Managing IT at San Quentin

Dan Marshall, a staff information systems 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 happy to be putting in technology there 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 putting technology infrastructure in here is not easy,” he says, sweeping his arm to indicate the surrounding complex of I-beams, razor wire and stone buildings pocked up and down 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”—here Marshall laughs—”they’re much more into stone and steel.”

Marshall is installing new technology at San Quentin as part of a court-ordered overhaul of California’s prison health care system. 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, U.S. District Court Judge Thelton 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, Henderson concluded the state had made no progress. Inside the prisons, one inmate dies every six to seven days. Henderson appointed 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.

Safety Comes First

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, according to John Hummel, former CIO with the receivership (he resigned in February). “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 by an inmate, 121 members of the San Quentin staff were assaulted by inmates in 2006, the most recent data available. In other words, once every three days an inmate, sometimes armed with a homemade weapon, attacked an employee there—one of the highest assault rates among the 33 prisons statewide.

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 is a former executive director of the Santa Clara Valley Health and Hospital System with 40 years in healthcare administration. After touring San Quentin to see for himself conditions he later described as “appalling,” Sillen decided to focus there first. (See Sillen’s San Quentin Project Outline).

“It is the oldest, most decrepit and most notorious prison in California. As such, it is a perfect laboratory for reform,” he said in one of his many letters to staff and inmates during his 21 months on the job (Sillen was fired in January).

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 so he could treat a patient was beyond anything I’d seen in any third-world country,” he says. “I was ashamed.”

Prison Healthcare and Public Health

Inmates in California’s overcrowded prisons must be screened and monitored for tuberculosis, syphilis and other communicable diseases. However, that job is nearly impossible, federal courts have found, with 5,000 inmates transferring between prisons each month and minimal, if any, technology for managing their medical records.

The prisons are also unable to provide consistent treatment for inmates with chronic diseases such as asthma, diabetes and seizure disorders. In 2006, Gov. Arnold Schwarzenegger declared a state of emergency in California prisons because of overcrowding, saying in part that prisoners faced “increased, substantial risk for transmission of infectious diseases.” So, too, does the public, when inmates are released.

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?

A New Culture for IT

Yet making IT important is not as straightforward as it sounds, according to Hummel. When he started as CIO of the receivership in 2006, Hummel says, he had to learn to live with one cultural truth: The warden is boss. Judge Henderson may have invested the receivership with the authority to administer, manage and operate the prison healthcare system, Hummel says, but the warden runs his or her prison. Keeping 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 in a car 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 specific drug doses 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 more than a decade ago to accommodate overcrowding—nurses look for inmates, who are assigned bottom or top bunks in rows of beds crammed into the room.

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. More than 500 inmates transfer in and out of San Quentin each week. Statewide, 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 application, 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 Tonya Church, San Quentin’s director of nursing, discussed how to improve that process last year. 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.”

Beyond IT Basics

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 next month (Maxor’s GuardianRx is used by healthcare networks of comparable size, such as Denver Health, which cares for about 160,000 uninsured patients in Colorado).

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 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.

Part 3: Prison Healthcare Reform on Probation