The Real Cost of Prisons Weblog

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.

What happens to inmates' medical records as they transfer between prisons.

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."

California's Prison Inmates

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."

# Total: 173,312
# Death row: 669
# Lifers: 30,048
# Average age: 36
# Average reading level: 7th grade
# Average sentence: 47 months
# Recidivism rate: 70%
Part 2: Managing IT at San Quentin
– Kim S. Nash, CIO

April 01, 2008
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."

How his feelings about his job have changed since IT improvements began.

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
Prison Healthcare Reform on Probation
– Kim S. Nash, CIO
April 11, 2008
In January, U.S. 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.

Learn more about using technology to fix California prison health care.

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.

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 Henderson. 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.

Henderson seized control, appointing Sillen 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.

In a "Plan of Action" he filed in November, Sillen outlined 22 objectives, from building more physical buildings at various prison sites to piloting a new grievance investigation procedure to installing systemwide 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.

Furthermore, Henderson noted, the receivership "must work more closely at this stage with all stakeholders." 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 deficit that halted budget talks between Gov. Arnold Schwarzenegger and the legislature for two months last summer Sillen is known to be prickly and confrontational—a style unlikely to persuade state legislators and Schwarzenegger, among others, to come together to support expensive prison overhaul projects. (More from Governor Schwarzenegger on Prison Overcrowding and Parole Proposals). Sillen could not be reached for comment.

A CIO in Charge

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."

Then in February, John Hummel, the receivership CIO, quit. He says the move is unrelated to Kelso's arrival. Hummel returned to Perot Systems as a chief technology officer.

In an interview the day before he resigned, Hummel talked about how his wife, his daughter and his neighbor objected to his work. "People in my own life would come along and say, What are you thinking?" he says. "My wife screamed at me about inmates getting free care."

Why prison inmates are entitled to adequate health care.

However, he says he left not because of any philosophical quandary but, in part, to work with advanced technologies. As to the ethics, Hummel says he was always clear about what he was doing.

"You do not judge people. You treat them. Period."

Kelso says he admires Hummel. "He has an extraordinary capacity and understanding of what good healthcare IT systems look like," Kelso says. Hummel's leaving "is a great loss for the receivership."

Dan Marshall, staff information systems analyst at San Quentin State Prison, manages much of the prison's IT. He has yet to meet Kelso, who spent his first several weeks on the job in the state capital reorganizing the receivership. Kelso let go 10 of the highest-paid people who worked for Sillen, including the CFO and the director of communications, but no one from IT. And while Sillen paid himself $775,000 for less than two years' work, Kelso put his own salary at $224,000.

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 in March that includes aggressive technology deadlines. (See Kelso's Strategic Plan). Kelso is also considering whether running one network for both medical and corrections applications would be faster and cheaper. "The vision of the new people may be different," Marshall allows. "But it'll all go forward." He's confident.

So far he hasn't been told to stop any projects.
An Enterprise on Probation

California citizens consistently vote tough on crime-mandated minimum sentences, three-strikes laws and strict punishment for probation violations. Still, broken-down prisons are just as 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.
About the California Department of Corrections

* Highest-ranking executive: Secretary James Tilton
* IT executive: Joseph Panora, assistant secretary, enterprise information services

The Prisons

* Number of prisons: 33
* Designed capacity: 82,936 inmates
* Population over designed capacity: 194%
* 2007 budget: $8.75 billion
* Staff: 57,641
* Oldest prison: San Quentin, a multiple-security facility built in 1852. Includes the state's only death row. Population exceeds designed capacity by 174%.
* Newest prison: Kern Valley State Prison, a maximum-security facility opened in 2005. Population exceeds designed capacity by 200%.

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. The way care occurs has gotten better; San Quentin's intake process is one example. New construction, with plans for more, is under way at many prisons. Some software, hardware and networks have been upgraded, or in some cases installed for the first time, in various institutions.

The receivership has spent more than $20 million so far, according to a report in February from the state Office of the Inspector General, with about $8.7 million of it going to IT, systemwide, and construction at San Quentin specifically. Maxor has been paid $2.8 million so far, the report says.

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." A lawyer for the thief told a San Francisco newspaper he plans to appeal.

Meanwhile, the tally of what Henderson calls "needless" death has not dropped. Sixty-six inmates died of preventable or possibly preventable causes in 2006, the latest year for which statistics are available, according to a federal audit. Death row is safer: Just 14 people have been executed in the past 28 years.

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