In the absence of telemedical capacity, inmates who need to see specialists typically experience delays because specialists enter the prisons on a scheduled, periodic basis rather than as needed. (This is not the case with the most acutely ill patients, who are taken to local providers or are transferred to FMCs on short notice.) By adding telemedicine to the local supply of visiting specialists, more physicians become available, and waiting times can be shortened, absent any countervailing increases in demand.
In this demonstration, the impact of telemedicine on waiting time could not be observed directly because prison staff did not maintain lists of waiting patients. An electronic record was created in the electronic SENTRY file for each waiting inmate, but when inmates saw the specialist, the record was overwritten with information about the visit. Both referral date and visit date are needed to calculate waiting times; the only surviving record of referral date was an inmate’s paper medical record.
To measure waiting times, several hundred initial encounters between an inmate and a specialist were identified during the year preceding the demonstration and the demonstration period. Paper medical records of these inmates were searched for dates of referral to specialists. Most records were unavailable because many inmates had moved out of the system or to another prison by the time of data collection, and their paper records went with them or had been archived. Inmates needing extensive medical or mental health care were transferred to FMCs, for example, and these were among the records no longer available for the waiting-time analysis. Thus the team was not able to observe waiting times for the patients of most clinical concern. Ultimately, researchers were able to calculate waiting time for a total of 150 initial encounters during the year preceding the demonstration period and 165 initial encounters during the first half of the demonstration period. The inability to find records for transferred or released inmates may have biased the comparison, although the direction and extent of that bias is difficult to discern.
Across all specialties examined, the average waiting time to see a specialist was 99 days prior to telemedicine and 23 days after telemedicine was introduced, for those encounters the team was able to measure (see table 4.1). The greatest declines were in orthopedics and dermatology.
| Table 4.1 Average Waiting Time Between Referral and Initial Consultation With a Specialist, Before and After Introduction of Telemedicine, by Specialty |
It is safe to attribute this improvement to telemedicine. The telemedicine demonstration was implemented frequently with clinics in several specialties, at reduced cost to the prisons. Increasing the frequency with which specialists are available would naturally decrease waiting times. This effect could also have been achieved by increasing the frequency of local specialists’ visits without relying upon telemedicine technology. There was no "supply constraint" on increasing use of local doctors, as the health services administrators at the three prisons agreed that their local visiting specialists would probably have been willing to come into the prisons more often. However, the prisons had to pay for the full cost of these visits by local specialists, but only for part of the telemedicine consultations. This no doubt created a special incentive to rely on remote sessions instead, and to do so frequently.