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Release: Jan. 24, 2000

UI telemedicine experts assess statewide prison telemedicine project

IOWA CITY, Iowa -- More Iowa prison inmates are receiving health care services at the University of Iowa without leaving the correctional facilities due to advanced, two-way video systems and diagnostic equipment that allow long-distance consultations between Iowa Department of Corrections (DOC) and UI medical staff.

Moreover, the quality of telemedicine care to prisoners and its cost-effectiveness will only improve as the number of consultations increases, according to a UI telemedicine expert.

"A couple of years ago, only a handful of states were developing prison telemedicine programs. So in many ways we've been at the forefront of providing this type of service," said Michael Kienzle, M.D., professor of internal medicine and associate dean for clinical affairs and biomedical communications in the UI College of Medicine. "However, as telemedicine expands -- not just in serving the prison population but in other areas of health services delivery -- it will be a common way to do certain medical consultations."

The collaborative prison telemedicine project between the UI and the Iowa DOC began in March 1997, using the Iowa Communications Network -- the nation's first state-owned, statewide fiber optic network established in 1989 -- and existing ISDN (Integrated Service Digital Network) technology. Both the UI and the prison telemedicine sites have high-resolution television monitors that allow the consulting physician at the UI and inmate/patient to interact visually and audibly in real time. Digital diagnostic equipment, including a digital exam camera, electronic stethoscope and radiologic light box, are also available to the referring medical staffs at the prisons' telemedicine workstations.

The first connections between the UI Hospitals and Clinics and the DOC were established at the Iowa Medical and Classifications Center at Oakdale and the Iowa State Penitentiary in Fort Madison. Today, all nine Iowa correctional facilities use the telemedicine services.

Each prison medical director determines which inmate/patient cases to present for telemedicine consultation. The medical director, or sometimes a nursing staff member, presents the case. Medical specialists at the UI Hospitals and Clinics provide the consultations.

"For the UI physicians, it's a regularly scheduled clinical assignment, just like any other clinical assignment," Kienzle said. "Each department determines who staffs the consultations."

The first telemedicine consultations with the DOC involved orthopaedics, dermatology and internal medicine. Cardiology consultations soon followed. Within a few months, consultations in gastrointestinal, general urology, surgery and otolaryngology also were available.

Traditional inmate/patient visits, in which a prisoner is escorted to the UI Hospitals and Clinics, have numbered around 4,500 visits per year. Since the prison telemedicine program began in 1997, 731 consultations have been conducted. Roughly half of these consultations are routine medication checks, or surgical or other medical procedure "follow-ups," Kienzle noted.

"Doing follow-ups via telemedicine means that we could conceivably have prisoners at several facilities waiting to come online with a consulting physician here at the UI," he said. "In terms of just the logistics of running a clinic, it's much more efficient -- not to mention the time saved in transporting a prisoner here and in direct communication between the referring and consulting physicians."

Security and public safety issues are also obviously minimized, since telemedicine eliminates the need for some prisoners to be brought to the UI, Kienzle added.

Ultimately, the cost-effectiveness of the prison telemedicine program will determine its viability. Kienzle, Susan Zollo, director of the UI Telemedicine Resource Center, and Paul Loeffelholz, M.D., medical director at the Iowa Medical and Classification Center at Oakdale, published a study in the Fall 1999 issue of Telemedicine Journal evaluating the program costs.

The researchers analyzed data from 274 telemedicine consultations from the program's first year (March 1997 to February 1998). They developed cost estimates for the nearly 4,400 Iowa prisoners transported to the UI Hospitals and Clinics during this period, as well as for the equipment, circuitry and personnel costs needed on both ends of the telemedicine network.

The analysis showed that the average cost to the state's prisons for an on-site visit to the UI was $115 during the study period. The researchers found that each of Iowa's correctional facilities would need to average 275 prison telemedicine sessions per year to reach this "breakeven point" of $115. The breakeven point for the UI would be around 2,000 telemedicine sessions annually. The cost studies did not include medical care, which was assumed to be relatively comparable for both on-site and telemedicine services.

These breakeven numbers for Iowa's prisons -- 275 telemedicine sessions per prison per year -- may seem high, considering that the total number of telemedicine consultations among all the prisons has been around 275 per year since its inception, but the goal is attainable, Kienzle said.

"If half of the 4,500 prison medical cases that are sent here each year were handled by telemedicine, both the correctional facilities and the UI would be very close to their breakeven marks," he said. "Telemedicine is not going to totally replace sending prisoners to the UI Hospitals and Clinics for certain types of care. But with careful planning, it can initially be cost-acceptable. As the volume of telemedicine consultations increases, and as telemedicine is reimbursed as a health service, it will certainly become more viable."

Medicaid has paid for some telemedicine services since January 1999, Kienzle noted, but so far reimbursement has been limited.

"We're starting to see more interest in certain types of telemedicine services," Kienzle said. "My prediction is that in 2000 we'll see more reimbursement for telemedicine from Medicare/Medicaid and from third-party insurers."

University of Iowa Health Care describes the partnership between the UI College of Medicine and the UI Hospitals and Clinics and the patient care, medical education and research programs and services they provide.