ORIGINAL RESEARCH

Provider Satisfaction and Patient

Outcomes Associated with a Statewide
Prison Telemedicine Program in Louisiana

Michelle Glaser, M.P.H.,1 Tom Winchell, M.P.A.,2 technology was adequate to conduct visit (93.4%), and a follow-up
Patty Plant, B.S.N., N.P., M.S.N.,3 Wayne Wilbright, M.D., M.S.,3 telemedicine appointment was requested (90.8%). Most providers
Michael Kaiser, M.D.,3 Michael K. Butler, M.D., M.H.A., C.P.E.,3 were satisfied with telemedicine for the visit overall (87.0%), be-
Matthew Goldshore, M.P.H.,1 and Manya Magnus, Ph.D., M.P.H.1 lieved that telemedicine improved patient prognosis (88.2%), and
perceived that the patient was satisfied (83.0%). This study suggests
1
Department of Epidemiology and Biostatistics, The George that telemedicine was an effective and accepted method of healthcare
Washington University School of Public Health and Health provision.
Services, Washington, DC.
2
LSU Health Sciences Center, New Orleans, Louisiana. Key words: telemedicine, health information technology, outcomes
3
LSU Health Care Services Division, Baton Rouge, Louisiana. evaluation

Introduction

T
Abstract elemedicine represents a unique opportunity to enhance
Health information technology including telemedicine offers poten- healthcare delivery in situations where distance or travel
tial to improve patient care outcomes. As part of the response to challenges present barriers to specialty or other care. In-
Hurricanes Katrina and Rita in 2005, the Louisiana State University carcerated individuals represent a specific population where
Health Care Services Division expanded its statewide telemedicine there may be benefits of telemedicine are accentuated; benefits may
program. The aim of this study was to evaluate provider satisfaction result from the elimination of need to travel great distances with
and patient outcomes associated with telemedicine when used for the security measures in place, halt regular clinics to accommodate
administration of prisoner medical care. Providers completed a prison patients, or provide specialty services to prisoners that would
survey following each patient encounter in real-time; questions were otherwise be unavailable.1–4 Between transportation and extra
adapted from standard satisfaction indices. Statistical methods in- guards, bringing a prisoner to a doctor’s appointment can be ex-
cluded uni-, bi-, and multivariable including ordinal regression pensive and has potential to be dangerous. Telemedicine offers a way
methods to characterize unadjusted and adjusted factors associated to decrease medical costs and improve care among incarcerated
with telemedicine use and provider satisfaction, and patient out- populations.1–4
comes. Data were collected between December 2007 and May 2008 The field of telemedicine, also known as telehealth, ranges from
and were analyzed using SAS and Stata. Out of 737 patient visits, systematic phone contact between providers and patients for mental
the majority of patients were African American (68.6%), men healthcare provision, to complex video visits with technological at-
(92.9%), seen for either infectious disease or mental health (46.2% tachments to provide clinical assessments such as electrocardiogram
and 50.2%), with most surveys completed by a physician (63.1%). (ECG) monitoring, otoscopes, dermatologic viewing, and more.5–7
Most telemedicine encounters were completed (92.8%), a treatment Uses of telemedicine include connecting prison populations to care as
plan was established (97.0%), the provider perceived that the well as facilitating contact between providers and patients in rural

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 SATISFACTION AND OUTCOMES ASSOCIATED WITH TELEMEDICINE IN PRISONS

areas where travel is a barrier to care. Multiple evaluations and re- lenges in obtaining real-time or near-real-time evaluation data re-
views have been conducted in the use of telemedicine for provision garding provider perceptions of the system, including information on
of mental healthcare,1,2,8–15 prison care,16 HIV=AIDS care,17–24 and satisfaction and patient outcomes, have been limited by poor re-
dermatology,25–28 among other disciplines. These consistently suggest sponse rates of providers or lengthy delays between point of service
an increasing acceptance of telemedicine as well as efficacy of the and data collection. For example, rural Canada32 and Alaska33 have
technology toward patient care improvements. Adolescent mental telemedicine programs that reach citizens who are too remote from
healthcare in detention centers and other settings has been shown to be doctors and hospitals to receive medical treatment; however, the
particularly responsive to the use of telemedicine technology.2,13,15 system has not yet published an extensive outcomes-based evalua-
In response to Hurricanes Katrina and Rita in 2005, Louisiana State tion of its services. The Alaska Federal Health Care Access Network
University (LSU) Health Care Services Division enhanced and ex- system has one of the country’s oldest telemedicine systems, which
panded its telemedicine program to facilitate continuity of care be- was designed to overcome physical geographic barriers to care.33
tween clinics as well as respond to the unique needs of prisoner Despite the system’s ability to generate system-based process eval-
health. Over 48 video endpoints in 8 public medical centers and 13 uation data, satisfaction and outcomes data were collected by paper-
prisons were created.17,29 The initial set of services included based survey, resulting in a response rate of just 40%.33
HIV=AIDS care, mental health including juvenile services from de- Additional studies are needed to track real-time provider percep-
tention centers, otolaryngology (ear, nose, and throat), dermatology, tion of prison system use of telemedicine and provider satisfaction
and neurology. At each prison telemedicine unit, self-contained carts with telemedicine, in conjunction with patient outcomes. Provider
were provided to link the prisoner patient with the provider. The satisfaction with health information technology including tele-
equipment includes a primary video conferencing system (Polycom), medicine is a central component needed for adoption and im-
with a secondary camera (AMD) used for dermatology and wound plementation of any health information technology (HIT) to be
care appointments as either a hand held or tripod-mounted lens. A successful.34–39
video monitor=television screen, with audio capabilities, is used for The aim of this study was to evaluate provider satisfaction and
all clinical, administrative, and educational procedures that are part patient care outcomes associated with use of telemedicine in
of the telemedicine encounter. An AMD=Welch Allyn otoscope and Louisiana prison clinics, using a method that captures real-time,
laryngoscope is used for the ear, nose, and throat appointments and electronically collected data.17,29
the AMD 3700 Telephonic Stethoscope is used for the cardiology
appointments. Additionally, there is a document camera capable of Materials and Methods
capturing, analog to digital conversion, and transmitting clinical In concert with a multidisciplinary team and based on a review of
images, radiographs, ECGs, and videos where digital copies do not the existing literature, an electronic survey was developed that would
exist. be automatically presented to providers at the closure of each tele-
In conjunction with the initial rollout in the prison health centers, medicine visit. The survey contained five Likert questions regarding
an electronic provider survey was developed to capture the provider the provider’s satisfaction with the telemedicine visit, perception of
experiences. The aim of the survey was to obtain real-time satisfac- prognosis, and patient satisfaction with telemedicine, as well as six
tion and outcomes data directly from providers at the time of tele- questions regarding patient outcome and disposition; questions are
medical care. Although multiple evaluations have supported displayed in Table 1. The questions were adapted from other evalu-
telemedicine’s association with patient and provider satisfaction and ations and literature, publicly available forms, reports, and publi-
positive care outcomes in prison settings and the general popula- cations.32,33,40–43 Data obtained from all visits prison and nonprison
tion,1,5,7,8,10,11,13,15,16,20,28,30,31 there remain gaps in telemedicine between December 2007 and May 2008 were analyzed.
evaluation research, many stemming from difficulties in adequate
response rate and reaching providers to gather data as well as ANALYSIS
sometimes minimal dissemination of results. Univariate and bivariate methods were used to characterize pro-
In a systematic review of the literature, one study found that be- vider satisfaction and perception of telemedicine at each specific
tween 1966 and 2005, 47 articles contained information on a com- visit, and its association with patient disposition and visit outcomes.
plete technical evaluation of a telemedicine program and that only 3 Responses on the questionnaire were first assessed for global asso-
of those used objective methods to complete the evaluation.5 Chal- ciations with characteristics of the visit (location, clinic, and purpose)

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GLASER ET AL.

Table 1. Evaluation Questions

QUESTION RESPONSE SET
Was this telemedicine visit completed? Yes=No

If No to question above, why? Telemed technology did not work

Patient refused visit

Patient no show

Clinician unavailable

Clinic or session cancelled

Clinic or session occurred

Was the telemedicine technology adequate to conduct today’s visit? Yes=No

What information was not available but was needed to either make a diagnosis
and=or treat the patient?

Was a treatment plan established?

What is the patient’s disposition? Inappropriate consultation—requires additional consult by referring clinician

Patient needs to be seen at provider site

Follow-up telemedicine encounter requested by provider

Telemedicine encounter needs to be rescheduled

Other

Based on your perception about today’s telemedicine visit, clinical decision making Completely agree=agree=neutral=disagree=completely disagree
was successfully accomplished?

Based on your perception, today’s telemedicine visit may have improved the
patient’s prognosis?

Based on your perception about today’s telemedicine visit, how satisfied are you Completely satisfied=generally satisfied=neutral=generally dissatisfied=completely
today’s telemedicine outcome? dissatisfied

What is your perception about overall patient satisfaction with today’s telemedicine
visit?

What is your perception about overall patient satisfaction with today’s telemedicine
visit?

and patients (age, race, and sex). Those found significantly associated All survey protocols and instrumentation were approved by the LSU
were then assessed to ensure assumptions underlying ordinal re- Health Sciences Center and George Washington University Medical
gression were met; if they were, ordinal regression was used to model Center Institutional Review Boards.
characteristics associated with agreement to the Likert statements.
Logistic regression was used to model characteristics associated with Results
completion of the visit, perception that technology was adequate for As shown in Table 2, the majority of patients were men (92.9%),
the visit, and whether a treatment plan was established. For all re- African American (68.6%), and over 18 years of age at the time of the
search questions, a was set to 0.05. Stata 9.0se was used for analysis. visit (54.1%). Visits were nearly evenly split between mental health=

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 SATISFACTION AND OUTCOMES ASSOCIATED WITH TELEMEDICINE IN PRISONS

psychology (52.3%) and HIV=infectious disease (46.1%). Physicians

Table 2. Characteristics of Patients and Visits,
December 2007 to May 2008 (n ¼ 737) completed the majority of the survey (63.1%). The telemedicine
visits were completed in 92.8% of the surveys, with 93.4% of re-
N (%)
spondents citing technology as adequate to complete the visits.
Sex In addition, 97.0% of respondents cited that they were able to es-
Female 52 (7.1)
Male 685 (92.9)
tablish a treatment plan during the visit. The vast majority of re-
spondents requested a subsequent telemedicine visit for their
Race patient’s follow-up (90.8%).
Black=African American 401 (68.6)
As shown in Table 3, there was substantial agreement with
White 138 (23.6)
Other 46 (6.2) statements indicating satisfaction with the telemedicine system:
88.2% completely agreed or agreed that the telemedicine visit may
Age (years)
have improved the patient’s prognosis, 89.4% completely agreed or
<18 338 (45.9)

18 399 (54.1) agreed that clinical decision making was successfully accomplished
with telemedicine visit, 83.6% were completely or generally satis-
Visit type
fied with the telemedicine visit outcome, 82.2% completely or
Mental health=psychology 371 (52.3)
HIV=infectious disease 340 (46.1) generally satisfied overall with telemedicine visit, and 83.0% per-
Dermatology=other 26 (3.5) ceived that the patient was completely or generally satisfied overall
with telemedicine visit. Perception at the negative or far negative
Degree of person completing survey
MD 465 (63.1)
side of the spectrum was less than 8% for each of the five state-
NP 94 (12.8) ments.
RN 119 (16.2) As shown in Table 4, after adjustment for all variables in the
Other 59 (8.0) models, providers reported that they were less likely to complete a
Telemedicine visit completed visit for patients <18 years (odds ratio [OR] 0.35 [95% confidence
Yes 684 (92.8) interval (CI) 0.13–0.96]), less likely to perceive that technology was
No 53 (7.2) adequate for patients <18 years (OR 0.26 [95% CI 0.07–0.09]), and
If visit was not completed, reason (n ¼ 53) more likely to establish a treatment plan for African American pa-
Patient refused visit 25 (40.3) tients (OR 4.64 [95% CI 1.54–13.98]). After adjustment for all vari-
Telemedicine technology did not work 14 (22.6) ables in the models, male sex was consistently and significantly
Patient no show 13 (21.0) associated with provider-perceived satisfaction with all facets of the
Clinic or session cancelled 10 (16.1)
system and achieved positive clinical outcomes, whereas age <18
Technology adequate to conduct visit was consistently and significantly associated with less satisfaction
Yes 648 (93.4) and agreement with the positive statements. For nearly all of the
No 46 (6.6)
Likert statements, physicians closing out the visits and taking the
Treatment plan established surveys were more likely to relate dissatisfaction with the system
Yes 715 (97.0) than nonphysicians.
No 22 (3.0)

Patient disposition Discussion

Follow-up telemedicine encounter requested 660 (90.8) This study suggests that there was an overall high level of sat-
Patient needs to be seen at provider site 33 (4.5) isfaction with patient outcomes associated with the Louisiana
Telemedicine encounter needs to be rescheduled 20 (2.8)
statewide telemedicine system. For use in connecting prisoners to
Return to referring clinician 5 (0.7)
Other 9 (1.2) specialty care as well as linking locations to care where distance
was a challenge to care delivery, telemedicine was an effective and
accepted method of healthcare provision. Most visits were com-
pleted; telemedicine was requested for follow-up visits for the
vast majority of patients when the technology was perceived as

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GLASER ET AL.

more likely to have providers perceive that the technology was not
Table 3. Provider Perception of Telemedicine and Patient
Outcomes, December 2007 to May 2008 (n ¼ 737) adequate for the visit at hand. This may reflect the difficulties in
treating this adolescent population in juvenile detention settings
N (%)
more than the telemedicine itself, but suggests that the technology
Based on your perception, today’s telemedicine visit may
should be carefully monitored for satisfactory outcomes among this
have improved the patient’s prognosis
Completely agree 279 (37.9) population. This is contrary to the findings of other investiga-
Agree 371 (50.3) tors2,13,15 who found telemedicine to be successful with adolescents,
Neutral 71 (9.6) including those in detention centers. Although women composed a
Disagree 3 (0.4) very small proportion of the sample, our measures suggest that the
Completely disagree 13 (1.8)
providers perceived the use of telemedicine to be more satisfactory
Based on your perception about today’s telemedicine visit, and with less satisfactory patient outcomes than that for their male
clinical decision making was successfully accomplished counterparts. Future studies are needed among samples with more
Completely agree 283 (38.8)
women to examine this more fully.
Agree 369 (50.6)
Neutral 62 (8.5) This study has several strengths and limitations. The survey was
Disagree 2 (0.3) inserted into the telemedicine electronic interface that sets ap-
Completely disagree 13 (1.8) pointments and contains patient data as a part of the electronic
Based on your perception about today’s telemedicine visit,
close-out procedures, which ensured maximum participation
how satisfied are you with today’s telemedicine outcome? among the providers; this increases the generalizability of the
Completely satisfied 281 (38.1) findings to the population of providers using the telemedicine
Generally satisfied 335 (45.5) program. The survey was developed by a multidisciplinary team
Neutral 65 (8.8) and was evaluated by sentinel providers before launch, to ensure
Generally unsatisfied 42 (5.7)
Completely unsatisfied 14 (1.9)
acceptability of the tool. During that period, however, the length of
the survey was found to be too long and the final survey omits
Based on your perception, what is your overall satisfaction several questions that could have lent context or depth to the re-
with the telemedicine system for this telemedicine visit?
sponses. Other than location, type of clinic, and the type of provider
Completely satisfied 283 (38.4)
Generally satisfied 323 (43.8) closing out the survey, few characteristics are available regarding
Neutral 73 (9.9) the providers. Future studies may examine whether provider char-
Generally unsatisfied 44 (6.0) acteristics such as comfort with computers or technology are as-
Completely unsatisfied 14 (1.9) sociated with satisfaction; if so, additional training may be
What is your perception about overall patient satisfaction provided to those most at risk of dissatisfaction with the system. Of
with today’s telemedicine visit? particular interest may be differentiating frequent telemedicine
Completely satisfied 267 (36.2) users from occasional users. The relative impact of satisfaction with
Generally satisfied 345 (46.8)
telemedicine may depend on how frequently the provider uses the
Neutral 75 (10.2)
Generally unsatisfied 37 (5.0) technology, as well as how comfortable the patient is with the
Completely unsatisfied 13 (1.8) system. In addition, more information beyond demographic char-
acteristics of the patients, such as diagnosis codes or other clinical
information, would enrich our understanding of the relationship
between telemedicine use in the prisons and provider satisfaction
adequate to meet the clinical needs of the patients. These results with evolving technologies. Additional research into the patient
suggest that the providers are successfully using the telemedicine perspective of telemedicine and satisfaction with the system are
technology to treat prisoners using these methods in mental needed. An additional limitation of the current cross-sectional
health=psychology and HIV=infectious disease. The type of ap- study is the inability to track trends in satisfaction or utilization
pointment that resulted in the greatest challenges included mental over a longer time frame. This temporal information would be
health televisits for residents of juvenile detention centers. These helpful to see if as the providers become more accustomed to the
patients were least likely to have their visits completed, and were telemedicine procedures, their levels of utilization or satisfaction

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 SATISFACTION AND OUTCOMES ASSOCIATED WITH TELEMEDICINE IN PRISONS

Table 4. Adjusteda Characteristics Associated with Provider Satisfaction and Patient Outcomes,
December 2007 to May 2008 (Odds Ratio [95% Confidence Interval]) (n ¼ 737)
SATISFIED WITH
TELEMEDICINE TECHNOLOGY CLINICAL TODAY’S SATISFIED WITH PERCEPTION
VISIT TREATMENT PLAN ADEQUATE FOR IMPROVED DECISION MAKING TELEMEDICINE TELEMEDICINE OF PATIENT
COMPLETED ESTABLISHED TODAY’S VISIT PROGNOSISb FACILITATEDb OUTCOMEb SYSTEMb SATISFACTIONb
Patient sex
Male 1.0 1.0 1.0 1.0 1.0 1.0 1.0 1.0
Female 1.09 (0.24–4.97) 0.34 (0.06–1.94) 0.82 (0.23–2.94) 0.41 (0.22–0.75)c 0.49 (0.27–0.89)d 0.38 (0.20–0.71)c 0.35 (0.18–0.66)c 0.40 (0.22–0.75)c

Patient race
Non–African 1.0 1.0 1.0 1.0 1.0 1.0 1.0 1.0
American
African 1.27 (0.71–2.25) 4.64 (1.54–13.98)c 0.95 (0.52–1.75) 1.10 (0.82–1.46) 1.12 (0.87–1.56) 1.08 (0.82–1.44) 1.05 (0.79–1.39) 1.25 (0.94–1.66)
American
Patient age
(years)

18 1.0 1.0 1.0 1.0 1.0 1.0 1.0 1.0
<18 0.35 (0.13–0.96)d 0.15 (0.18–1.34) 0.26 (0.07–0.90)d 1.59 (1.06–2.39)d 1.56 (1.03–2.35)d 1.73 (1.16–2.59)c 1.54 (1.03–2.29)d 2.14 (1.43–3.20)e

Provider type
Nonphysician 1.0 1.0 1.0 1.0 1.0 1.0 1.0 1.0
Physician 1.01 (0.34–2.98) 2.24 (0.27–20.61) 2.73 (0.79–9.53) 1.46 (0.97–2.20) 1.87 (1.24–2.82)c 1.64 (1.10–2.47)d 1.89 (1.27–2.81)c 1.61 (1.08–2.40)d
a
Adjusted for all other variables listed.
b
OR > 1.0 indicates increasing disagreement with statement and dissatisfaction with system; OR < 1.0 indicates increasing agreement with statement
and satisfaction with system.
c
p < 0.01.
d
p < 0.05.
e
p < 0.001.

change. As the telemedicine system in Louisiana evolves, time- over time and in provider and patient satisfaction with the technol-
trend analyses can be conducted to see if there are trends in sat- ogy as it broadens and is implemented elsewhere throughout the
isfaction and usage over time. state.

Conclusions and Recommendations

Telemedicine is an integral part of the growing health information Acknowledgments
technology field. Telemedicine offers an immediate and real step The authors wish to acknowledge the contribution of all providers,
toward improving the healthcare provided to prisoners in Louisiana faculty, and staff engaging in this study as well as the patients seen,
as well as individuals needing specialty care between rural and urban without whom this study would not have been possible. Michelle
locations. Providers are no longer inconvenienced by security mea- Glaser was a student at GWU at the time of her participation in this
sures and work interruptions experienced with face-to-face consul- study. She is currently a CDC/CTSE Applied Epidemiology Fellow.
tations with the prisoners, offering the potential for realization of This study was funded in part by the LSU Health Care Services
cost savings over time as well as improved care for prisoners. On- Division and the LSU Health Sciences Center.
going prospective evaluation of provider satisfaction and association
between telemedicine usage and patient outcomes will enable system Disclosure Statement
improvements over time. Future evaluations will explore changes No competing financial interests exist.

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GLASER ET AL.

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