Health Care Behind Bars

In 2004 at San Quentin, the 156-year-old prison where the state of California keeps some of its most dangerous criminals, doctors saw an inmate for high blood pressure, diabetes and renal failure. The inmate got two drugs that, according to court documents, made his kidney problems worse. His blood pressure climbed so high his eyes bled. Yet, a year passed before prison medical staff referred the inmate to a kidney specialist at a local hospital. He never got to go - the records are unclear about why - and he died three months later. If only, as on the outside, there had been a database to alert prison doctors of drug interactions. If only there had been software to schedule appointments. If only there had been basic Internet access, e-mail and electronic data about patients, so that prison medical staff could share information. That patient might have lived.

More than 170,000 inmates crowd California's 33 state prisons - more than double the number the prisons were built to hold. Inside those bars, one inmate dies every six to seven days because of "deplorable" medical care, according to US District Court Judge Thelton Henderson. In 2001, 10 inmates at nine prisons, including San Quentin, accused the state of violating the Eighth Amendment with medicine that amounts to cruel and unusual punishment. In 2002, Henderson agreed with the inmates, pronouncing California's prison healthcare system unconstitutional. The state settled the case, agreeing to fix the problems. But by mid-2005, after six days of hearings, Henderson concluded the state had made no progress. He seized control, appointing a receiver - a federal overseer - to hire new people, change processes and install basic IT found even in small rural hospitals in the US.

The aim of the receivership (officially the California Prison Health Care Receivership) isn't to offer criminals state-of-the-art health care. It's to do no harm. The decision and other court material relay story after story of how inmates didn't get the right medications on time. Or they didn't see specialists when they should have. Or they were treated by incompetent doctors whose personnel records didn't document their failings. Or no one knew the inmate was sick because his medical record was wrong. Or lost. Today, after three more years, the system still falls short of constitutional standards. There are some improvements: nurses added, some doctors replaced; some software installed to, for example, track pharmaceuticals at some prisons. But there's a lot to overcome.

Typewriters and Dot-Matrix Printers

For years, in some cases, for decades, several prisons lacked working phones for the medical staff. Others relied on antique Brother typewriters to fill in forms and leaky, lightless trailers in which to store them. Prison employees soaked printer ribbons in ink by hand because the dot-matrix printers were so old that manufacturers no longer made replacement parts. While the prison healthcare budget had grown from $556 million (about Rs 2,224 crore ) in 2000 to $1.6 billion (about Rs 6,400 crore) last year, most of the money went to staff and medical supplies, not to infrastructure or technology. "Data management, which is essential to managing a large healthcare system safely and efficiently, is practically non-existent," Henderson wrote. "This makes even mediocre medical care impossible."

For technology managers at California prisons, the federal takeover is a rare opportunity. When organizations run so little technology, providing e-mail makes you a hero, says Dan Marshall, staff IS analyst at San Quentin. Marshall manages much of the prison's IT. In many ways, the prison healthcare overhaul looks like any big IT project. Corporate CIOs will recognize some of the obstacles:

uncertain funding, skeptical users, having to please separate groups of people often at odds with each other, keeping projects afloat when the boss gets fired. "It's all there, only more dramatically in the prison system," says John Hummel, who was CIO for the receivership from 2006 until he resigned early 2007. But in other ways, the project stands apart. How do you set up a WAN among buildings made of stone walls three feet thick and reinforced with steel? When it's time to install a telecom switch, can you get the OK to schedule armed corrections officers to guard your tools from thieving, violent prisoners? Then there are ethics. Wrestling with the moral dimensions of installing systems to help a rapist get his dermatitis cream isn't typical CIO fare. You get a green field on which to make your IT mark - for a constituency many would rather forget about, and some say deserve to die.

Processing Prisoners

Processing Prisoners

In the hills north of San Francisco's famous Golden Gate Bridge stands the infamous San Quentin State Prison. A 27-year-old Johnny Cash, though never locked up there, visited to sing about injustice. Today, Scott Peterson, convicted in 2004 of killing his pregnant wife, Laci, and their unborn baby, is there awaiting execution. San Quentin holds 5,400 murderers, rapists, violent felons, parole violators, drug criminals and many, many three-strikes offenders. The prison is also one of five intake centers for inmates entering, or returning to, the California system. The average state inmate is a 36-year-old male who reads at the seventh-grade level and is sentenced to just under four years.

Before they get housing assignments, prisoners must be screened for medical, dental and mental health issues. The results determine where they serve their time. Someone with a respiratory illness, for example, shouldn't go to Pleasant Valley State Prison in Coalinga, where the local valley fever lung infection routinely sickens hundreds of inmates and staff. All day at San Quentin, white buses pull in and out of a secured parking area overlooking the cool, blue bay waters. Cuffed and chained, inmates in denim outfits file out. Guards lead them to the Reception and Release Center. One recent breezy morning, Director of Nursing Tonya Church, who manages the prison's 126-member nursing staff, ducks inside the center. Dozens of prisoners stand in barred or glassed-in holding cells or sit on folding chairs. Staff in scrubs examine inmates while corrections officers keep watch. There's little room to move.

Every few minutes a nurse barks an inmate's last name, a call to step up. Church's nurses perform eye, ear and tuberculosis tests. They take blood to identify conditions such as diabetes and hepatitis. They record a brief medical history - such as allergies, handicaps,communicable diseases - and do a physical exam. A doctor sees newcomers to assess serious problems, prescribe drugs or do a psychiatric evaluation. "We try to average about 75 inmates a day," she says. Intake happens in this one building, and just one aspect of the process so far is computerized: blood-test results. Outside firms Quest Diagnostics and Foundation Laboratories set up Web portals through which healthcare workers can view and download lab results.

The rest of the process is still recorded on paper, mostly folders containing fourpart forms with check boxes to describe a patient. Even so, Church says, thanks to the receivership there have been big improvements. The prison got money to construct this bigger building; crowded as the new space is, it now includes private exam rooms and networked PCs to view those lab results and print chart labels. Before the receivership, there was no room for doctors to work, just nurses and technicians. Mental health and dental exam rooms were in other buildings. To complete a screening, prisoners had to be escorted by corrections officers to different clinics around San Quentin's 440 acres. Medical forms often got misplaced along the way.

Sometimes there weren't enough guards scheduled, Church says, so inmates would have to wait, on occasion, for several days. Administrators would have to assign temporary housing to inmates who hadn't been fully screened. Usually they stayed in the general population. Sometimes that caused problems. For example, unless an inmate came with a known history of mental problems or was acting erratic on arrival, a psychiatric evaluation waited, she says, sometimes endangering, in particular, first time inmates with suicidal tendencies. Throughout California state prisons, 30 prisoners killed themselves in 2007 and an estimated 480 tried. Today, mental health screens occur the day an inmate arrives, so staff can spot potential suicides sooner, Church says. While Church likes the changes so far, she looks at what else needs to be done. "Each institute has its own obstacles to overcome," she says, noting that because of San Quentin's age there are lots of low ceilings in buildings not wired for many electrical outlets, as well as asbestos and lead paint issues. "A lot of people feel they've stepped back in time when they come to work here."

Obstacles to IT

Obstacles to IT

Dan Marshall, a staff IS analyst at California's San Quentin State Prison, doesn't mind working around the physical obstacles to installing technology at a prison dedicated when Abraham Lincoln was president. He's just to be doing it at all.

Walking through a dim cement passageway connecting San Quentin's cafeteria on one end and the Treatment and Triage Area at the other, Marshall cheerfully points out IT impediments. "You can see from the size of this place that putting technology infrastructure is not easy," he says, sweeping his arm to indicate the surrounding complex of I-beams, razor wire and stone buildings pocked by chipped paint. It's not only the size and sprawl of the facility that presents challenges. "If it was your typical office building, we'd be dealing with drywall. Because it's prison, "they're much more into stone and steel."

To deliver even basic medical care, doctors and nurses at San Quentin needed a network. Marshall opted for wireless networks using Nortel gear. His office, underneath the warden's office, now serves as the communications room, with cabling and servers inside. He's set up clusters of virtualized Dell servers, running VMware with an EMC SAN, to control the wireless infrastructure as well as for print and file serving. While scouting for places to put wireless access points Marshall remembered that runs of fiber optic cable had been installed but never turned on.

Four years ago, the state had installed fiber in most prison buildings but the project lost funding before the needed switches and hubs could be bought, says Hummel. "Dan had this beautiful spiral, all truncated and ready to go," he says. Now clinics, offices and some corrections officers' stations throughout San Quentin have access to either a wired or wireless computer network, Marshall adds. Engineers from Nortel, a state subcontractor, came to help Marshall and the four other IT analysts at San Quentin install the wireless equipment. But it was no easy visit. To get an outside vendor on prison grounds involves background checks, vehicle searches and, usually at overtime rates, special assignment of guards to protect the people working on the project. "You have to think: are you putting yourself in a position that if something were to happen that you have no help?" He casually steps aside to let pass a guard gripping the triceps of a man in handcuffs and the white jumpsuit of someone in protective custody.

Although Marshall himself has not been attacked, 121 members of the San Quentin staff were assaulted by inmates in 2006. Once every three days an inmate, sometimes armed with a homemade weapon, attacked an employee there - one of the highest assault rates in the state. Marshall has worked at San Quentin for 14 years - his first seven in nursing, the last in IT. Before the receivership, he'd begun to stagnate. He still felt dedicated to serving people who need help, he says, and helping the medical staff do their important work. But maintaining 120 standalone Windows NT 4.0 and XP PCs held little appeal. He wanted to use new technologies that would change the working conditions for the doctors and nurses.That wasn't happening at San Quentin, so he was  hunting for a new job. Then Judge Henderson took over. Marshall met the receiver, Bob Sillen, and his new boss, Hummel. Sillen had 40 years in healthcare administration behind him.

Worst Conditions Need Most Attention

After touring San Quentin to see for himself conditions he later described as "appalling," Sillen decided to focus there first. "It is the oldest, most decrepit and most notorious prison in California. It's perfect for reform," he said in one of his many letters to staff and inmates during his 21 months on the job. Hummel, meanwhile, was astounded, and excited at the opportunity to transform the IT backwater of the entire prison health system. He was a senior manager at outsourcer Perot Systems and before that, CIO at Sutter Health, a network of hospitals and doctors' offices in California, for nine years.

Early in his career, he had worked with doctors in poor countries, helping set up hospitals and data management. "Walking into San Quentin and watching water come dripping down out of the showers of death row and having to hold a plastic tarp over the doctor as he treated a patient was beyond anything I'd seen in a third-world country," he says. "I was ashamed." Such passion touched Marshall. So did the prospect of the receivership freeing up funds for technology. He decided not to quit. In fact, he says, he started thinking, How long will it take for me to change San Quentin's culture to make IT important? Yet making IT important is not as straightforward as it sounds, says Hummel. When he started as CIO of the receivership in 2006, Hummel says, he had to learn to live with one truth: the warden is boss. Judge Henderson may have invested the receivership with the authority to administer, manage and operate the prison healthcare system but the warden runs the prison.

Custody of inmates is the warden's number one job; everything else is secondary. Hummel made sure to visit as many prisons as he could throughout his tenure, to discuss "very real concerns of theirs" about technology projects. During the wireless installation at San Quentin, he recalls, one of his and Marshall's tasks was "simply proving to the warden and corrections officers that this was not going to stop their walkie-talkies from working," he says, "or that a gang member sitting a mile and a half away couldn't possibly steal that signal." Marshall, meanwhile, tries to use his nursing background to bridge the cultural gap between San Quentin's medical and IT staffs. Take the process of dispensing medications to inmates. Each morning and evening, nurses wheel carts loaded with drugs to cell blocks where inmates live. They walk up and down rows of cells. If their patients are housed in the gym - a 'temporary' measure the state took over a decade ago to accommodate  overcrowding - nurses look for inmates, who are assigned bottom or top bunks.

Marshall did this drill many times as a nurse and says that often, nurses can't find all their patients on first rounds.

An inmate might be at a clinic or at work. Or maybe gone from the prison altogether. Over 500 inmates transfer in and out of San Quentin each week. State-wide, weekly transfers number 5,000. There's a 24-hour lag between when an inmate changes prisons and when the master housing roster database gets updated."I would come back with a deficit of hundreds of inmates I couldn't find," Marshall recalls. The nurse would then typically return to the pharmacy or the medical records room hoping to find updates to the housing roster app, an Oracle database running on a Hewlett-Packard MPE server and accessed via a dumb terminal. With any fresh information then available, the nurse would head back out. "It could take most of a day," he says. Knowing this, Marshall and Church discussed how to improve that process. Once the wireless network was in, Marshall was able to set up PCs in satellite clinics and housing units around the campus to access the roster database. "There were two places to look up this information previously," he says. "Now there are 250." Meanwhile, there is not yet any electronic way to thoroughly track the medications San Quentin prescribes, orders, receives, dispenses and discards - or how much it all costs. To do all that, the prison is due to switch on pharmacy management software by Maxor.

The goal in California is to better manage the 21,000 prescriptions prison doctors write each month by monitoring, for example, how many get administered properly and how much medication gets wasted or stolen. Analysis of pharmacy billing at Pleasant Valley State Prison, which has already installed Maxor, resulted in the arraignment in December of two contract pharmacists who did work at the prison,

on charges they had embezzled $1 million (about Rs 4 crore) from the state. Police searched the pharmacists' homes and found 30,000 prescription drugs, some bearing prison labels. But even when the Maxor application is fully rolled out at all 33 prisons, none of them will be able to share data with each other, at least not for a few years. That feature would be useful when, say, inmates transfer between institutions. Instead of doctors at the receiving prison having to write fresh prescriptions for a new inmate, existing prescriptions would follow the inmate to his new location. "Less wasted medicine," explains Church, "and more continuity of care." However, that won't happen until later phases of the Maxor project, not yet committed to time lines, she says. IT time lines generally are uncertain right now, as Sillen and Hummel are no longer with the receivership.

The Politics of Getting the Job Done

The Politics of Getting the Job Done

In January, US District Court Judge Thelton Henderson fired Bob Sillen, the federal receiver who had been appointed to fix California's prison healthcare system. Henderson praised Sillen's reconnaissance and understanding of the scope of the  problem but criticized him for not moving quickly enough. In a 'Plan of Action' he filed, Sillen outlined 22 objectives, from building more physical buildings at various prisons to piloting a new grievance investigation procedure to installing IT. Though he devised milestones for each objective at intervals six months to three years out, Sillen didn't envision returning the prison medical system to state control for a decade. Further, Sillen is known to be prickly and confrontational - a style unlikely to persuade state legislators and Gov. Arnold Schwarzenegger, among others, to come together to support expensive prison overhaul projects.

While Judge Henderson gave the receiver wide powers to make change and hand the state the bill, the money must be appropriated by state lawmakers. Right now, the state is running a $14.5 billion (about Rs 58,000 crore) deficit. Sillen could not be reached for comment. Replacing Sillen is Clark Kelso, the former CIO of the state. Kelso, who is also an attorney with a degree in philosophy, has a reputation for collaborating and brokering peace between different groups. He has worked in all three branches of California state government, including a tricky job turning around the state Department of Insurance after a corruption scandal in 2000.  "The reason you have to have the receivership is because the state wasn't able to do it on its own," Kelso notes. "California is in the midst of a very serious budget crisis. No question that there are going to be some tough discussions ahead. I approach those as opportunities for dispute resolution. I'm not going to look for conflict." Marshall knows that some IT plans made by Hummel and Sillen are iffy now. They envisioned the healthcare system running its own network separate from that of the overall department of corrections. But Kelso released a new strategic plan that includes

aggressive technology deadlines. Kelso is also considering whether running one network for both medical and corrections apps would be faster and cheaper. "The vision of the new people may be different," Marshall allows. "But it'll all go forward."

On Probation

Prisons are consistently underfunded and understaffed, state and federal analyses show. And the state overall remains intermittently paralyzed by budget crisis after budget crisis, going on two decades. The receivership has progressed at the prisons where the state had, or could, not. Incompetent doctors, some exposed as unlicensed or under disciplinary action, have been fired. Care has gotten better; San Quentin's intake process is one example. New construction is under way at many prisons. Some software, hardware and networks have been upgraded, or in somecases installed for the first time. The receivership has spent more than $20 million (about Rs 80 crore) so far, according to a report from the state Office of the Inspector General, with about $8.7 million (about Rs 34.8 crore) of it going to IT, system-wide, and construction at San Quentin specifically.

But still health care in prisons throughout California "remains below constitutional standards," Henderson wrote when he removed Sillen. Other courts have noticed. One San Francisco Superior Court judge recently ruled that a jewel thief with Crohn's disease didn't have to go to state prison. He could instead start his 12-year sentence in county jail. The judge, Hummel says, "felt that within 12 years, it was a reasonable thing in treating Crohn's disease that the inmate would die by medical neglect." An appeals court overruled the decision, acknowledging the poor healthcare system but saying one cannot conclude "that all persons with serious medical problems...will in fact receive constitutionally inadequate medical care." Meanwhile, the tally of what Henderson calls "needless" death has not dropped. Sixtysix inmates died of preventable or possibly preventable causes in 2006, the latest year for which statistics are available. Death row is safer: just 14 people have been executed in the past 28 years.