At the Intersection of Health and Justice

by David Cloud, JD; Michelle Dougherty, MA, RHIA, CHP; Robert L. May II; Jim Parsons, MSc; Paul Wormeli, MS; and William J. Rudman, PhD, RHIA

The concentration of incarcerated individuals with mental health and physical problems in the United States has led to the labeling of jails and prisons as the “hospitals of last resort” for those unable to access healthcare services in the community. As funding for community behavioral health services has dwindled, the number of people with serious psychiatric conditions in the nation’s correctional facilities has grown.1,2 There are currently three times as many people with serious mental illness in jails and prisons than in state hospitals.3 A 2006 Bureau of Justice Statistics report estimated that 705,600 adults with mental illness were housed in state prisons, 70,200 were housed in federal prisons, and 479,900 were housed in local jails, at an annual cost to taxpayers of $9 billion per year.4,5 These statistics signal the importance of improving data sharing between the criminal justice and community healthcare systems to increase treatment access and coordination of services for the medically underserved.

While correctional facilities were never intended to serve as hospitals or community clinics, they are the only places in the United States where an individual has a constitutionally protected right to basic healthcare;  and continue to deliver an increasing volume of healthcare services to one of society’s sickest populations.6 Thus, jails and prisons present a unique, opportune environment for public health interventions that aim to engage high-needs populations in health services that tend to slip through the cracks of other safety net care systems.7 Unfortunately, the standard of care for those with chronic health conditions cycling in and out of correctional facilities continues to lag behind the services available in the community. Technological innovations in information management used to improve healthcare delivery in community settings have generally not been applied in jails or prisons. The absence of health information technology in criminal justice settings creates barriers to communication between healthcare providers working behind bars and those in mainstream health systems; which can lead to preventable morbidity and mortality, increased risk of medical errors, inefficiencies in care coordination, and recidivism.

Improving communication between treatment providers working in correctional and community health settings through better information sharing can yield a range of benefits. People transitioning from prison to the community experience a 12.5 times higher risk of death during the first weeks following their release.8 Research shows that increasing access to care and continuity of services for this population as they transition between systems can improve health outcomes, reduce emergency room visits, and prevent re-arrest.9, 10 Just as access to appropriate care and clinical documentation are vital within correctional facilities, continuity of care when accessing services in the community after release is essential for the 7 million people cycling through jails and the 700,000 individuals released from prison each year.11

Leading organizations such as the Institute of Medicine recognize that health information technology (HIT) will play a transformative role in addressing urgent gaps in the quality of care in communities with limited resources. HIT will also help achieve parity and close the “quality chasm” that exists between the accessibility and quality of behavioral health and physical healthcare services.12 Though studies on the subject to date have been limited, the available research indicates that building bridges between siloed information systems and organizational boundaries can ameliorate health disparities in underresourced settings.13

To successfully navigate the legal, ethical, cultural, and technological challenges that agencies face when sharing sensitive health information across organizational boundaries, there is a pressing need for the establishment and formalization of data governance standards and policies, specifically those that relate to the safe and secure exchange of healthcare data. The creation of an oversight body that will ensure compliance is paramount to the success of such an endeavor, given the sensitivity of the data shared and the potential harm if data are not protected appropriately. To address issues related to continuity of care, healthcare costs within the prison population, the incidence of violent crime within the community, and recidivism, it is crucial to establish a cross-system collaborative model between the criminal justice and healthcare systems to ensure appropriate information flows.

The establishment of a board tasked with systematically providing expertise aimed at the integration of these two systems through the development of a data governance structure and definition of appropriate policies will ensure increased data integrity. Further, this board would support the application of the National Information Exchange Model (NIEM) to facilitate information sharing and data exchange. The establishment of standards that can be implemented in a practical manner across relevant healthcare and criminal justice systems is necessary to identify both the overlaps and the gaps that exist between the two systems. This model would include (but not be limited to) collecting data on:

  • What information is collected by each system
  • What information is needed by each system from the other system
  • What format would best facilitate the exchange of information
  • What technical capabilities are presently in place and what new information systems are emerging
  • How the two systems can best interface to prioritize areas with the most critical or crucial need (such as areas where data sharing should begin)

By outlining the incongruent areas and points of similarity, it will be possible to identify the highest priority use cases for information exchange, which would in turn determine where the creation of unifying standards for information exchanges should begin and where existing standards development processes could be leveraged.

The importance of building a connection between the criminal justice and healthcare systems to tackle a set of complex social problems at the intersection of public health, public safety, human rights, and social justice cannot be overstated. As healthcare reform continues, coverage of comprehensive health services must break down structural barriers to access by building capacity for integration, coordination, and expansion of HIT. Available systems must address health disparities and inequities for the millions of people passing through the criminal justice system. Leaders in the justice and healthcare sectors must work together and develop interagency solutions that enhance interoperability between the justice and healthcare data systems.

David H. Cloud, JD, is a program associate at the Vera Institute of Justice’s Substance Use and Mental Health Program in New York, NY.

Michelle L. Dougherty, MA, RHIA, CHP, is the director of research and development for the AHIMA Foundation in Chicago, IL.

Robert L. May II is the assistant director of program and technology services at the Integrated Justice Information Systems (IJIS) Institute in Ashburn, VA.

Jim Parsons, MSc, is director of the Substance Use and Mental Health Program at the Vera Institute of Justice in New York, NY.

Paul Wormeli, MS, is executive director emeritus of the Integrated Justice Information Systems (IJIS) Institute in Ashburn, VA.

William Rudman, PhD, RHIA, is the executive director of the AHIMA Foundation and vice president of education visioning at AHIMA in Chicago, IL.


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4 James, D. J., and L. E. Glaze. “Mental Health Problems of Prison and Jail Inmates.” Bureau of Justice Statistics Special Report, September 2006.

5 National Alliance on Mental Illness. “Fact Sheet: Spending Money in All the Wrong Places.” 

6 Estelle v. Gamble, 429 U.S. 97, 97 S.Ct. 285 (1976).

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11 Freudenberg N., Daniels J., Crum, M., Perkins, T., and B.E. Richie. “Coming Home from Jail: The Social and Health Consequences of Community Reentry for Women, Male Adolescents, and Their Families and Communities.” American Journal of Public Health. 95, no. 10 (2012): 1725–1736.

12 National Research Council. Improving the Quality of Health Care for Mental and Substance-Use Conditions: Quality Chasm Series. Washington, DC: The National Academies Press, 2006. Available at

13 Millery, M., and R. Kukafka. “Health Information Technology and Quality of Health Care: Strategies for Reducing Disparities in Underresourced Settings.” Medical Care Research and Review 67, no. 5 (2010): 268S–298S.

Article citation:
Cloud, David; Dougherty, Michelle; May, Robert L, II; Parsons, Jim; Wormeli, Paul; Rudman, William J.. "At the Intersection of Health and Justice" Perspectives in Health Information Management (Winter, January 2014).