Data sources: SMD, paper records, and telemedicine data.

Waiting time was calculated as the interval between the date of a referral to a specialist and the date the patient-specialist encounter actually occurred. For the period preceding the demonstration, SMD data were used to identify the first encounter between an inmate and a given type of specialist (for example, an orthopedist). Because data extended 6 months prior to this baseline period, the first encounter could be determined with some precision. SMD does not contain a field for referral date, but the consult referral form in an inmate’s medical record has a space for the referral date. This was the source used to identify referral dates for the predemonstration period, from which the interval between referral and first encounter was calculated.

Only waiting times for the first encounter between an inmate and a specialist were computed because specialists often order followup visits on specific dates -- for example, to return for followup in 3 weeks. The research team did not have access to all of these orders to see if they were followed, but it would be incorrect to label that 3-week wait as a delay, for it may be the proper interval between encounters. By focusing instead on the time to the first encounter, a more accurate representation of the accessibility of specialist services is obtained. Intervals between referral and external encounters were not computed because there were very few telemedicine-substitutable external encounters to consider, and many of those medical records were no longer available.

Inmates relocate often within BOP prisons, and their medical records travel with them. By the time the research team arrived to look through medical records, a year had passed since the start of the predemonstration period and many medical records were no longer available. For those records that could be found, the referral date was entered on some but not all forms. There were very few observations for many specialties at each prison. Only a few specialties at each prison had sufficient data for the predemonstration period to warrant a comparison with the demonstration period. The data presented are for those specialties for which calculated waiting time was based on more than a handful of cases. During the demonstration period, some internal encounters continued; their referral dates were collected and waiting times calculated in this same manner.

For telemedicine encounters, researchers initially planned to use the same approach: relying on medical records as the source for referral dates. When the research team realized how problematic this strategy was proving to be for the internal encounter referral dates, the telemedicine site coordinators began collecting referral dates on the telemedicine encounter forms. This referral date was used to calculate waiting time for the first encounter between a remote specialist and an inmate.