Friday, June 11, 2010

What are best practices for telemedicine, and do they change in and out of prison?

Interestingly, I learn from the Texas Public Policy Foundation that the Texas Medical Board has proposed new rules restricting out of state telemedicine providers. The rule that's got telemedicine providers kicking up a fuss reads:
A distant site provider may treat an established patient's new symptoms that are unrelated to a patient's preexisting condition provided the patient is requested to be seen in a face-to-face visit by a physician within 72 hours. A distant site provider may not provide continuing telemedicine medical services for these new symptoms to a patient who is not seen within 72 hours. If a patient's symptoms are resolved within 72 hours such that continuing treatment for the acute symptoms is not necessary then a follow-up face-to-face visit is not required.
So new symptoms would require at least the opportunity for a first-hand followup, while preexisting, already diagnosed conditions (including presumably chronic ones) could be treated mostly through telemedicine alone.

These rules won't apply to Texas prison health care, but they interest me because Texas prisons were the laboratory in which telemedicine practices first developed (California is considering copying the model), and from the testimony I've heard at the Lege, Texas' prison telemedicine program likely isn't meeting that standard, particularly after recent staffing cutbacks.


Pam said...

What are the costs of telemedicine? Is it cheaper than an personal visit? My guess is it would be. So I don't understand why they are cutting funding. Also is it completely by telephone or is there video involved?

Gritsforbreakfast said...

They didn't cut funding for telemedicine, they cut on site staff.

And it's a video hookup, not just a phone conversation.

Pam said...

Thanks for the clarification. I realize that personal contact with a doctor is preferable, but I do think that telemedicine has some merit. I have a cousin who is a nurse. She calls patients on a regular basis to make sure they are using their medications properly. She can also monitor their blood levels and blood pressure remotely. She says that this program works pretty well, especially for chronic conditions.

sunray's wench said...

The whole point of telemedicine is that it means you can review and diagnose someone in another country if you want to. Seems to defeat the point if the law makers want to restrict access to out of state medical staff.

Gritsforbreakfast said...

They're not restricting telemedicine to out of state staff, outside the prison system the Medical Board is adding regulations for out-of-state providers.

The rule implies they shouldn't use telemedicine for diagnosis without at least an option to see a doctor in person. There isn't the same requirement to treat ongoing maladies and preexisting conditions.

Anonymous said...

What do you all think of conducting a mental health session via telemedicine? For example: an inmate sits in a room and talks to a psychiatrist on a TV.

Gritsforbreakfast said...

I've said before, if it's possible to have "phone sex" I suppose it's possible to have "telepsychiatry," see here and here. ;) Sen. Whitmire has raised exactly the question you do, wondering how a paranoid person might react to a television interacting with them. I have no knowledge about the clinical pros and cons, though I generally consider telemedicine the physicians' version of fast food. My sense from public discussions with lawmakers is that it makes mental-health treatment even more prescription-driven, which is already its tendency. But UTMB uses "telepsychiatry" pretty commonly in TX for both adults and juveniles.

Anonymous said...

Wow! Thank you for the links. I originally checked this blog out to see all the gossip about UTMB & the RIFs and think I may become a full time reader. Anyway, I wanted to clarify that most of our patients are not in a paranoid state while talking to the psychiatrist. Whitmire should've used a better example. I'm more worried about patients with PTSD and MDD trying to "open" up to a TV! Luckily most of our counseling and history taking is done face to face with a therapist. It is sad to say but the TV is for MEDS only! I personally am torn; can't decide if it's unethical or if it's monetarily beneficial.

R. Shackleford said...

Erm, does it seem to anyone else that the folks who are in prison need some face to face psych time more than any other group? I mean, if you have a segment of the population that's so obviously in trouble, wouldn't you want them to have the best mental care available so they get fixed and don't do w/e it is that landed them in prison again? Also, psych stuff is supposed to be totally private, and I would have grave concerns that any session between a patient and a psychiatrist would be taped and stored in some archive, to be pulled out and slammed into the patient's head repeatedly at his/her next trial/parole hearing.

Anonymous said...

"Luckily most of our counseling and history taking is done face to face with a therapist."

What counseling? What history taking? Are you sure you're talking about the Texas prison system?

I know someone who was hospitalized 5 times, once for more than 3 months in the 5 years prior to entering the prison system. She was delusional when she committed the crime that resulted in her incarceration. She she have been declared insane but she agreed to take a plea to spare her family having to go through a very public trial.

I was told, in writing, that they don't bother to get past medical records. How can a psychiatrist treat someone who has seriously mentally ill and has had multiple hospitilizations without reviewing past treatment records?

You have an inmate with a significant history of serious mental illness but, as far as I know, has not received one counseling session in the two years she's been there.

Try to get a straight answer from anyone about an inmate's medical care. Its impossible.

Futhermore, the medication she is on makes her more susecptible to the heat (as most psychotropic meds do). Last summer they moved her to the night shift for work after she suffered an episode of heat exhaustion. This summer they have her working in the heat of the day in the kitchen where steam coming from the dishwashers makest it even hotter. They allegedly have a policy where they are supposed to monitor people on these meds for heat problems but apparently the policy is ignored.

Counseling? Yeah right.

Anonymous said...

9:28, you are naive and/or must be receiving incorrect information.

I work at an intake facility where we receive approximately 20-30 offenders a day. Each offender is screened THREE times...once by medical, again by TDCJ, oh and again by mental health. Based off of this and information received from their county jails, offenders receive a one on one session with a licensed counselor. At this time, they can either spill their guts or sign a treatment refusal for any mental health services. Offenders on any psych meds are automatically scheduled to see the psychiatrist. Just to clarify, by this point, they have now seen someone FACE TO FACE 3-4 times.

For the offenders that stay on the unit, they see the psychiatrist within 30-days of their arrival and again every 8-wks, 3 or 6-months. If a diagnosis is unclear, FREE WORLD RECORDS ARE DEFINITELY ORDERED! I KNOW THIS FOR A FACT! Group is held every Friday and counseling is offered and often encouraged on a daily basis.

I don't know where your family member is housed but I am telling you how it works at our unit where she most likely came through.

Oh and patients on particular psych meds ARE given heat restrictions. Keep in mind that medical can only assign a patient a restriction but TDCJ assigns where they work...NOT MEDICAL OR MH. Unfortunately, steam from a dish washer does not qualify as a heat restriction. Think about it for a second...can your relative unload her dishwasher at home on psych meds? Yep, she can do it in prison too! These restrictions are in place for the hoe squad, outside yard and the chain bus, ETC.

You obviously have no idea what you're talking about and have received 2nd hand information.

DeathBreath said...

My, my, my, well, goodness gracious, I have stumbled on quite an interesting blog. I seriously doubt there are many on this site who have my years of experience with these pig agencies. Actually, it is hard to imagine the mutant offspring these two agencies would produce, but I can assure you, it is unholy. I am going to remain anonymous because I would rather trust a pedophile hosting a young girl's pageant, without supervision, than almost anyone associated with this insatiable vortex, UTMB. And, it is no accident that two pirates occupy the same street. UTMB sits right down the street from Maison Rouge, the abode of the pirate Jean Lafitte. So, I am going to sit back and analyze this site for accuracy. Then, I might make several pointed comments. I doubt they will be complimentary.

DeathBreath said...

Well, I see where the dear Senator, "In-The-Know" Whitemire has been commenting about the system he knows so very much about. Interesting. By the way, Senator, why did the Crain Unit wave people through security searches when the Crain unit was being dedicated? Yes, the Governor and his droppings entered the prison units without any search, period. You see, they were special. So, please, tell me all you know about the sytem. I am all ears! I'll see if you know what you are talking about. I was in the system during Ruiz and beyond! Oh, this is rich.

Anonymous said...

I have it in writing from a psychologist employed by TDCJ that prior treatment records are not requested. If you'll provide an address I'll gladly send you a copy.

Gritsforbreakfast said...

9:53, please send a copy to

Scott Henson
Austin, TX 78701-1477


Anonymous said...

"You obviously have no idea what you're talking about and have received 2nd hand information."

And you are obviously incompetent moron. THink about it. THe diswashers used in those kitchens are nothing like my dishwasher at home. They are working in an enclosed building when temperatures are 95+ with steam pouring out of industrial dishwashers. Your statement comparing this to the dishwasher in my kitchen is simply moronic. Last summer she had an episode of heat exhaustion because she was not being properly monitored for such problems.

Obviously, it is that don't know what you are talking about. Again, I'll gladly provide you the letter from the psychologist which states they do not get prior medical records.

Your information about group and counseling is also wrong. Maybe that's the case in your unit but where this person is housed she has never had the opportunity to attend either group or counseling. By the way, when dealing with someone with aerious mental illness, seeing a psychiatrist (or more likely a nurse practiciner) once every 3 to 6 months is not adequate.

With people like you running the system, no wonder its so screwed up.

Anonymous said...

Scott, Ill find the letter this evening and send it to you.

DeathBreath said...

I can assure you that MHS has repeatedly addressed the need to send for all psychiatric records at the state jail level. Otherwise, you are completely blind with respect to etiology, treatment history, etc. You don't know what you are talking about. If someone is not following directives, then that is a an entirely different matter. Trust me, you don't know anything about the severity of psychopathology that frequently comes in from county jail. And, to better control the patients, county jails tend to over-medicate with the clinical acumen of a chimp. Think of a Viking ship. UTMB staff are in the bottom of the ship being whipped without any quarter. Do you actually think you can treat significant psychopathology and deal with all of the whining psychopaths with these staff shortages? And, it is going to get worse because the buffoons in the Texas legislature don't know what the hell they are talking about. I think someones little feelings were bruised. Perhaps, it is a narcissistic injury.

Can't believe I'm actually reading this crap! said...

Ah, poor inmate who just so happened to commit her crime during a supposed psychotic episode gets sent to prison and actually has to work? Oh no!

Anonymous said...


I'm not incompetent and I'm definitely not a moron. I'm a well educated woman who doesn't make a whole lot of money but does actually care about the well being of sick offenders. Sometimes when you see incorrect information being posted, you feel obligated to defend yourself. In this case, you have repeatedly said I am lying and I'm not. I cannot account for what they do at other units (although I have several collegues at these other units who would also argue with your statements). I am not familiar with TDCJ dishwashers and perhaps my comparison was not appropriate. BUT, regardless of unit, certain restrictions are mandatory with particular psych meds and therefore mental health did their part. For you to attack mental health because TDCJ assigned her to the kitchen, NOT fair. My point is, at my unit, we do request free world records, we do offer counseling and group, our patients do see a PSYCHIATRIST (MD!) every 4-6-8 WEEKS and/or 3-6 months. Every case is different. I don't think one offender's experience should represent the Mental Health Dept of all units.

Anonymous said...

I apologize for calling you a moron but the dishwasher comment was really, really stupid. Additionally, I have gotten some really stupid answers from TDCJ staff when trying to get information about medical treatment.

You told me that I dont' know what I'm talking about. I found th letter and just mailed it to Scott. If I don't know what I'm talking aboutt then James Montross, PHD, Director of Mental Health Monitoring & Liason, TDCJ Health Services Divsion doesn't know what he's talking about. That is where my information came from.