The doctor is in … your laptop

March 21, 2012

In August, 2005 Stephen Slevin of New Mexico was convicted of Driving While Intoxicated. What happened next is the stuff headline writers dream of.

Slevin, 58, testified he was held in solitary confinement for two years without ever being prosecuted, and was not given proper medical care (claiming he pulled his own tooth when he was denied access to a dentist) or even regular medication to treat his chronic depression. News photos revealed a startling before and after: the clean-shaven, tanned man in his fifties starkly juxtaposed alongside a bearded, wild-eyed thing. He looked as if he had aged about twenty years. The jury awarded Slevin $22 million in one of the largest federal civil rights settlements in history involving an inmate.

In the jail’s defense, Dona Ana county spokeman Jess Williams issued a statement claiming all was not as it appeared to be. He said Slevin was offered a chance to join the general jail population, but declined. Similarly, Williams maintained that for the first five months of Slevin’s confinement he had requested and received medical attention and purchases, after which period he refused those, too. The county reported Slevin’s 22-month stay was “entirely” in the hands of then-district attorney Susana Martinez’s office, the public defender’s office and state District Court. Williams also issued this statement:

"Medical rounds were conducted three times daily, and prescribed medications were dispensed to Slevin and other detainees. The Dona Ana County Detention Center has historically faced significant challenges in terms of treating mentally ill detainees, but the challenges were consistently addressed throughout the time Slevin was incarcerated, and the efforts continue to this day."

The tech solution

In fact, changes have been made. Inmates at the Dona Ana detention center now have access to kiosks where they can log in and communicate with medical staff, and express any concerns they may have to jail staff. In the past, inmates turned in hand-written requests to receive medical attention. This particular ‘Case of the forgotten man’ actually speaks to a common problem many corrections facilities face. That is, the persistent difficulty in hiring and retaining qualified counselors and psychiatrists. The reasons are many: jails are notorious for overcrowding and inadequate staffing. It can also be a chore to lure qualified physicians outside of urban hospital settings to work inside rural jails.

One way to get around some of these hurdles is to take diagnoses and treatment online. Telemedicine, which has been around since the 1990s as a way to treat patients remotely, applies videoconferencing technology to health care, allowing clinicians at one site (called hub sites) to provide services to any number of clinics at distant locations (called receiving sites). Using specialized diagnostic equipment specifically adapted for use in telemedicine, clinicians can see diagnostic images, perform examinations, and hold live interactive discussions with patients and institutional health care staff. The only thing missing is extended travel times, significant threats to security and a full-time physician wandering a corrections facility wondering what to do with his down time.

Doctors behind bars

As technology evolves (and minds open) it seems more viable than ever for patients to chat with a doctor screen to screen. It’s been proven cost-effective in many a healthcare landscape, including hospitals, schools and nursing homes. While the technology is all but status quo in the court room, some in the industry wonder why more corrections facilities aren’t taking advantage.

Dr. E. Richard Dorsey is the president of Telepsychiatry Inc. in Newport Beach, Calif., a private medical group which provides intrastate and interstate services, including program development, psychiatric consults, and direct patient care. Telepsychiatry, Inc. consults to several agencies, including the California Department of Corrections. “Prisons are the absolute best (for telemedicine),” he says, “Because … you can get better doctors. A lot of doctors – solid, middle-of-the-road doctors, aren’t about to go to the rural areas in the first place; they’re certainly not going to go behind prison walls.” Today’s prisons are put into rural areas because urban areas don’t want them. Land is cheap, labor is cheap and jobs are good. But where does that leave wards of the state in need of care specific types of care?

“Probably in the old days, prison healthcare didn’t amount to anything; they were left to die and it didn’t matter much,” says Dorsey. “The problem now is that Federal courts have required a fairly high standard of medical services for prisoners, and therefore the problem is how do you get the technical people … doctors, nurses, especially doctors … to come into rural areas? Most of them don’t want to.”

A growing network

As effective as telemedicine proves to be, concerns and misconceptions linger. One is economic. In years past, the practice hasn’t always been exactly feasible. Some places required terminals costing upwards $20,000. Then dial-up and, recently, DSL and high-definition came along. Since then, operating costs have gone down significantly.

Dr. Avrim Fishkind, a psychiatrist in Houston, rarely sees his patients in person. Fishkind has worked in emergency psychiatry for about twelve years. “Back in 2000 most emergency psychiatry was being done in a very small number of places, mainly special emergency rooms within teaching hospitals and universities, called psychiatric emergency spaces or PESs. And so even though we were proud of all the work we were dong, we probably weren’t touching more than one percent of all psychiatric emergencies”. In reality, he recalls, most psychiatric emergencies were occurring in emergency departments without psychiatric emergency spaces, places like jails, schools, shelters and on the streets. The only way they could think of to solve the problem was by using telemedicine.

“Right around 2007 the cost of equipment had dropped enormously.” says Fishkind. “The pressure to help law enforcement and judges, the judicial system and patients and their family, and emergency departments had all reached a fever pitch.”

In November 2007 Fishkind and his colleagues opened DHS Telehealth and Psychiatry. Since then they’ve grown from one doctor and one office manager to over 25 psychiatrists, and an advanced nurse practitioner. They receive around 60,000 patient contracts a year with over 30 organizations in Texas and Los Angeles. They’re even on cruise ships.

Transportation is generally the biggest cost-savings attributed to remote care practices. At DHS one psychiatrist sitting in Houston can see an emergency patient in Houston, and then thirty to forty minutes later see to an emergency call in Dallas. Twenty minutes after that they might see another call in Alpine Texas, which is 150 miles from a psychiatric treatment center. Fishkind notes: “So that one psychiatrist in the course of an 8-hour shift can travel what would have taken four to 5000 miles travel to cover distance, and suddenly be available in a lot of different type facilities.”

The importance of a secure connection

Other facilities might have concerns regarding security and HIPAA compliance. Linda McKenny, RN, is a senior health care services manager who oversees the Office of Telemedicine Services (OTS) at the California Prison Health Care Services (CPHCS). She manages the telemedicine program statewide at all 22 adult institutions. Each institution determines its own physical telemedicine clinic setup, and can choose from 25 available specialties, including primary care and telepsychiatry. Like any healthcare appointment, security and privacy is of the utmost importance.

“We have firewalls, and we have our chief security officer that makes sure that any of the telecommunications and video streams that we have set up are encrypted,” says McKenny. Encryption allows users to keep track of each IP address. CPHCS does not allow physicians to work from home or remote areas. McKenny adds, “You’ve got an actual healthcare session going on and we want to respect the rights and privacy of individuals the same as if it was a physical examination.”

The CPHCS program also mandates that equipment is locked up every evening. In fact, CPHCS and other purveyors of telemedince maintain that cooperation with custody is a crucial ingredient to success, as they are the ones working with directly with doctors and must oversee day-to-day operation. Custody personnel should be involved – in everything from the kick-off of a new clinic expansion to implementing safety measures and procedures inside the session itself.

What about patients? Are they comfortable taking their most personal maladies and grievances to someone three thousand miles way … via screen? Fishkind assures that in today’s world it’s practically a non-issue. “For one thing, technology’s more prevalent and it’s generally more acceptable. And then two, people are astonished when their mind wraps around the idea; that … the doctor’s making house calls, right? And they’re getting help quickly. It doesn’t take long for them to realize that this is a fairly miraculous thing that’s happening.”

Mobile devices and quick-prescribe meds

Could facilities just use Skype? This notion is still up for debate. The problem is Skype’s technology runs on an outside server. “So our transmission passes through somebody else’s server and we cannot control what happens to it,” says Fishkind. He does not endorse Skype as a HIPAA-compliant technology that adequately maintains patient privacy. The way to continue to ensure security is through a direct point-to-point connection with another secure device.

As one might guess, mobile devices are also entering into the remote-medical arena. ClearSee, a new technology from a company called Life Size, lets users see each other without problems or additional equipment, safely and securely on mobile devices, phones and iPads.

Additional concepts for the future include inexpensive devices that can be installed in a consumer’s home that would allow monitoring and even video conversation with the physician, making it possible to prescribe and mail medication without need for additional transportation. This might be especially useful in a corrections setting where, like in Slevin’s case, a patient requires regular medications and monitoring.

But for the moment, all corrections facilities really need for successful telemedicine sessions is a screen, a microphone and a camera and some management. Fishkind says, “If you can turn on a cable box and scroll to your favorite show and press the button, you can use this equipment.”

“It surprises me,” adds Dorsey. “I think there must be something I haven’t thought of … why one or more of the big [detention centers] or companies haven’t jumped on this and built their own provider network.”

More doctors, less transportation, less risk. It seems an over-simple solution. Then again, maybe it’s simply the future of corrections healthcare.

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