Putting telemedicine be­hind bars

Modern Healthcare - - NEWS - By Erica Te­ichert

Dr. Vinh Pham treats dozens of pa­tients from New York City’s Rik­ers Is­land jail com­plex with hep­ati­tis C and other in­fec­tious dis­eases. He knows their frus­tra­tion with the process of ac­cess­ing spe­cial­ist care—and its qual­ity. In­mates can spend six to eight hours shack­led in hold­ing pens and sit­ting in traf­fic

as they travel to NYC Health & Hos­pi­tals’ Belle­vue cam­pus for five min­utes with a doc­tor. “That was frus­trat­ing for the pa­tient be­cause they went through this tremen­dous ef­fort to get there and they could only have this very, very lim­ited time to get their con­cerns ad­dressed,” Pham said.

Pham and his col­leagues came up with a so­lu­tion. Ear­lier this year, they in­tro­duced telemedicine to Rik­ers Is­land, which has some 55,000 in­mates come through its doors an­nu­ally.

Since the ini­tia­tive be­gan in May, 52 in­mate pa­tients have had vir­tual check­ups and in­for­ma­tion vis­its with Belle­vue’s in­fec­tious dis­ease, gas­troen­terol­ogy and urol­ogy spe­cial­ists. They al­low Pham and oth­ers to spend up to 30 min­utes with a pa­tient an­swer­ing ques­tions and or­der­ing treat­ment when nec­es­sary.

The in­mates “just pal­pa­bly seem more re­laxed and sat­is­fied with the en­tire en­counter and ex­pe­ri­ence than they used to,” Pham said.

“It used to be a very neg­a­tive ex­pe­ri­ence.” De­mand for in­mate health­care is ris­ing as the U.S. prison pop­u­la­tion ages. The num­ber of in­car­cer­ated men over the age of 55 jumped 82% from 1999 to 2007, ac­cord­ing to the U.S. Bureau of Jus­tice Sta­tis­tics. More than 18% of fe­male in­mates in 2011 were over 50 years old, and that pro­por­tion has grown faster than their male coun­ter­parts over the years. Fe­male prison pop­u­la­tions are also more ex­pen­sive to treat than their male coun­ter­parts.

Pris­on­ers are sicker than the gen­eral pop­u­la­tion. About 40% of pris­on­ers re­port they have at least one se­ri­ous chronic ill­ness. In­mates are also at least seven times more likely to have a chronic hep­ati­tis C in­fec­tion. At Rik­ers, NYC Health & Hos­pi­tals es­ti­mates that 12% of the average daily pop­u­la­tion has hep­ati­tis C.

Pro­vid­ing care to in­mates isn’t easy or cheap. Cal­i­for­nia’s Leg­isla­tive An­a­lyst’s Of­fice es­ti­mated that trans­port­ing, guarding and med­i­cally treat­ing an in­mate could cost more than $2,000 per day, and a Pew Char­i­ta­ble Trusts re­port found health­care costs for prison in­mates reached nearly $8 bil­lion in 2011. That price tag con­tin­ues to rise de­spite grow­ing pres­sure to cut cor­rec­tional fa­cil­ity bud­gets.

"The in­mates just pal­pa­bly seem more re­laxed and sat­is­fied with the en­tire en­counter and ex­pe­ri­ence than they used to. It used to be a very neg­a­tive ex­pe­ri­ence

Dr. Vinh Pham, right, of NYU Lan­gone's Hos­pi­tal for Joint Dis­eases, speak­ing with Dr. Zachary Ros­ner

Many fed­eral, state and lo­cal cor­rec­tional fa­cil­i­ties are turn­ing to telemedicine as a cost-ef­fec­tive so­lu­tion for pro­vid­ing high qual­ity care. Telemedicine first sprang up in pris­ons in the 1990s as a way to pro­vide spe­cialty care for pris­on­ers with­out ramp­ing up trans­porta­tion and se­cu­rity spend­ing, ac­cord­ing to the U.S. Jus­tice Depart­ment.

It’s taken longer for state and lo­cal jails to har­ness telemedicine, even though they in­cur more than 90% of the costs of cor­rec­tions in the U.S., ac­cord­ing to the Cen­ter for Eco­nomic and Pol­icy Re­search in Wash­ing­ton, D.C.

NYC Health & Hos­pi­tals and Rik­ers are slowly and me­thod­i­cally rolling out the new tech­nol­ogy. In May, the sys­tem fun­neled $650,000 into a pi­lot pro­gram. So far, only about a dozen doc­tors and pa­tient co­or­di­na­tors en­gage in vir­tual vis­its, which are lim­ited to in­fec­tious dis­ease, gas­troen­terol­ogy and urol­ogy spe­cial­ists.

“We have a broad as­pi­ra­tion to do more of this across ser­vices,” said Dr. Homer Ven­ters, chief med­i­cal of­fi­cer of NYC Health & Hos­pi­tals. “But when we start, we need to identify staff that are re­ally go­ing to cham­pion this.” Ven­ters pre­vi­ously over­saw New York City’s cor­rec­tional health pro­gram for the Depart­ment of Health and joined NYC Health & Hos­pi­tals when the sys­tem took the lead on the pro­gram.

Pham is one of those cham­pi­ons. The sec­tion chief of in­fec­tious dis­ease at NYU Lan­gone Med­i­cal Cen­ter’s Hos­pi­tal for Joint Dis­eases, Pham has treated Rik­ers Is­land in­mates for eight years on an af­fil­i­ate agree­ment be­tween the health sys­tems. “Vinh has been very ded­i­cated to get­ting this project off the ground,” said Dr. Zachary Ros­ner, deputy di­rec­tor of med­i­cal ser­vices for NYC Health & Hos­pi­tals.

Pham has seen his pa­tients warm up to the vir­tual vis­its. Dur­ing a visit, Pham sits in his of­fice at Belle­vue with a two­screen setup that al­lows him to see the pa­tient and his or her elec­tronic health record. The in­mate joins the video con­fer­ence from a clin­i­cal space on the is­land. Un­shack­led and ac­com­pa­nied by a pa­tient nav­i­ga­tor, the in­mate can ask Pham about their con­di­tion and op­tions for con­tin­u­ing care af­ter leav­ing Rik­ers. Guards stand watch out­side the room for con­fi­den­tial­ity and se­cu­rity rea­sons.

The goal is to give hep­ati­tis C pa­tients the tools needed to man­age their in­fec­tion, Pham said, even if they’re re­leased ear­lier than ex­pected. “I make it clear to the pa­tients that this is about pre­ven­tive health,” he said.

Hep­ati­tis C drugs are no­to­ri­ously ex­pen­sive, cost­ing up to $100,000 to for a year’s worth of treat­ments. NYC Health & Hos­pi­tals has bud­geted $2.5 mil­lion in fis­cal 2017 for hep­ati­tis C drugs, and $5 mil­lion in the en­su­ing years. In ad­di­tion, it has part­nered with Merck to re­ceive dis­counts on its new hep­ati­tis C treat­ment, Zepatier. Those ini­tia­tives should help the health sys­tem triple the num­ber of in­mates who will re­ceive the treat­ment.

The vir­tual vis­its have also been used in gas­troen­terol­ogy and urol­ogy to pro­vide test re­sults, pre-op vis­its and eval­u­a­tions for in­mates with con­di­tions in­clud­ing mild ane­mia, Crohn’s dis­ease, ul­cer­a­tive coli­tis or dif­fi­culty with uri­nat­ing.

“We’ve al­ways viewed our role in cor­rec­tional health as part of the public health sys­tem,” Ros­ner said. “When peo­ple are frus­trated dur­ing a very dif­fi­cult time for them, we do feel that hav­ing ro­bust health sys­tems in place can make a pos­i­tive out of a very dif­fi­cult sit­u­a­tion.”

Al­though Rik­ers’ telemedicine pro­gram has started small, the fa­cil­ity has a ro­bust in­mate in­take pro­gram that could help NYC Health & Hos­pi­tals quickly ramp up telemedicine vis­its. Upon en­ter­ing Rik­ers Is­land’s jail, each in­mate gives a com­plete med­i­cal his­tory and gets a phys­i­cal ex­am­i­na­tion, no mat­ter the length of their stay. Cor­rec­tional health providers will flag in­mates that could ben­e­fit from spe­cial­ist care or even a telemedicine visit dur­ing this process, Ros­ner said.

The in­take process is com­pre­hen­sive and can in­clude HIV test­ing and vac­ci­na­tions, ac­cord­ing to Ven­ters. “It’s like a hos­pi­tal ad­mis­sion,” he said.

For years, fed­eral pris­ons have had a more ro­bust telemedicine pro­gram than lo­cal and state jails do. In­mates in fed­eral prison tend to serve much longer sen­tences and the Jus­tice Depart­ment has sup­ported us­ing the tech­nol­ogy for decades. An average stint at Rik­ers lasts 55 days, mak­ing it dif­fi­cult for the lo­cal jail to even sched­ule spe­cial­ist and telemedicine ap­point­ments be­fore in­di­vid­u­als leave.

In Jan­uary, NYC Health & Hos­pi­tals for­mally took over the en­tire cor­rec­tional health pro­gram for the city’s jails. Ven­ters said that helped Rik­ers get its telemedicine pi­lot pro­gram off the ground.

“We were a health sys­tem on the out­side try­ing to in­no­vate with a whole other or­ga­ni­za­tion,” he said. “Since we came into Health & Hos­pi­tals, we’ve be­come a whole fam­ily.”

Rik­ers and the health sys­tem are look­ing at sev­eral pos­si­bil­i­ties for ex­pand­ing its telemedicine pro­gram, in­clud­ing psy­chi­atric con­sul­ta­tions and other spe­cialty ser­vices. It also plans to add ad­di­tional NYC Health & Hos­pi­tal cam­puses to the telemedicine net­work.

“I see this as just the be­gin­ning,” Pham said. “I’m very op­ti­mistic.”

"We've al­ways viewed our role in cor­rec­tional health as part of the public health sys­tem. When peo­ple are frus­trated dur­ing a very dif­fi­cult time for them, we do feel that hav­ing ro­bust health sys­tems in place can make a pos­i­tive out of a very dif­fi­cult sit­u­a­tion."

Dr. Zachary Ros­ner, deputy di­rec­tor of med­i­cal ser­vices for NYC Health & Hos­pi­tals

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