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For other articles and previous issues click here. July 26, 2004 Electronic
Medical Records Go to Jail Bar coding behind bars? Go inside the joint to learn how one company is making it work. If you don’t look too hard, it would appear to be quite like a doctor’s office. As in any medical department, you’d see an examination room, a lab draw area, an x-ray room, and a medical records area with some 1,000 charts, many several inches thick. There is paper everywhere—forms, orders, reports, and medical histories. Doctors and nurses screen patients, perform diagnostic tests, and administer drugs. Here’s the difference: The patients, who are uniformed and wear bar-coded ID badges, may be held in locked cells for medical observation. They wear bar-coded bracelets that are scanned as they move from area to area, and their fingerprints are monitored by biometric devices. Felons or delinquents, they’re among a small group of Americans guaranteed access to complete healthcare. And now, increasingly, they, as well as those responsible for their care, are benefitting from the transition from paper to electronic medical records (EMRs). The provision of healthcare in correctional facilities is fraught with challenges in addition to those that occur in more ordinary settings in what correction professionals call the free world. Like virtually everywhere else, providers and staff are plagued by the proliferation of paper. They’re frustrated by the task of deciphering handwriting, the constant search for charts, and the repetitive collection and duplication of information. At the same time, they must provide care on a 24-hours-a-day, seven-days-a-week basis in an arena where security is paramount. To reap the same benefits as its counterparts on the outside—and to help meet both the routine and unique challenges of serving a captive population—one company is turning to technology, taking EMRs to the “big house.” Corrections Corporation of America (CCA) designs, builds, and operates prisons, jails, and detention facilities for government partners in 22 states. In most cases, it owns the facilities, although in some instances it manages state-owned facilities. The leading provider of correction services to government agencies, the CCA began the private corrections industry. The Nashville, Tenn.-based corporation is the sixth largest corrections system in the nation, managing 62,000 inmates—only the federal government and four state systems surpass its reach. While its primary customers are state departments of corrections and federal government agencies, such as the Bureau of Prisons, the Immigration and Naturalization Service, and the U.S. Marshals Service, the CCA is also responsible to what it considers a secondary client—the taxpayers—who, as John Tighe, vice president of health services, notes, put the money in the government coffers. It’s part of a larger effort on the part of the CCA to automate many aspects of its operation of correctional facilities. At two of its facilities in Arizona, the CCA has begun the rollout of a new inmate management system that will eventually be implemented in its remaining 57 facilities. The system stores prisoner information, including photographs and biometric data, and helps facilitate prisoner movement throughout the system. This technology is being harnessed to accomplish a variety of objectives, including reducing the amount of paper, improving the ability to track and control inmates in the system, and increasing cost efficiency. Companies in the private corrections business, such as the CCA, take on the responsibility not only to house, feed, and offer programming and services to prisoners but also to provide them with constitutionally based care, including mental, physical, and dental health services. “We operate like a closed-panel HMO in that we’re paid a fixed amount of money from the government—whether state, local, or federal—to take care of the inmates’ needs,” says Tighe. “And out of that fixed dollar amount we have to provide the facility all of the services. We have to feed and clothe the inmates, staff the facility, and provide complete medical care, so you might say we work on a fixed capitated basis.” The CCA employs doctors, nurses, and dentists and tries as much as possible to provide care from within the system. Anything that can be done for inmates on-site is done in the prison setting, including clinics, physicals, dental care, screenings for contagious diseases, administration of drugs, routine treatment, and mental healthcare. When the need for outside services arises—for example, if a patient requires an MRI, cardiac consultation, or hospitalization—the CCA purchases those services from providers and facilities in the free world. Considering that each correctional facility is staffed 24 hours a day, seven days a week and provides a wide range of health services to as many as 3,300 inmates—many of whom may be residents for eight years or more—there’s clearly an enormous volume of medical documentation. In the process of developing the broader new inmate management system, the need to move toward an EMR quickly became apparent. Tighe describes the conversion as a simple process of going to a nearly paperless environment. While in the free world the implementation of EMRs is typically anything but simple, the CCA’s approach so far has been smooth and successful. “We’re converting our facilities systematically one at a time to a complete electronic health record. From the time of the inmates’ intake to the facility to the time of their discharge, all documentation, ordering, charting, notes, and medication administration are done in the electronic record, so there’s no paper,” explains Tighe. In instances where paper is unavoidable—for example, when an inmate must go to a hospital emergency department that does not employ electronic records—the paper record is scanned into the EMR system and then destroyed. When exploring the possibilities, CCA was certain of one thing: It didn’t want to reinvent the wheel by developing its own medical record software. It was aware that a lot of work had already been done in that area, yet finding a good fit with existing products was a daunting prospect. “There were very well-recognized and [well]-regarded software vendors who did hospital work and were making some good products, but we’re not a hospital,” Tighe says. “Our inmates are outpatients, and we found these products very tertiary in their application. We liked some of what we saw, but it was too complicated.” The CCA also looked at office practice/outpatient software but found that its focus tended to be on billing—on capturing enough information to get a bill out as opposed to achieving a completely electronic medical record. While security issues don’t have the same urgency in free-world healthcare facilities, they’re of utmost importance to the CCA and they helped drive its system choices. When individuals are going to be incarcerated, the primary intake is focused on security protocols and systems. (In the prison business, intake refers to the process of screening and booking new inmates into the facility.) The information that’s collected pertains to basic identifying information, inmate history, and items such as the prisoners’ aliases, gang affiliations, and property and possessions. It is critical that the CCA is able to integrate these data into the health record so intake efforts are not duplicated and providers have adequate security information and information to provide adequate healthcare. The inmates’ mug shots, for example, move across into the health records so that the first time a doctor or nurse sees the prisoners, they can identify them by their photograph in the record. Bar codes and iris scans are also transferred into the record at the time of intake. Information about where a prisoner comes from and his or her gang affiliation becomes critical when scheduling. “You don’t want to have two inmates sitting in a waiting room and find out that they’re incompatible,” says Tighe. The need to move information around in this particular manner narrowed the CCA’s list of preferred vendors. For a variety of reasons, the CCA ultimately selected two technology partners: IDX Systems Corporation and Allscripts Healthcare Solutions. On site visits, the CCA found that doctors were most satisfied with this product because it was user-friendly. Most were thrilled to have implemented it and were making the most of its clinical applications, explains Tighe, who adds, “Everybody knew that behind-the-scenes billing capabilities were important, but they were excited about what they could do in their practices with this information.” In addition, he says, IDX and Allscripts were willing to work with the CCA to automate, create enhancements, and develop additional software in response to the company’s unique needs, such as those pertaining to medication administration. In the free world, a doctor may prescribe a medication for a patient, who then fills the prescription at the pharmacy. In correctional facilities, says Tighe, “you don’t give inmates bottles of medications that they can move around. That’s like contraband.” Correctional facilities distribute the medication to inmates and therefore must have medication administration records (MARs) that document drug delivery. The EMR system is completely operational in one of the CCA’s Arizona facilities, with the second test facility to soon follow suit. “We’re going to take a breather now for a few months,” says Tighe, “and make sure that we optimize the system and work out the bugs, which have been few. Then we’ll hit with a vengeance in the fall and start rolling out and implementing the system facility by facility.” Initially, the CCA employed a superuser format for training—a process adapted after testing. “On our first rollout, we picked the superusers based on who we thought would really get into it, and sometimes we ended up using our best nurses or doctors,” says Tighe. Rather than second-guessing, the CCA then tried letting people get used to the technology and selected those who liked it, making them superusers. “That system is working very well for us,” he says. “We started out with using consultants, as most companies do, but now we have people in these facilities who are incredibly knowledgeable about the system and they’re now training the next generation of superusers.” The CCA has been exceedingly pleased with the ease of implementing its EMR initiative and with the capabilities the vendors have provided. One of the reasons the process moved along unimpeded—as is so seldom the case in hospitals—is that there was no need for decision making by committee. “We are one company of some 60 facilities, and we can make decisions for the entire company,” Tighe explains. “We didn’t have to get the consensus of every doctor in the group, which makes a huge difference.” This doesn’t mean the CCA didn’t get considerable physician input to ensure that it was getting the most user-friendly system possible and that the staff wouldn’t find its use oppressive. But unlike hospitals, where voluntary medical staff can admit their patients elsewhere if they don’t buy into the system, the CCA employs its doctors and nurses, and it will only hire clinical staff who want to use technology in their patient care delivery. “It’s been embraced very positively by almost everyone,” Tighe says. “We think it gives us a real edge not only with our customers but also in recruiting and retaining the kind of workforce we want in our facilities. We want people who want to spend more time in patient care and less time in documenting and fooling around with paper.” Being protocol-driven may also have given the CCA an edge over its hospital counterparts. “We typically handle an inmate in a certain way,” explains Tighe. “We have a specific drug formulary process and a pharmacy and therapeutics process that’s very organized, so we do things pretty much in the same way in all of our facilities.” He likens the CCA to Kaiser Permanente in many respects—Kaiser being a model of an institution with many branches that all do things in a like manner. “Just like there’s a Kaiser way, there’s a CCA way that lends itself to automation,” says Tighe. He notes, for example, that one could load into the system 50 nursing protocols that are manually done more or less the same way in every CCA facility, making it simpler to automate those protocols. The EMR and medical management software give correctional facilities the ability to have legible progress notes in their records. Although that’s a plus in the free world, it’s especially important when care involves contract physicians and others from outside the facilities. The system also gives practitioners the benefit of being able to quickly build notes on a patient and easily update their problem lists. Staff doesn’t have to track down charts but instead has immediate and simultaneous access to records that are always up to date. In addition, says Tighe, the system allows the CCA to use bar code technology to be able to efficiently and quickly distribute medications to the inmates. Staff capture the bar code on the inmate ID badges. In a process called “pill call,” inmates line up to receive medication. Their ID badges are scanned and an LPN distributes medication to the laptop that can be wheeled to anywhere in the facility. Once medications are distributed, TouchWorks automatically moves the information into the MARs. In addition, the software will prompt doctors if they prescribe a medication that conflicts with other medications the inmate is already taking. Furthermore, Tighe explains, the system allows facilities to link to the ordering system through the pharmacy in real time to take advantage of a distribution system for refilling medication. This eliminates the need for the manual process of ordering medications. Physicians also have visual cues that let them know which drugs are on the formulary and which are not. They can still order off the formulary, but whereas in the past they would have to fax forms and requests—which often got waylaid or lost—now they enter information onscreen to justify their request to go off formulary. The system electronically moves that information to a physician in the field who does peer review. The reviewer can pull up the medical record, review the data and the doctor’s rationale, and then approve or deny the request electronically. If the request is approved, the approval goes automatically to a remote drug distribution system, which ships the medication immediately. Another important benefit of the system can be seen in the bottom line. “Since we operate like a closed-panel HMO, data is my business,” Tighe says. “I’ve got to have data on the inmates, to know what’s going on with them clinically, and to be able to tie that to cost so that I always know where I stand with respect to my expenditures for these inmates. And the system itself brings obvious cost efficiencies, reducing, for example, the labor time involved in manual drug administration by replacing it with bar codes and automatic charting.” Tighe says inmates are contracting more complicated and chronic illnesses. “Having one comprehensive problem list, one allergy list, and not having to hope that somebody transcribed something correctly can bring incredible savings from a risk standpoint,” he says. Tighe sees the use of EMRs in correctional facilities as an example of what can be achieved by those who take up the challenge of making the most of technology. “The President of the United States has said that in 10 years he wants to see the entire country using electronic health records,” he says. “We’re a customer of the federal government and take care of many federal inmates, so our ability to have an electronic health record in place in correctional facilities is a step forward for agencies such as the Bureau of Prisons and the U.S. Marshals Service, who are able to turn around and say to the commander in chief that here’s a place where we’re making it happen.” — Kate Jackson is a staff writer at For the Record. |
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