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Best practices in jail-based health care, part I
By Paul Sheehan , COCHS Chief Operating Officer
Published: 09/08/2008

0908ekg Editor’s note: This story is provided by Community Oriented Correctional Health Services, which helps correctional agencies partner with community health providers, from its quarterly newsletter, COCHS Connection

In part one, author Paul Sheehan discusses the use of electronic medical record software systems in jails. Next week, in part two of two, Sheehan details the benefits of electronic medical record software systems.

In the health care world at large, there is a lot of talk about “best practices.” Sometimes called treatment algorithms, practice guidelines or protocols, or, more loosely, “gold standards,” they are the agreed-upon components of medical care for specific diagnoses, based on either the best available medical evidence or expert consensus, that lead to optimum patient outcomes.

For example, people with diabetes need to have their blood-sugar levels monitored regularly, and they should be screened for diabetic retinopathy, a disease of the eye related to diabetes. There are protocols for how best to treat patients who enter the emergency room with signs of a heart attack.

Efforts are being made to embed best practices into systems of care to help ensure that patients get the right care at the right time. The most common way of doing this is through electronic medical record (EMR) software systems, ideally with automated clinical decision supports that prompt providers on appropriate next steps and warn of potential adverse effects.

Entering the Information Technology Age For jails, the idea of automating medical records and clinical care processes is still very new. This lack of experience with integrated information technology (IT) systems can present serious barriers to jails that are trying to implement a community- based approach to health care.

These integrated systems allow jails and community health providers to share information about their patients, coordinate care across a continuum, and ensure best practices.

Robert B. Greifinger, MD, professor of health and criminal justice and a Distinguished Research Fellow at John Jay College of Criminal Justice in New York, says that jails need to create organized systems to ensure access to needed care, continuity of care, and coordination of care. This is important because jails must meet a constitutional requirement of providing inmates with access to timely and appropriate health care.

In addition, the Supreme Court has ruled that jails cannot practice what is called “de- liberate indifference” to serious medical needs.

Greifinger explains: “Inmates are en- titled to be protected against unnecessary death and unnecessary deterioration of function, so long as the institution was aware of the serious medical need, or should have been aware.”

For example, if an inmate has diabetes, jail officials not only must ensure appropriate treatment of the diabetes, but they must also determine whether the inmate has conditions associated with diabetes, such as retinopathy, and treat those conditions appropriately to prevent loss of function. That means both controlling blood-sugar levels for the diabetes and ensuring that the inmate’s vision is not deteriorating from possible retinopathy.

Step-by-step practice protocols can help providers identify inmates’ medical needs in a timely fashion and treat them appropriately. In one local initiative, the District of Columbia’s Department of Corrections (DoC) has developed a best practice protocol to screen inmates for gonorrhea and Chlamydia with a urine test at booking.

Jail officials are working to embed this protocol into the DoC’s EMR system. DC is one of the first major cities in the U.S. to implement a program bringing community-based health care to jail inmates.

By screening offenders at booking, jail officials protect both inmates and their communities from sexually transmitted dis- ease (STD), according to Keith Barton, MD, medical director of Community Oriented Correctional Health Services (COCHS).

“Most inmates in county jails are released within 14 days, and many are released within 48 hours,” Barton notes. “If we wait for the standard sick-call process to identify in- mates with these common STDs, it often won’t happen.”

“Meanwhile, infected inmates with few or no symptoms are contagious, particularly to their spouse or sexual part- obtained at booking can identify these mild or asymptomatic cases in time for treat- ment to start in jail,” Barton says.

Providing a Spectrum of Care

STD screening is only one of many protocols that need to be in place to help ensure proper inmate care. For sheriffs and jail administrators, this presents a dilemma. Jail inmates are at high risk for a host of communicable and chronic diseases, as well as mental health and substance abuse problems.

Many have had little if any contact with the health care system prior to entering jail. But these factors do not relieve jails of their responsibility to provide good health care.

“Jails have to be full-service medical providers, because inmates have no access to any other health care while they are in jail,” says John Abbey, president of Abbey Group Consultants, a consulting firm that specializes in developing and integrating IT for public safety organizations.

Abbey believes that automation of clinical practices through an EMR system offers the best solution. Whether a jail operates its own medical program or contracts with a private firm, it must establish practice protocols for standards of care that protect inmates’ health, Abbey says.

The best protocols are developed with the involvement of medical staff and then submitted to peer review. Greifinger agrees that automation can make the job easier, but stresses that the key is to create effective systems for scheduling appointments, ensuring follow-up, and measuring quality to improve performance.

Also vital: linking the medical record system to the jail locator system, so that correctional officials know where their patients are – whether they’re in custody or not.

“Jail locator systems are almost all automated, but they need to be linked to the medical record,” Greifinger says. “So if a person has a medical appointment for next Friday but he’s going to be discharged before then, his name should come off the appointment book. Hopefully, he’ll be seen in the community.”

Abbey notes that, in correctional medicine, probably fewer than half of the processes involved in delivering care are clinical. Instead, they tend to focus on issues like initiating the medical encounter, generally through screening at booking; inmate classification; transportation; and security.

Prior to joining COCHS as chief operating officer, Paul Sheehan was employed by the Hampden County Sheriff's Department and Correctional Center in Massachusetts. There, he developed and managed a wide variety of facility and community-based inmate programs, including education, substance abuse treatment, vocational, and domestic violence.

To subscribe to the COCHS free, quarterly newsletter, COCHS Connection, send an email to newsletter@cochs.org. Please indicate whether you’d like to receive the newsletter by email or in hard copy through the mail.


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