What are best practices for telemedicine, and do they change in and out of prison?

Interestingly, I learn from the Texas Public Policy Foundation that the Texas Medical Board has proposed new rules restricting out of state telemedicine providers. The rule that's got telemedicine providers kicking up a fuss reads:

A distant site provider may treat an established patient's new symptoms that are unrelated to a patient's preexisting condition provided the patient is requested to be seen in a face-to-face visit by a physician within 72 hours. A distant site provider may not provide continuing telemedicine medical services for these new symptoms to a patient who is not seen within 72 hours. If a patient's symptoms are resolved within 72 hours such that continuing treatment for the acute symptoms is not necessary then a follow-up face-to-face visit is not required.

So new symptoms would require at least the opportunity for a first-hand followup, while preexisting, already diagnosed conditions (including presumably chronic ones) could be treated mostly through telemedicine alone.

These rules won't apply to Texas prison health care, but they interest me because Texas prisons were the laboratory in which telemedicine practices first developed (California is considering copying the model), and from the testimony I've heard at the Lege, Texas' prison telemedicine program likely isn't meeting that standard, particularly after recent staffing cutbacks.

Should California pursue Texas-style university-based model for prison healthcare?

Here's a little more detail on California's deliberations about shifting prison health care to the state university system, modeled after Texas' example and promoted by a company affiliated with UTMB, from the Associated Press:

The University of California will form a special committee to study whether it should take over inmate health care for the state's troubled prison system, the chairman of the university system's Board of Regents said this week.

Regents Chairman Russell Gould announced the committee, which university officials said will study issues including the cost, effect on labor relations, and the university's liability in inmate lawsuits. Health care has been so bad in the state's 33 adult prisons that a federal judge appointed a receiver in 2006 to make improvements.

A study by a company affiliated with the University of Texas has criticized the receiver for running up costs as part of the improvement effort. It projected California could save more than $4 billion over five years and $12 billion over 10 years by shifting control to the University of California.

Federal receiver J. Clark Kelso would not comment, said spokesman Luis Patino.

NuPhysicia, the UT-affiliated company, said the university system could improve care and efficiency by hiring the prisons' doctors, dentists and other medical workers, and by providing other care through video hookups that link university physicians to their patients. The study also promoted electronic record-keeping and centralized hospitals to cut costs.

NuPhysicia grew out of the telemedicine programs at the University of Texas medical branch, where UC's senior vice president for health services, Dr. John Stobo, was president. Stobo was the non-executive founding chairman of NuPhysicia's board of directors, which has raised conflict-of-interest concerns.

The Board of Regents said Stobo never received money from NuPhysicia and cut all ties to the company when he left Texas in 2007.

Gov. Arnold Schwarzenegger supports the UC proposal as a way to bring costs for inmates' care closer to those in other states. California currently spends $2.4 billion annually on prisoners' medical care, close to a quarter of the prison system's $11 billion budget.

"This is radical surgery on a broken system that will save the state billions," said Schwarzenegger spokesman Aaron McLear.

The NuPhysicia study said California spends more than $41 a day on health care for each of its roughly 160,000 inmates, compared to less than $16 per day in New Jersey and around $10 in Georgia and Texas. All three states have similar arrangements with university systems there.

The company's telemedicine systems could yield the biggest cost savings in its California proposal by reducing face-to-face meetings between doctors and inmates.

Until UC System vice president John Stobo, who was NuPhysicia's board chair when he was president of UTMB, chose the company he helped found to advise the university, NuPhysicia was marketed as a telemedicine service provider, not a policy consultant. But now this private company, which spun off from UTMB with the university as a formal partner (with a 35% stake), is promoting a telemedicine based system in California that, oh by the way, is the primary service they were created to market. Fancy that.

The model NuPhysicia is promoting: Providing video hookups at prisons so doctors at university medical schools can "examine" patients from afar without ever sullying their schedules with prison visits. That's what Texas does at our state prisons, but the system hasn't been as great a success as one might hope. The system failed so miserably at the Dallas County Jail it cost UTMB their contract. When UTMB managed Dallas jail healthcare, as Grits noted in 2006, "For every month spent in the Dallas County Jail, you're more likely to get a staph infection [3.4% chance] than you are to hit 'snake eyes' when playing craps in a Vegas casino (~2.77% chance). Wanna roll the dice?"

Later in 2006, UTMB officials told the Sunset Commission that doctors providing care via telemedicine to state prisoners see 60 patients in eight hours, typically in shifts from 4 a.m. to noon. As a doctor in the Texas Senate pointed out at the time, that amounts to roughly 7 minutes per patient:

Sen. Bob Deuell from East Texas, who is a medical doctor, sounded skeptical of the telemedicine system. He questioned during the Sunset hearing how high the quality of care could be for patients who only saw their doctor that short a time and only over a video feed.

Those sorts of official descriptions of Texas' system led this blog to observe in 2007 that "'Telemedicine' is the physicians' version of fast food, a cheap, industrial, low-quality product that promotes dehumanized social relations for both health workers and customers." It's arguably good for some things and not others, but nobody's taken the time or done the outcomes-based testing to determine the difference. Instead, the tactic is treated as a cure-all when at best it should be a supplement to traditional hands-on care.

I've thought from the get-go that UTMB should make telemedicine work better in Texas before exporting the idea elsewhere. At a minimum, before California follows Texas down this particular garden path, it'd be good to see independent evaluations of UTMB's system instead of only self-interested, vendor-driven analyses from NuPhysicia.

There's also a more fundamental question regarding the conflicting missions of med schools and corrections agencies and whether joining these institutions at the hip could negatively effect the culture of either or both institutions.

Has UTMB's stewardship of prison health services worked well in Texas? Can we sufficiently document positive results to the point where we may confidently suggest exporting these methods - particularly telemedicine? Color me skeptical. After all, Texas hasn't worked out all the kinks in our own system. California officials should look long and hard at this proposal and get a second opinion before taking Dr. Stobo's and NuPhysicia's advice about copying Texas' model. A university-run prison health system hasn't solved all Texas' problems and has sometimes created a few.

See related Grits posts:

• UTMB-linked consultant advising California on prison healthcare
• Faculty blog fears healthcare for TX prisoners gives UTMB a black eye
• UTMB should make telemedicine work better at Texas prisons before exporting it
• I guess if it's possible to have "phone sex" you can have "telepsychiatry"
• Death sentence for stealing a Playstation: Texas prison healthcare problems not unusual
• Lack of accountability explains why counties dropping UTMB healthcare
• Healthcare poor for kids in TYC, committee told
• UTMB mental healthcare quality declining at TYC

Prison healthcare in disarray after Hurricane Ike

TDCJ officials yesterday updated the Legislature publicly for the first time (to my knowledge) on the status of health care services provided by the University of Texas Medical Branch at Galveston (UTMB) after the prison hospital located on the island was closed because of Hurricane Ike. Reported Mike Ward at the Austin Statesman ("After Ike damaged Galveston hospital, prisoners shipped elsewhere in Texas," Nov. 14)

Brad Livingston, the prison system's executive director, said administrators at the University of Texas Medical Branch at Galveston have promised to reopen some of the prison hospital's 365 beds later this month, but a full reopening is indefinite. Currently, a limited number of inmates are going to the facility for clinic visits, not overnight stays.

"It creates a real challenge," Livingston said. "It goes without saying that security risks go up."

Instead of sending convicts to Galveston for treatment, prison officials for weeks have been housing the bulk of them in public hospitals at the University of Texas at Tyler, Huntsville Memorial Hospital and a hospital in Conroe, among others. ...

In other parts of Texas, convicts are being transported to local hospitals for treatment or they are being treated at prison infirmaries — normally reserved for minor care.

In addition to extra costs of treatment at local hospitals, officials said convict-patients also require around-the-clock security. "There will be additional costs. How much, we don't know at this point," said Dr. Lanette Linthicum, the prison system's medical director.

Livingston and UTMB officials, who on Wednesday got orders to lay off 3,800 UTMB employees as a result of an estimated $710 million in hurricane-related damage to the Galveston complex of hospitals and labs, said they also do not know the final cost of the alternate care.

"(UTMB) has promised us they will eventually return Hospital Galveston to pre-Ike conditions," Livingston said. "We're not thinking about moving the (prison) hospital out of Galveston."

Livingston told the committee the state currently has about 150 inmates in free-world hospitals - the largest number, 60 beds, at UT-Tyler, with another 20 inmates at Huntsville Memorial.

I wish we'd heard whether UTMB's telemedicine program is up and running and how they're providing specialty care with UTMB's Galveston facility decimated and a third of their staff laid off, but one suspects these problems aren't going away and the issue will be revisited as the Lege session approaches.

How will UTMB layoffs affect prison healthcare?

As Galveston Island continues to dig itself out from the refuse, has anyone heard what effect Hurricane Ike has had on medical care delivery in Texas prisons? Recent news of up to 4,000 proposed layoffs makes me think the University of Texas Medical Branch at Galveston must be struggling to meet its contractual obligations for providing prisoner healthcare after the big storm destroyed more than $700 million dollars worth of facilities.

By contract, essentially acting as a capitated HMO, UTMB-Galveston provides medical care for 80% of prisoners in the state, much of it via "telemedicine" where inmates are seen via teleconferencing link by doctors in Galveston. The Texas Tech medical school handles the other 20%. But with Galveston Island devastated and UT's facilities there in tatters, UTMB just announced widespread layoffs, reports the Houston Chronicle:

A day after elected officials claimed they had helped avert a planned layoff of thousands of employees at the University of Texas Medical Branch, the interim chancellor of the UT System said a "significant" portion of workers will lose their jobs.

The layoffs will come as a direct result of damage inflicted by Hurricane Ike, which cost the academic medical center about $710 million in building damage, ruined equipment, revenue losses, cleanup and evacuation. Insurance will cover about $100 million, said Kenneth Shine, the interim chancellor and executive vice chancellor for health affairs, in a story Thursday in the Austin American-Statesman.

"We recognize there have to be significant reductions in force on the island," Shine said. "It's a very challenging situation."

According to Shine, some of the 85 buildings on campus took on as much as 8 feet of water, and storm damage essentially destroyed the hospital's kitchen, blood bank and radiology department.

In addition, the center's main revenue source, a 500-bed hospital at the campus, is expected to return as a 200-bed hospital for the foreseeable future. With the hospital and other revenue generators out of commission or at reduced capacity, the medical branch will likely operate at a deficit beginning as soon as next month, Shine said.

This announcement raises many more questions, especially for the state prison system, than the article answers. How will these layoffs affect UTMB's contract with TDCJ, which already was an underfunded, understaffed hodge podge of services held together by "telemedicine" out of Galveston? Has TDCJ reduced medical services in the wake of Ike, one wonders? And if so, how is that playing out in the field? After all, Ike hit Galveston on Sept. 12, nearly a month ago. (Thank heavens the main pharmacy is located in Huntsville; if it had been destroyed, I'm not sure how the agency would operate.)

Prisoners at the hospital in Galveston were evacuated to Tyler, where the UT-Tyler Hospital continues to handle their care. But it's not designed as a prison hospital, nor is it likely equipped to act as the center of UTMB's telemedicine services. The Chronicle reported that the prison hospital "wasn't badly damaged, but many of the required auxiliary services, including a pharmacy, aren't yet available."

Certainly the system must be flexible and I have tremendous sympathy for those in Galveston who've lost their homes and in many cases, now, their livelihood. But the medical school is also the health care system for 106 prison units holding more than 150,000 prisoners (from UTMB's perspective, read: "patients"), about 40 of whom die every month regardless of the weather. (That's more than California even though their prison system is larger.) It's one thing to scale back services for a month or so in response to disaster, but if UTMB lays off most of their staff and their facilities in Galveston are out of commission, is UTMB even capable of fulfilling its TDCJ contract anymore? Quien sabe?

I'll poke around today and see what else I can discover on this topic; check back for updates at the end of this post. And anyone with first-hand knowledge of what's going on inside the prisons with UTMB-delivered healthcare services, please let us know in the comments.

UPDATE (10/10) I put out some feelers and am still waiting to hear back. Most UTMB buildings, though, are currently not open even for employees. Also, in addition to buildings and labs, many computers were damaged and heaven knows how long it will take to sort out their information systems. Certainly it will be a profound test of their backup systems, at the very least.

Telepsychiatry at TYC: Can you imagine [a psychiatrist] having a paranoid person and telling them, 'Talk to the TV screen!'

Arriving home a couple of hours in, I've been listening to the TYC oversight hearing at the Texas Lege for the last hour or so, and a telling discussion arose about the lack of specialized treatment frequently ordered by courts for serious offenders.

While capital offenders mostly get the treatment they need, the committee was told, other serious offenders do not. In response to questions from Rep. Sylvester Turner, it came out that only 40% of sex offenders sentenced to TYC receive the treatment that courts order for them.

However, because limitations on state resources caused the youth to not receive treatment, the youth are not penalized and kept in the system longer, explained the attorney leading the release committee (who, in a small-world moment, it turns out was a roommate of mine in a past life, though I've not spoken to her for many years - Hi Karen!). Instead, they're evaluated based on their progress in what's been dubbed the "transitional" treatment program. (The new "Connexions" treatment program is being piloted at the Al Price unit in Beaumont, and it could take as long as 15 months to roll out system-wide.)

Part of the problem is that TYC does not employ enough psychiatrists - they pay for the equivalent of 5.5 full-time psychiatrists per week, a substantial portion of which is done through "telespsychiatry." Corsicana, the "mental health" unit for TYC, only gets 34 psychiatrist's hours per week, and TYC pays for about 220 hours total system-wide. That seems really low for a system with around 2,500 troubled kids!

This is an issue where I'm 100% with Sen. Whitmire; I've never understood exactly how you provide psychiatric services over the TV. During an aside, Whitmire wondered to Chair Jerry Madden,while waiting for a witness to arrive, "Can you imagine [a psychiatrist] having a paranoid person and telling them, 'Talk to the TV screen!'"

No kidding! From what I've heard of telepsychiatry in Texas prisons and jails (I've called telemedicine the "physician's version of fast food") the whole system seems pretty minimalist.

I was also interested to hear estimates that TYC's population may decline to less than 2,000 by the end of the year, a trend I'd predicted in a public policy brief last fall on changing TYC policies. (To those who scoffed - I'm talking to you Plato - hah!)

I came in on the middle of a fairly intense discussion, and I'm going to go back to listen to the full hearing later, but the discussion of mental health shortages and the failure to provide court-ordered sex offender treatment really jumped out at me. I wonder what those local judges think when TYC releases those kids without having received the treatment they ordered? Since TYC controls both the release decision and the parole division, I guess the judges don't have much say. Maybe others who know more about all this can better explain how that works? Why hasn't some judge already just ordered TYC to provide more treatment ... by telegraph or pony express, if necessary?

MORE: See initial coverage of the hearing from the Dallas News, from KXAN-TV, and from AP.

On the sunny side of the street: Is it time for an independent evaluation of 'telemedicine'?

Since I've posted quite a bit of critical material about healthcare in Texas prisons over the years, I thought it only fair to share what Correctional Managed Health Care E.D. Alan Hightower told the Senate Criminal Justice Committee yesterday are the three most important improvements at TDCJ healthcare since UTMB and Texas Tech took over the system. I personally learned quite a bit from the discussion.

First, the main benefit from operating the prison health system through UTMB appears to be reduced drug pricing. Because UTMB is a state hospital that does indigent healthcare, it qualifies for "340B drug pricing," which dramatically lowers its pharmacy costs. As mentioned earlier, 48% of TDCJ's pharmacy costs go for inmates with HIV. (As an aside, the committee was informed that "Big Pharma" is lobbying Congress right now to end reduced 340B pricing, so it's not inevitable those reduced prices will continue.)

Except for emergencies, all prescriptions in TDCJ are filled in Huntsville at a state of the art, UTMB-run pharmacy using entirely electronic prescription and medical records. Shifting to the cheaper drug prices saved UTMB about $1 million per month. In addition, because all medication is delivered to units in blister packs, unused medication is recycled, saving the state an additional $8 million per year.

In the past, drugs were delivered from Huntsville to outlying units in TDCJ trucks driven by prison trusties, but in recent years it's become more cost effective to simply ship them via UPS, said Dr. Raimer.

Hightower said the second important change for inmate healthcare delivery under the two university systems (UTMB and Texas Tech) was a shift to entirely electronic medical records integration of medical records (upgrading from paper files) into a central system accessible from any unit by medical personnel.

The third big improvement, said Hightower, has been the expansion of "telemedicine," which he said has been invaluable for providing additional consultations at rural units. He and other speakers cited Fort Stockton, in particular, as a spot where the state can't find nurses and doctors, and said that facility was particularly reliant on telemedicine.

In past hearings on this topic, senators had questioned the short amount of time spent per patient in a telemedicine setting - about seven minutes per patient, on average. This time Dr. Ben Raimer came prepared with better answers to such questions. He pointed out that TDCJ and UTMB operated chronic care clinics for a variety of specialized ailments, including HIV, mental health, liver and heart disease, and diabetes.

For those chronic ailments, he said, inmates are housed closer to medical facilities and specialists who can help them on an ongoing basis. Raimer said telemedicine was used more as a triage tool (though that seems to contradict past hearings where we learned they prescribe medications in a telemedicine setting), and that more serious cases received more extended attention.

That certainly makes me feel a little better about "telemedicine," which UTMB pioneered and is now marketing in a spin-off company, of all things. To the extent telemedicine really is just a triage tool, it could be extremely useful. As a substitute for on-site medical personnel, though, which appears to frequently be how it's used, seven minutes per patient is just not an adequate consultation for anyone with a serious problem.

I'd still like to see some medical school or other independent academic (not a Texas institution) evaluate the quality of care being delivered via telemedicine to Texas inmates compared to face to face doctor interactions. Is the quality of care at least close to the same? Maybe such studies exist, but I've never seen them, and if Texas prisons have become so reliant on a basically untested methodology, I think it's high time for an independent evaluation.

UTMB should make telemedicine work better in Texas prisons before exporting it

"Telemedicine" is the physicians' version of fast food, a cheap, industrial, low-quality product that promotes dehumanized social relations for both health workers and customers. And to judge by the results UTMB has had in Texas, health outcomes under telemedicine are quite poor.

But that won't stop UTMB from subsidizing a private start-up firm to market the idea to other prison systems and the private sector. The Houston Chronicle reported over the weekend ("Virtual care, real profit," Aug. 25):

The group that helped pioneer remote medical treatment of prison inmates in Texas hopes to commercialize that technology and market it beyond government contracts.

The University of Texas Medical Branch in Galveston is expanding part of its telemedicine group as a for-profit startup, dubbed NuPhysicia, with $5 million in funding from Houston-based private equity group Sanders Morris Harris.

Being Texas, it's not enough that we develop some of the worst corrections policies on the planet, our taxpayers subsidize the export of those bad ideas to other places and the private sector.

That's what's happening here. UTMB is responsible for most inmates' care, but rather than adequately staff prison medical facilities, they've relied on this gimmick they've dubbed "telemedicine" to give medical care through video conferencing systems.

The result: UTMB's Ben Raimer testified to the Texas Legislature last year that they were "very close" to providing unconstitutionally poor levels of health care. Legislative hearings on the subject pinned blame on the telemedicine system, as Grits reported in November:

Prison doctors see 60 patients in eight hours using telemedicine systems, sometimes from 4 a.m. to noon, witnesses told the commission.

So let's think about that. At most, assuming docs take no bathroom or meal breaks, and with zero time between prisoners, that would mean prison docs using telemedicine systems spend 8 minutes per patient. Since all that is unrealistic, with 15 minutes per hour for restroom breaks, meal breaks, and time transferring from one to another prisoner, medical visits are likely to be more like 7 minutes long. And your workday, for the doc, starts at 4 a.m.?! Who would want that job?

Sen. Bob Deuell from East Texas, who is a medical doctor, sounded skeptical of the telemedicine system. He questioned during the Sunset hearing how high the quality of care could be for patients who only saw their doctor that short a time and only over a video feed.

UTMB hasn't fixed problems with Texas prisoner health systems, but they're now planning to export those systems to other locales for profit. How much sense does that make? Ironically, UTMB cited low spending on Texas prisoner healthcare in the article as a selling point for its program, but the writer doesn't mention that the state suffers poor health outcomes to go with its low spending. The Chronicle reported:

Half of UTMB's telemedicine patients are prison inmates.

Texas spends 46 percent of what California does per prisoner for health care, in part because telemedicine has driven down costs.

Texas spent $7.66 per inmate per day for health-related expenses in 2006 while California spent $16.60 per inmate per day, according to figures compiled by the Texas State Auditor's Office.

Electronic Health Network will continue to exist and treat Texas inmates.

NuPhysicia will pay UTMB to use its technology and some of its staff for governmental and private telemedicine contracts outside of Texas.

Texas' low spending on healthcare should be no selling point when UTMB publicly admits to being "very close" to providing care so poor it violates patients rights! In fact, it's odd to see UTMB citing that $7.66 figure as a positive - they told the Legislature that number needed to increase substantially, and said it could go as high as California's costs if the courts ever required UTMB to provide similar levels of care.

I must admit, part of me doesn't like the idea of a public university subsidizing for profit private investments. I don't see why UTMB should get legislative appropriations if they're going to spend millions to start private businesses. Hell, I'd like a few million in legislative appropriations to start a small business, if you don't mind!

But beyond those public policy concerns, UTMB shouldn't be selling its telemedicine program to the public as some big, cost saving success when the truth is, judging from prisoner outcomes, it produces a poor product.

Death sentence for stealing a PlayStation: Texas prison healthcare problems not 'unusual'

Charles Billops, Jr. went to prison at age 17 for stealing a PlayStation and some DVDs from a house in Cedar Hill, a Dallas-Fort Worth suburb. But his stint in the Youthful Offender Program at the Clemens Unit in Brazoria wasn't supposed to be a death sentence.

Even so, that's what it turned out to be.

The state of Texas recently settled a civil lawsuit in response to claims by Billops' family that Charles failed to receive proper medical treatment before he died--from an undiagnosed brain abscess due to a sinus infection--in prison custody. The state will pay $250,000 to compensate for his 2003 death, reported the Dallas News ("Inmate's death: 'Terribly wrong' or 'very unusual?'," Nov. 18), but does not acknowledge any fault.

That may have settled this case, but I wouldn't be surprised to see more such "unusual" cases in the future.

The other day I listened to state officials testifying before the Texas Sunset Advisory Commission that the state was "very close" to providing an unconstitutionally poor level of care to prison inmates. Witnesses and legislators discussed the state's "telemedicine" program, where doctors see inmate patients by video, letting them describe or show their symptoms but not allowing for a full examination. Prison doctors see 60 patients in eight hours using telemedicine systems, sometimes from 4 a.m. to noon, witnesses told the commission.

So let's think about that. At most, assuming docs take no bathroom or meal breaks, and with zero time between prisoners, that would mean prison docs using telemedicine systems spend 8 minutes per patient. Since all that is unrealistic, with 15 minutes per hour for restroom breaks, meal breaks, and time transferring from one to another prisoner, medical visits are likely to be more like 7 minutes long. And your workday, for the doc, starts at 4 a.m.?! Who would want that job?

Sen. Bob Deuell from East Texas, who is a medical doctor, sounded skeptical of the telemedicine system. He questioned during the Sunset hearing how high the quality of care could be for patients who only saw their doctor that short a time and only over a video feed.

To be clear, Mr. Billops' care wasn't shortchanged because of telemedicine. Indeed, telemedicine would have been an upgrade in his case. Even though he "lost 52 pounds in less than 100 days in prison," reported the News, he "never saw a doctor." Still, his story seems to fit into the pattern of minimalist care described in the hearing as common practice for Texas prisons.

California's prison health system last year was essentially put into receivership under direct control of a federal court due to its poor medical care, witnesses told the Commission, and officials expressed fears at the Sunset hearing that Texas might be subject to similar litigation. This case makes you understand why.

Charles Billops, Jr. would be 21 years old if he were alive today, with his whole life ahead of him. Nothing about his juvenile crimes justifies what happened to him once he was in the state's custody. His death should be a wake-up call for the state, and certainly for the 80th Legislature.