Dr. Todd R. Wilcox, MBA, CCHP (certified correctional health professional) is medical director of Wellcon, a health care delivery group for the correctional industry. He also serves as the medical director for the Salt Lake County jails in Utah and the Maricopa County Correctional Health Services in Phoenix, Arizona, home to the third-largest jail in the country. In addition, Wilcox is a senior consultant with Phase 2 Consulting, a nationally-known health care consulting group. His extensive experience in the field has convinced him that correctional health care is quickly becoming the new public health care system, but correctional health care faces two obstacles to provide truly effective care: lack of operational data and lack of funding. Here, he discusses the importance of correctional health care and how corrections facilities can make the most of the resources they have.
Correctional News: You have worked on a task force for the National Commission on Correctional Health Care on the electronic medical systems. Is there anything new to report on electronic medical records?
Todd Wilcox, M.D.: What the task force looked at was an initial overview of what it takes to do an electronic medical records project in a correctional facility. We did some presentations on that for NCCHC’s conferences. Just recently, NCCHC has come back and said you know, there’s a renewed interest level in electronic medical records and we’d like you to do some more work on that. We’re seeing that nationally on the consulting side of what we do. We’re getting a lot more facilities that are looking to do electronic medical records and are asking for assistance with how to set up that project.
Electronic medical records continue to improve, and there have been really significant steps forward in their sophistication, complexity and quality. At the same time, many correctional facilities are coming under significant pressure to control their costs as well as justify to their funding agencies how they’re spending their money effectively. There are a lot of barriers to entry into the electronic medical record world. Converting an entire system over is a very significant project. However, the benefits of doing that far outweigh the difficulty in doing it, but a lot of government agencies have not really seen the wisdom of doing a project like that, so they have not made the funding of those projects a priority.
Correctional health is really many years behind the private sector when it comes to our information structure, and facilities, particularly large facilities, are seeing that this has been a real deficit in their overall management. This is because they just don’t have very good data to explain what it is that they’re doing, and the inefficiencies that are created within a corrections health care organization are so significant that they can’t overcome them just by adding additional staff. It’s been very difficult for the industry to put electronic medical records in place. The few places that do have them have really enjoyed the benefits of that. At my jail that I run in Salt Lake, we were really one of the first jails in the country to do fully-integrated electronic medical records system, and it has revolutionized our ability to do care there.
CN: Can you give me an example of that?
TW: Well, it really has revolutionized our ability to track the health care that we deliver so that our completion rate, our quality and the thoroughness with which we do things have improved significantly. For a disease like tuberculosis, where you have to read the PPD skin test two days after you put it on the prisoner, in a jail setting in particular there is a phenomenal amount of movement of prisoners from one cell to the next, one unit to the next,. Trying to find those hundreds of prisoners every 48 hours is just a Herculean task. When we switched over to an electronic medical record, because the record system updates us as soon as the prisoners move, it becomes much easier for us to find everyone and to know what tasks need to be done. So our successful completion rate of that test has gone up dramatically.
Another example I can give you is that in many places where a paper chart system is in place, there is a really long backlog in filing lab reports that come in about prisoners. The physicians can’t really give very good care if they don’t have the data that they need in order to make decisions. Back when we were on a paper system in Salt Lake, our filing backlog was such that it took many days before that information would get into the chart. Now, it’s scanned right in or fed in electronically and is made available right away to the clinicians who can use it to make appropriate medical decisions.
CN: Let’s focus on the idea of correctional health care as community health care. Is that something that you have encountered resistance to, or is it an idea that’s gaining acceptance?
TW: I think it’s an idea that is gaining acceptance over time, and we’re starting to see many more initiatives that are focused on controlling public health problems in the incarcerated population. But more needs to be done. Correctional health has really become the de-facto caregiver, especially for mental illness.
The thing that is lagging is that the resources for doing that have not kept up with the demand for care. So, as mental health programs in communities have closed down, and as many of the mentally ill have been shifted into the correctional facilities, they’re sending the patients our way, but they’re not sending the dollars our way. I see this all over the country where the correctional facilities have become the number-one caregiver to the mentally ill, yet the community resources that do mental health care in the community are still better funded than the correctional system is, but we’re doing all the work. Correctional health is the new public health system.
Our elected officials, our fiscal managers, the people who study all this need to acknowledge just how much care we do in a correctional facility, and they need to fund us appropriately. We don’t mind doing the care, but you need to give us the resources to do it with. That’s been one of the messages that the electronic medical records systems have been able to tell. When we really tally up how much care we deliver, and we show that to the people who are in charge of the money and the policies, it’s staggering to them how much care we deliver in a correctional facility. Then we call their attention to the fact that our budgets really have not kept up with this amount of care and we’re doing the work, but we’re not getting the money.
CN: What would you say are the main benefits of containing these health problems before the prisons are released?
TW: The main benefit is that it’s a good way to focus your efforts and concentrate your efforts in this era of lack of money, lack of resources and lack of staff. If you’re able to concentrate your delivery of care in a group that is in one place – you don’t have to go out and find them – you have a fairly good chance of having good follow-up data and good follow-up visits with the patients. It just makes everything more efficient. And given the overcrowding that is occurring in our prisons and jails, there’s a much bigger push to release these folks out into the community. So, if you’re able to control the disease and deal with things before they get released, then when they are released into the community, you don’t have to deal with that problem at a community level. It’s already been taken care of.
To me, that’s the big shift that has to occur. There needs to be an acknowledgement that we have a great environment to do this care in, we’re mandated to do it under the law, so we need to be funded appropriately. Unfortunately, until the dollars catch up with the demand on care, it really makes it hard for us to be effective at what we do. That’s one of the messages that we have for folks. There are limited total resources, but we’re the ones who have the huge volume of patients, and you need to invest your money into those areas because we can make maximum use of it.
CN: What are some of the other challenges faced by health care in a correctional setting?
TW: Well, I think everybody’s faced with a challenge of resources. There’s always more need that there is money to do health care in corrections. I think there are challenges with respect to the difference between the security requirements in correctional facilities and the health care requirements, and that sometimes causes us to have difficulties in taking care of prisoners. There’s also a very significant public relations barrier, because many of the elected officials don’t view correctional health as a priority that the public is interested in. They don’t always take the broader view that these people are all going to be returning to their community and that the most inexpensive way to deal with these problems is while they’re incarcerated, as opposed to waiting until they’re out in the community and having public funds and the community take care of health problems that could have been addressed here
CN: You had mentioned something about security issues with inmates and getting them the care they need. Can you talk a little bit more about that?
TW: Every correctional facility faces challenges in the delivery of health care. There are many things that are barriers to the delivery of health care and sometimes, the security needs of the facility become barriers to our ability to deliver health care in an effective way. Sometimes there will be lockdowns and sometimes officers have different priorities than the health care staff, so prisoners are not able to be pulled out to be seen by the health care staff. Sometimes prisoners are ordered to go to court when we’ve made arrangements for them to go to the hospital to have a certain type of exam done. The legal and the security side of the world takes priority in a correctional setting and that really causes us a lot of dilemmas on the health care side, because it presents barriers to our ability to deliver good health care. We accept that as the nature of where we do business, but the impact of that can be fairly significant sometimes.
For example, at one jail facility we had an outbreak of chickenpox. The only way to control chickenpox is to put people in quarantine, and you have to keep them in quarantine for a significant period of time. For between 30 and 40 days, they have to be in full quarantine. Well, when you quarantine a large group of prisoners who are in the process of going to court and all that, it presents incredible havoc to the system, because these people can’t get to court, they can’t be seen, they can’t have visitation. Sometimes there are breakdowns in that pure quarantine setup because of other priorities. We’ve had the prolongation of the outbreak because other priorities have weighed in, and we were not able to do it as a pure, 100-percent quarantine of that group.
CN: Is there some way that correctional facilities can impress upon the public the importance of providing adequate health care to prisoners while they are incarcerated?
TW: I think those of us who work in the industry spend a lot of time talking about the benefits of why it’s good to do health care for the incarcerated population. The problem is that we mostly talk amongst ourselves about that. I don’t see the lay media doing very much work on trying to explain why this is thought to be a priority. A lot of people who study this, those in public health, policy folks at the federal level, the health care staff who work in correctional facilities, have all seen the benefit of doing an appropriate level of health care for this population. But that message has not really been successfully communicated to the public. I think we all continue to hope that people will look at this from a broader perspective, that enlightened authors will begin to start talking about why this has a benefit to the greater society, but right now I just don’t see a lot of that out there, so we continue to struggle with this perception problem. Given the dollar figures for what we spend on correctional health the mainstream media should be interested. Nationally, it is a phenomenal amount of money.
CN: Is there anything else you’d like to add?
TW: The key is to have good information, and the electronic medical record allows you to do that. Once you have good information, then you can do the health care much more effectively and actually much cheaper than if you don’t have that good information. So it’s all about information control in health care. That’s the thing that makes or breaks the difference.