The doctor is in … your laptop

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 regular medication to treat his chronic depression. News photos revealed a startling before and after: the clean-shaven, tanned man in his 50s alongside a thin, bearded, wild-eyed transformation. He looked as if he had aged about 20 years. The jury awarded Slevin $22 million in history’s single largest federal civil rights settlement 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 on the county’s website:

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 jails and prisons face. That is, the enduring difficulty in hiring and retaining qualified medical staff.

It’s not always easy to lure physicians outside of urban hospital settings to work inside rural jails; so some facilities are looking for options online. Telemedicine, which has been around since the 1990s as a way to treat patients remotely, applies video conferencing 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 roaming the cells, wondering what to do with his or her down time.

Doctors behind bars

As technology evolves (and minds open) it seems more reasonable than ever for patients to chat with a doctor via screen. It’s been proven cost-effective in many a health care 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.

“In the old days, prison health care didn’t amount to anything; prisoners were left to die and it didn’t matter much,” says Dr. E. Richard Dorsey, president of Telepsychiatry Inc. in Newport Beach, Calif. “Now federal courts have required a fairly high standard of medical services, 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.”

Telepsychiatry Inc. provides intrastate and interstate services, including program development, psychiatric consults, and direct patient care. The company consults to several agencies, including the California Department of Corrections. “Prisons are the absolute best (for telemedicine) because you can get better doctors,” Dorsey says. “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. But where does that leave wards of the state in need of a specific type of care?

A growing network

As easy as “phoning it in” sounds, concerns and misconceptions linger. One is economic. In years past, the practice hasn’t always been exactly feasible. Some places required terminals costing upwards of $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 12 years. “Back in 2000 most emergency psychiatry was being done in a very small number of places—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.” he says. “The pressure to help law enforcement and judges, patients and their family, 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 more than 25 psychiatrists, and an advanced nurse practitioner. They receive around 60,000 patient contracts a year with more than 30 organizations in Texas and Los Angeles. They’re even on cruise ships.

Transportation is generally the biggest cost-savings attributed to remote care. At DHS a psychiatrist in Houston can see an emergency patient in the same city, then see an emergency call in Dallas 30 minutes later. Twenty minutes after that the doctor 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 4 [miles] to 5,000 miles to travel, and suddenly be available in a lot of different-type facilities.”

Enabling a secure connection

Another common concern involves 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 clinic setup, and can choose from 25 available specialties, including primary care and telepsychiatry. Like any health care appointment, security and privacy is of the utmost importance.

“We have firewalls, and we have our chief security officer to ensure that any of the telecommunications and video streams that we have set up are encrypted,” says McKenny. Encryption lets users 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 health care session going on and we want to respect the rights and privacy of individuals the same as if it were a physical examination.”

The CPHCS program also mandates that equipment is locked up every evening. McKenny and other purveyors of telemedicine agree that cooperation with custody personnel is crucial to success, as they are the ones working directly with doctors and participating in day-to-day operation. Custody should be involved in everything from the kick-off of a new clinic expansion to implementing safety measures within the session itself.

And what about the 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. He adds, “People are astonished when their mind wraps around the idea that … the doctor’s making house calls ... 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.”

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 and administrators cannot control what happens to the transmission. Fishkind does not endorse Skype as a HIPAA-compliant technology that adequately maintains patient privacy.

As one might imagine, mobile devices are entering into the remote-medical arena, too. 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 a 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.

But for the moment, all facilities really need for successful doctor-patient discourse is a screen, a microphone, a camera and some management. Fishkind says, “If you can turn on a cable box, 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 haven’t jumped on this and built their own provider network.”

In sum: more doctors, less transport, less risk. It seems an over-simple solution. Then again, maybe it’s simply the future of health care.

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