The use of telemedicine in correctional facilities.

Abstract

Telemedicine is the use of two-way telecommunication technology, multimedia, and computer networks to deliver or enhance health care. This technological advancement is transforming the way in which prison inmates are receiving health care, provide significant implications with regard to financial costs, and ensures security of inmates and correctional personnel. Scant research exists regarding myriad issues associated with the use of telemedicine in correctional facilities. This article will provide an overview of the history of telemedicine, the application of telemedicine in correctional facilities, legal and ethical implications associated with telemedicine, the benefits and barriers related to the use of telemedicine, and current and future trends associated with its use.

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Technological advances have begun to revolutionize the ways in which correctional facilities are operated. According to Gaseau (1999), corrections officials are beginning to use technology as a manpower multiplier, and technology provides an opportunity to enhance the safety of correctional employees and the safety of prisons. Technological advances that are widely used and have been found to be effective are surveillance and security technologies, tracking and detection devices, the use of automated management technologies, and communication technologies, which include teleconferencing. These technologies have yet to impact the correctional system the way in which telemedicine has.

Telemedicine, also known as telehealth, is defined as the use of electronic signals to transfer medical data from one site to another via the internet, intranets, personal computers, satellites, or videoconferencing telephone equipment in order to improve access to health care. This may include photographs, health assessment, diagnosis, intervention, consultation, supervision, x-ray images, audio, patient records, and videoconferencing (Telemedicine Information Exchange, 1997). Telemedicine includes the use of advanced telecommunications technologies to exchange health information and provides health care services across time, social and cultural barriers and geographic locations (Reid, 1996). This mode of technology consists of a network of remote sites from which patients are presented for treatment via telecommunications to physicians located at a hub site (Perednia & Allen, 1995; Turner, Nacci, & Waldron, 1999). In the late 1980s, telemedicine was recognized as a way to reach people living in rural communities. However, this form of telecommunication has impacted every facet of the correctional system from issues associated with safety and security of prison inmates to the physical health and well being of persons incarcerated. Telemedicine can range as something as simple as two health professionals discussing a case over the telephone to a sophisticated use of satellite technology to broadcast a consultation between health care providers at facilities in different cities or states (Brown, 2000). In what follows, this article will provide an overview of the history of telemedicine, the application of telemedicine in correctional facilities, legal and ethical implications associated with telemedicine, and benefits and barriers related to the use of telemedicine.

The History of Telemedicine

The practice of medicine through telecommunications, or telemedicine was developed and fostered in the early 1960's when the National Aeronautics and Space Administration (NASA) first put men in space (Welsh, 1999). NASA continued exploring the use of telemedicine by funding telemedicine research projects in the late 1960's and early 1970's where fifteen telemedicine projects were active. One of the pioneer telemedicine projects developed by NASA to deliver health care via telecommunications was the Space Technology Applied to Rural Papago Advanced Health Care (STARPAHC). This project allowed for health care delivery to the Papago Indian Reservation in Arizona. According to the Telemedicine Research Center (1997), the project ran from 1972-1975 and was implemented and evaluated by the Department of Health, Education, and Welfare, the Indian Health Service, and people of Papago. The targeted goal of this project was to provide health care to the isolated Papago Reservation by using a van staffed with Indian paramedics and a variety of medical instruments including electrocardiograph and an X-ray machine. The van was linked to specialists at the Public Health Service Hospital by a two-way microwave transmission (Telemedicine Research Center, 1997).

Another integral role NASA played in the advancement of telemedicine occurred in 1974 when a study was conducted with SCI Systems of Houston to determine the minimal television system requirements for accurate telediagnosis (Telemedicine Research Center, 1997). In so doing, high-quality videotapes were made of an actual medical exam conducted by an on-site nurse and supervised by a physician watching a closed-circuit television. Systematically and electronically, these videotapes were degraded to less than broadcast quality. Subsequently, the original and degraded videos were then shown to randomly selected groups of physicians who attempted to reach a correct diagnosis.

Results from this study yielded four very useful findings regarding the effectiveness of telecommunications in providing adequate health care. First, statistical significance between the means of the standard monochrome system and the lesser quality systems did not occur until the resolution was reduced below 200 lines or until the frame rate was below 10 frames a second. Second, there was no significant difference in the overall diagnostic results as the pictorial information was altered. Third, there was no significant difference in remote treatment designations of TV system type that would cause detriment to patients. Finally, the supplementary study of transmissions of 25 cases using televised radiographic film showed no diagnostic differences between the televised evaluations and direct evaluations when the televised evaluations were above 200 lines and special optical lenses and scanning techniques were utilized (Telemedicine Research Center, 1997).

NASA furthered the use of telemedicine for adequate health care by funding the first international telemedicine project in 1989 known as Space Bridge to Armenia/Ufa. Following a powerful earthquake that struck the Soviet Republic of Armenia in December 1988, the United States offered medical consultation to the Soviet Union by several medical centers in the United States. Under the guidance of the US/USSR Joint Working Group on Space Biology using video, audio and facsimile between a medical center in Yerevan, Armenia and four medical centers in the United States, medical consultations were provided. This project was extended to Ufa, Russia to aid burn victims after a fiery railway accident (Telemedicine Research Center, 1997).

Nearly ten years later, several correctional settings began to explore the use of telemedicine through pilot projects. These projects grew out of a need to better understand the feasibility of remote telemedical consultations in prisons and to estimate the financial impact of implementing telemedicine in the prison system. Hence, the United States (U.S.) Department of Justice began installing telemedicine networks in Federal correctional facilities. The goals of these projects were to determine the extent to which remote encounters with specialists via telemedicine would overcome local problems in accessing needed specialists and improve security by averting travel outside the prison walls. Secondary goals were to provide data that determines the costs and utilization to support a decision about whether and where to implement telemedicine in other correctional facilities (U.S. Department of Justice, 1999).

Among the first pilot telemedicine projects among correctional facilities was the Ohio Department of Rehabilitation and Correction Telemedicine Pilot Project launched in 1994, effectively linking the Ohio State University Medical Center with the Southern Ohio Correctional Facility, Ohio's maximum security prison (Wilkinson & Gailiun, 1998). This project was developed with the ultimate goal of replacing transportation of dangerous offenders via state highways with the transportation of medical information on those offenders via telecommunications links. Secondary expectations were to improve the timeliness and efficiency of health care delivery, and save on transportation and overtime costs by eliminating unnecessary round-trip hospital visits. This project yielded very significant results and has become a leader in the use of telemedicine among correctional facilities and recognized as the third largest nonradiological clinical program in the world (Wilkinson & Gailiun, 1998).

An additional pilot project included the United States Penitentiary and the Federal Correctional Institution in Allenwood, Pennsylvania, the United States Penitentiary in Lewisburg, Pennsylvania; and the Federal Medical Center (FMC, a prison health facility) in Lexington, Kentucky (U.S. Department of Justice, 1999). Each of these sites were networked for telemedicine with the Department of Veterans Affairs (VA) Medical Center in Lexington, Kentucky. Both the VA and FMC in Lexington served as hubs for providing specialist physicians and other health care practitioners for remote telemedical consultations with prisoners in the three Pennsylvania prisons from September 1996 through December 1997.

Analysis of this demonstration project revealed that telemedicine was adopted quickly and was used frequently in several medical specialty areas. Physicians reported that telemedical consultations were effective substitutes for direct, in-person consultations in some specialties (e.g., psychiatry and dermatology), but less than adequate in others (e.g., cardiology and orthopedics). Trips to local specialists were minimized and transfers by air charter were averted as a result of telemedicine during the entire demonstration. Telemedicine also improved such quality care indicators as time between a prisoner's referral to a specialist and access to doctors with more experience in the treatment of various medical manifestations. Also, prison administrators in the project hypothesized that the prisons were calmer, with few incidents of violence because of the improved psychiatric care available through telemedicine (U.S. Department of Justice, 1999).

Telemedicine and Its Applications in Corrections

Many correctional facilities are generally located in remote areas where it is sometimes difficult for inmates to receive access to appropriate medical specialists at reasonable costs. Additionally, transporting inmates to medical specialists outside the facility poses a hefty monetary expense, as well as increase security risks for officers who are taken away from their primary duty post to transport inmates. According to May (2001), the cost of transporting a prisoner to a specialist can range from a few hundred dollars to as much as $1,000 per trip. However, the decreased costs of technological equipment allows correctional facilities to use telemedicine as a medical tool, and by so doing stretch their healthcare dollars.

The capabilities of telemedicine in correctional settings offer the opportunity of expanding access to health care providers. Information about persons who need treatment and/or diagnostic services can be transmitted rapidly to physicians or other health care providers located in other parts of the country, as well as provide access to medical specialists in various parts of the world. According to the National Institute of Justice (2002), the information communicated can be as limited as a written report of laboratory tests, or may be as complex as a digitized x-ray image or a real-time high-resolution video conference. Using the latter, a physician sitting thousands of miles away sees a patient on a video screen and images produced by a wide variety of diagnostic devices, including ultrasound and optical fiber probes. Specialists can also remotely direct nurses, physician assistants, and physicians in the treatment of patients. Darkins and Cary (2000) identified five clinical aims of telemedicine:

* To get factual advice about a technical aspect of care or treatment

* To ask for a second opinion or a corroborative opinion in relation to a course of action recommended for a patient

* To help make an exact diagnosis or differential diagnosis on the basis of a clinical history, clinical examination, and investigations

* To ask for a recommendation about how best to treat a patient and what that treatment should consist of

* To ask advice on the appropriateness of transfer of a patient for care elsewhere and how this transfer should be most safely accomplished

The ability of telemedicine to broaden the supply of health care providers has the potential to overcome some of the barriers to effective inmate care that results from the structure of the health care industry. According to the National Institute of Justice (2002), this can be characterized by a high degree of physician specialization, which results in patient care being provided by a number of different primary care physicians and specialists, all of whom may not be associated with formal organizations or networks.

Physician specialization is also another factor that has significant implications. First, accessibility of specialist care is exceedingly limited in thinly populated regions of the country, which is where many prisons are located. However, the practice of an individual primary care physician requires a population base of between 3,000 and 5,000 people to support it, but the population required for supporting certain types of specialists is much larger. Second, in regions where specialists are rare, those who do exist acquire monopolistic powers over consumers. The ability of patient/consumer, or those who purchase services on their behalf, to negotiate the fees paid for services or the conditions under which they are delivered is correspondingly diminished.

By virtue of installing telemedical communications equipment to remotely located health care providers who are then able to communicate directly with specialists located elsewhere allow consumer's leverage (i.e., prison administrators) to become far greater. Those that are required to ensure quality health care for inmates are no longer limited to the locally available medical care. As such, correctional administrators receive more advantageous pricing in a far more competitive market place. If patients or those who manage their care actually use less costly specialists via telemedicine networks with sufficient frequency, in place of higher priced local provider, reductions in health care expenditures might be obtained.

While telemedicine is of great benefit to correctional facilities, it is important to understand the various forms of technologies that currently exist. Brown (2000) identified two primary types of technological applications that are currently being used in correctional facilities. The first type of telemedicine is called the stored and forward process, which is used for transferring digital images from one location to another. With this process, a digital image is taken using a digital camera, known as storing, and then forwarded to another location. Teleradiology, the sending of x-rays, CT scans, or MRIs through the store and forward images process is the most common application of telemedicine today (Brown, 2000). The digital images may be transferred within a building, between two or more buildings in the same city, or from one location to another anywhere in the world. This is typically used in non-emergent situations when a diagnosis or consultation may be made in 24 to 48 hours.

Telepathology is another commonly used form of telemedicine in correctional facilities and also uses the store and forward digital image process. This allows pathology images or slides to be sent from one location to another for diagnostic consultation. The use of this process has been very effective in dermatological exams. Digital images may be taken of skin conditions, and sent to a dermatologist for diagnosis.

Two-way interactive television is the other widely used form of telemedicine. This process is used when a face-to-face consultation is necessary, and involves the patient, their provider and a specialist. Video conferencing equipment at both locations allows a direct consultation to take place. The technology has decreased in price and complexity over the past five years, and many programs now use desktop videoconferencing systems and a variety of configurations of an interactive consultation. This means that inmates requiring health care would not have to be transported from correctional facilities for medical treatment.

Legal and Ethical Implications

Telemedicine provides a wealth of health care opportunities for prison inmates and many cost saving and security benefits that are sure to change the way in which correctional facilities operate nationally. As such, telemedicine is becoming a very acceptable way to provide health care services to prison inmates at the federal, state, and local levels. However, ethical and legal issues must be carefully adhered to in an effort to provide the best services possible. According to Kiley (1998) the Internet and computer technology has destabilized drug and health regulatory mechanisms and the traditional physician-patient relationship. The very qualities that make the internet such a rich market place--its decentralized structure, global reach, immediacy of response, and ability to facilitate free-ranging interchange--also make it an exceptional channel for potential misinformation, unethical use, concealed bias, covert self-dealing, fraudulent practices, and evasion of legitimate regulations.

Major issues associated with telemedicine are confidentiality and security. Given the sensitive nature of health care information, and the high degree of dependence of health professionals on reliable records, the issues of integrity, security, privacy, and confidentiality are of particular significance and must be clearly and effectively addressed by health and health-related organizations and professionals. Two factors make the matter a subject of particular importance: the intrinsically sensitive nature of patient data; and the growing use of network computing, particularly the Internet, for healthcare information processing. The health sector has not addressed information security in a comprehensive manner (Goodman, 1998). Health care organizations face a great variety of security, privacy, and confidentiality risks and must be made fully responsible for maintaining all aspects of security and confidentiality of data and information. Proactively, at the point of systems procurement, development and implementation, relevant correctional administrators must address possible issues associated with data sharing, data security, and confidentiality. Regulations and technical standards for privacy assurance and maintenance of data integrity and access security must be reasonable, in terms of recognizing the realities of health care delivery, the variability of application environments, and the diversity of national ethical values and legal systems (Darkins & Cary, 2000).

Current office practice, policies, and procedures should be integrated into the telemedicine process, which will also positively impact physician support and use of telemedicine. Darkins and Cary (2000) provided six suggestions regarding the minimum relevant data required for effective telemedicine:

* Patient name and identifiers, e.g., date of birth, address, social security or inmate identification number

* Date, time, and duration of consultation, and who participated

* Clear reasons why the consultation was initiated and what were its objectives

* Agreed and disputed findings in the history and examination

* Recommendations as a result of the teleconsultation, any clinical responsibilities assigned, and what was communicated to the patient

* Whether both sides and the patient were satisfied with the process and outcome of the consultation; if not, why not?

Two additional issues that are major legal and ethical considerations regarding the use of telemedicine in correctional facilities include licensure and accreditation, and dispersion of liability. Telemedicine creates conflicts between states, or countries, over the rules and regulations of accreditation and licensure (Hodge, Gostin, Jacobson, 1999). Medical licenses are issued by each state, and rules for accreditation may differ between states. Therefore, it is illegal to practice medicine in a state other than the one where licensure and accreditation is received. one primary question focuses on the legalities associated with an inmate in one state receiving telemedical treatment from health care professionals in another state. In such an instance, liability and dispersion of liability becomes a major concern. Use of teleconsultation, teleassistance, and telemedicine in general disperses liability for damage between many parties (Hodge, Gostin, and Jacobson, 1999). Liability, model of care, and medical malpractice must be seen under a novel perspective as telemedicine involves more than one provider, usually geographically distant and subject to diverse practice and legal value system. The question of who is responsible when several parties are involved becomes an important one. Existing statutes for malpractice become muddled when jurisdictions are mixed.

Diagnosing health irregularities via telecommunications or telemedicine, also known as telediagnosis, may present an ethical challenge. As beneficial as telemedicine may be, there is no substitute for being in the room with a patient. Too much reliance on remote diagnosis or assistance can result in inaccurate diagnosis and is therefore unethical (Goodman, 1998).

Traditionally, local standards are considered the yardstick against which health practice is evaluated, and they determine the parameters for eventual litigation. Such issues have been reviewed and recommendations regarding a code of practice proposed (Goodman, 1998; Eysenbach, 2000). Guidelines regarding the ethical and legal aspects of telemedicine are in the process of being developed by national and international trade authorities, professional and technical organizations, and by national regulatory agencies. Medical software is increasingly considered as another form of medical device. An extensive review of legal aspects associated with telemedicine in the United States has been compiled in the Compendium of Telemedicine Laws (Schanz, 1999). Darkins and Cary (2000) identified seven common legal considerations that must guide the decision to utilize telemedicine programs:

* Are there any licensure considerations relating to how clinical responsibility is apportioned between the practitioner as the remote consulting site and the advisor at the specialist center?

* What reimbursement mechanisms and contract agreements are needed to ensure payment is made for telemedicine services provided?

* Does any of the telemedicine equipment used to provide services need to conform to medical devices legislation?

* What is the relationship between the telemedicine program and the telecommunications carrier, particularly in respect of any break in service and its speed of restitution and associated compensation?

* Does the telemedicine program need to take out a clinical indemnity policy as well as standard insurance cover?

* Are the licensure considerations that relate to work in different countries and/or different states?

* How will privacy and confidentiality regulations be met?

Ethical and regulatory questions and national and international legislation addressing multiple issues related to quality of information in the Internet and telemedicine are a matter of present concern of many organizations. Hence, a critical issue for correctional facilities with regard to the provision of telemedicine services is the development of policies and procedures in the area of telemedicine. Additionally, it is important to establish an ethical code of conduct focused on content, advertising and privacy issues, and fraud detection designed to ensure that inmates and correctional staff are provided with health information that is reliable and safe.

Benefits and Barriers of Telemedicine

Telemedicine and its various uses are not perceived to be a panacea for the myriad problems that correctional facilities currently face regarding adequate health care for prison inmates. However, technological advances, namely telemedicine, has had a considerable impact with regard to safety and security, cost savings, and time management among correctional staff. The availability of quality healthcare services via telemedicine offers many advantages to correctional facilities. According to Wilkinson and Gailiun (1998), the benefits of telemedicine in correctional facilities have exceeded all expectations. Telemedicine has afforded correctional facilities the opportunity to offer inmates access to quality health care and yet reduce the number of potentially dangerous offenders in transit to medical facilities. As communicated previously, prior to the advent of telemedicine services, correctional facilities were required to encounter expenses associated with security personnel and drivers needed to transport inmates to healthcare facilities. Because many correctional facilities are located in rural areas, this would sometime mean that both inmates and personnel would spend at least four to six hours away from the facility. Additionally, health care concerns alleged by several inmates, would result in several trips to health care facilities being made throughout any given month. While some inmates have legitimate health concerns, there are also those that fabricate and exaggerate injuries in an attempt to enjoy the benefits of being outside of prison confines.

Telemedicine has been very instrumental in expanding the accessibility of specialty care that was previously available on a very limited basis and at times was cost prohibitive. Video consultations with doctors providing specialized health care has allowed inmates to receive optimal care at a reduction in costs to the correctional facility and without inmates every leaving the facility.

Videoconferencing is another form of telemedicine that has opened up new possibilities for continuing education for health practitioners in correctional facilities that are limited due to necessities of their job or because they are in rural areas. Brown (2000) stated that teleconferencing is an ideal way for correctional health care providers to obtain continuing education and remain abreast of current medical information and technological advances that exist in their profession.

As with most entities that produce benefits, there are usually barriers involved, and telemedicine is without exception. Telemedicine lends itself well to medical practitioners that are both in state and out-of-state. To date, most patient satisfaction studies indicate that patients on the whole are satisfied with long distance care (Brown, 2000). However, many states will not allow physicians to practice unless licensed in their state, which causes fear of malpractice lawsuits among physicians. Some physicians are also skeptical about the use of technology and lack of `hands-on' interaction with patients.

Many opportunities for telemedicine at correctional facilities have been hampered by the lack of appropriate telecommunications technology that can require extensive investment in technical expertise as well as hardware and software to undertake the kind of systemic change teleconferencing technology requires (Wilkinson & Gailiun, 1998). Not only is it important to have staff support, it is also critical that leadership decisions emanate from management and not from technical staff. Therefore, correctional administrators must become familiar with technological applications in order to avoid costly mistakes. Furthermore, regular telephone lines are inadequate for most telemedical applications. Brown (2000) stated that many rural areas do not have access to cable wiring or other forms of telecommunication access required for more sophisticated uses, and exorbitant costs may be associated with telecommunications circuits. Therefore, some correctional facilities that could benefit the most from telemedicine may not have access.

In addition to having state-of-the-art equipment available, it is also important to have adequately trained technical support personnel. According to Wilkinson and Gailiun (1998), there are hidden costs for training efficient personnel that are often underestimated, particularly since programs that are most effective include a technical site coordinator at each institution involved in telemedicine, as well as an administrative support person.

Conclusion

Correctional facilities face the enormous challenge of efficiently and effectively providing quality medical care to their inmates, while also maintaining issues associated with security, transportation, and financial costs. Telemedicine has brought about changes in the way in which prison inmates receive treatment that heretofore were unfathomable, with the benefits exceeding all expectations. The use of Telemedicine in correctional facilities is consistently moving from being tentative pilot projects to full-blown medical services management centers. Telemedicine programs that exist in correctional facilities have been proven to provide quality health care in a timely fashion, while ensuring public safety as a result a reduced need for off-site medical treatment and transport. Telemedicine has the potential to bring to correctional facilities the best that correctional health care has to offer the most cost-effective manner ever. However, correctional facilities must have in place the financial backing that allows for appropriate technical support personnel, suitable hardware and softwear, and ethical and legal standards that are adhered to by all persons involved, Only when such resources exist will correctional facilities maximize the full benefits of telemedicine.

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Sonja Feist-Price, University of Kentucky, KY Neena Khanna, Pennsylvania State University, PA Elias Mpofu, University of Kentucky, KY Lynda Brown Wright, University of Kentucky, KY

Dr. Feist-Price is an Associate Professor in the Department of Special Education & Rehabilitation Counseling; Dr. Khanna is a post-doctoral student in assistive technology in the Department of Special Education & Rehabilitation Counseling; Dr. Mpofu is an Associate Professor in the Department of Counselor Education, Counseling Psychology & Rehabilitation Services; and Dr. Wright is an Associate Professor in the Department of Educational & Counseling Psychology.