Health Briefs A Health Data System for New York State Correctional Facilities JACK FROOM, MD, BARBARA HOWE, PHD, DARLENE MANGONE, AAS, CHRISTINE SWEARINGEN, MPH, AND PERRY S. WARREN, MA
Introduction The inadequacy of prison health care has been reported in several recent evaluations of United States correctional facilities.1-8 However, data on the magnitude and specifics of health needs and services in these facilities remain scarce. This paper reports on the implementation of a comprehensive health data collection and medical records system in three New York State correctional facilities.
taught about the new data collection system. Three important aspects of the new system are: 1) a nurse screening procedure; 2) a non-prescription pharmacy counter; and 3) a problem-oriented medical record set-up. Each of these innovations was introduced in keeping with the above-mentioned goal of maximizing utilization of extant personnel's skills at the same time that new data collection routines were being introduced.
Procedures
Methods and Material In the initial stage of the project, a multi-disciplinary team evaluated the health care delivery and medical records system in three of New York State's correctional facilities. At that point, up to 10 per cent of inmates at some of the facilities were coming to sick call and having encounters with prison physicians on any given day. The evaluators focused on the logistics of implementing a new health data collection system in the diverse and often understaffed state facilities. In each case, their recommended changes were designed to maximize immediately the effective use of existing personnel in the delivery of care while implementing the new data collection routines. Following the initial site visits, a pre-test set of new medical forms was prepared for the three demonstration sites, and a series of two-day seminars were held for all of the facilities health personnel. At these seminars, providers were Address reprint requests to Dr. Jack Froom, The Family Medicine Program, University of Rochester School of Medicine and Highland Hospital, 885 South Avenue, Rochester, NY 14620. Ms. Mangone and Mr. Warren are also with The Family Medicine Program; Dr. Howe is Assistant Professor of Sociology, SUNY at Buffalo; Ms. Swearingen is with ABR Associates, Boston. This paper, submitted to the Journal September 13, 1976, was revised and accepted for publication November 15, 1976.
250
Under the new procedure, the initial contact of the inmate with the medical care system now can occur at a nonprescription pharmacy station. With administration and medical director's approval, the non-prescription pharmacy provides such items as foot powder, hair tonic, and aspirin. Inmates are permitted to obtain limited, pre-packaged quantities of these items without nurse or physician contact. These pharmacy encounters are recorded on a daily pharmacy list. All inmates whose medical needs cannot be met at the non-prescription pharmacy are screened by a nurse who handles simple problems such as upper respiratory infections, minor skin rashes, or minor trauma. An inmate may then see the physician if he desires or if the level of care required is beyond the capability of the nurse. The core of the new medical record system is the problem-oriented medical record.9' 10 With this approach the screening nurses as well as physicians may record and classify on an inmate's ambulatory health record the problems presented at each encounter. As the provider enters a problem on the multiple copy ambulatory record form,* he/she assigns to it the proper code number from the International Classification of Health Problems in Primary Care."1 12 In *Copies of form are available on request to senior author. AJPH March, 1977, Vol. 67, No. 3
PUBLIC HEALTH BRIEFS
this way, he/she is making a computer-ready record of the problems presented by each inmate at each encounter. The data from all of these precoded forms are then entered regularly from each facility into a central state computer.
TABLE 1-Percentage Distribution of Diagnostic Categories Treated during December 1975 According to Facility. Diagnostic Category
Evaluation The introduction of the new health delivery procedures and forms at the three state correctional facilities was made on a trial basis. As a result of feed-back solicited from the providers during the trial period, minor revisions were made in the forms and procedures, which are now being introduced in the rest of the state's facilities. From the demonstration phase two major results were observed. First, as a consequence of the modifications in the organization of delivery, patients who are referred to physicians or who request physician care now number only about ten per cent of the total daily sick call. The rest of those coming to sick call are now provided for at the non-prescription pharmacy or the nurse's screening station. For a large state facility, this means that only 20 patients per day, rather than 150 to 200, now may meet with a physician. Thus the most seriously ill inmates can receive amounts of physician's time not previously available. The second major outcome of the new system is the availability of systematic data on the health problems being encountered in each facility. Among the reports generated from the demonstration period are summary statistics on the daily encounters at each facility. These data are useful in assessing workloads and planning appropriate personnel coverage. Another report lists daily contacts for specific disease by inmates at each facility. This information can help physicians assess underutilization of medical services by those inmates who may need continuous observation or treatment for serious illnesses. A third report that can be generated from the new system is a monthly profile of the diagnostic behavior of the health care providers at each correctional facility. Table 1 is an example of such a report. Already this report has indicated striking differences in the distribution of diagnoses by category of disease among the three demonstration facilities. It is expected that these statistical reports will provide the basis for further improvements in health care delivery in these facilities. It is hoped also that these data as well as the health data collection approach introduced here will be useful in planning health care for other institutionalized populations. REFERENCES 1. American Medical Association. Proposal for a program to im-
prove medical care and health services for the inmates of the na-
AJPH March, 1977, Vol. 67, No. 3
Facility
Facility
Facility
#11
#18
#21
Total
(N=2605) (N=1325) (N=583) (N=4513) 4.1 3.6 3.5 3.6 0.0 0.0 0.0 0.02 0.7 1.1 0.5 0.9 0.1 0.1 0.1 0.0 8.7 4.7 1.3 9.6 5.2 4.6 2.6 12.3 1.4 4.9 3.3 3.0 Circulatory System 21.1 25.7 11.0 Respiratory System 21.0 2.2 6.1 5.8 Digestive System 6.5 1.7 0.2 1.6 0.8 Urinary System 8.6 5.5 6.0 Skin/Subcutaneous 4.9 2.2 3.2 1.5 6.9 Musculoskeletal Physical Signs & 11.7 12.8 13.0 3.9 Symptoms 12.7 17. Accidents, Etc. 11.6 26.6 10.1 21.4 31.4 19.6 18. Supplementary 2.6 99.9 Total 100.0 100.0 99.8 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 12. 13. 16.
2.
3. 4. 5. 6. 7. 8. 9.
10. 11.
12.
Infective Neoplasm Endocrine Blood Diseases Mental Disorders Nervous System
tion's jails and prisons and juvenile determination facilities. Chicago: AMA Division of Medical Practice, March, 1973. American Medical Association. Medical Care in U.S. Jails: Report on the 1972 AMA Medical Survey of U.S. Jail System. Chicago: AMA Center for Health Services Research and Development, February, 1973. Brecher, E. M., Della Penna, R. D. Health care in correctional institutions. National Institute of Law Enforcement and Criminal Justice, 1975. Goldsmith, S. B. The status of prison health care. Public Health Reports 89:569-575. Also see his Prison Health: Travesty of Justice. New York: Neale Watson, 1975. Medicine Behind Bars. Health/Pac Bulletin No. 53:2-9, 1973. New York State Special Commission on Attica, Special Report. New York: Bantam, especially pp. 63-72. Prison Health Project. Common Health 2:4 1-28, Fall 1973. Prison health services. N. Engl. J. Med. 200:856-857, 1974. Froom, J. The problem-oriented medical record. Journal of Family Practice 1:48-51, 1974. Weed, L. Medical Records, Medical Education and Patient Care. Cleveland: The Press of Case Western Reserve, 1969. International Classification of Health Problems in Primary Care. American Hospital Association. 1975. Manual of the International Statistical Classification of Diseases, Injuries and Causes of Death. Geneva: World Health Organization, 1967.
ACKNOWLEDGMENTS The authors are grateful to: Ian T. Loudon, MD, Assistant Commissioner for Health Services, William A. Clermont, FACHA, Associate Director for Health Services, and Gail S. Chase, Health Data Analyst, for their encouragement, enthusiasm, and help in the implementation of this project.
251
Introduction The inadequacy of prison health care has been reported in several recent evaluations of United States correctional facilities.1-8 However, data on the magnitude and specifics of health needs and services in these facilities remain scarce. This paper reports on the implementation of a comprehensive health data collection and medical records system in three New York State correctional facilities.
taught about the new data collection system. Three important aspects of the new system are: 1) a nurse screening procedure; 2) a non-prescription pharmacy counter; and 3) a problem-oriented medical record set-up. Each of these innovations was introduced in keeping with the above-mentioned goal of maximizing utilization of extant personnel's skills at the same time that new data collection routines were being introduced.
Procedures
Methods and Material In the initial stage of the project, a multi-disciplinary team evaluated the health care delivery and medical records system in three of New York State's correctional facilities. At that point, up to 10 per cent of inmates at some of the facilities were coming to sick call and having encounters with prison physicians on any given day. The evaluators focused on the logistics of implementing a new health data collection system in the diverse and often understaffed state facilities. In each case, their recommended changes were designed to maximize immediately the effective use of existing personnel in the delivery of care while implementing the new data collection routines. Following the initial site visits, a pre-test set of new medical forms was prepared for the three demonstration sites, and a series of two-day seminars were held for all of the facilities health personnel. At these seminars, providers were Address reprint requests to Dr. Jack Froom, The Family Medicine Program, University of Rochester School of Medicine and Highland Hospital, 885 South Avenue, Rochester, NY 14620. Ms. Mangone and Mr. Warren are also with The Family Medicine Program; Dr. Howe is Assistant Professor of Sociology, SUNY at Buffalo; Ms. Swearingen is with ABR Associates, Boston. This paper, submitted to the Journal September 13, 1976, was revised and accepted for publication November 15, 1976.
250
Under the new procedure, the initial contact of the inmate with the medical care system now can occur at a nonprescription pharmacy station. With administration and medical director's approval, the non-prescription pharmacy provides such items as foot powder, hair tonic, and aspirin. Inmates are permitted to obtain limited, pre-packaged quantities of these items without nurse or physician contact. These pharmacy encounters are recorded on a daily pharmacy list. All inmates whose medical needs cannot be met at the non-prescription pharmacy are screened by a nurse who handles simple problems such as upper respiratory infections, minor skin rashes, or minor trauma. An inmate may then see the physician if he desires or if the level of care required is beyond the capability of the nurse. The core of the new medical record system is the problem-oriented medical record.9' 10 With this approach the screening nurses as well as physicians may record and classify on an inmate's ambulatory health record the problems presented at each encounter. As the provider enters a problem on the multiple copy ambulatory record form,* he/she assigns to it the proper code number from the International Classification of Health Problems in Primary Care."1 12 In *Copies of form are available on request to senior author. AJPH March, 1977, Vol. 67, No. 3
PUBLIC HEALTH BRIEFS
this way, he/she is making a computer-ready record of the problems presented by each inmate at each encounter. The data from all of these precoded forms are then entered regularly from each facility into a central state computer.
TABLE 1-Percentage Distribution of Diagnostic Categories Treated during December 1975 According to Facility. Diagnostic Category
Evaluation The introduction of the new health delivery procedures and forms at the three state correctional facilities was made on a trial basis. As a result of feed-back solicited from the providers during the trial period, minor revisions were made in the forms and procedures, which are now being introduced in the rest of the state's facilities. From the demonstration phase two major results were observed. First, as a consequence of the modifications in the organization of delivery, patients who are referred to physicians or who request physician care now number only about ten per cent of the total daily sick call. The rest of those coming to sick call are now provided for at the non-prescription pharmacy or the nurse's screening station. For a large state facility, this means that only 20 patients per day, rather than 150 to 200, now may meet with a physician. Thus the most seriously ill inmates can receive amounts of physician's time not previously available. The second major outcome of the new system is the availability of systematic data on the health problems being encountered in each facility. Among the reports generated from the demonstration period are summary statistics on the daily encounters at each facility. These data are useful in assessing workloads and planning appropriate personnel coverage. Another report lists daily contacts for specific disease by inmates at each facility. This information can help physicians assess underutilization of medical services by those inmates who may need continuous observation or treatment for serious illnesses. A third report that can be generated from the new system is a monthly profile of the diagnostic behavior of the health care providers at each correctional facility. Table 1 is an example of such a report. Already this report has indicated striking differences in the distribution of diagnoses by category of disease among the three demonstration facilities. It is expected that these statistical reports will provide the basis for further improvements in health care delivery in these facilities. It is hoped also that these data as well as the health data collection approach introduced here will be useful in planning health care for other institutionalized populations. REFERENCES 1. American Medical Association. Proposal for a program to im-
prove medical care and health services for the inmates of the na-
AJPH March, 1977, Vol. 67, No. 3
Facility
Facility
Facility
#11
#18
#21
Total
(N=2605) (N=1325) (N=583) (N=4513) 4.1 3.6 3.5 3.6 0.0 0.0 0.0 0.02 0.7 1.1 0.5 0.9 0.1 0.1 0.1 0.0 8.7 4.7 1.3 9.6 5.2 4.6 2.6 12.3 1.4 4.9 3.3 3.0 Circulatory System 21.1 25.7 11.0 Respiratory System 21.0 2.2 6.1 5.8 Digestive System 6.5 1.7 0.2 1.6 0.8 Urinary System 8.6 5.5 6.0 Skin/Subcutaneous 4.9 2.2 3.2 1.5 6.9 Musculoskeletal Physical Signs & 11.7 12.8 13.0 3.9 Symptoms 12.7 17. Accidents, Etc. 11.6 26.6 10.1 21.4 31.4 19.6 18. Supplementary 2.6 99.9 Total 100.0 100.0 99.8 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 12. 13. 16.
2.
3. 4. 5. 6. 7. 8. 9.
10. 11.
12.
Infective Neoplasm Endocrine Blood Diseases Mental Disorders Nervous System
tion's jails and prisons and juvenile determination facilities. Chicago: AMA Division of Medical Practice, March, 1973. American Medical Association. Medical Care in U.S. Jails: Report on the 1972 AMA Medical Survey of U.S. Jail System. Chicago: AMA Center for Health Services Research and Development, February, 1973. Brecher, E. M., Della Penna, R. D. Health care in correctional institutions. National Institute of Law Enforcement and Criminal Justice, 1975. Goldsmith, S. B. The status of prison health care. Public Health Reports 89:569-575. Also see his Prison Health: Travesty of Justice. New York: Neale Watson, 1975. Medicine Behind Bars. Health/Pac Bulletin No. 53:2-9, 1973. New York State Special Commission on Attica, Special Report. New York: Bantam, especially pp. 63-72. Prison Health Project. Common Health 2:4 1-28, Fall 1973. Prison health services. N. Engl. J. Med. 200:856-857, 1974. Froom, J. The problem-oriented medical record. Journal of Family Practice 1:48-51, 1974. Weed, L. Medical Records, Medical Education and Patient Care. Cleveland: The Press of Case Western Reserve, 1969. International Classification of Health Problems in Primary Care. American Hospital Association. 1975. Manual of the International Statistical Classification of Diseases, Injuries and Causes of Death. Geneva: World Health Organization, 1967.
ACKNOWLEDGMENTS The authors are grateful to: Ian T. Loudon, MD, Assistant Commissioner for Health Services, William A. Clermont, FACHA, Associate Director for Health Services, and Gail S. Chase, Health Data Analyst, for their encouragement, enthusiasm, and help in the implementation of this project.
251
