Telemedicine consultations completely replaced conventional consultations in some specialties, but substituted for few, if any, conventional consultations in others. This yielded an overall increase in consultations provided by a combination of conventional and remote specialists.

Figure 2.1 shows trends in the numbers of monthly consultations provided conventionally by specialists visiting the three Pennsylvania prisons prior to the initiation of telemedicine and afterwards, the number of telemedicine consultations each month after the demonstration began, and the total combined volume of both telemedicine and conventional, in-prison consultations.¹

These counts of conventional, in-prison consultations are limited to those for which specialties could be identified in the BOP automated medical data files (the Sensitive Medical Data, SMD): psychiatry, dermatology, orthopedics, and cardiology. These specialties accounted for 84 percent of all teleconsultations. For purposes of comparing conventional and telemedicine consultations, all other specialties were excluded from the monthly counts of conventional in-prison and remote consultations.

As figure 2.1 shows, total consultations (conventional plus telemedicine) increased during the demonstration period, due to a combination of reduced conventional consultations and additional telemedical consultations. The change happened quickly. During the last 2 months of the demonstration, telemedicine consultations (and, therefore, all consultations) increased still further, although this pattern was not uniform at all remote sites. The numbers of conventional, in-prison consultations at USP-Lewisburg declined from March through December 1996 (see figure 2.2), the months before telemedicine became available.

When telemedicine became available in January 1997, it rapidly became the dominant form of specialty consultation, and the combination of telemedicine and some remaining conventional consultations provided about as many encounters as had been delivered by conventional medicine alone in 1996.²

At USP-Allenwood, the frequency of conventional, in-prison specialist consultations had been increasing for a few months prior to the introduction of telemedicine. This trend eased, but the addition of telemedicine resulted in an overall increase in total consultations (see figure 2.3).

At FCI-Allenwood, there were fewer conventional, in-prison consultations during the year preceding the demonstration than at the other prisons. These consultations, which had been largely with psychiatrists, quickly dropped to zero when telemedicine was initiated and were replaced with an equal number of telepsychiatry consultations (see figure 2.4). Conventional consultations then increased slightly, largely in cardiology -- probably because more inmates needed cardiology services during the demonstration period. There appeared to be a complete substitution of telepsychiatry for conventional psychiatry, but little substitution of telecardiology for conventional cardiology.

Lewisburg would be expected to report higher numbers for specialist encounters because it has a larger primary population than the other two prisons. During the 12-month period preceding the demonstration, the average daily population was about 1,500, compared with about 1,000 at USP-Allenwood and about 1,100 at FCI-Allenwood. If the level of medical need was the same at each of the three facilities, and if the ratio of demand to services provided inside the prisons was the same, Lewisburg would be expected to experience about 50 percent more encounters each month with specialists. Indeed, Lewisburg had about 50 percent more consultations than USP-Allenwood, but FCI-Allenwood had very few consultations.³

The effects of telemedicine on conventional, in-prison consultations were less significant at FMC-Lexington. As the earlier figure 1.1 indicates, the facility did not begin to function as a remote site until late in the demonstration period. Half of the teleconsultations were with a remote podiatrist. Because SMD data do not indicate conventional encounters with podiatrists, utilization trends before and after telemedicine’s implementation could not be tracked. Because so few other types of telemedical consultations occurred between FMC-Lexington and specialists at VAMC, before-and-after trends were not mapped.

These differences in utilization rates may have reflected differences in the frequency with which specialist clinics were held in each of the prisons. For example, USP-Lewisburg brought in an orthopedist approximately twice per month before the demonstration began, while the Allenwood facilities each held orthopedic sessions once every 2 months. USP-Lewisburg held eight dermatology clinics during the year preceding the demonstration, while USP-Allenwood held only one. There may have been differences in the morbidity in the populations at each of the three facilities, but other factors probably accounted for the different frequency of scheduled clinics:

• Administrative decisions to allocate budgets for care differently.

• Decisions to provide a greater proportion of care internally by staff physicians rather than consulting specialists.

• Difficulties in obtaining services from consultants willing to work inside the prisons.

• Differing reliance on specialists working in nearby hospitals.

For example, administrators at FCI-Allenwood reported that although they could have made good use of dermatology and cardiology services on a quarterly basis, they could not afford these specialists at local market rates. Therefore, FCI-Allenwood relied on primary care staff to handle dermatology cases and took small numbers of prisoners to cardiologists outside the prison walls when necessary.

The mix of telemedicine and conventional, in-prison consultations differed not only among the various institutions, but also among different specialties. Telemedicine virtually replaced the conventional prison specialist in psychiatry; in the three other specialties tracked unambiguously over time, the total volume of consultations increased (see figure 2.5).

At all prisons, use of consulting psychiatrists coming into the prisons virtually ended with the introduction of telemedicine technology. The few such encounters reported during the telemedicine demonstration period occurred largely during the first weeks -- perhaps because they were already scheduled. (See tables C.1 and C.2 in appendix C for the monthly utilization of telemedicine by specialty.) Prison staff in all three facilities reported being very satisfied with the psychiatrists located at FMC-Lexington, who served as the remote specialists for all psychiatric telemedicine encounters. Indeed, they were more satisfied with the quality of these psychiatric services than those delivered previously by the local consulting psychiatrist.⁴

At USP-Lewisburg, the number of psychiatric encounters was about the same before and during the demonstration; what changed was the technology for conducting them. In the predemonstration period, there was an average of 22 consultations per month with the visiting psychiatrist. Following the introduction of telemedicine, there were 22 per month, but all were provided by telemedicine. In the other two facilities, the introduction of telemedicine appears to have increased the total number of psychiatric encounters. At USP-Allenwood, for example, the total number grew from 6.5 per month prior to telemedicine’s implementation to 17 per month during the demonstration period. At FCI-Allenwood, the increase was less dramatic but nonetheless an increase: from 11 per month to 15 per month. Again, this may have resulted from the perceived quality and competence of the remote psychiatrist, compared with his local counterpart, although changes in prisoners’ needs for care cannot be ruled out.

Telemedicine also substituted for in-prison consultations with dermatologists. An average of 6 dermatology consultations per month during the predemonstration period increased to 14 per month during the demonstration. Seventy-seven percent of the dermatology consultations during the demonstration period were provided via telemedicine.

Telemedicine also substituted for orthopedic consultations in all facilities, but conventional, in-prison orthopedic consultations also continued. Lewisburg averaged 19 monthly orthopedic consultations during the predemonstration period, and 16 per month during the demonstration -- with 23 percent of the encounters during the demonstration provided remotely. At USP-Allenwood, the total number of orthopedic encounters increased from 3 to 16 per month, on average, with 20 percent of these provided remotely. (The increase in conventional orthopedic consultations was reportedly due in part to a new orthopedist who had a practice of ordering more followup visits.) At FCI-Allenwood, the number of monthly orthopedic encounters remained small (an average of three per month throughout the entire period); 28 percent during the demonstration period were provided remotely.

Very few (18) telemedicine consultations were held with cardiologists. These consultations were for patients with coronary artery disease or valvular heart disease and for secondary prevention, such as chest pain. During the year prior to the demonstration, there were very few in-prison consultations with visiting cardiologists. These numbers are too small to base any inference about substitution rates. They indicate, however, that telemedical consultations were considered feasible in at least some proportion of the cases.

¹ The curves shown in figures 2.1 through 2.4 do not precisely indicate the numbers of different consultations in each month, but are smoothed to represent trends better. For actual numbers of consultations, see tables C.1–C.3 in appendix C.

² Lewisburg’s use of telemedicine in some months was severely restricted because of security problems unrelated to telemedicine.

³ The inconvenience of transporting inmates from FCI to USP for telemedicine may have contributed to the reluctance to use telemedicine.

⁴ Despite the near cessation of in-prison psychiatric consultations, prison administrators did not cancel contract with local specialists becuase they did not want to dislocate those relationships entirely; this demonstration was being tested for only 12 months, with no guarentee that telemedicine would continue to be available afterwards.