Talk:Health IT in Prisons & Jails

ELECTRONIC HEALTH RECORD USE IN PRISON: THE ADVANTAGES OF ADOPTION

BACKGROUND: Prison systems supply medical care to all incarcerated offenders in much the same way that non-correctional clinics and hospitals do and use an Electronic Health Record (EHR) with the same advantages as non-correctional clinics, including legibility, instantaneous inter- and intra-clinic communication, potential for streamlining processes and money savings around non-repetition of tests and studies. [1] A correctional setting does, however, benefit from adoption of an Electronic Health Record in ways that are unique to corrections.

The following is the experience of University of Texas Medical Branch-Correctional Managed Care (UTMB-CMC) with using the Electronic Health Record, “PEARL”, in providing care to the patients incarcerated with Texas Department of Criminal Justice across the state. There are more than 150,000 inmate offenders incarcerated in Texas in approximately 110 units. The EHR used by UTMB-CMC is also used for the Texas Juvenile Justice System, with approximately 1500 inmate offenders in 5 units.

MEDICATION DISPENSING AND PHARMACY SAVINGS: The use of an EHR in an incarcerated setting offers unique advantages or ease in accomplishing the following items.

• Tracking of compliance for medications that are taken by the patient at a pill window (the place where medications are distributed to patients in prisons) and of verification that medications which are ordered “Keep on Person” have been picked up from the pill window. Not all medications may be carried by the patient. Ordering medication “KOP” (Keep on Person) allows the patient to get a few weeks’ supply to carry on his/her person and take on their own. Non-KOP meds are distributed several times daily at the pill window in a dose-by-dose fashion.

• Reclamation of medications that have not been in the patient’s hand, allowing for repackaging and re-dispensing in the Central Pharmacy. UTMB-CMC issued 4,648,023 prescriptions from the Central Pharmacy to the unit pill windows between September 2013 and the end of August in 2014 at a total cost of $40, 981,459 and was able to reclaim $8,251, 776 in medication that had been dispensed to the unit but which was never picked up by the patient from the pill window.[2}

• Documentation of refusal of medications. Patients routinely come to a pill window for their medications and take some of them, but not all of them. This is easily recorded for the provider to see at a follow-up visit.

• Allows Medication Aides or Nurses to prepare to pass medication in areas of the prison where the patients are not allowed to go to the pill window to pick up medication. This is especially helpful and important in packing a medication cart for administrative segregation areas where medications are passed cellside . This is accomplished by importing a patient’s housing area and matching it with their prescriptions. This activity is arduous and potentially inaccurate when done on paper.

• Recording of insulin dosing (which is generally dispensed in the medical area of a correctional facility due to the restriction on a patient carrying needles), especially sliding scale insulin that is given in the clinic in association with a specific blood sugar that was done at that time. This allows the provider to easily see whether the patient needs to have their insulin adjusted without searching for a flow sheet.

• Comparison of prescribing practices and reclamation numbers between providers and different units in the system. Recognizing outliers allows for choosing best practices and spreading them.

• Changing from one drug to another in the same class if pricing changes and a new drug is going to be used (for instance, UTMB-CMC recently switched their preferred ACEI from Enalapril to Lisinopril).

• Continuity of care regarding the medication profile when a patient transfers between units, which happens frequently. Patients that are incarcerated also may travel to several different units and spend a day or two at each on the way to and from a specialist referral appointment.

• Increased certainty of dispensing medications to the correct patient and to accurately identify patients who are traveling off of the unit or are being discharged or paroled so that their medications can be packaged to travel with them. Bar code scanning especially could be used on the receiving end to ensure that medications that are traveling with the patient are taken off of the transport vehicle, since that patient is not allowed to hold onto these while traveling.

CONTINUITY OF MEDICAL CARE IN TRANSFER SITUATIONS: These situations are critical and a lack of continuity of care either between prison units or between free-world facilities and prison units can result in a bad outcome for the patient.

• When an EHR is in use, a receiving provider can readily see what the plan was for the patient and when he was to be seen at the previous facility so that appointments at the new facility can be set up. When the paper charts were used, this was more difficult and often the paper charts were not readily available with the patient upon arrival to a new unit. Often, specialists’ consult notes did not make it into the paper chart before the patient had left their offices and were not available to the receiving provider at the unit for order processing. Or, at times, even if the specialty note was available in the paper chart, the notes had been done in triplicate and the copy in the chart would not be legible.

• EHR allows the discharge planners for special needs and the parole division to determine who needs follow up after their incarceration. Many medical conditions will require follow up care after leaving the prison system or will have compliance to treatment for the medical condition monitored after they leave the system on parole. These diagnoses can easily be identified by creating a report tol; look at specific ICD codes on the problem list.

• Using an EHR allows housing personnel to ensure that patients in the system that require special housing are all housed properly. For instance, the state of Texas has special housing for incarcerated patients with blindness, low vision, profound hearing loss and deafness, dialysis patients, pregnant patients, spinal cord injuries above T7 and wheelchair-bound patients. These codes can be queried and matched to their housing assignment to verify that the patient is in a place where care or security is ideal for their situation.

DEMONSTRATION OF ACCESS TO CARE: Access to care is closely monitored by all correctional systems and oversight organizations as this has been recognized as an important challenge for the incarcerated population, who cannot access care freely at any other site like a non-incarcerated person is able to.

• An EHR allows the state of Texas to document when requests for care are received and when the care is delivered. If access to care is not being achieved, steps are taken to make care more available.

• Access to care can also be demonstrated by job description when using an EHR. Texas uses “reminders” for appointments requested for nursing or providers and when the reminders are closed as having been seen, the care is documented. The reminders are different for nursing, providers or other staff, allowing differentiation of the time that care is received by job title.

BED CONTROL: Skilled nursing beds are a precious commodity in most correctional systems and when skilled nursing care is no longer needed, the bed can be freed to receive another patient. This also saves money if patients are waiting in an inpatient setting for a step down bed to open for transfer.

• The EHR used by UTMB-- CMC program has developed nursing plans of care for patients being admitted to skilled nursing beds. These plans outline the duties that the nurse will need to perform for that patient and the reminders for these tasks would be closed as completed when those services are no longer needed. Once there are no open Nursing Plans of Care reminders, it is an indication that the patient no longer needs skilled nursing care and can be transferred to another bed.

DATA COLLECTION: Prisons are an important point of contact for public health interventions.

• A correctional system which uses an EHR is readily able to pull information by diagnosis for transmission to departments of health or other interested parties.

• A system that uses an EHR is able to gather pertinent information about qualities of patients with specific diagnoses for planning purposes. For instance, with the advent of extremely effective hepatitis C treatment and its large price tag, information can be gathered about which patients urgently need treatment (patients with high grade hepatic fibrosis, patients co-infected with Hepatitis B or HIV, patients with liver transplants) and which patients can be triaged to a less urgent group. This information can be used to plan budgets and to arrange treatment settings and staffing. The Texas Department of Criminal Justice houses all patients actively receiving protease inhibitor treatment for Hepatitis C in a cohort.

• The EHR used by correctional managed care has developed a dashboard that allows “slicing” of data to show patient demographics with diagnoses and control of these disease states. For instance, it would be possible to program the dashboard to look at our heaviest patients who also suffer from diseases caused by obesity and potentially plan an intervention for this group. This would not only improve patient care but save money as well.

• Potentially, an EHR in a prison system that can track housing could also track contacts of a patient with a potentially contagious condition requiring isolation. It could also alert unit staff for the potential need of isolation if certain diagnoses are entered in a set period of time. For instance, if a group of providers at one unit see 10 patients with diarrhea in one day from a certain dorm, that dorm should be locked down and its occupants isolated until it could be verified that there was not an outbreak of infectious diarrhea. If the providers cannot recognize this situation is happening immediately because they each saw 2 of these patients, there would be a delay in recognizing that there might be a potential outbreak and would slow response. If the EHR were set to recognize certain diagnoses and match them to housing, it could alert the unit staff of the need to investigate a possible outbreak.

• Interfaces between the public health departments that tracks immunizations or public health diseases can be created and potentially decrease time spent investigating which vaccines or treatments are needed and decrease waste. This is especially helpful in the Juvenile Justice system where ensuring childhood vaccination is a very high priority.

• An EHR allows recognition of repetitive public health screening activities that are needed and can be set to program follow up, when indicated. For instance, if a patient has been incarcerated before and is returning to the system and has already been shown to have a positive syphilis screen or HIV screening test or has had DNA taken for the federal database, this can readily be recognized upon re-arrival to the system and either not repeated or the proper test can be ordered. If a TB skin test is placed, the EMR can trigger a follow up appointment to read it in 2 days.

COMPLIANCE WITH BOARD RULES AND FEDERAL LAWS: There are frequently laws that affect the need for reporting that can be much easier to comply with when using an EHR.

• Texas medical board requires that midlevels are overseen by a physician and that charts are reviewed. The EHR can be programmed with the oversight relationship and automatically transfer notes at a set percentage to an overseeing physician for co-signature.

• Pharmacy boards have many rules about being able to track medication receipt from wholesalers and the distribution to the unit pharmacy sites. This is much easier to demonstrate using an EHR than paper printouts, especially considering the volume of medication that is distributed in a correctional system.

COMMUNICATION WITH CORRECTIONAL STAFF:

• An EHR allows the provider seeing the patient to enter the patient’s restrictions for housing or work that can be transmitted to corrections staff. This eliminates the need to keep a manual list.

• An EHR allows automatic transmission of diet orders to the prison kitchen.

• An EHR interface could potentially be used to track commissary purchases in patients who are not responding to therapy when non-compliance to diet may be contributing.

TELEMEDICINE: Telemedicine is heavily utilized by the UTMB-CMC for the delivery of healthcare with real advantage in cost, access to care for the patient and safety of the public. Telemedicine would be extremely difficult to use without an EHR.

• Telemedicine (and the associated EHR) allows for medical care to reach areas of Texas where there are prisons, but it is difficult to retain providers. UTMB-CMC conducted 110,511 telemedicine visits between September of 2013 and the end of August in 2014.[3] Telemedicine is used for nearly all of the hepatitis and HIV clinic visits, a large percentage of mental health visits and primary care visits and many other specialty visits, especially pre- and post-op consultations.

• The use of telemedicine for many of these visits voids the need for arranging transportation for a patient (which would always require correctional staff to accompany the patient) and makes the visit less rigorous for the patient who would not need to ride shackled on a bus to the appointment.

• Telemedicine allows for care that might otherwise require a visit to an emergency room at a local hospital. These visits require at least 2 officers per shift with the patient, require transportation and are considered a point of escape risk. Hospitals used by the public may also be uncomfortable with having an inmate that is shackled and accompanied by security in their emergency room. Crimes such as rape have occurred when an inmate is transferred to a hospital. If these visits can be avoided, it benefits all.

CONCLUSION: The use of an Electronic Health Record offers a myriad of advantages for correctional health systems that are unique to that venue and are in addition to the advantages experienced by general medical care delivery settings for non-incarcerated individuals. These advantages range from improved patient care, tracking of housing, continuity of care, medication delivery, cost savings and public protection.

REFERENCES: 1. "HealthIT.gov." The Benefits of Electronic Health Records (EHRs). USA.gov, 11 Mar. 2015. Web. 22 Apr. 2015. 2. Zepeda, Stephanie D., Pharm.D. "Meds." Message to the author. 20 Apr. 2015. E-mail. 3. Smock, Stephen R. "Telehealth Encounter Summary." 18 Apr. 2015. E-mail.

Created by Jane M. Moultrie