Four years ago 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. That's about as many people as live in Tempe, Ariz., and it's 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 U.S. 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 information technology found even in small rural hospitals in the United States. 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.
An "unconscionable degree of suffering and death is sure to continue if the system is not dramatically overhauled," he wrote, explaining his decision. 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. Some improvements have been made—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 in 2000 to $1.6 billion last year, most of the money went to staff and medical supplies, not to infrastructure or technology that could have made operations more efficient. "Data management, which is essential to managing a large healthcare system safely and efficiently, is practically nonexistent," Henderson wrote. "This makes even mediocre medical care impossible."
For technology managers at California prisons, the federal takeover opens a rare opportunity. When an organization runs so little technology, networking a few PCs to provide e-mail makes you a hero, says Dan Marshall, staff information systems 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 in early February to return to his former employer, Perot Systems.
But in other ways, the project stands apart. How do you set up a wide-area network 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? And the ethics debate never ends. 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.
How Nurses Process 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, a cramped wood structure near the recreation yard.
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 raises her voice to be heard above the noise and explains what goes on.
Her 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 aspects 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.
Change Happens Slowly
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 four-part forms with check boxes to describe a patient: diabetic, heart disease, orthopedic problems and so on. 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 in the existing intake center, 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. With mental health screens now happening at San Quentin the day an inmate arrives, staff can spot potential suicides sooner, Church says: "If he's never been to prison before and there are any suicidal tendencies, those usually show up sooner rather than later," she says. "So now we identify those risk factors on day one, instead of day four or five, after he's hanging."
While Church likes the changes at San Quentin so far, she has worked there 14 years and looks, tough-minded, 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."