Telepsychiatry Inc. provides intrastate and interstate services, including program development, psychiatric consults, and direct patient care. The company consults to several agencies, including the California Department of Corrections. “Prisons are the absolute best (for telemedicine) because you can get better doctors,” Dorsey says. “A lot of doctors—solid, middle-of-the-road doctors—aren’t about to go to the rural areas in the first place; they’re certainly not going to go behind prison walls.”
Today’s prisons are put into rural areas because urban areas don’t want them. But where does that leave wards of the state in need of a specific type of care?
A growing network
As easy as “phoning it in” sounds, concerns and misconceptions linger. One is economic. In years past, the practice hasn’t always been exactly feasible. Some places required terminals costing upwards of $20,000. Then dial-up and, recently, DSL and high-definition came along. Since then, operating costs have gone down significantly.
Dr. Avrim Fishkind, a psychiatrist in Houston, rarely sees his patients in person. Fishkind has worked in emergency psychiatry for about 12 years. “Back in 2000 most emergency psychiatry was being done in a very small number of places—jails, schools, shelters and on the streets—the only way they could think of to solve the problem was by using telemedicine.
“Right around 2007 the cost of equipment had dropped enormously.” he says. “The pressure to help law enforcement and judges, patients and their family, had all reached a fever pitch.”
In November 2007 Fishkind and his colleagues opened DHS Telehealth and Psychiatry. Since then they’ve grown from one doctor and one office manager to more than 25 psychiatrists, and an advanced nurse practitioner. They receive around 60,000 patient contracts a year with more than 30 organizations in Texas and Los Angeles. They’re even on cruise ships.
Transportation is generally the biggest cost-savings attributed to remote care. At DHS a psychiatrist in Houston can see an emergency patient in the same city, then see an emergency call in Dallas 30 minutes later. Twenty minutes after that the doctor might see another call in Alpine, Texas, which is 150 miles from a psychiatric treatment center. Fishkind notes: “So that one psychiatrist in the course of an 8-hour shift can travel what would have taken 4 [miles] to 5,000 miles to travel, and suddenly be available in a lot of different-type facilities.”
Enabling a secure connection
Another common concern involves security and HIPAA compliance. Linda McKenny, RN, is a senior health care services manager who oversees the Office of Telemedicine Services (OTS) at the California Prison Health Care Services (CPHCS). She manages the telemedicine program statewide at all 22 adult institutions. Each institution determines its own clinic setup, and can choose from 25 available specialties, including primary care and telepsychiatry. Like any health care appointment, security and privacy is of the utmost importance.
“We have firewalls, and we have our chief security officer to ensure that any of the telecommunications and video streams that we have set up are encrypted,” says McKenny. Encryption lets users keep track of each IP address. CPHCS does not allow physicians to work from home or remote areas. McKenny adds, “You’ve got an actual health care session going on and we want to respect the rights and privacy of individuals the same as if it were a physical examination.”
The CPHCS program also mandates that equipment is locked up every evening. McKenny and other purveyors of telemedicine agree that cooperation with custody personnel is crucial to success, as they are the ones working directly with doctors and participating in day-to-day operation. Custody should be involved in everything from the kick-off of a new clinic expansion to implementing safety measures within the session itself.
And what about the patients? Are they comfortable taking their most personal maladies and grievances to someone three thousand miles way, via screen? Fishkind assures that in today’s world it’s practically a non-issue. For one thing, technology’s more prevalent and it’s generally more acceptable. He adds, “People are astonished when their mind wraps around the idea that … the doctor’s making house calls ... and they’re getting help quickly. It doesn’t take long for them to realize that this is a fairly miraculous thing that’s happening.”