Report 2009-107.1 Recommendation 10 Responses

Report 2009-107.1: California Department of Corrections and Rehabilitation: It Fails to Track and Use Data That Would Allow It to More Effectively Monitor and Manage Its Operations (Release Date: September 2009)

Recommendation #10 To: Correctional Health Care Services, California

To minimize costs through the use of telemedicine, Health Care Services should review the effectiveness of telemedicine consultations to better understand how to use telemedicine.

Annual Follow-Up Agency Response From December 2013

This recommendation has been fully implemented. The mission of Telemedicine Services, as outlined in the 2008 "Federal Receiver's Turnaround Plan of Action," is to improve access to care for patient-inmates. However, telemedicine also provides cost-effective care with reduced guarding and transportation costs. The implementation and expansion of telemedicine, has led to improved access to medically necessary specialty services statewide. OIG results indicate that court-ordered timeframes for patient-inmate specialty referrals increased from a 71% compliance rate in Round 1 (2008) to 94% compliance rate in Round 3 (2012) (Attachment 1).

Utilization of telemedicine continues to increase as the inmate population decreases (Attachment 2), indicating acceptance and effectiveness of the modality for medical consultations. Telemedicine-appropriate referrals seen via telemedicine have also increased (44% -2011, 53% -2012 and 59% -2013; Attachments 3-5). Institutional utilization management follows a standardized process with community-standard clinical guidelines to approve referrals (Attachment 6) and determine appropriateness for telemedicine before the consultations. In addition, Telemedicine conducted the following expenditures analysis on the per-encounter cost basis (Attachment A). The analysis indicates that while the annual operational costs of Telemedicine have been steadily contained, we have been improving access to care with the same level of resources. The average estimated per telemedicine encounter savings have been steadily maintained at around $226 per encounter for the last three fiscal years.

California State Auditor's Assessment of Annual Follow-Up Status: Resolved

Health Care Services states that its mission of telemedicine, while providing some costs savings with reduced guarding and transportation costs, is to improve access to care. It provided documentation of its increased use of telemedicine and asserts a standardized referral process for telemedicine referrals to ensure appropriateness, and presumbly effectiveness, of its telemedicine program.

Annual Follow-Up Agency Response From September 2012

Historically, CCHCS has been exploring various ways on how to review effectiveness of telemedicine consultations in comparison to specialty services provided onsite in institutions and services provided offsite in provider facilities. Quality Management and Utilization Management efforts and expertise within CCHCS have expanded markedly in the past several years and continue to mature; however, the provider quality and utilization metrics collected to date do not adequately differentiate telemedicine specialty encounters, outcomes, subsequent utilization, or other quality or effectiveness measures to assist in this review. In addition, current contract provisions for telemedicine specialty services do not include systematic deliverables that can be utilized to assess effectiveness.

With the initiation of primary care services via telemedicine supporting on-site primary care in three institutions (ISP, PVSP, and SATF), with over 6,900 patient encounters in FY 2011-12, the ability to compare performance measures (e.g., Health Care Services Dashboard Indicators) for patient-inmate populations served by telemedicine primary care providers versus those served by on-site primary care providers for the same institution is being pursued to establish an effectiveness metric. Telemedicine Services is seeking access to those data to perform those analyses. The future implementation of an enterprise electronic medical record system creates the opportunity to follow patient-inmates receiving telemedicine specialty and primary care to review health outcomes as compared with similar patient-inmates receiving specialty and primary care that is not delivered through telemedicine. Education and culture change efforts for staff and management in some institutions remain to improve utilization of telemedicine for appropriate specialty referrals.

CCHCS is considering options on future contractual requirements for metrics on specialty telemedicine providers, specialists providing services in institutions, and specialists providing services offsite to aid in comparisons of relative effectiveness. In the future, analyses of outcome measures to assist in a review of the effectiveness of telemedicine encounters shall become routine as reliable data sources and staff expertise to accomplish this is developed.. The lack of data to assess and technical analysis expertise has delayed implementing this recommendation. CCHCS is trying to address both of these deficiencies in order to improve efficacy and quality assessments for telemedicine services to inform policy decisions.

California State Auditor's Assessment of Annual Follow-Up Status: Not Fully Implemented

All Recommendations in 2009-107.1

Agency responses received after June 2013 are posted verbatim.