Medical science changes quickly. Evening news broadcasts inform us regularly about newer and better drugs, new diseases, better ways to scan the body, foods to avoid or consume, and more. The methods for delivering medical treatment are changing, too: It is no longer necessary for the two parties involved in a medical encounter, a patient and a health care provider, to be in the same location simultaneously. The telephone has enabled doctors to practice limited aspects of medicine over vast distances without travel, a benefit of great importance to persons in remote areas. With further advances in digital and communications technologies, the number of health care applications that can be administered remotely is increasing rapidly. Today's telecommunications infrastructure of satellites, the Internet, and telephone wires, coupled with advances in the ability to capture, store, transmit, and display electronic representations of medical information, allow doctors to do many things remotely that they have traditionally done in person.
Because the problems associated with traveling to deliver or receive medical care are substantial, telemedicine, loosely defined as the remote delivery of health care via telecommunications, is a concept that is rapidly becoming a practical method of health care delivery. Suppose people in Florida could visit the Mayo Clinic in Rochester, Minnesota, without leaving their home State? Suppose an American sailor on an aircraft carrier in the Mediterranean could be treated onboard by doctors at Bethesda Naval Hospital without leaving the ship? What if x-rays taken at a rural clinic in Colorado could be transferred electronically to an urban medical center in Denver for immediate diagnosis by a radiologist? These are not medical fantasies; rather, they are technology applications currently in practice worldwide.
America has many disturbing health care problems, among them cost and access. Estimates from 1996 are that Americans spend approximately 14 percent of their annual earnings on health care, up 4.4 percent from 1995. The U.S. Department of Health and Human Services estimates that approximately 24 percent of Americans live in rural areas with limited access to health care services. For obvious reasons, many in the health care profession need to know if telemedicine's advantages could offer solutions to these two vexing health care problems.
Prisons are in some respects a microcosm of American society, and thus telemedicine offers prison managers a viable means of addressing the issues of cost and access to specialists. Prison officials are required by the constitution of the United States to provide health care for prisoners. Health care costs for prisoners are increasing, just as costs of medical care in free society are increasing. Prison population demographics show a trend toward older offenders who are serving longer sentences and who have greater health care needs. Furthermore, prisons are often located in remote geographic areas where access to health care specialists is difficult to arrange. Providing specialized medical attention may entail an expensive trip outside the secure perimeter for the prisoner, or a time-consuming and expensive visit to the prison by specialists.
Telemedicine is promising for prison use in a number of ways. This technological innovation is seen as a possible solution to rising health care costs, which can compose 20 percent or more of total prison operating costs. It also offers additional security advantages, since some prisoners may use outside medical trips to attempt escape. The use of telemedicine provides medical advantages for prisoners that should help to create more tranquil and manageable prison environments. Difficult medical cases that could take months to resolve under normal circumstances can be treated more quickly because the pool of specialists is larger and more accessible.
The Federal Bureau of Prisons' (BOP's) interest in telemedicine began some years back after a dramatic escape attempt occurred when an inmate from the Federal Penitentiary at Lewisburg, Pennsylvania, was on an escorted medical trip to a local hospital. An escort officer was murdered during the incident, making the event especially tragic and the need to do something to protect escort staff more salient. BOP considered adding telemedicine to its health care regime, but at the time, telemedicine equipment and communication costs were prohibitively high. BOP elected instead to make significant improvements to escort security procedures.
BOP's interest in telemedicine continued, however, and officials noticed that costs were falling and technology was improving. But officials were reluctant to make a wholesale change without compelling evidence that a new approach could replace conventional medicine at a reasonable cost. There were no scientific investigations to consult to help them make a decision.
The U.S. Departments of Defense (DoD) and Justice (DOJ) have a preexisting agreement to jointly develop and demonstrate emerging technologies of mutual interest to both law enforcement and the military. The National Institute of Justice (NIJ) is DOJ's lead agency, while the Defense Advanced Research Projects Agency (DARPA) is the lead agency for DoD. NIJ and DARPA determined that a demonstration of telemedicine technology in Federal prisons would have relevance to State and local prisons and to military operations. They agreed to jointly sponsor and manage the demonstration through a special program team, the Joint Program Steering Group (JPSG).
To develop and implement this program, JPSG assigned the Department of the Navy's Space and Naval Warfare Systems Command (SPAWAR) Center in Charleston, South Carolina, as the technical agent. Through an existing SPAWAR Systems Center services contract, Tracor Systems Technologies, Inc., was awarded a delivery order to design, procure, install, and evaluate a telemedicine system. Tracor subsequently issued a subcontract to Abt Associates Inc. to evaluate the telemedicine demonstration.
BOP agreed to participate in the demonstration by allowing the modification of medical practices in three Federal prisons in Pennsylvania and one prison medical center in Kentucky to accommodate a telemedicine network. The remote sites in the network are linked to the Department of Veterans Affairs (VA) Medical Center in Lexington, Kentucky, where VA specialists provide medical services to BOP at a cost that is generally lower than could be obtained in communities near the prisons. The reimbursement BOP pays the VA is "unsubsidized," hence the VA receives an amount for services that offsets the total amount the VA actually pays for doctors, including fringe benefits. Fees for communications and equipment also are unsubsidized. The absence of subsidies is very important because it means that projected savings resulting from this telemedicine arrangement translate into actual savings for taxpayers -- not a shift in cost from one part of government to another.
The evaluation that follows demonstrates convincingly that, after telemedicine was established within the prisons, it was widely embraced by officials and prisoners. Further, the evaluation establishes that a correctional agency such as BOP can add telemedicine to its medical program with the expectation that taxpayer dollars will not be wasted and, if anything, substantial savings associated with the new technology may be realized. At the moment, BOP continues to practice telemedicine, and more than 1,600 consultations have occurred since the network was established. The network has been transitioned smoothly from the JPSG project team to BOP, and utilization levels remain stable. The evaluation that follows will help BOP and State, local, and military entities determine what future role telemedicine might play in their health care delivery systems. NIJ will release subsequent reports and documents from JPSG's Biomedical Technology Program to provide guidance on implementing a telemedicine network.
Many Thanks
Douglas McDonald and his colleagues at Abt Associates Inc. conducted this evaluation. Some of the people who made the demonstration possible may not have contributed directly to the Abt evaluation, and hence they escaped notice in the Acknowledgments section of this report. We want to make sure these people receive the recognition they deserve.
Several people in BOP's Health Services Division (HSD) contributed significantly to the demonstration. Senior Deputy Assistant Director Ron Waldron has had a longstanding interest in testing telemedicine in prisons, and his assistance and support were crucial to the success of the project. HSD's Health Care Specialist, Rad Clark, worked diligently to see that the necessary agreements were in place. We also want to thank Assistant Director and Chief Medical Officer Kenneth Moritsugu and BOP Director Kathleen Hawk-Sawyer for providing their support as well as access to health care resources underscoring the importance of the demonstration. In BOP's Contracts Division, Chief Contracting Officer Craig Unger, his staff, and Contracts Specialist Vernon Smith provided valuable assistance.
Wardens at the telemedicine remote sites provided the leadership that was necessary for the technology to take hold. They were Jim Holland (USP-Allenwood), J.D. Lamer (USP-Lewisburg), Marge Harding (FCI-Allenwood), and Art Beeler (USMC-Lexington). Jim Holland was especially helpful and a true champion of telemedicine. Art Beeler deserves special thanks for sharing the services of his medical personnel with other institutions and for recommending the Lexington VA hospital as a hub site. Also at the Lexington Federal Medical Center, Chief of Medicine Richard Ramirez, Chief Psychiatrist John Eisenbach, and Psychiatrist Luis Morales deserve recognition for their assistance.
At the VA Medical Center in Lexington, Kentucky, Helen Cornish, Director, and William Hogerty, Special Assistant to the Director, deserve recognition for having the vision to enter into this challenging partnership with the other agencies; their support throughout the demonstration was invaluable. The many fine VA physicians who provided consultant services should also be mentioned. Foremost among them are Drs. Herbert Kaufer, Margaret Terhune, Malkanthie McCormick, Craig Chasen, and Charles Zimmermann.
The demonstration produced many deliverables, but none of greater significance than the evaluation that follows. Abt Associates Inc. prepared the report. We are indebted to them for their excellent work.
Finally, we wish to thank the implementation team -- an amalgam of persons from various organizations. Eddie Broyles from SPAWAR Systems Center, Charleston, South Carolina, was Senior Systems Engineer and Technical Agent for this demonstration; he was responsible for management of project funding and overall implementation, including management of the prime contract. Herman Walker, Project Engineer with Tracor Systems Technologies, Inc., was responsible for executing the contract with SPAWAR. Under his direction, Tracor provided nearly all of the services necessary to procure, install, and evaluate a telemedicine network. He was responsible for the daily implementation and problem solving associated with a project of this size and for management of various Tracor employees and subcontracts. Tracor employees Roddy Traxler and John Smith assisted him. Tracor consultants Allan Turner and Jordana Bernard performed many important duties in the areas of program development and implementation, training, evaluation, equipment selection, report development, and liaison. Finally, from Systems Planning Corporation, Chris Tillery helped with project funding and preparing documents and agreements necessary for interagency coordination.
Peter L. Nacci, Ph. D.
Program Manager, Biomedical Technology Program
Co-Chairman, Joint Program Steering Group
National Institute of Justice and Defense Advanced Research Projects Agency