Position Statements

Use of Telemedicine Technology in Correctional Facilities

Background
The concept of telemedicine refers to the use of electronic communication and information technologies (“telecommunications”) to provide or support clinical care at a distance. The Joint Working Group on Telemedicine, an interagency working group of the Department of Health and Human Services, further defined telemedicine as:

The delivery and provision of health care and consultative services to individual patients and the transmission of information related to care, over distance, using telecommunications technologies, and incorporating the following activities:

1. Direct clinical, preventive, diagnostic, and therapeutic services and treatment, including procedures where a provider may be present with the patient, and clinical training and consultative clinical Grand Rounds, if used for decision making regarding the clinical care of a specific patient
2. Consultative and follow-up services
3. Remote monitoring, including the remote reading and interpretation of results of patient’s procedures
4. Rehabilitative services
5. Patient education provided in context of delivering health care to individuals (CDRH 1996)

Video conferencing in which physicians are at both ends of the transmission is perhaps the most common application for telemedicine technology. Also common is the transmission of x-rays electronically (O’Connor, 1996). Telemedicine technologies are successfully being applied to a wide variety of medical disciplines including radiology, pathology, neurology, cardiology, pediatrics, emergency medicine and even mental health.

It is widely recognized that the greatest benefit of telemedicine is the ability to provide medical expertise to remote areas that might otherwise go without. Other potential benefits include enhanced access to the expertise of specialists, improved quality of care, reduced professional isolation for rural health care professionals, and in many cases, a reduction in overall costs.

Telemedicine has the power to facilitate the provision of medical care, including specialty care, to rural areas which may have a lower healthcare professional-to-population ratio. It can also shorten the diagnosis and treatment process by reducing the time required for patients to be seen by a succession of providers. Instead, specialists and general practitioners examine patients and discuss treatment options together. It is this collaborative environment on which supporters base their claims of improved quality of care. Additionally, telemedicine can reduce the duplication of services and overhead costs of providing care, and has been found to reduce the isolation of health care professionals by facilitating peer contact for both patient consultations and continuing education (Williams, 1995).

Using these technologies, telemedicine can make a critical difference in rural areas where the distance between a patient and a health care specialist can be hundreds of miles. The same technologies also have been employed successfully at correctional facilities, with additional benefits to both the inmate population and surrounding communities.

As an example, the most widely recognized cost saving benefit of the use of telemedicine comes from reducing the need for travel which, in the correctional arena, has broad implications. The need to transport an inmate outside the confines of a correctional facility can be a significant barrier to providing medical care. It is possible for one radiologist to service a number of locations using teleradiology. And a specialist could provide direction to correctional health care staff, eliminating the need to admit an inmate. This is a significant benefit to the correctional industry as attracting and retaining talented health care professionals is a constant challenge.

For all of the benefits provided by telemedicine technologies, there are still barriers to its use.  Regulatory issues (including interstate licensure, malpractice, patient confidentiality and FDA regulations), budget constraints, insufficient administrative support, and fear of the impact on the health care system are a few barriers encountered by correctional health care facilities that have implemented telemedicine technologies.

The issue foremost in the legal spotlight is the delivery of telemedicine services across state lines.  Carefully defining and documenting the roles of practitioners in each consultation is vital.  Licensure and telemedicine malpractice cases will most likely look to standards of care in the community where a patient was treated. It is expected that the physician licensed in that state will have the responsibility of framing consultations in the context of the appropriate state laws and applicable clinical guidelines (Schneider, 1996).

Historically, funding for most telemedicine research has been provided by the federal government through grants. Over the years the availability of federal funds has fluctuated. Many of the telemedicine projects which continue today have received funding from a number of entities including the sponsoring health care facility, government agencies, phone companies, vendors, and private philanthropic organizations. Correctional facilities have always experienced difficulties in funding, and the purchase or leasing of even basic equipment may be unrealistic for some facilities. Working with universities and large medical research facilities may provide correctional facilities opportunities for incorporating telemedicine into their health services.

Position Statement
The use of telemedicine affords correctional facilities many opportunities for reducing operational costs associated with providing health care to confined individuals. Policies and procedures must clearly define the purpose and instances in which telemedicine may be used in a correctional facility. Regardless of the type and combination of technologies used to provide medical care, the basic principals governing the physician/patient relationship must remain intact.

This responsibility can be met in large part by ensuring that telemedicine policies and procedures comply with the National Commission on Correctional Health Care’s Standards for Health Services that have been developed for prisons, jails and juvenile detention and confinement facilities. Particular attention should be given to the standards for Policies and Procedures, Comprehensive Quality Improvement Program, Privacy of Care, Continuing Education for Qualified Health Services Personnel, Orientation Training for Health Service Staff, Initial Health Screening, Access to Health Care, Mental Health Evaluation, Health Record standards, Informed Consent, Right to Refuse Treatment and Medical Research.

Compliance with the standards will provide the necessary foundation for the appropriate use of telemedicine in correctional facilities. Further attention must be paid to professional licensing regulations and interstate commerce laws which may apply when telemedical consultations cross state boundaries.

1. Use of Telemedicine in Correctional Facilities
   Policies should outline the circumstances under which the facility will allow confined individuals to be treated through the application of telemedicine. The policy should identify which health professionals may assist with a telemedicine consultation and which cases are appropriate (and which are not) for telemedicine consultations. The ultimate responsibility for the patient and action taken as a result of the telemedicine consultation should also be defined by policy.
   
   Back-up arrangements for urgent and emergent situations beyond the scope of the telemedicine system and the abilities of the remote-site personnel should be included in facility policies. Arrangements should also be made for “hands-on” evaluations and treatment for situations where the requirements of the physical examination exceeds the capabilities of the remote-site personnel and/or when physical examination (palpitation of lymph nodes as an example) is an integral part of determining the proper course of patient care. Additionally, doctors should have a mechanism through which patients can be seen by appropriately-trained medical personnel when necessary.
   
   Equipment standards should also be addressed by written policy. The minimum acceptable technology standards should be clearly identified and issues such as transmission speed, resolution and audio quality should be clearly documented.
   
2. Patient Consent, Documentation and Storage of Information
   Patients must consent to a telemedicine consultation just as they would to any face-to-face encounter with a physician. If the transmitted images will be recorded as part of the diagnostic or therapeutic process, the consent form should include discussion of the capture and use of the images. A facility’s policy should address information ownership and how images or recordings will be maintained. Images and recordings should be considered part of the patient’s medical record and should be kept for the same time period state law requires medical records to be kept. A note should be made in the patient’s record indicating the availability and location of these recordings (AHIMA, 1995).
   
   Policy should define what constitutes “adequate medical records” regarding telemedicine consultations (i.e. whether fax copies of medical records are acceptable for patient charts, etc.). Policy should also specify how patient medical records will be maintained, and in what form.  Hard copy back-up of electronic records should be maintained and an emergency plan established in case of electronic system failure (“computer system crashes”).
   
   
3. Licensing
   Remote site and consultant personnel must be properly licensed. If the telemedicine consultation involves more than one state, personnel must be licensed in the transmitting and the receiving state(s).
   
   
4. Training and Education
   Health care professionals in correctional facilities will require training in the use of the chosen technologies. This will not only involve initial training on the equipment, but continuing education as well. Involved professionals should stay current on the advances in the applications of telecommunications technology and external issues impacting its use.

Adopted by the National Commission on Correctional Health Care Board of Directors
November 9, 1997

References
Brecht, R. M. (1997). Correctional telemedicine: An overview. In N. Neuberger (Ed.), Telemedicine Sourcebook, 1998. New York: Faulkner & Gray.

Freeman, T. (1994). Telemedicine and CHINS: Interviews with two experts. Journal of American Health Information Management Association, 65(8), 40-43.

Gonzales, W. (1996). Recommended principles for accrediting bodies: Setting of standards for access to care teleconsultations.

Gonzales, W. (1996, November). [Use of Telemedicine in Correctional Facilities]. In R. Hilton (Chair), Minutes of the Policy and Standards Committee. Conducted at the annual meeting of the National Commission on Correctional Health Care in Nashville, Tennessee.

Huston, J. L. M. (1996). Telemedical records: The weak link in telemedicine. Journal of American Health Information Management Association 67(6), 69-71.

Kennedy, M. D. (1996). The strategic use of telecommunications: Lessons learned and the path ahead.  Telecommunications.

Lorton, L., & Legler, J. D. (1996). A telemedicine trial. Journal of American Health Information Management Association 67(4), 40-42.

O’Connor, K. (1996, July/August). Making distance smaller: Telemedicine technology is connecting patients with appropriate care. Healthplan.

Siwicki, B. (1996, September). Telemedicine live, via satellite. Health Data Management.

United States Department of Commerce, National Telecommunications and Information Administration (NTIA). (January 31, 1997). Telemedicine Report to Congress.

United States Food and Drug Administration (July 11, 1996). Appended report on telemedicine-related activities of the Center for Devices and Radiological Health, FDA.