries;

* Protecting patient confidentiality; and

* Providing a minimum set of security standards for the management and protection of individually identifiable medical information.

HIPAA compliance in a correctional setting is manifold and far-reaching, positively impacting operational efficiency, staff accountability, documentation and litigation management. For additional information about HIPAA, visit: www.aha.org/hipaa/hipaahome.asp or http://aspe.hhs.gov/ admnsimp/.

Guidelines for Evaluating Health Care Information Systems

By leveraging technology, correctional health care organizations not only gain the ability to improve processes and patient safety, but also gain the ability to record and analyze progress in reducing adverse events. No technology will displace the art and sensitivity of a clinician's skill and judgment, but this expertise only can be enhanced by a system that manages the routine but critical task of tracking where inmates are housed and their medical information. Users should consider the following when comparing Health Care Information Systems (HIS):

Gather basic information about the provider. Purchasing a new medical information system is much more than buying a commodity. Instead, it is the creation of what should be a mutually beneficial partnership. As such, it is important that organizations learn as much as possible about potential HIS partners. Early in the evaluation process, data regarding provider reputation, standing within the industry and client base, should be examined. The HIS provider should possess a proven track record of delivering, in a timely manner, reliable, clinical operational solutions in facilities that are comparable in size and with similar needs to that of the procuring organization. Additionally, it should be determined whether the provider's vision matches the client's, with the proposed solutions engineered to meet the business and operational requirements faced today, as well as those of the ever-changing landscape of future health care.

As the need for seamless data-sharing across an organizational unit increases, the HIS company should possess the experience and expertise to create interfaces to existing systems (offender management, laboratory, scheduling and billing application) and devices to facilitate the exchange, and to maximize the investment.

The financial strength of the prospective HIS partner should be evaluated to determine if the company has the fiscal structure and dedicated personnel to meet its current obligations, as well as to support future needs. The company's commitment to research and development should be assessed: To ensure that their applications will be maintained, developed and enhanced, providers should reinvest a significant portion of their annual revenue into infrastructure and new ventures.

Client support presents another area of concern to be evaluated. Organizations should consider the potential HIS partner's capabilities during the implementation process as well as ongoing support once the solutions are in place. Providers should have a proven methodology and the resources necessary for a successful conversion. Additionally, access to 24-hour support should be available to facilitate prompt resolution of mission-critical issues. Client commitment also can be assessed in how the provider addresses matters of licensure and upgrades. Are enhancements made available to the client as part of the ongoing monthly support fees? Is the license issued on a perpetual or term basis?

Because the practice of medicine significantly can vary between organizations, cookie-cutter products that deliver a one-size-fits-all approach should be avoided. The ideal solution is one that is architecturally designed to support a high degree of flexibility to meet specific client needs and it should be readily available and presented in an easy-to-use format. Providing the ability for the client to adapt the system on its own eliminates the need for costly modifications to source code and eliminates issues associated with custom programming.

Solutions should incorporate state-of-the-art industry standards, such as a true Windows environment, featuring a graphical user interface that promotes efficient end user training and acceptance. Prospective HIS providers should take advantage of the power and scalability of three-tiered client-server technology.

The seamless flow of data across entire organizations between disparate legacy systems is becoming a paramount issue facing the health care community. Solutions should be open, thereby facilitating communication, One measure to promote an open nature is adherence to standard data transport protocols, such as Transmission Control Protocol/Internet Protocol (TCP/IP). Another is to comply with Health Level Seven (HL7) Standards, which is a developing organization operating within the health care arena. The group's mission is to provide standards for the exchange, management and integration of data that support clinical patient care and the management, delivery and evaluation of health care services -- specifically, to create flexible, cost-effective approaches, standards, guidelines, methodologies and related services for interoperability between health care information systems. All HIS providers should comply with HL7 requirements.

Providers that design their solutions upon a single, integrated architecture afford an advantage over those that are built on disparate platforms. The ability to seamlessly incorporate modules that address the unique needs of the various domains of care (care provider documentation, pharmacy operations, the special requirements of correctional health care, etc.) promotes the real-time sharing of data across the continuum of care and increases the likelihood of optimum outcomes. An electronic medical record (EMR) that features online EMAR facilitates closing the loop on the medication process and provides efficiency, accountability and safety.

While most products are capable of performing automation of basic departmental operations and providing a rudimentary degree of clinical functions, the challenges facing clinicians require systems with more robust and sophisticated functionality. The incorporation of an industry standard referential drug database provides automated support related to drug/drug interaction checking, drug/allergy notification, drug/food warnings and duplicate therapy alerts. Additionally, bilingual (English and Spanish) patient medication education leaflets may be supplied through this feature.

Also benefiting clinicians are systems that provide advanced decision support capabilities. As data become available from systems across the entire organization, the ability to capture, evaluate and act on this information becomes imperative. Through user-defined rule systems, clinicians may incorporate a system of warnings with multiple notification modalities that provide reports and alerts of critical laboratory results, conflicts between ordered medications and procedures, and enforcement of organization-specific policies. Reporting of all available data is accomplished through a robust, full-feature, ad-hoc report-writing application, as well as furnished, standard reports.

All systems being considered should facilitate compliance with all applicable state and federal regulations. The health care community at large must begin to ensure compliance with HIPAA, whose impact on the correctional health care community will not be discerned for some time. At a minimum, all potential HIS solutions should include a complete "audit trail" functionality that is embedded within the infrastructure of the application. This audit trail should attach a time, date and user stamp to all transaction activity (creation, review, modification, printing, etc.) pertaining to each medical record. Each system must be able to control access to the information and functions within the application. In many cases, a multilevel, role-based security model controls access to the field.

Conclusion

Correctional health care providers are faced with the same complex challenges as those of their peers in the private sector. However, the unique restrictions, requirements and realities of security operations and facility design compound those issues. As organizations explore solutions for enhanced inmate care and improved operational efficiencies, it becomes apparent that information management is the cornerstone. The ability, not only to input data regarding clinical events, care activity and general operations, but also to harness the collection of information from multiple sources (dietary, medical, pharmacy, inventory and security computer systems) in the form of usable intelligence will be a necessity. Only then will organizations truly be able to connect the appropriate person, knowledge and resources, at the appropriate time and location to achieve optimal outcomes. An EMR serving to augment clinician skill, provides the foundation for such a solution -- a foundation that facilitates efficient, cost- effective, timely, inmate health care, resulting in patient safety and that makes correctional health care smarter.

Tom L. Allison is director of correctional operations for Cerner Corp. John H. Clark, MD., is chief medical officer for the Los Angeles County Sheriff's Department.

REFERENCES

Bates, D.W., D.L. Boyle, Vander Vliet, et al. 1995. Relationship between medication errors and adverse drug events, Journal of General intern Medicine, 199-205.

Kahn, L.T., J.M. Corrigan and M.S. Donaldson. 2000. To err is human. Committee on Quality of Health Care in America. Washington, D.C.: Institute of Medicine.

Raschke, R.A., B. Gollihare, T.A. Wunderlick, et al. 1998. A computer alert system to prevent injury from adverse drug events. Journal of the American Medical Association, 280(15): 1317- 1320.

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