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Chapter 1. Introduction

Health care has become one of the largest expenditures for corrections programs nationwide. In 2005, the US correctional enterprise spent approximately $3.1 billion on providing health care to the incarcerated population, an amount growing annually at the rate of 10%.2 Similarly, in 2004, the US spent $1.9 trillion on health care, an annual increase of 7.9%, representing 16% of the national GDP.3 This alarmingly fast increase in health care spending has prompted the correctional community and the health care community in general to look for new models and strategies for managing the health care environment. Health Information Technology (HIT), and more specifically an Electronic Health Record (EHR), is seen by many as the ultimate tool for improving the quality of health care delivery, lowering health care costs, and providing better information to patients and physicians. According to many, a nationwide EHR system has the potential to revolutionize the delivery of care to an increasingly mobile population and significantly reduce medical errors stemming from lack of access to complete medical records, ineligible handwriting, and discontinuance of care.

Unfortunately, the complexity associated with the transition from a paper to an electronic record, whether in civilian or custodian setting, is consistently underestimated. The complexity of this transition stems from the centrality of record creation and the management and use processes in the day-to-day activities of professionals involved in the delivery of health care. In the correctional setting these complexities are significantly compounded. The particular characteristics of the environment make an already complicated effort even more difficult. In any organization, the design of a new record format is relatively easy compared to the effort associated with changing organizational procedures and practices as necessitated by adoption of an EHR. Inserting an EHR system into the day to day activities of doctors, nurses, and medical records professionals will require them to work differently. In this case, so too will corrections officers, prison superintendents, regional medical directors, prison reception center staff, and parole officers, to name just a few.

Although there is a wealth of information about the impact of EHR systems generally, information about the impact in a custodial setting has not been studied in any systematic way. Nevertheless, EHR systems are expected to provide valuable benefits in the correctional setting, ranging from restraining growing health care costs1, to improving public safety by eliminating travel by inmates to specialty care appointments, to improving quality of care for inmates by offering easy and timely access to a high-quality medical record.

This document reports on a project conducted on behalf of the New York State Department of Correctional Services (NYS DOCS) to explore the likely benefits and associated costs of an EHR


2 Perez, Arturo, 2005. “States Wrangle With Corrections Budgets”, State Legislatures, May 2005.

3 2004 National Health Expenditure Data. Center for Medicaid and Medicare Services.


The New York State Department of

Correctional Services (DOCS) has 70 facilities and approximately 63,000 inmates. It is the fifth largest correctional department in the country with only the federal prison system, Texas, California, and Florida exceeding it in size and complexity.

for NYS DOCS. The project, A cost benefit analysis of an electronic health record for NYS DOCS, was initiated in the summer of 2005 by the former New York State Department of Correctional Services Commissioner, Glenn Goord.

The project was carried out in three overlapping phases. Phase one involved research on the EHR landscape in the United States generally and within the context of the correctional community, as well as research on the commonly agreed upon costs and benefits associated with EHR adoption and use (see Appendix A for Literature Review). Phase two focused on the development of a comprehensive description of the medical services environment in NYS DOCS. This included the identification and high-level modeling of key business processes associated with medical care in NYS correctional facilities and the primary stakeholders in these processes. The project also included an analysis of the various aspects of the medical record itself and related policies and management issues such as HIPAA and enterprisewide data standards. Phase three focused on a more detailed analysis of the policy, management, and technology issues related to the adoption of an EHR within NYS DOCS. Phase three was comprised of interviews with staff from a number of medical services units throughout the state. The challenges facing medical services unit staff as they deliver medical services to inmates and their perspectives on the costs and benefits related to the adoption and use of an electronic medical record were explored during these interviews (see Appendix B for project methodology and interview questions).

Chapter two introduces the definitional issues associated with an EHR and provides some information about current practices in health information technologies and EHR in particular. Chapter three outlines the source of many of the environmental and organizational challenges facing NYS DOCS in the transition to an EHR. The benefits of an EHR both generally and in a correctional context are introduced in chapter four together with barriers to implementation at NYS DOCS found in the environmental analysis. Finally, chapter five provides a set of recommendations designed to assist NYS DOCS in their efforts to fully realize the benefits of an EHR as well as a brief discussion of related cost estimation issues.