Assessment of Stakeholder Perceptions and Cost of Implementing a Telemedicine Specialty Program at Correctional Facilities in North Carolina

Abstract

Background

Delivering in-person health care to the more than 1.2 million incarcerated adults can be expensive, logistically challenging, fragmented, and pose security risks. The purpose of this study was to evaluate the implementation of a specialty care telemedicine program in statewide prisons in North Carolina during the COVID-19 pandemic.

Methods

We evaluated the first 6 months of implementation of a new telemedicine program to deliver specialty care to adults incarcerated in 55 North Carolina prison facilities. We measured patient and practitioner perceptions and the impact on the cost of care.

Results

A total of 3232 telemedicine visits were completed across 55 prisons within the first 6 months of the program. Most patients reported that the ability to use telemedicine contributed to their overall personal well-being and safety. Many practitioners found that working with the on-site nursing staff to conduct physical exams and to make collective decisions were key drivers to the success of telemedicine. A direct relationship was found between the telemedicine experience and patients’ preference for future visits such that as satisfaction increased, the desire to use telemedicine increased. Telemedicine reduced total costs of care by $416,020 (net: −$95,480) within the first 6 months, and $1,195,377 estimated in the first 12 months postimplementation (95% confidence interval: $1,100,166−$1,290,587).

Conclusions

Implementing specialty care telemedicine in prison facilities enhanced patient and practitioner experiences and reduced costs within the prison system. The implementation of telemedicine in prison systems can increase access to care and reduce public safety risks by eliminating unnecessary off-site medical center visits.

Introduction

Providing health care to the more than 1.2 million incarcerated American adults is quite challenging. First, prisoners are sicker than the general population. ¹ About half of the people incarcerated in state prisons have at least 1 chronic condition, with 10% reporting heart conditions, and 15% reporting asthma, percentages far greater than those for the population at large, even when comparing similar age groups. ² The infrastructure of most prisons and jails is conducive to spreading disease, with frequent changeover of correctional officers and staff increasing the risk of exposure. ³ Second, additional security and transportation requirements make care for prisoners more expensive, collectively exceeding $8 billion annually. ^4,5 Third, transporting patients between facilities for care is logistically complicated and often results in information fragmented between different electronic (or paper) health records. ⁶ Finally, clinicians and staff working within prison facilities suffer higher risks of burnout and emotional distress, impacting the quality and continuity of care. ^5,7,8

Historically, adults incarcerated across North Carolina’s 55 prison facilities requiring specialty care were either transported to Central Prison Regional Medical Center (CPRMC) to see specialists working within that facility or transported to a local nonprison health care facility for care outside the prison system. Care both in prison or outside was expensive, logistically challenging, risked fragmenting care through documentation in non–Department of Public Safety (DPS) electronic health record (EHR), and posed security risks. For these reasons, in 2019 the North Carolina General Assembly passed a law to enable prisoners to receive specialty care in their local facilities via telemedicine. ⁹

The COVID-19 pandemic made prison health care even more challenging, given the need to prevent disease transmission, limited personal protective equipment, and challenges transporting patients between different prisons. ^10,11 Accordingly, it spurred the DPS and University of North Carolina (UNC) Health to expedite the new telemedicine specialty care program. Telemedicine has been used in prisons mainly to provide mental health services to prisoners ^12–14 ; however, little is known about the feasibility of delivering specialty care via telemedicine in prisons during times of crisis.

Our hypothesis was that prisoners might resist the use of telemedicine services because of the sudden implementation without sufficient training and education, the lack of prior experience with the technology, and concerns around lack of confidentiality and privacy. ¹⁵ The objective of this study was to assess how the telemedicine specialty care program was implemented in the North Carolina prison system, to evaluate the patient, staff, and clinician telemedicine experiences, and to present quantifiable health care access and cost improvements. The findings of this study are important for policy makers and government officials to understand the facilitators and barriers to telemedicine use within correctional facilities.

Methods

We conducted a cross-sectional study of prisoners receiving specialty care through telemedicine in North Carolina prison facilities. North Carolina has a total of 55 prison facilities with a capacity of 35,000 individuals, of which 52 facilities are for men (Supplement A). The program focused on several specialty care areas, including hematology, oncology, dermatology, rheumatology, gynecology (OB-GYN), nephrology, infectious disease, gastroenterology, endocrinology, pulmonology, neurology, hepatology, general surgery, orthopedics, otolaryngology, cardiology, urology, and an HIV clinic. The scope of specialties was determined via discussions between DPS and UNC regarding the health needs of incarcerated individuals.

We built telemedicine stations in private spaces in all North Carolina prisons. This included procuring telemedicine software and equipment (Cisco WebEx DX80, San Jose, CA, and peripheral examination devices), training administrative and nursing staff to schedule and assist with telemedicine visits, and developing a web-based scheduling portal. We also co-developed telemedicine workflows and developed a referral triage process. We worked with the UNC Health physician network to designate practitioners in each participating specialty to provide care via telemedicine. Each practitioner was trained to perform telemedicine visits and document these encounters in the DPS electronic health record system. We reassigned patients to those practitioners and adjusted their schedules. Data collection took place from June 1, 2020 to November 30, 2020. Institutional review board exemption was obtained from the North Carolina DPS and from UNC to complete the study.

Study setting and participants

In the prison setting, an on-site telepresenter supports telemedicine visits by managing equipment setup, initiating the call, and using the telemedicine software. Prior to going live, a domain expert (TC) trained practitioners and medical records staff members for the role of on-site telepresenter. As part of the implementation strategy, a pilot study was conducted in a single facility to test the web-based scheduler, workflow, and software, which resulted in refinements to the clinical workflow, survey instruments, and software usability prior to going live at all 55 prison facilities. Waivers were obtained from the state Department of Information Technology to allow UNC practitioners security access through the DPS firewalls. Telepresenters and patients were asked to participate in a voluntary satisfaction survey. Practitioners were asked to participate in a satisfaction survey at the end of their telemedicine shift to avoid disruption to the telemedicine clinic schedule.

The workflow was designed as follows. At the time of the appointment, the patient presents to the medical facility within the local prison camp where a telepresenter uses Cisco DX80® equipment to initiate a call to the remote telemedicine practitioner. During the visit, the telepresenter remains in the room and only intervenes if asked by either the patient or the practitioner. Postvisit, the practitioner documents the visit summary and follow-up information in the institution’s electronic health record (EHR) system.

Study materials

A domain expert (SK) developed tailored versions of the validated Telemedicine Satisfaction Survey to assess practitioner, patient, and telepresenter experiences. ¹⁶ The practitioner survey collected demographic information on the professional role, specialty, gender, estimated visit duration, and date. The patient survey collected demographic information on age, gender, and race. Telepresenter surveys collected no demographic information. Practitioner and patient surveys included 2 open-ended questions about the telemedicine experience: (1) What aspect of telemedicine did you like? (2) What aspects of telemedicine did you not like? Additionally, the surveys included 1 question for patients and practitioners about their preference for health care delivery mode between in-person and telemedicine visits.

Practitioners surveys were administered once at the end of the telemedicine shift to reduce disruption to the workflow. Practitioner surveys were collected from 3232 telemedicine visits between June 1 and November 30, 2020. Patient and telepresenter surveys were voluntarily provided at the end of each telemedicine visit. Patient and telepresenter surveys were collected from 1252 telemedicine visits between June 1 and August 30, 2020, with a response rate of 38.5% and 62.8%, respectively, which falls within the average range of typical response rates of 10%60%. ¹⁷ The total survey response rate for the study was 49%.

Outcomes

The primary study endpoints were patient and practitioner experiences, measured by satisfaction surveys. Secondary endpoints were cost savings, measured by transportation and implementation costs.

Implementation measurements

North Carolina prison facilities are spread across the state. For cost-savings calculations, we chose to group facilities by the travel time to CPRMC, rather than by geographic regions, which misrepresents the data because of the wide variances in travel time within a single region. Therefore, all facilities were distributed over 4 groups based on the travel time to CPRMC (Supplement B). We calculated the cost and time savings for the telemedicine visits by computing the cost and time needed to conduct those telemedicine visits in person.

Cost calculations included transportation costs to and from the CPRMC, and the cost of the accompanying correctional officers, all of which are statewide rates. Implementation costs included the cost of purchasing Cisco DX80 licenses, computer stations, and internet stethoscopes at each of the prison facilities. Transportation costs included the hourly rate for 2 accompanying correctional officers, vehicle rental rate, and the number of miles from the facility to CPRMC where all visits would take place. The cost of vehicle rental (hourly rate) was $0.57 per mile driven. This covers the cost associated with a rental vehicle, wear and tear, and gasoline consumption. The hourly rate for a correctional officer was $30.05 per hour on a given trip, which is the standard overtime rate used because of the miscellaneous tasks associated transportation of incarcerated individuals to and from the hospital. For each transportation van, at least 2 correctional officers are required. At least 1 van per region transported several prisoners each day. On average, there are 7 prisoners per van per trip.

Time calculations include prison admission and release time, transportation time, wait time, and service time. Distance (miles) and time (h) calculations between prison facilities and the prison hospital were determined using ArcGIS Pro (New York, NY). Data were organized and analyzed using Microsoft Excel (Redmond, VA).

Analytical approach

To classify and analyze the telemedicine facilitators and barriers reported by patients and practitioners, we utilized the Benson framework. The Benson framework provides a taxonomy of person-reported outcome and experience measures that can apply to telemedicine experiences. ¹⁸ We used patient-reported taxonomy for patients’ quotes, and staff-reported taxonomy for quotes from practitioners and telepresenters. For each survey, we categorized the participants’ response to 1 or more of Benson’s measures. Categories were determined by a domain expert (SK) by considering the whole end-to-end process and were based on the defined patient-reported experience and outcome measures, as well as the staff-reported experience and outcome measures. We constructed 2 tables to summarize the main facilitators and barriers to telemedicine use: 1 for patients, and another for practitioners and telepresenters.

For 1-year projections, we used the confidence interval (CI) function to calculate the confidence interval of the cost and time savings with a significance of 0.05 (ie, a confidence level of 95%). Summary statistics, including mean (SD) values and frequency distributions, were generated to characterize the 3 survey populations. Participant satisfaction outcomes were adjusted from text responses to numeric responses, with excellent as 5, very good as 4, good as 3, fair as 2, and poor as 1.

Results

A total of 3232 telemedicine visits were completed in 55 North Carolina prisons within the first 6 months of the program. Of the total 1,584 survey responses, 482 (30.4%) patients, 316 (19.9%) practitioners, and 786 (49.6%) telepresenters reported positive overall telemedicine experience, as shown in Table 1. Of the 448 patients, 424 (94.6%) were males and 24 (5.4%) were females. Of all visits, 882 (27.3%) visits were from the 10 facilities located within 2 hours from CPRMC, 1197 (37%) were from the 20 facilities located between 2 and 4 hours away, 853 (26.4) were from the 15 facilities located between 4 and 6 hours away, and 300 (9.2%) were from the 10 facilities located between 6 and 8 hours away from CPRMC.

Table 1:

Patient, practitioner, and telepresenter telehealth experience ratings by age, sex, and race

Incarcerated individuals characteristics	Participants, N (%)
All patients	482 (100%)
Race
American Indian or Alaska Native	25 (5.5%)
Asian	3 (0.67%)
Black	225 (49.1%)
Native Hawaiian or other Pacific Islander	10 (2.2%)
White	195 (42.6%)
Sex
Men	424 (94.6%)
Women	24 (5.4%)
Age
18–34	69 (14.7%)
35–50	156 (33.3%)
51 or older	244 (52.0%)
All practitioner	316 (100%)
Gender
Male	217 (73.06%)
Female	80 (26.94%)
Professional title
Physician	211 (71.53%)
Physician assistant	60 (20.34%)
Nurse practitioner	8 (14%)
All telepresenters	786 (100.00%)
Telehealth medium
Video	743 (97.10%)
Telephone	22 (2.88%)
Total	1584

Patient experience

Patients had differing opinions on the use of telemedicine within prison facilities. The majority of patients reported that the ability to use telemedicine contributed to their overall personal well-being and safety by eliminating travel time to the hospital and reducing risk of COVID-19 exposure during the pandemic (Table 2). Patients reported that avoiding the strict security protocols, including strip searches and shackling, were driving factors for them to choose telemedicine. On the contrary, patients reported specific barriers that hindered their use and future acceptance of telemedicine. Privacy was a major barrier to telemedicine use; patients reported discomfort using computers to communicate with their practitioner coupled with concerns around adherence to Health Insurance Portability and Accountability Act protection protocols in prison facilities compared to medical centers. Digital readiness and confidence in telemedicine were major barriers for patients who found that affected the practitioner–patient interaction, which may also hinder practitioner judgment of the patient’s condition.

Table 2:

Telehealth facilitators and barriers with direct quotes from patients by themes.

Participant group	Patient-reported outcomes (based on Benson framework a )	Patient telehealth assessment quotes
Facilitators	Service integration Product confidence	“Very convenient and treatment was just as good as in-person visit” (52, male, Black)
	Personal well-being Adherence	“Very easy and comforting/didn’t need to be strip-searched” (60, female, Black)
	Shared decisions Digital confidence	“It was safe and convenient right now and the doctor was respectable and understanding” (52, male, Black)
	Personal well-being Adherence	“Something new and with pandemic SAFETY FIRST!” (42, male, Black)
	Fatigue Patient experience	“I like the time saved by not having to be in a car or van for 2 hours” (56, male, Black)
	Health status Patient experience User satisfaction	“Social distanced. Same benefits of an in-person encounter (ie, person/contact), but practitioner did not have to travel. Good situation!" (65, female, White)
	Personal well-being Adherence Health confidence	“That I don't have to be shackled” (47, male, Black)
Barriers	Service integration Digital confidence Behavior change	“There are no hands-on, so the doctor could not physically examine the injury. I believe being in a doctor’s presence beats making a judgment visually on a screen.” (34, male, American Indian)
	Privacy Digital readiness	“Not comfortable with computers or facility HIPAA protection” (40, male, Black)
	Behavior change	“Didn't get to take a ride in car, which is a good change of scenery sometimes.” (59, male, Black)
	Privacy Digital readiness	“Loud, broadcasting, no privacy. I will not be using telehealth again I did not like it.” (34, male, Black)
	Digital readiness Patient experience	“Some things do require hands-on evaluation and that isn’t possible with telehealth” (28, male, White)
	Behavior change Digital readiness Patient experience	“Lack of personal contact” (52, male, White)
	Product confidence	“The computer malfunctions” (32, male, Black)

^aBenson T. Measure what we want: a taxonomy of short generic person-reported outcome and experience measures (PROMs and PREMs). BMJ Open Quality 2020;9:e000789. doi: 10.1136/bmjoq-2019-000789. ¹⁸

Practitioners, despite their gender or specialty, found merits in using telemedicine to see their patients in prison facilities. Many practitioners found that working with the on-site nursing staff to conduct physical exams and to make collective decisions were key drivers to the success of telemedicine. Practitioners voiced that telemedicine increased the level of access to care in prison facilities by reducing patient refusal and no-show rates for in-clinic appointments. Most practitioners (75%) found value in using telemedicine for follow-up visits where an established relationship with the patient already exists from a previous in-clinic visit. On the contrary, some practitioners (10%) reported that the inability to conduct a physical exam on the patient is a major barrier to telemedicine, especially for certain health conditions within specialties such as gOB-GYN and cardiology. Additionally, practitioners were concerned about the lack of clinical workflow integration such as postvisit documentation into the EHR and the inability to retrieve real-time laboratory results.

Most telepresenters indicated that the use of telemedicine improved the well-being and safety of patients and practitioners by eliminating transportation and exposure to COVID-19 infection. Telepresenters were concerned about the reliability of the telemedicine equipment to conduct accurate physical exams, and they were concerned about the lack of training on the telemedicine system and equipment.

Table 3:

Telehealth facilitators and barriers with direct quotes from practitioners and telepresenters by themes

Participant group	Practitioners-reported outcomes (based on Benson framework a )	Practitioners telehealth assessment quotes
Practitioners
Facilitators	Well-being Service integration Shared decisions Staff relationships	“It is safer for the patient and myself during the current crisis. It does allow me to triage patients for in-person visits. The staff and the patients are very helpful during these visits to help facilitate the evaluation.” (Female, otolaryngology)
	Service integration Staff relationships Shared decisions	“Most of the follow-up visits can be performed via video visits. New visits can be accomplished with the help of the nursing staff to assist with the physical exam as directed by the clinician.” (male, orthopedics)
	Service provided	“Ability to attend to several HIV+ patients and adjust their antiretroviral therapies” (male, infectious diseases)
	Access to care	“Decreases refusal rate and improved access to care, invaluable given COVID-19 situation, increases quantity of practitioners (more practitioners willing to provide telehealth care than on-site care)” (female, infectious diseases)
	Service provided	“Easy to perform and allow for patients to remain in their facilities” (female, oncology)
	Innovation readiness Patient satisfaction	“Was finally able to see a patient who has refused for years to travel to the Central Prison Clinic. Telehealth finally allowed me to attend this patient. Patient was very receptive and agrees to a follow-up appointment via telehealth.” (male, infectious disease)
Barriers	Job confidence Care integration IT capability	“I am having trouble with all the details of the process. There are so many things to learn, and I'm not sure if I am doing it right. And it’s hard to know if I am not. Scheduling is really difficult. I haven't figured out a good and reliable way to get notes into EPIC. The way I'm doing it now, it’s a whole additional thing to remember that may easily get lost in the shuffle.” (female, nephrology)
	Service provided Quality of care	“Difficult to see non-verbal cues of understanding, questions. No sensitive exams.” (female, OB-GYN)
	IT capability	“Can’t examine (put hands-on) the patient.” (male, endocrinology)
		“Decreased ability to meaningfully connect with the patient. Physical exam grossly inadequate. Some patients are difficult to clearly understand in this format.” (male, cardiology)
	Care integration IT capability Innovation readiness	“Inability to get labs in real-time, multiple no shows, inaccurate directory” (female, subspecialty)
Telepresenters
Facilitators	Work well-being	“No COVID-19 risks. No transportation needed.”
	User satisfaction	“Everything is very convenient for all parties involved.”
	Health status Work well-being Patient well-being Staff well-being	“Custody staff do not have to transport to other locations, which enhances public safety by decreasing probability of an incident. During COVID-19 decreased transmission of virus.”
	Service provided Innovation process	“The ease of checking patients in, save transport time.”
Barriers	IT capability	“Visual loss during visit.”
	Product confidence	“Clarity of stethoscope, zero clarity using camera for mouth. Doctor could not hear devices.”
	Shared decisions Innovation readiness	“No sufficient training on the equipment.”
	Staff relationships Privacy	“Medical issues should be on a personal one-to-one visit with a doctor not a TV.”

^aBenson T. Measure what we want: a taxonomy of short generic person-reported outcome and experience measures (PROMs and PREMs). BMJ Open Quality 2020;9:e000789. doi: 10.1136/bmjoq-2019-000789. ¹⁸

Preferences for future delivery modalities

A direct relationship was found between the telemedicine experience and patients’ preference for future visits such that as satisfaction increased the desire to use telemedicine increased (Figure 1). Of the patients who rated their telemedicine experience as excellent (244 [51%]), 190 (78%) indicated they would utilize telemedicine as a modality for future visits. It was found that patients that had a poor experience were more willing to continue with telemedicine than those that simply had a fair experience. There were 33% of patients who rated their telemedicine experience as poor indicated they prefer to use telemedicine in the future.

Figure 1:

Preference of future appointment type (telemedicine vs in-person) based on the current telemedicine experience by patients and practitioners.

For practitioners who rated their telemedicine experience as excellent (139 [45%]), 133 (96%) indicated they prefer telemedicine as a modality for future visits. Similar to patients, 23% of practitioners who rated their telemedicine experience as poor indicated they prefer to use telemedicine in the future. It is important to note that 97% of telemedicine visits assessed in this study were conducted via video.

Telemedicine cost and time savings

The total cost of implementing telemedicine in all prison facilities was $511,500 (Figure 2A). After implementing telemedicine, more than 27,500 hours were saved in correctional officers’ time completing in-person appointments at CPRMC (Figure 2B). The transportation cost savings from using telemedicine was $416,020 (net: −$95,480) within the first 6 months. Extrapolating this to an entire year, we estimated a net savings of $1,195,377 in transportation costs over the first 12 months of implementation (95% CI: $1,100,166–$1,290,587; Supplement C). The extrapolation accounted for the staggered implementation of new specialties and the ramp-up period experienced during the first 6 months. The estimated net financial effect, savings minus implementation cost, after 1 year will be $683,877.

Figure 2:

Cost–benefit analysis of telemedicine implementation in North Carolina prisons. (A) The cumulative actual and projected cost saving by prison group and in total over 1 year postimplementation, (B) the cumulative actual and projected time savings by prison group and in total over 1 year postimplementation, (C) thetrip transportation cost to CPRMC for each of the prison groups, (D) the average round-trip transportation time savings per trip to CPRMC for each of the prison groups.

*Trip length is defined as the length of time from leaving the prison facility, transportation time, wait time, appointment time, and return trip to the facility.

**Brackets are defined as < 1.9 hours, 2–3.9 hours, 4–5.9 hours, and 6–8.9 hours.

Cost-savings per trip varied based on the distance of the prison facility from CPRMC (median: $1,631.48; range: $1,152.74–$2,283.86; Figure 2C). Time savings per trip varied based on the distance of the facility from CPRMC (median: 8.6 h; range: 6–12 h; Figure 2D). A projection of 81,000 hours can be saved in in-person trips to CPRMC over the first 12 months of implementation (95% CI: 75,26588,363).

Discussion

We found that implementing a specialty telemedicine program in prison facilities during the COVID-19 pandemic improved patient and practitioner experiences, reduced total costs, and increased access to specialty care clinics within the prison system.

Patients reported that the use of telemedicine improved their well-being, overall health status, and level of confidence. Major barriers reported by patients were privacy concerns, readiness to use telemedicine, and the sudden behavioral change from in-person contact to virtual visits. Although we hypothesized that prisoners would resist using telemedicine because it eliminates trips outside the prison, our findings show that patients accepted and were quite satisfied with it. Additionally, we found a direct relationship between the telemedicine experience and patients’ preference for future visits: As satisfaction increased, the desire to use telemedicine increased.

For practitioners, the top facilitators were the ability to make shared decisions with the patients, overall enhancements in staff relationships, and the readiness to use telemedicine. A main barrier for expanding telemedicine use among practitioners was the inability to conduct physical exams, particularly for cardiology and OB-GYN, which hinders the accurate assessment of the patient’s condition. Additionally, practitioners sometimes felt challenged utilizing the prison system and conducting a remote physical examination. The shift to telemedicine encouraged practitioners to see patients and increased health access to subspecialty clinics, which improved care coordination and information continuity and reduced security risks.

The implementation of telemedicine in prison systems during the COVID-19 pandemic enabled the continuity of care by allowing patients and practitioners to communicate remotely, which also promoted cost savings, and increased public safety by eliminating unnecessary off-site medical center visits. Care provided outside an inmate’s home facility entails significant travel expenses, especially because at least 2 correctional officers must accompany the patient throughout the entire visit. By eliminating any outside travel and additional security requirements, telemedicine visits were significantly less costly, especially when long travel distances are avoided. Because the initial implementation cost of building the telemedicine program was relatively high, net savings during the first 6 months were negative. However, because implementation costs are incurred only once, within 12 months we project significant net savings that will continue for the future. TTelemedicine programs require time to reach a break-even point and to experience cost savings, which may be different from other health care settings. Previous studies reported that the initial cost for telemedicine studies for equipment and implementation costs were in the range of $100,000–$250,000 however, the number of sites and volume of specialty clinics and practitioners varied compared to our study. ^19–21 Additional research is needed to assess the long-term monetary implications and ongoing cost of telemedicine programs, including the cost of training staff, implementing additional specialties that require additional or new technology, and costs associated with replacing technology over time because of wear and tear. ²²

In general, a current challenge to successful telemedicine implementation is the lack of internet bandwidth resulting in blurry video feed or call drop. Although this study utilized high-speed internet in the prison facilities, it is unknown whether the available internet bandwidth at prison facilities located in rural or remote regions would be adequate for telemedicine. Also, although a telemedicine program may be suitable and effective to treat specific health conditions, there are certain conditions and specialties where patients may require an in-person appointment with the practitioner so that physical exams or blood tests can be performed, which are not possible via telemedicine, and the lack of such in-person contact may hinder patient outcomes. More research is needed to identify the adequate health care delivery model based on patient characteristics and health conditions. Additional research is also needed to identify chronic conditions that would significantly benefit from the addition of telemedicine.

Previous research findings

Growth in health care spending for prisoners is attributed to challenges related to the delivery of health care in prisons such as the distances from hospitals and clinics. ^23,24 This study confirms that transportation costs alone created a substantial overhead cost for prison facilities and states. Telemedicine is capable of reducing transportation costs by eliminating unnecessary visits to hospitals and clinics.

Studies on the perceptions of prisoners and practitioners on the use of telemedicine are scarce. ^25–27 Prisoners and practitioners gave high ratings for their comfort level and overall satisfaction when using telemedicine. ^14,28,29

Incarcerated populations have higher rates of arthritis, diabetes, HIV, hepatitis, and sexually transmitted disease compared to the general population. ³⁰ In 2018, 97% of prisoners with hepatitis C did not receive treatment. ³¹ Our study validates the medical needs of prisoners, as the highest utilized telemedicine specialties included orthopedics, endocrinology, hepatology, and HIV.

Limitations

This study has several important limitations. The patient surveys did not collect personal health identifiers, which prevented us from calculating the exact patient survey response rate. Although we do not have evidence on why the response rate for patient surveys was lower than for practitioners and telepresenters, it is plausible that personal characteristics such as education levels, personal motivation with surveys, and privacy concerns contributed to patient participation rates. The study included the only 2 prison facilities for women in North Carolina, which limited the number of surveys obtained from female prisoners. Additionally, we could not assess patient outcomes, so cannot determine if there were any adverse effects of telemedicine compared to in-person care. Furthermore, as 97% of the telemedicine visits were conducted via video, we could not assess differences between care delivered via video vs telephone call. Finally, because the exact route for each van could not be determined, we needed to estimate the travel distance to calculate the drive time and distance avoided by utilizing telemedicine. Furthermore, for 12-month cost estimates, we assumed the same monthly volume of telemedicine visits.

Conclusions

Implementing a statewide specialty care telemedicine program within a large prison system was feasible and well received by both patients and practitioners. The telemedicine program has been shown to improve both practitioner and patient experiences, provide profound increases in access to health care, and tresult in significant projected reductions in the total cost of care year over year. We expect telemedicine to remain a central care-delivery modality well beyond the COVID-19 pandemic.

Supplementary Material

Supplementary Material 1