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Recommendations for a National Mass Patient and Evacuee Movement, Regulating, and Tracking System

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Prisons and Jails

Corrections Typology and Definitions

Jails and prisons differ in the type of inmates they hold, their daily and annual population, and the manner in which they are operated.  People with all types of medical conditions and at all levels of ambulatory ability are arrested and incarcerated in jails and prisons.

Typology of Jails and Prisons

Typology Jails State Prisons*

Criminal Justice Status of Inmates

Pretrial (not sentenced)

Sentenced (up to 2 years)

Sentenced (2 or more years)

Organization

Operated by the Sheriff or County

Autonomous units, not part of larger structure (there are regional and national Sheriffs' Associations, but they do not have authority over Sheriffs.)

Each State Department of Corrections (DOC) operates the prisons, sets policies and has authority over the prisons.  However, each facility has a degree of autonomy and many policies and practices are at the discretion of the Warden.

Average Daily Population (ADP) and Annual Population

Jails have high inmate turnover and many short stay (a few hours to 14 days) inmates.  As a result ADP is much lower than the number of inmates that pass through annually.

Stable inmate population with much less turnover than jails.

Inmates with Serious Medical Conditions

Typically not held, transferred to medical facility or other supervision option.  Most facilities have medical units where inmates go for acute conditions.

Some States have one or more facility for inmates with serious medical conditions, but they are often held at regular facilities, sometimes in special units.

All facilities have medical units where inmates go for acute conditions.

Medical and Other Programs

Less common due to the short length of stay.

Medical services and other programs are more common, but vary by system and facility.


* The Federal Bureau of Prisons (FBOP) operates Federal prisons and several private companies operate private prison facilities around the country. This report does not address the needs or readiness of private prisons. 

Correctional Health Care.  Correctional health care is increasingly provided by private companies who contract with corrections systems, often in a managed care arrangement.  There are a few major private health care contractors and numerous smaller ones.  This trend may have consequences for a national patient tracking system as the contracts for health care are regularly renewed and change hands; agreements with one contractor may not be agreeable to or even known about by the next contractor.  Even if agreements are made with the correctional facility/system, the medical department (or contractor) would be responsible for ensuring that medical information can and will be provided to the proposed system.  (Abt recently conducted a survey of correctional medical departments for the U.S. Department of Justice and found that when there had been recent turnover in private contractors, the new health care vendor often did not have access to inmate medical data from their predecessor.) 

Inmate Health Care Needs.  Correctional facilities house a large number of inmates with infectious diseases, including conditions such as HIV and hepatitis C that require regular medication, as well as an increasing number of inmates with chronic diseases.  They also often house a large number of inmates with mental health conditions.  Inmates with mental health conditions cannot be evacuated without continuous medication and supervision, to assure that evacuation is safe for them and those around them.  

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Existing Corrections Information Systems

The different segments of the criminal justice system (police, court, DA, jails, prisons) almost never use the same information technology (IT) systems.  In some cases the police operate or maintain the electronic administrative systems for their local jail, but this does not guarantee that it is an integrated system.  Data, whether administrative or medical, are maintained and accessed at the "department" level (e.g., individual jail, county department of corrections).  In addition, medical and administrative data are usually in two separate systems, and administrative records are more likely to be in electronic form than are medical records.  

Corrections Administrative Records.  IT systems to manage corrections administration are almost universal (very small facilities may still have paper systems) and track the exact location of each inmate inside the facility, at all times.  These tracking data are checked several times a day through inmate "head counts".  Most administrative record systems are homegrown or modified off-the-shelf systems, and do not connect to any other system in the criminal justice system or at the State or Federal level (except of course for the Federal Bureau of Prisons institutions).  One jail respondent explained that their emergency plan included printing out this database hourly when they are on alert for an evacuation, in case the computers go down.

Corrections Electronic Medical Records (EMRs).  There is no comprehensive information on how widespread EMRs are in jails or prisons.  But there are some data from a variety of sources, including a 2005 Abt Survey of Infectious Diseases in Correctional Facilities that included questions on the use of EMRs and, more broadly access to computers and the Internet.  The survey included the Federal BoP, the 50 State departments of corrections, and the 50 largest jails in the country.  Survey results show that correctional systems that have an EMR may not be able to connect to the Internet (to upload data to a national evacuation tracking system) and that many correctional institutions lack computers and/or Internet access.

Access to Computers and the Internet and Use Or Planned Implementation of EMRs

Correctional Facility

Access to Computers in Medical Unit

Access to Internet in Medical Unit

Currently Uses EMR

Plans EMR in next 12 months

33 of 50 Largest Jails

79%

55%

39%

22%

46 of 50 State Prisons and the Federal Bureau of Prisons

57%

43%

32%

15%


Data from Abt Associates Inc. 2005 Survey of Infectious Diseases in Correctional Facilities.

Corrections officials interviewed about evacuation tracking also reported that:

  • Only about 10% of the jails that apply for certification from NCCHC (an accrediting body for correctional health care) use EMRs.
  • Most large jails have EMRs.
  • In many departments of corrections, a minority of facilities have EMRs; moreover they are not always connected to each other or the central office for data sharing.

Home grown systems that have evolved over time are very common for both administrative and medical data.  However there are many vendors for each type of system and few facilities have "enterprise" solutions that contain both administrative and medical data. 

Unique IDs: Each facility/system may assign multiple ID numbers to each inmate for different purposes, and State prison systems will have at least one shared ID across facilities.  There is no shared ID number across criminal justice entities (e.g., courts, jails, prisons).  EMR IDs are probably be even less standardized.  

Demographic Information: No standard administrative or medical data elements are required to be reported to an outside body.  Presumably many systems collect a relatively similar core data set in terms of client demographics and criminal justice involvement, but the manner in which it is captured, the field names and the data formats vary widely. 

Overall Health Status: There is generally no medical information in the administrative record.  No correctional system that we spoke to had an EMR that can identify inmates with certain needs (e.g. wheelchairs, special medications), and none have a mechanism for easily identifying inmates who would need assistance evacuating.  Detailed health information is available in the EMR in individual records, but as with hospital EMRs these systems probably cannot generate lists of persons in wheelchairs, persons requiring specific medications, etc.  

The administrative and the facility census data are very accurate.  The completeness and accessibility of medical data will vary by system, when there is any EMR at all.  A major concern is that many correctional systems do not have remote backup for their systems so if the facility's computers are down they cannot access records and may never be able to retrieve them. 

Some prisons have explored alternative methods for tracking inmate movements.  One we spoke with priced an RFID (radio frequency identification) system with handheld devices to scan each inmate's ID#, demographics, security level and medical data. The estimated cost for one large jail was $1.8M for RFID, software and hand-held devices.

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Special Evacuation Issues in Jails and Prisons

Three themes came up in the discussion of advanced planning for emergencies that highlighted some of the difficulties in planning for an inmate evacuation.  First, it is difficult to set up agreements for transportation, housing, and other resources for inmates prior to an emergency because other correctional facilities are concerned about the liability and payment issues that might arise if they agree to accept inmates from another facility during an emergency.  Private companies that could provide transportation, housing, etc., generally have reservations about aligning themselves with correctional systems.  Second, during an emergency mutual aid agreements and emergency orders will be put in place that will either make other systems/companies more willing to cooperate or will require them to do so. Third, inmates and correctional facilities will be the lowest priority for public resources and the correctional facilities assume that they will have little access to community resources or transportation. 

Corrections Evacuation Plans and Strategies.  Some correctional facilities told us that they would not evacuate, even under an evacuation order.  A concern with this strategy is that inmates will be at risk if there is loss of power or damage to the building.  Inmates in segregation may be more at risk.

Others plan to evacuate vertically (or within the facility/complex) by moving only inmates in affected areas of the facility to other parts of the facility/complex. Since the Katrina experience, many facilities have revisited this concept and now realize that much depends on the nature and extent of the disaster.  For example, in the event of flooding some degree of vertical evacuation may be possible; in an earthquake where the entire facility is damaged or destroyed, the building would have to be evacuated.  One jail's plan includes cordoning off a city block outside the facility and holding inmates there until they can be moved elsewhere.

Evacuating to other (safe) correctional facilities is now being considered by more officials.  In some cases, tents could be set up in the yard of another facility that has insufficient cell space to house the evacuees.  If a correctional facility in another State is the closest alternative, more complex arrangements would be needed, as well as payment between the two States. 

Some officials are considering use of large unused buildings, armories, National Guard facilities or fairgrounds that are reasonably close but out of harm's way. Concerns include security, who will pay, and liability—all of which are partially resolved when an Emergency Operations Center is established and issues an executive order requiring sharing of resources (mutual aide).

Some low risk inmates could safely be released to self-evacuate.  One jail reported that they have used this strategy on three previous occasions and each time all but one of the released inmates returned to the jail after the emergency.  (Prisons do not have this option.) 

Experts from the National Institute of Corrections advised us that emergency preparedness is not currently a major concern for jails and prisons.  Few correctional systems have any type of emergency plan, and existing plans are generally out of date and have not been recently reviewed.  Correctional staff receive very little training on emergency preparedness, and few use drills to practice for evacuation.  Given the expense and security needs of moving inmates for a drill (within or out of the facility), they are rarely done.  The task is so daunting that many facilities have not developed any evacuation plan at all.

The emergency preparedness plans that do exist in corrections can address a variety of emergencies and take a variety of forms:

  • Plans for mass escape or hostage taking incidents.
  • Plans for fire (required for some accreditations).
  • Some plans for specific disasters (e.g. hurricane, earthquake, bioterrorism).
  • Some generic plans that are adapted for each type of emergency (corrections is moving   towards generic as this simplifies staff training).
  • Plans for on-site evacuations (if part of the facility becomes uninhabitable).
  • Plans for off-site evacuations, for situations that affect just the facility and also for those that affect the entire community.

National Incident Management System (NIMS), coordinated by the Federal Emergency Management Administration (FEMA).  It was developed for fire departments and adopted by police departments, and is used in corrections but considered a "poor fit."

Transportation Resources in Correctional Facilities. Under normal circumstances, inmates are transported "outside the walls" in specially secured vehicles with specific officer-to-inmate ratios depending on the security status of the inmate (minimum, medium or maximum security).  Facilities generally have only a few transports to handle each week and even the largest do not have sufficient vehicles, fuel and staff to evacuate an entire jail or prison.  In addition, inmates will need to be supervised by correctional officers in the required ratios at the evacuation destination; the officers will not be able to return to the facility to move more inmates out.  Virtually all available officers would be used in the "first wave" of the transport, leaving none for subsequent roundtrips to and from the facility.

Jail systems vary in the extent to which they own buses to transport inmates.  Jails that are attached or located in close proximity to the courts may not have buses because inmates are walked back and forth to court.  More remote jails have many vehicles to transport inmates.  When inmates are moved from jail to prison (to serve longer sentences) the prison system is responsible for transportation.  Some jails have formal or informal agreements with municipal agencies to use city or school buses in an evacuation, however most officials we spoke with were not optimistic that inmates would have priority in the event of a community-wide disaster. Most divisions of corrections do have a fleet of buses and vans for moving inmates between facilities, which they could deploy in an emergency, but not enough to evacuate all threatened facilities in an area the size of that affected by Katrina.   (Note that in the New Orleans evacuation, many staff members transported inmates in their private cars.)

Inmate Identification During and After Evacuation. The most common plan for identifying inmates during an evacuation is to issue plastic bracelets marked with an ID number.  This ID number would not associated with any of the administrative or EMR Ids; it would be recorded and linked with the inmate's name (and could become the unique ID number that is uploaded to a national tracking system).  In some jails, inmates already wear a bracelet throughout their incarceration printed, with the following data elements (not a barcode): picture from booking, jail and criminal ID numbers and name. No medical information or emergency alerts are included (e.g., diabetes).

Bracelets may be a poor identification strategy for inmates.  When the New Orleans Parish Prison was evacuated, inmates were issued bracelets that were color-coded based on security level.  Almost all the inmates, except the lowest level of security, cut or chewed the bracelets off before the buses deposited them at the prison that was used as their evacuation site.  This meant that there was no way to identify any of the inmates for either security purposes or to treat them for medical conditions.

Medications.  In facilities with "keep on person" (KOP) medication policies where inmates control their own supply of medication, each inmate could bring their current supply of medication with them during an evacuation. Some inmates, and some medications, must be controlled and administered by trained medical personnel.  Medication might need to be dispensed in-transit during an evacuation as well as afterwards.  Correctional staff will need to be responsible for assuring that inmates continue to receive necessary medication throughout an evacuation. 

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Privacy and Confidentiality in Corrections

Prison records contain information about inmates' crimes, sentences, medical records, and other potentially sensitive information.  Many States post information on all sentenced inmates on their Web sites, so this information is not considered private or protected, but for people being held prior to trial, there would be confidentiality concerns. Correctional officials have concerns about information security and who will have access to each type of data.  The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is relevant for prisons, but the special security considerations raise additional issues.  There are also concerns about legal issues and a general sense that the legal department would have to approve their participation in the proposed system.

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Correctional Staff Perceptions: Benefits of Evacuation Tracking

Corrections officials were interested in an evacuation tracking system.  For those that have electronic data but no backups (or whose systems are too damaged to access), the national system could be a temporary back-up—assuming data are uploaded quickly enough before the facility's own system fails.

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Data for Other People Needing Evacuation Assistance

In addition to the institutional records described above, there are other databases that could be used to "pre-populate" a database of persons who need to be assisted—and tracked—during an evacuation. Some of these other databases may be electronic, but some may be print or written lists that cannot be as readily accessed. The need for evacuation assistance and tracking of non-institutionalized persons could be substantial; an official from the Department on Disability in Los Angeles estimates that 25 to 30 percent of the general population will need evacuation assistance.74 

  • Hotel and resort guests. During hurricanes in tourist areas, hotels become temporary shelters for any of their guests who cannot secure evacuation transportation, and for others whose homes are unsafe. Hotels have accurate lists of all registered guests; these lists are often maintained in a central database for hotel chains. Most hotel guests need little more than transportation to a safe airport, but it might take several days before that is possible.
  • Evacuation Pre-registration.  Florida counties offer residents the opportunity to pre-register for evacuation assistance.  People who know that they will require this assistance can pre-register for help.  During an evacuation, emergency managers will attempt to verify whether help is indeed needed, and send emergency responders to assist.  Ventilator-dependent (and other electricity-dependent) patients, those who are bed-bound or wheelchair-bound and without any transportation assistance, and anyone else who knows that they will not be able to self-evacuate safely, can pre-register.  Miami-Dade County has such as system; its registration form is at http://www.co.miami-dade.fl.us/oem/pdfs/EEAP.pdf.  In addition to identifying and location information, the form asks for the applicant's health status (there are check boxes for 15 different conditions), whether they use medical equipment requiring electricity, whether a companion will accompany them to a shelter, and whether they use a wheelchair, walker, guide dog, or crutches. According to a county emergency manager in Florida, most of these registries are small—many people prefer not to be on such a list for reasons of privacy.  Recent hurricanes have heightened awareness of the need to pre-register and the voluntary registries are expanding gradually.75
  • Local Special Assistance Lists. Many fire departments offer disabled persons who might need to be rescued (e.g. in a fire) the opportunity to be listed, so that responders are aware that a disabled person lives in a house.  In addition to those who are mobility impaired, persons with communication impairment (deaf, mute) may voluntarily add their names to such a list.
  • MedicAlert and other emergency pager systems have lists of clients who might require assistance, especially in a rapid evacuation.
  • Vocational rehabilitation and independent living centers have lists of persons receiving personal home aide (not home health) services and will likely know which require mobility assistance. 

74. 2006 personal communication with Angela Kaufman, Project Coordinator, Los Angeles Department on Disability.
75. 2006 personal communication with David Freeman, Orange County, FL.


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