Telemedical capabilities in prisons and other settings offer the prospect of expanding access to health care providers. Information about persons who need treatment and/or diagnostic services can be transmitted rapidly to physicians or other health care providers located in other parts of the world. The information so communicated can be as limited as a written report of laboratory tests. The information also can be as complex as a digitized x-ray image or a real-time, high-resolution video conference during which a physician sitting thousands of miles away sees a patient on a video screen and images produced by a wide variety of diagnostic devices, including ultrasound and optical fiber probes. Specialists can also remotely direct general physicians in the treatment of patients so presented.

Telemedicine’s ability to broaden the supply of health care providers has the potential to overcome some of the barriers to effective prison health care that result from the structure of the American health care industry. This industry is characterized by a high degree of physician specialization, which results in patient care being provided by a number of different primary care physicians and specialists, all of whom may not be associated with formal organizations or networks. Physician specialization has significant implications. First, the accessibility of specialist care is exceedingly limited in thinly populated regions of the country (where many prisons are located). Whereas the practice of an individual primary care physician requires a population base of between 3,000 and 5,000 people to support it, the population required to support certain types of specialists is much larger. Indeed, for some specialties, the required base exceeds the populations of many large urban centers. Second, in regions where specialists are rare, those who do exist acquire monopolistic powers over consumers. The ability of patient/consumers, or those who purchase services on their behalf, to negotiate the fees paid for services or the conditions under which they are delivered is correspondingly diminished.

If, by virtue of installing telemedical communications equipment, a remotely located health care provider can communicate directly with specialists located elsewhere, the consumer’s leverage in the marketplace becomes greater. Consumers are no longer limited to the locally available medical care. More advantageous pricing may be available in this broader and, it is hoped, more competitive marketplace. If patients or those who manage their care actually use less costly specialists via the telemedicine network with sufficient frequency, in place of higher priced local providers, reductions in health care expenditures might be obtained. These savings come at a substantial price, however, as the needed equipment and telecommunications charges can be quite costly.

A few State prison systems have installed telemedicine systems, and many others are evaluating the decision to use them. BOP had been considering the use of telemedicine but was unable to assess its merits because there was no reliable basis for estimating the cost of the system or whether it would meet prisoners’ needs. This demonstration was primarily intended to supply the missing information to support that decision and develop a model for estimating the cost of telemedicine under different assumptions about costs and utilization. The costs of technology change rapidly. During the 2 years between the planning of this demonstration and its evaluation, the costs of the telemedicine equipment and communications services used for the demonstration fell significantly. Therefore, any future implementation will face cost conditions different from (and generally more favorable than) past experience. This report is intended to help prison administrators in Federal, State, or local governments assess the fiscal impact of implementing telemedicine in their correctional organizations.

It is certainly possible that telemedicine is not always cost effective but that other important benefits are obtained. For example, the availability of additional -- and different -- specialists through the telemedicine network may make needed care more accessible to patients and may lower the security risks associated with transporting prisoners out of prison.

Accessibility is of special significance in prisons. The Federal courts have ruled that prisoners in all correctional facilities -- local, State, or Federal -- have a constitutionally protected right to similar levels of health care as are available to citizens not imprisoned. Failing to provide that access places departments of correction at substantial risk of lawsuits and court-ordered mandates. Where accessibility to health care providers is limited because of geography or other barriers, telemedical capabilities may facilitate better care. Even if the provision of this telemedicine capacity is costly, the benefits of improved access may be judged to outweigh the costs.