INTRODUCTION

The post-release period is a particularly vulnerable time for individuals leaving prison.1 Disproportionately high rates of chronic conditions, mental illness, and substance use disorders among this population compound the risk of morbidity and mortality after release.2 Lack of information transfer and poor coordination between correctional and community health care providers further disrupt care and exacerbate health risks for individuals leaving prison.3,4

The process and cost of medical record transfer following release from United States (US) prisons, a key initial step in care coordination, has not been systematically examined, but could inform policies to reduce post-incarceration morbidity. We investigated state-specific policies and fees required to obtain medical information from departments of corrections (DOCs).

METHODS

We conducted a telephone survey with DOCs in all 50 states and the District of Columbia between April 09, 2018, and June 08, 2018. Callers self-identified as medical students requesting information about medical record transfer methods, costs for providers and patients, estimated processing times, and processes for obtaining a release of information. Phone numbers of DOC medical record administrators were acquired through an online search. This study was deemed exempt by the University of Michigan Medical School Institutional Review Board.

We tabulated survey results and depicted the cost of obtaining a 50-page medical record in each state when requested by both health care providers and former patients.

RESULTS

Forty-three states and the District of Columbia responded to the survey (response rate, 86.2%). Of the states that did not participate, six were unable to be reached by telephone and one declined to provide information. Most DOCs offered copies of medical records by mail (42/44, 95.5%) or fax (31/44, 70.5%). Fewer states had the capacity to send records through email (14/44, 31.8%) or via an electronic record system (2/44, 4.5%).

Costs associated with provider and patient requests for medical records varied considerably across the 43 states and District of Columbia. The majority of DOCs (33/44, 75%) offered records at no cost to health care providers, often citing continuity of care clauses. Conversely, only 11.3% of DOCs (5/44) offered free medical records directly to patients. Five DOCs (11.3%) did not allow patients to access their own records without a subpoena and one state, Louisiana, required subpoenas from both patients and providers.

Estimated costs for a 50-page medical record document, excluding scaled postage, personnel, and legal fees, ranged from $0 to $86.28 for former patients and from $0 to $64.52 for outside providers (Fig. 1). This page number was selected to demonstrate variability between states, but does not represent a known average. Estimated, non-validated processing times varied from same-day to approximately 90 days. Infrastructure and personnel challenges were often cited as major barriers to timely transfer of medical records.

Figure 1
figure 1

a Cost of 50-page DOC medical record by state for providers—United States, 2018. b Cost of 50-page DOC medical record by state for former patients—United States, 2018.Various PDFs attached:Figure1A (non-titled)Figure1B (non-titled)Figure1A_TitltedFigure1B_TitledPlease let me know if there are any issues with these versions.

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DISCUSSION

In this national survey, costs to patients and community health care providers requesting medical records from state prisons varied considerably. Most DOCs required former patients to pay a fee to access their medical records. Moreover, identification of individuals responsible for processing medical records at each DOC proved challenging. These findings raise both practical and ethical concerns regarding access to one’s medical information during high-risk periods post-incarceration.

Care continuity was frequently cited as justification for waiving costs to providers seeking medical records. However, the lengthy processing times and high costs observed in our survey, particularly for patients, may detract from these care continuity goals. Transparent and free medical record distribution could improve continuity of care for individuals transitioning back into the community from prison. Future work should examine whether post-incarceration care and health outcomes are associated with the barriers to medical record transfer identified in this study.