Full opinion text
FINDINGS OF FACT AND CONCLUSIONS OF LAW ENSLEN, Senior District Judge. Step on a man’s foot once, and a polite apology will do. Do it twice, and a profuse apology is in order. Do it thrice, and you have left the land of apology and entered the arena of self-defense. I. FACTUAL FINDINGS A. Hearing Process 1. Hearing was held in this matter on October 11-13, 2006 to receive proofs regarding three motions by Plaintiffs. After hearing, which could not accommodate all of the parties’ proofs, the Court issued a scheduling Order, on October 16, 2006, to receive additional proofs (exhibits, de bene esse depositions and other proffers). Said Order required the filing of all proofs regarding Plaintiffs’ Motion to Reopen Judgment Regarding Mental Health Claims by October 31, 2006. Those proofs were duly filed and the Motion resolved by the Court’s Opinion, Order and Preliminary Injunction of November 13, 2006. The balance of the supplemental proofs, regarding Plaintiffs’ Motion for Further Relief and Motion for Order to Show Cause, were to be filed by November 17, 2006. That date was subsequently extended on November 17, 2006 due to the request by Defendants and in recognition of the demands of the briefing. The revised date was set for November 21, 2006. The supplemental briefing and exhibits were then timely filed by parties. B. A Brief Explanation of Terms 2. This case involves a long history and a department of state government, the Michigan Department of Corrections (“MDOC”), in love with acronyms and other linguistic short-hands. The basic terms are as follows: “CMS” refers to Correctional Medical Services, the for-profit company hired to provide medical staff for the MDOC, including specialty services staff, who are, generally speaking, independent contractors. “DWH” refers to the Duane L. Waters Hospital, the in-patient care facility at the MDOC, which facility was recently “demoted” in its licensing to a Health Care Center, though the reference to hospital has persisted in practice. DWH also contains an infirmary for convalescence of hospital patients. The “Hadix facilities” refers to the set of prison facilities, including DWH, which were part of the former Central Complex of the State Prison of Southern Michigan (“SPSM-CC”) at Jackson, Michigan and/or were created to provide services in connection with those prison facilities. “RGC” refers to the Charles Egeler Reception and Guidance Center, a Hadix facility which receives new prisoners into the MDOC system. “JMF,” a Hadix facility, refers to the Southern Michigan Correctional Facility. JMF also houses a dialysis unit for providing dialysis services and a “C-Unit,” a unit for convalescence and care of infirm dialysis patients and others. “Parnall,” a Hadix facility, refers to the Parnall Correctional Facility. The G. Robert Cotton Correctional Facility and Cooper Street Correctional Facility are also at Jackson, but are not Hadix facilities. “SERAPIS” refers to the ambulatory electronic medical record system used by the MDOC, the implementation of which has been a painfully slow process in its completion. “CCC” refers to Chronic Care Clinics, which are medical clinics used at Hadix facilities to regularly deliver care to chronically-ill prisoners. C. Consent Decree and Violation Histories 3. This suit was filed in the United States District Court for the Eastern District of Michigan in 1980 to redress a variety of unconstitutional conditions, including inadequate mental health care, at certain designated Jackson, Michigan prison facilities operated by prison officials of the MDOC pursuant to- 42 U.S.C. § 1983. In 1985, a Consent Decree was entered by stipulation of the parties with the approval of United States District Judge John Feik-ens. 4. Section II.A of the Consent Decree pertained to medical care for prisoners within the Hadix facilities. The section promised to each Hadix prisoner “medical services consistent with contemporary professional health care standards.” (Consent Decree § II.A.1.) The Decree further promised a fully-licensed hospital, medical screening, regular access to health care unimpeded by custodial staff, and staffing and new procedures sufficient to fulfill those promises. (Id. at § II.A.1-5.) In addition to other important matters, including special diets and medicines, the Decree also promised that quality assurance audit processes would be used to insure proper health care access, adequate care and supervision of care providers. (Id. at § II.A.6-12.) 5. Judge Feikens initially transferred enforcement of the medical care provisions of the Consent Decree to this Court by Order of June 5, 1992 pursuant to 28 U.S.C. § 1404(a). Hadix v. Johnson, 792 F.Supp. 527, 528 (E.D.Mich.1992). The purpose of the Order was to promote uniformity and effectiveness of remedy in light of this Court’s enforcement of a Consent Decree involving the same issues' in a separate suit — United States v. Michigan, Case No. 1:84-cv-63. Id. See also Hadix v. Johnson, 228 F.3d 662, 665 (6th Cir.2000) (discussing history of suit). 6. Despite the success of the Decree in fostering improved conditions as to many aspects of the Decree, the provision of health care has remained both a troubled and troubling aspect of the Decree. Progress in this suit was delayed between 1996 and 1999 due to appeals involving the interpretation and constitutionality of section 802 of the Prison Litigation Reform Act (“PLRA”), P.L. 104-134, codified at 18 U.S.C. § 3626. In December 1999, after such delay, the Court conducted a compli-anee hearing. The result of that hearing was a February 18, 2000 set of Findings of Fact and Conclusions of Law, which determined that certain provisions of the Decree should be terminated, but found constitutional violations as to other portions requiring self-remedy by Defendants. (See Feb. 18, 2000 Findings of Fact & Conclusions of Law; Feb. 18, 2000 partial termination Order; Oct. 29, 2002 Findings of Fact & Conclusions of Law (“2002 Findings”) at 1.) 7. Another evidentiary hearing was held in May 2002, which charted the progress of such self-remedy. The 2002 Findings following that hearing filled 266 pages and discussed hundreds of cases of inadequate or neglected medical care. Of particular concern in those Findings were the following failures: (a) the failure of the health care system to provide timely access to care to patients with urgent and emergent serious medical problems (2002 Findings ¶¶ 217 & 324); (b) the failure of the system to provide timely access to specialty care, which failures include the delaying of surgery of -a lung cancer patient for over a year and the repeated failure to transport another patient to chemotherapy appointments (with one exception), which failures caused death in both cases (2002 Findings ¶¶ 728, 729 & 860); and (c) the failure of the system to provide a readable, comprehensive and current medical record to care providers (2002 Findings ¶¶ 790-867). 8. As a consequence of these and other Eighth Amendment violations, the Court enjoined Defendants to comply with the instructions for remedy in Section XIII of the Findings. (Order & Inj., Oct. 29, 2002.) Phase one of the medical remedy was the appointment of a medical monitor. (Id. at ¶¶ 1437-38.) After interview of candidates, Robert Cohen, M.D., was appointed medical monitor pursuant to an Order of this Court authorizing independent monitor F. Warren Benton to so appoint him. (Order of Apr. 21, 2003.) This appointment was to be followed by the development of a remedial plan by the Monitor and the parties. (See 2002 Findings ¶ 1440.) However, the requirement of a remedial plan was later vacated, not because it was inappropriate, but it was contained in the same paragraph which required a heat-related remedy as to which the parties came to an agreed resolution which involved vacating that paragraph. (See id. at ¶ 1442; Order of June 6, 2003.) However, apart from those technical details, there continued at the time a mounting crisis in health care, which has fully consumed the resources of the parties, the Court and the Medical Monitor in seeking solution. We have been bailing, not sailing. C. Medical Status Reports and Preliminary Injunction Plan 9.Dr. Cohen’s first medical Status Report was filed with the Court on July 13, 2004. The second was filed on January 13, 2005. The third was filed on September 12, 2005. The basic similarity between all three was extensive commentary on gross failures of care, inadequate care, and preventable injury, disease, and loss of life. The Court also received emergency correspondence concerning systemic failures (collapse of pharmacy and the death of T.S.), which are discussed further. (Letter of June 2, 2006, Dkt. No.2035; Letter of Aug. 14, 2006, Dkt. No.2088.) 10. In particular, the Third Report noted a “crisis” in medical service provider staffing as of March 2005, which was exacerbated by the discharge of a delinquent doctor, Dr. Faghihnia. Another problem was that additional physician responsibilities were being placed upon the medical staff with the transfer of “C-Unit” — a unit for treatment of dialysis patients and other chronically-ill patients too sick to live in general population — to the Hadix facilities. (Third Report at 13 (Dkt. No. 1897 and also received as Pis.’ Ex. 5A).) 11. Problem cases noted in the Third Report included, by way of example: patient 1, a patient who died of an untreated staph infection and gastro-intestinal bleeding while housed in administrative segregation (id. at 11); patient 2, a patient with HIV, Sicca Syndrome (chronic extreme dryness of the mouth and esophagus causing difficulty swallowing) and excessive weight loss (down to 108 pounds), who did not receive a pureed diet, and was not treated for abdominal pain, crumbled teeth and painful lesions (id. at 16-20); and patient 3, a 29-year-old cancer/HIV patient whose rectal cancer treatment was delayed by eight months due to delay in a simple diagnostic test and delay in referral for radiation (id. at 20-23). The Third Report included specific comments on 10 patients of 23 files surveyed, including dialysis patients, diabetics, and cancer patients, whose treatment were all grossly deficient and deemed representative of the facility care. 12. During the later Preliminary Injunction hearing discussing the Third Report, Dr. Cohen also reported to the Court another instance of a prisoner death (A.R.) caused by grossly negligent care. In that case, a brittle diabetic was grossly over-prescribed insulin by his physician and no in-patient care or endocrinologist consultation was ordered to monitor the diabetic’s blood sugars and care. (Hr’g Tr. of Oct. 19, 2005 at 21.) The patient asked for a glucometer to self-monitor his blood sugars, which request was not granted, and then predictably died overnight of hypoglycemia, causing heart failure. (Id.) The medical staff also took some 20 minutes to respond to the emergency and the patient was not effectively treated by on-duty medical providers before the Emergency Medical Technicians arrived. (Id.;, see also Order of Dec. 16, 2005, explaining case in greater detail.) 13. As a consequence of these and other failures, which the Court found to be violations of the Eighth Amendment, the Court granted Plaintiffs’ Motion for a Preliminary Injunction, which Injunction required Defendants to propose a corrective plan for Court approval. (Prelim. Inj. of Oct. 19, 2005; see also Am. Prelim. Inj. of Nov. 23, 2005.) The Plan was timely filed by Defendants. (Plan re Prelim. Inj. of Oct. 19, 2005.) The Plan was some twenty pages in length and required, among other things, the following: (1) regular physician rounds in segregation' (Plan 2); (2) the audit of medical care for chronically-ill prisoners in segregation and other selected cases as part of the quality assurance process (id. at 3); (3) the establishment of an infirmary at DWH for patients needing infirmary care with 24-hour nurse and physician staffing (id. at 3^t); (4) establishment of a Unitary Medical Record System including- all laboratory studies, all medications, complete with a link between SERAPIS and the pharmacy computer system, and an expansion of SERAPIS to include all clinical areas (id. at 6); (5) automatic renewals of all chronic medications (id. at 9); (6) refinement of the job description of the Jackson Medical Director to include more active medical service provider, dialysis and CMS oversight (id. at’ 11); (7) autopsies for all prisoner deaths (id.); (8) better communication, follow-up and monitoring regarding CMS referrals for specialty care (id. at 12-13); (9) monthly staff meeting regarding the Dialysis Program (id. at 14); and (10) enhanced staffing of service providers to meet the increased demands of the expanded clinical responsibilities at the Hadix facilities (id. at 19-20). 14. This Court held a hearing regarding such Plan, on January 11, 2006. The next day, the Court approved the Plan with some important modifications including: (1) selected paragraphs were stricken as factually inaccurate; (2) the SERAPIS computer system, or equivalent system, was to be applied to pharmacy and laboratory records of prisoners at DWH and C-Unit; (3) monthly reports were required to specify the timeliness of specialty consultations, which were to be delivered in a timely way; (4) a full-time nephrologist or internist was to be added to the C-Unit; (5) all patients in segregation were to be medically reviewed within one week; and (6) Dr. Cohen was authorized to consult with a nephrologist to obtain specialty review of patient files as necessary. (Order of Jan. 12, 2006.) The language of the Plan document, which was drafted together by the parties and Dr. Cohen, expresses the parties’ consensual understandings and relationship at the time. It did not express exact deadlines nor precise formulas for accomplishing certain objectives because the parties were working cooperatively at that time. 15. Defendants failed to timely appeal either the Preliminary Injunction or the Order approving and implementing the Plan. D. Possible Successes, Fiascos and Administrative Responses 16.Not all of the news about prisoner treatment at the Hadix facilities has been adverse. Defendants have. implemented the December 2005 Plan and other beneficial programs since then, and are now reporting certain measures of systemic improvement as a consequence of those changes. (Defs.’ Tr. Br. 1-5.) For example, they have reported hemoglobin ale averages for diabetic patients that show the percentage of patients in good control exceeding community averages for diabetic patients in good control. (Id. at 5; Craig Hutchinson, M.D., Dep. 5-6.) How much of this improvement is due to health care as opposed to dietary control or the general facility layout itself (i.e., prisoners have assigned diets and must walk distances to obtain food and services) is not known, though the numbers are positive nevertheless. Three other positive developments have also coalesced to the benefit of diabetic care: (1) the opening of the DWH infirmary described above; (2) a pilot program to provide glucometers to inmates to self-test their blood sugars; and (3) Defendants’ recent decision to provide endocrinology consults to brittle diabetics who were not benefitting from standard internist care. (See Defs.’ Tr. Br. 3; Hutchinson Dep. 101.) In the Court’s judgment, these improvements are not only helpful, but essential to ensure adequate medical care to diabetic patients. 17. In part, the DWH infirmary was intended to address out-of-control diabetic patients such as A.R., who needed medical monitoring, especially at night, to guard him from deadly hypoglycemia reactions due to both a change in his insulin regime and poor control generally. Self-use of glucometers by able diabetic patients is the standard of care in the community for important reasons. See Am. Diabetes Assoc., Standards of Med. Care in Diabetes (Position Statement), Diabetes Care 27 (Suppl.l): S15-S35 (A.D.A.2004.) Diabetics who are unsure whether they are experiencing the onset of hypoglycemia need to check their blood sugars emergently (in a matter of a few minutes when blood sugars are precipitously low) to determine whether to treat the hypoglycemia with glucose (sugared food stuffs) before they lose their capacity for self-treatment (unconsciousness). The testing is also required to avoid unnecessary self-treatment, which would otherwise expose them to hyperglycemia (which has long-term negative health consequences and short-term consequences when extreme) and fluctuations in blood sugar which would otherwise complicate their treatment. This testing is particularly important at p.m. hours before the patient sleeps — since a hypoglycemic reaction at night is likely to go untreated and, if severe enough, may cause death. 18. In the Court’s judgment, the fact that self-monitoring is only now becoming available is an admission of past error, though Defendants are to be commended nevertheless for their corrective actions. They are also to be commended for having determined that endocrinologist consultations are necessary for some diabetic patients and will be made available. This is important because certain brittle diabetics, particularly type 1 diabetics whose long-term insulin regimes become ineffective over time and type 2 diabetics who are insulin dependent and experiencing difficulty with their regimes, often need specialist assistance to accomplish safe and effective treatment. 19. The infirmary beds at DWH were added in January 2006. (Defs.’ Tr. Br. 3.) According to Defendants, this unit has greatly assisted patients returning from hospitalization. (Id.) Defendants are also now adding some 28 beds to C-Unit (dialysis patient unit), which beds are scheduled to be completed in mid-December 2006. (Id.; Barbara Hladki De Bene Esse Dep. 34.) Defendants anticipate that this will benefit care in C-Unit. (Id.) 20. Defendants also report success in maintaining HIV patents in Hadix facilities at a 73 percent full suppression rate. (Hutchinson Dep. 4.) In the opinion of Dr. Craig Hutchinson, M.D. this rate compares favorably with the state’s overall rate of 81 percent given that the sickest of the HIV patients are channeled to the Hadix facilities. (Id.) Plaintiffs have challenged this assertion. In particular, as noted by Plaintiffs’ counsel and Dr. Hutchinson, the number does not represent prisoners housed at C-Unit and Duane Waters Hospital (areas where the sickest inmates are located). (Id. at 51.) So, it is impossible to say whether the overall rates at the Hadix facilities represent a quality healthcare response.' 21. Defendants also report the results of a prolonged experiment regarding their “pill lines” — lines to deliver medicines to certain inmates. They experimented with calling inmates to the “pill line” by “pod” instead of by “block” (the larger housing unit). (Defs.’ Tr. Br. -3.) This experiment did not work and complicated the ability of patients-, including diabetics, to get to the food hall to eat their meals. (Id.) They then tried calling inmates two “pods” at a time to the pill line, and found that this approach was far better. (Id. at 4.) They now plan to physically modify the pill delivery facilities to allow more inmates to line up inside (out of the inclement weather). (Id.) There was no plan, however, to speed delivery by use of more dispensing lines. The reason this ready solution was not proposed is obvious from the record as explained below: Defendants are grossly under-staffed for nursing care. (See also Debbie Roth Dep. 67-68.) 22.Another bit of news qualifies as both a fiasco and a belated success. The fiasco part of the story began on May 31, 2006 when Dr. Robert Cohen, M.D., the medical monitor, was visiting the Hadix facilities for a routine inspection. (Pis.’ Ex. 5(B) at bates no. 322330; Trial Testimony (“T.T.”), vol. Ill, 584.) Prisoners then informed him that medication refills due since May 26, 2006 had not been filed. According to Dr. Cohen, nothing was being done to address the debacle because when the pharmacy computer system was checked, it reported the unfilled orders as filled. (Id.) Dr. Cohen determined that this problem was not exactly recent in that it affected some prescription refills as early as May 19, 2006. (Id.) He also reported that as of the morning of June 1, 2006 pharmacy staff was, after deliberation, making no efforts to cure the problem. (Id.) The cause of the delay was the loss of pharmacy staff (retirement of a pharmacist), a failure of the SERAPIS computer system, and the delayed implementation of a new private pharmacy system for chronic medications. (Id.) Some effort was, however, being made by health care staff to fill some prescriptions through the local Walgreen’s pharmacy, though “no rapid effective solution to this critical problem had been formulated or implemented.” (Id.) 23. Based on Dr. Cohen’s discussions with senior staff on the afternoon of June 1, 2006, he requested that the new outside remote vendor (PharmaCorr, Inc.) attempt to provide early and emergency refills of the chronic care medications. (Id.) Because of the grave concern and the lifesaving nature of the medicines involved, Dr. Cohen asked that daily reports be provided to help him and Department staff ascertain that all refills were being provided and the extent of the delays. (Id. at 322329-322331.) Dr. Pramsteller has shared these concerns in his testimony that certain chronic medications (e.g., cardiac medications, HIV medications, etc.) cannot be interrupted without creating “a big problem” (ie., predictable bad outcomes). (See Pramsteller De Bene Esse Dep. 23.) 24. These events later caused the depositions of the Jackson Medical Complex Director of Nursing, Debbie L. Roth, and the Jackson Medical Complex Administrator, Barbara Hladki, to be taken. Ms. Hladki was deposed on September 21, 2006. Ms. Roth was deposed on September 29, 2006. As of the dates of their depositions, they were not fully aware of the crucial role that Dr. Cohen had played in restoring pharmacy services to many prisoners. (Hladki Sept. 2Í, 2006 Dep. at 48-50; Roth Dep. 24-28.) They were also not too keen to give Dr. Cohen credit for acting emergently until confronted with the timing of his correspondence and the sequence of the events. (Id.) 25. The happy part of this fiasco was the early recruitment of PharmaCorr. This was happy for a variety of reasons. First of all, the Court has every reason to believe that PharmaCorr will function like other reliable commercial remote pharmacy services — fill and place orders consistent with the standards of care in the community. That is, the prescriptions will be regularly filled by PharmaCorr staff with computer programs used to ensure that orders are provided timely and the ordered prescriptions are not contra-indicated either by patient health or drug interactions. Indeed, Barbara Hladki has already testified that her initial experience with PharmaCorr has been one which has improved automatic refills of chronically needed medicines. (Hladki Sept. 21, 2006 Dep. 31.) 26. Such improvement, though, is not without some complications in that Defendants do not anticipate that PharmaCorr will be connected to the SERAPIS medical records system until middle to late January 2007. (Defs.’ Tr. Br. 2, 15.) Until then, Defendants cannot fully insure that pharmacy care meets community standards. Furthermore, Dr. Cohen expressed reservations at the time of hearing that the system had not yet obtained the functionality necessary to alert care providers about chronic medication orders requiring automatic renewal, which is an essential part of an operative pharmacy system. (T.T., vol.HI, 585.) 27. Returning to the fiasco category, a brief comment is warranted as to the case of P.H. P.H. died of complications of treatable hyperthyroidism after his care was neglected for over a year because Defendants perennially ignored both his need for medical care and the care for paranoia which was causing him to refuse medical treatment. Rather than simply repeat the Court’s earlier discussion of the case in its November 13, 2006 Opinion, the Court now adopts that discussion here by reference. Defendants have sought to add to that record with testimony of Bency Mathai, M.D., the physician who was responsible (together with the mental health team) for sending the paper work to Lansing to seek probate court appointment of a medical guardian to approve care on P.H.’s behalf. (Mathai De Bene Esse Dep. 7-16.) Dr. Mathai’s account makes clear (consistent with Dr. Cohen’s previous account) that she acted promptly and in the best interest of P.H. However, this testimony does nothing to excuse any subsequent delay caused by others in Lansing who received the paper work. (Id.) Nor does such testimony attempt to excuse or defend the very prolonged delay in medical treatment and psychological treatment caused by other providers that occurred prior to Dr. Ma-thai’s consultation with P.H. The Court understands that the guardianship proceedings were intended to expedite treatment, but those proceedings did not begin until P.H. had been effectively delivered to the probate court system on the precipice of death. 28.The other certain fiasco that Dr. Cohen “discovered” during a routine visit was the August 6, 2006 death of T.S. This death was reported to the Court by letter of August 14, 2006. (Dkt. No.2088.) The Court has already commented extensively upon that death and the grossly defective medical and mental health care which promoted it. (See Op. of Nov. 13, 2006.) Rather than repeat those words again, the Court adopts them here by reference with two brief additions. The first is due to the recently released autopsy of T.S., which the parties have presented by Stipulation to become part of the evidentiary record. (Stip. of Nov. 17, 2006; attach. A & Order of Nov. 21, 2006 granting Stip.) The Autopsy Report, which was based in part on a Toxicology Report recently completed, gave the cause of death (consistent with Dr. Walden’s prior opinion) as complications of hyperthermia and dehydration. (Id.) The complications likely caused an electrolyte imbalance that not irregularly causes heart arrhythmia and failure. (Id.) 29. Second, in advance of T.S.’s death, the Department of Corrections had announced a “case management” system to monitor medically high-risk inmates in administrative segregation. (Defs.’ Tr. Br. 4.) As Defendants put it, that system “is not fool proof.” (Id.) “Fool” is the operative word in that sentence, as applied to all care T.S. received prior to his death, including from custody, medical staff and psychological staff. Since the death of T.S., Defendants have taken steps to communicate a need for custody staff, medical staff and mental health staff to share information to protect patient welfare. (Defs.’ Tr. Br. 4 & Ex. B.) At the same time, however, this effort must be conducted consistent with standards of medical confidentiality. 30. Defendants have also made a case management effort which is directed to prevent the lapse and failure of services in critical cases (e.g., cancer treatment, cardiac treatment, etc.). (Id.) It is not explained how this system will reliably function, however, when many of the impediments which has caused a lack of service in the past (failure of transportation, unavailable specialists and indifferent and overworked providers) continue unabated. 31. Defendants have announced in their Trial Brief another recent attempt to study and reform their health care efforts. Exhibit C to the Trial Brief is a Request for Proposal — meaning that Defendants were seeking a bid as to a two-phase study of their health care system, with phase one to be completed by April 1, 2007 and phase two to be completed six months later. Defendants represent that they intend to employ the National Commission on Correctional Health Care (and any subcontractor it selects) to perform such study. (Defs.’ Tr. Br. 5 & Ex. C.) At this point, it would be speculative to predict either any success or improvement as a consequence of a distant study, particularly when such studies in the past have only served to cut timber and line file drawers. E. The Specialty Care Debacle Continued 32.Perhaps the most remarkable testimony the Court received at the last hearing involved the dialogue between Dr. Pramsteller, the Michigan Department of Corrections Medical Director, and Dr. Cohen, the medical monitor. Both were curious to know whether the rather tentative remedy in their Plan to fix specialty care delays, monthly reporting to the Court of delay numbers, had resulted in any improvement. The sheer numbers provided established that 30 to 40 percent of the specialty care was being provided outside of the time deemed medically necessary. (T.T., vol.III, 589.) Dr. Pramsteller and Dr. Cohen, in order to assess the harm of such delay, randomly picked six cases of delayed specialty care from a list of such cases. (Id. at 589, 593.) In two of those cases, the delay did not threaten any imminent harm, though in one of those cases it may have caused prolonged pain. (Id. at 589-90.) In the remaining four cases, the delay was presenting the prospect of unnecessary death and grossly unnecessary suffering, In the case of D.R., a patient with blood in the urine, it took medical staff 40 days to perform testing (IVP x-ray), which showed that one of his kidneys was blocked and not functioning due to a kidney stone, and his treatment was further delayed for several weeks after the test was performed. (Id. at 590-91.) 33. Another patient C.W.S., a 50-year-old with coronary artery disease, had a stent in his left main coronary artery, the most dangerous place for blockage. (Id. at 591.) He had been using nitroglycerin and, because of increasing frequency of chest pain with activity and at rest, had increased nitroglycerin usage to several times per day. (Id.) He had chest pain radiating to his neck and arm with heavy substernal pressure. (Id.) This is the basic medical school definition of an impending heart attack. (Id.) Defendants’ response was to schedule a 30-day consult. (Id.) C.W.S. had needed the consult immediately. (Id. at 591-92.) When he was finally seen, after more than 30 days, testing showed a 70-percent blockage of the left coronary artery with stenosis in the right coronary artery as well. In Dr. Cohen’s opinion, the patient was fortunate to have survived the prolonged delay in treatment. (Id. at 593.) The patient was referred directly by the cardiologist for emergency coronary artery bypass surgery. At the time of the review by Drs. Cohen and Pramstaller, the surgery had taken place and the patient had returned to JMF. Remarkably, on the day of their review, physician staff at JMF were unaware that C.W.S. had surgery, and were not aware that he had returned to their facility. 34. J.F. was the third adverse delay case. He was a patient with end stage renal disease who was complaining about rectal bleeding and displayed two abnormal polyps during a barium enema on June 21, 2005. (Id.) He was scheduled for a colonoscopy in two months, but, according to the chart, custody cancelled his appointment. (Id.) He was then not seen again for the condition until the delay was discovered by medical staff on April 21, 2006 and his colonoscopy appointment rescheduled for July 24, 2006. (Id.) No attempt was made by providers to schedule the case emergently notwithstanding the past delay and real prospect of cancer. (Id. at 594.) Eighteen days after the colo-noscopy took place, on August 11, 2006, the results were reported as high grade dysplasia, an abnormal, non-cancerous but possibly pre-cancerous lesion. (Id.) No follow-up was ordered despite the medical risk. (Id.) 35. D.U. was the last adverse case studied. D.U. had complained of a mole which was increasing in size on his back on June 25, 2005. He kited repeatedly and was then seen on July 8, 2005 and diagnosed with a “melanocystic skin mole” which the doctor (who no longer works for Defendants) determined should be “watched closely,” but no biopsy was ordered." (Id. at 595.) Follow-up was ordered in two months, at which time (September 8, 2005) the doctor determined that the “mole” should be surgically removed within two weeks. As of October 10, 2005, this had not occurred. The patient saw a nurse on that date and complained that the growth had persisted for a long period of time, and he was told to use a hot compress. (Id.) An October 14, 2005 appointment to remove the “mole” was cancelled by a medical provider and rescheduled for October 21, 2005, which also did not occur. (Id.) The patient was seen by a physician assistant (“PA”) and told the PA that he had family history of cancer. (Id.) This resulted in another request for surgical excision which was ignored. (Id.) 36. By January 20, 2006, the “mole” was seen by medical staff and was then a black-red mass measuring .5 by .7 inches square in the interscapular area with irregular margins. It was noted to be bleeding. On January 30, a physician performed a wide excision of the lesion and ordered follow-up care and testing. (Id. at 596.) A February 7, 2006 pathology report showed malignant melanoma. Thereafter, Dr. Fatu (staff physician) attempted to obtain the patient’s immediate referral to the University of Michigan melanoma clinic for cancer treatment, but the attempt was somehow administratively derailed while the patient was sent to an oncologist instead of a melanoma treatment center. (Id.) The required urgent standard of care — -a sentinel node biopsy— which is used to determined if the metastatic cancer has spread to the lymph system was not performed until April 12, 2006 (another gross and inexcusable delay). That biopsy did show that the cancer had spread while the patient was not receiving effective cancer therapy. (Id.) 37. As noted above, these cases are remarkable both because they were randomly selected from a list of delayed referrals and because the system of monthly reports instituted in January 2006 provided full notice to Defendants of the dangerous treatment delays. The monthly specialty reports (Pis.’ Ex. 88) themselves are interesting because they show relevant data as to specialty care. Dr. Pramsteller has testified that he regularly evaluates similar data, especially as to diseases such as heart disease, cancer, diabetes and dialysis patients — which diseases have regular fatal outcomes and use significant economic resources. (Pramsteller De Bene Esse Dep. 35-36.) He further commented that the Radix facilities require a large portion of the state medical resources because of the population of sick inmates housed there. (Id.) He classified cancer and heart disease as the two most expensive medical conditions., (Id.) 38. To take January 2006 and cancer as an example, the January 2006 report showed 48 hematology/oncology patients were seen at DWH in January and another 25 were “pending” to be seen at DWH. (Pis.’ Ex.88 at bates no. 321678.) Offsite, nine hematology/oncology patients were seen and ten were pending. (Id.) Although the report listed two off-site cancer treatment centers, the report showed that no care was authorized as to those centers. (Id.) Later versions of the report did not even list those centers. The February 2006 data for onsite specialty care in this category showed 12 patients were seen, two were rescheduled, 13 were pending and five were past pending. (Id. at bates no. 321739.) As to offsite “radiation/oncology,” five were seen, ten were pending and three were past pending. (Id. at bates no. 321740.) The March 2006 data for onsite specialty care in this category showed 16 patients seen, one rescheduled, 14 pending and seven past pending. (Id. at bates no. 321789.) The offsite numbers were 12 patients seen, 11 pending and six past pending. (Id. at bates no. 321791.) The April 2006 onsite numbers were 8 patients seen, two rescheduled, seven pending and six past pending. (Id. at bates no. 321846.) The April offsite numbers were 12 seen and seven pending with none past pending. (Id. at bates no. 321847.) The May onsite numbers were three seen, seven pending and three past pending. (Id. at bates no. 321902.) The May offsite numbers were nine seen, two rescheduled, six pending and two past pending. (Id. at bates no. 321903.) 39. To skip to the later months, the summary sheets are not informative as to cancer treatment because CMS shifted to an “automatic” approval process for cancer referrals to facilitate treatment. (Hutchinson Dep. 98-99.) This was done because, “We knew that simply the time required for even expeditious handling of all the pieces of paper ... would not deliver some of the cancer care within the time frames that needed to occur.” (Id.) Although Dr. Hutchinson proclaims that CMS has caused a “fix” to the system, both the above examples,- the statistics and the brute facts do not bear out that blithe conclusion. For the- month of August, which lacks the summary sheet, the “patients seen” report still shows that many cancer patients were seen beyond the prescribed treatment parameters. For example, patient W.D. had a diagnosis of tongue cancer. (Pis.’ Ex. 88 at bates no. 322119.) He was to be - seen in ten days, but was seen in 43 days because of “first available specialist schedule....” (Id.) Similarly, M.W. had lung cancer and was to be seen in 21 days; he was seen in 27 days and no explanation was -given for the delay. (Id.) Patient R.C. had T-Cell Lymphoma and was to be seen in 14 days; he was seen in 21 days with no explanation for the delay. (Id.) Patient X.W. also received delayed treatment for cancer of the esophagus. (Id.) Although some of these delays may seem inconsequential in length, the thorny problem for cancer patients is that their course of treatment (from initial symptoms, to diagnosis, to excision of the cancer (when possible) and to multiple follow-up procedures (radiation and chemotherapy)) requires multiple rounds of waiting and scheduling and potential cancellation due to illness, transport problems, doctor unavailability, etc. This scenario, in the best of circumstances, leaves the inmate fighting for life amidst both the intended and unintended, but equally profound, cords of custody. 40. Defendants themselves admit that they are'unsatisfied with their own progress in improving the specialty referral process. Here is what defense counsel wrote: Even with the Defendants’ November 15, 2006 specialty care report, based on October data, the percentage of DWHC specialty care requests reported as “excess” or “late” was twice that of the JMF and SMT facilities. While this last report is an improvement from the reports early this year, more work needs to be done. (Defs.’ Tr. Br. 11.) F. More Medical Malfeasance 41. Other negative cases were reported by Dr. Jerry Walden, M.D., Plaintiffs’ medical expert. Those cases were discovered by Dr. Walden as a product of 13 days of medical tour and inspection by Dr. Walden in September and October 2005 and April and May 2006. (Pis.’ Ex. IB at 1.) Dr. Walden summarized these cases in his Report of July 10, 2006. (Id.) Here are some of the low lights of what Dr. Walden found. 42. Regarding cancer treatment, Dr. Walden had concern about four patient files which he did not have access to for review: patients 105, 106, 107 and 108. (Id. at 27.) He was, however, able to review the charts of four other prisoners which showed remarkable indifference to patient well-being. In patient number 109, the patient was seen as a follow-up for blood in the urine in February 2004. (Id.) His family history showed cancer on both sides of his family. (Id.) Thereafter, he regularly saw physicians because he could not sleep at night due to bladder pressure while he continued to have blood in his urine. (Id.) These many visits were treated as either over-active bladder or bladder infection. (Id.) Finally, on August 9, 2004, a physician noted the possibility of bladder malignancy and testing was done. (Id.) The testing was inconclusive while the patient continued to complain of pain and had persistent blood in the urine. (Id. at 27-28.) After continued complaints, he was seen by urology, who scheduled him for cystocopy and IVP testing. (Id.) The testing was eventually performed on October 18, 2004 and on October 19, 2004, the test results showed a 6 centimeter tumor on the bladder. (Id.) The tumor, once discovered, was too large to permit transurethral resection of the tumor (the less invasive technique) so in March 2005, surgeons removed the patient’s bladder and created a new bladder from his bowel. (Id.) As of May 2006, the patient had lost over 50 pounds. (Id.) The patient also complained that after the bladder surgery, doctors had difficulty reaching a urologist to treat his bladder symptoms and nearly caused a serious medical complication. (Id.) 43. Patient 110 was another like case. He had recurrent bladder cancer and blood in the urine was ignored for a prolonged period. (Id.) It took some six months between the time that blood in the urine was noted and a urologist appointment was eventually completed. (Id.) 44. Patient 111 was diagnosed and treated for metastatic cancer. (Id.) Although he was treated, he was denied pain medication over a two month period, and this denial caused the cancellation of one of his cancer appointments. (Id.) 45. Patient 112 was another patient who was treated for malignant rectal cancer. (Id.) According to Dr. Walden’s Report, the care was delayed by some.five years because cancer care was not given soon after he arrived in custody. (Id.) A colostomy was eventually performed. (Id.) Dr. Walden is of the opinion that patient 112 will likely die of such cancer. (Id.) 46. As for cardiology, Dr. Walden’s Report likewise discusses approximately 20 problematic patient records from 2005. (Id. at 14-17, 21-22.) He found a like number of problematic cases for 2006. (Id. at 17-21.) A few selected cases are cited now as exemplary of the kinds of indifferent care delivered at the Hadix facilities. 47. Patient 44 had extreme hyperli-pidemia. (Id. at 17.) He had triglyceride levels 10 times normal levels and cholesterol of 444. (Id.) He was not seen on an appointment for repeat testing. (Id.) When he was seen next, an EKG was ordered and showed a septal infarction with possible inferior ischemia. (Id.) The care providers did not treat either the hyperlipide-mia or the unstable cardiac condition. (Id.) 48. Patient 48 had hypertension that was over-treated with multiple medications. (Id. at 18.) His blood pressure was not regularly monitored and vital signs were not being recorded in his record. (Id.) He also had bleeding in his intestinal tract that was being ignored, with no plan for either a colonoscopy or a gastroscopy. (Id.) 49. Patient 53 complained of chest pain with activity. (Id. at 20.) An EKG was performed which showed abnormal results. (Id.) At the time, the patient had a very elevated cholesterol and a history of a past catheterization and long-term tobacco and cocaine use. (Id.) No urgent care was scheduled. Dr. Walden’s comment: “This man needs a stress test or an emergency room visit now.” (Id.) 50. As for diabetic patients, notwithstanding the positive comments made above, Dr. Walden’s report noted some continued problems in the treatment of hypoglycemia, brittle diabetics and other diabetics with uncontrolled treatment regimes. Dr. Walden devotes some ten pages of his Report to such cases. (Id. at 5-14.) The cases noted below are representative of serious Hadix treatment failures regarding treatment of hypoglycemia. Indeed, Dr. Hutchinson similarly testified that to his knowledge, there were three or four patient deaths at Hadix facilities due to complication of hypoglycemia (which is treatable if promptly recognized and treated) within the last two years. (Hutchinson Dep. 51.) 51. Dr. Walden’s overall impression was, “I am still amazed that the need to prevent hypoglycemia hasn’t been more effectively addressed by the administration and that CMS has not focused on this problem.” (Pis.’ Ex. IB at 5.) Dr. Walden noted some death cases due to hypoglycemia and further noted that although the policy is to treat all patients with blood sugar readings of less 50 mg/dl with intravenous glucose, this does not regularly occur. (Id.) 52. Patient 4 died of hypoglycemia. (Id. at 5-6.) He had a severe hypoglycemic reaction without any referral to a physician. (Id.) He later died of complications of a second instance of severe hypoglycemia. (Id.) 53. Patient 20 is a paraplegic who is wheelchair-bound. (Id. at 11.) His care was complicated by the fact that custody transport to specialist appointments sometimes left him unable to eat his meals and, thus, prone to hypoglycemia. (Id.) 54. Patient 22 had severe hypoglycemia on March 12, 2006 and was unconscious. (Id. at 12.) He was treated with IV glucose. (Id.) However, post-reaction adjustment to his regime did not occur consistent with community medical standards. (Id.) 55. Patient 25 is a dialysis patient with a recent history of severe hypoglycemia. (Id.) He was given a Glucagon injection (a chemical that induces the liver to produce glucose) for hypoglycemia on March 28, 2006. (Id.) This followed several earlier incidents of serious hypoglycemia. (Id.) On March 20, 2006 his blood glucose readings were 26, 31, 53 and 76 mg/dl, respectively, and he received two Glucagon injections. (Id.) At 11:55 p.m., staff was called to his cell when he was unresponsive and his blood sugar was 39 mg/dl; he then received his third Glucagon injection of the day. (Id.) He did not have successful follow-up care and Dr. Walden (who had warned Defendants) noted that his care had not improved as of June 14 (since he had other reactions on or about June 12). (Id.) This is clearly an example of a patient needing urgent specialist care whose needs have been under-served. (Id.) 56. Other serious patient care/treatment problems were noted in the following areas: access to health care (id. at 22-44); medical record deficiencies (id. at 24-25); treatment of methicillin-resistant staphly-coccus infections (id. at 25-27); dialysis care deficiencies (id. at 29-35); surgical care (id. at 35-36); custody treatment (id. at 36-39); nursing issues (id. at 39^41); and medication problems (id. at 41-42). Also remarkable in his Report are prolonged discussions of cases in which CMS delayed patient care and other cases in which delayed and/or negligent care were a factor in patient deaths. (Id. at 42-64.) G. How Much to Make of a Bunch of Deaths 57. One of the issues repeated in the briefing and argument is the statistical question of how to treat the individual gross treatment failures. Defense counsel argues in part that the treatment failures do not show deliberate indifference to the “class as a whole.” (Defs.’ Tr. Br. 6.) The basis for this argument is given as Lewis v. Casey, 518 U.S. 343, 116 S.Ct. 2174, 135 L.Ed.2d 606 (1996), a case in which the Supreme Court repelled a request for class-wide relief as to First Amendment access violations because only two actual deprivations to class members were shown and the “constitutional violation has not been shown to be systemwide.... ” Lewis, 518 U.S. at 360,116 S.Ct. 2174. 58.When the Supreme Court made that announcement, it most assuredly did not mean that every class member must be a victim of a violation for system-wide relief to stand. What it did mean was that occasional violations which are not rooted in systemic causes, do not warrant system-wide relief. As an example, the number of inmates with untreated cancer at any given month is small as a percentage of the total prison population (between 10 to 50 at the Hadix facilities as an example). However, the systemic failure to timely treat those persons is clear from the statistics given that there was a 30 to 40 percent delay rate past the physician assigned deadlines for timely care of prisoners generally and a similar rate of delay for cancer patients. Furthermore, the rate of non-care and delayed care is even higher given that the record reflects that physicians were often not protective enough of the right to treatment in assigning treatment dates, and often failed to take the initial diagnostic steps necessary to promptly diagnose cancer. Many deaths have occurred because of such systemic failures, and these failures have occurred in regular treatment patterns (e.g., deaths due to delinquent treatment of hypoglycemia, delinquent treatment of dialysis patients, etc.) 59. The testimony of Dr. Creekmore, explained at length in the Court’s November 13, 2006 Opinion and adopted here by reference, likewise supports a conclusion that Defendants’ malfeasance was systemic. This is particularly so given the history of a facility which has not met constitutional standards repeatedly. Defendants may wish that by simply pointing out an obvious red herring — that most people are not sick most of the time regardless of their medical treatment — they may -wish away their involvement in this suit. It is not so. Wake up Dorothy. You are not in Kansas anymore. H. Work Without Workers 60. Apart from the individual case failures explained above, even Defendants’ staff has testified that staffing and related facility failures are making the job of delivering timely and necessary medical care untenable. Debbie Roth, the Director of Nursing, testified that she had current staff vacancies (which were being addressed- by temporarily using nurses from other facilities) and also that even if all vacancies were filled, the full staff complement would have difficulty in performing assigned work due to the sheer volume and complexity of the work. “If I was fully staffed in all my facilities, it would still be difficult for the nurses to keep up with the workload.... We need more allotted staff positions, and we need more staff, both.” (Roth Dep. 50.) 61. Regarding the SMT facility, Roth testified that she needed “two additional R.N.s for the day shift, two on the afternoon shift and one on the night shift.” (Id. at 51.) She also testified that additional staff was necessary to cover vacation and sick leave for regular staff. (Id.) Regarding JMF, she testified that three additional staff positions were necessary and a third night-shift nurse would also be beneficial. (Id. at 52.) Similarly, she testified that RGC needed three additional staff nurses, though not a night-time nurse given that RGC involves short-term prisoner stays, shorter daily hours of operation, and a smaller percentage of very sick inmates. (Id. at 52-53.) 62.These opinions were shared by Dr Cohen both about nursing and physician staffing. Dr. Cohen testified: There have been critical nursing and physician shortages at the Hadix facilities over the last six months. During a three month period, [in JMF] there were only two physicians and one physician assistant on limited duty providing care. This situation exist[ed] almost through September and resulted in extreme delays in physician review of abnormal laboratory studies, especially consultations and their ability to see nurse referrals from sick call and kite evaluation. The inadequate physician staffing compromises the ability of nurses to refer patients for M.D. evaluation and schedules were so packed in September that physicians at JMF could not follow-up on their own patients because their schedules were so filled up for weeks ... ahead. Correctional Medical Services has been aware for a long time that they have been unsuccessful [in] recruiting and retaining physicians in the Hadix facilities, and this is documented in the minutes between CMS and MDOC, but they have not taken yet the necessary action to provide direct employment, including benefits, accrued vacations, and health insurance to the vast majority of their physician employees. If they do so, they would become much more competitive and would have access to a large pool of board certified physicians whose immigration status requires them to have full-time jobs in order to remain in this country. Nursing staffing in the Hadix facilities has been in disarray. The fact that in September just as these hearings were approaching the nursing staff was three days behind in their evaluation of kites is due to the inadequate number of nursing staff..... (T.T., vol.ni, 580-82.) 63. Dr. Cohen’s comments about the kite system are important to understand. The kite system is utilized by prisoners to communicate important requests for services, advice and medicine. Typical kites might ask for a prescription refill, indicate that a prisoner needs to see a physician regarding an ailment or ask for clarification regarding medical advice or a treatment regime for the prisoner. When these requests go unanswered, particularly as to a chronically-ill population dependent on daily medications and treatment advice, they create the real possibility of patient injury and death. Dr. Cohen discovered during one of his September tours that JMF nursing staff were three days behind in responding to kites and notified MDOC administrative staff. Debbie Roth, following up on Dr. Cohen’s investigation, received confirmation from a substitute RN (one drafted from another facility) that there was a three-day-old stack of kites to be reviewed. (Roth Dep. 48.) Roth then drafted still other staff, two RNS from other facilities, to address the three-day backlog of kites at JMF, but could not reduce staffing at other facilities for any prolonged period due to the needs at those facilities. (Id. at 48-50.) In other words, the conditions that caused this problem have persisted and make repetition of this and other critical problems likely. 64. A related staffing issue is the use of LPNs almost exclusively at the Hadix facilities to meet required staffing. Fifty percent of the RN staffing is provided by contract staffing. (Roth Dep. 70.) Of that group, 60 percent are LPNs, even though they are assigned to replace RNs. (Id. at 55.) This has resulted in the use of LPNs to take action on prison kites, actions which they are not qualified to perform in some cases. (Id.) This situation contradicts Defendants’ previous representations that prisoner kites were being reviewed exclusively by RNs. (See 2002 Findings at ¶ 89.) The medication kites that the LPNs review typically may have symptom components (e.g., I need more inhalers because I used them too quickly). 65.Craig Hutchinson, M.D., of CMS had a somewhat less dire opinion about the staffing inadequacies. He viewed the Ha-dix facilities as 92-93 percent fully staffed though “I haven’t done an accounting of the hours.... ” (Hutchinson Dep. 23.) In Hutchinson’s opinion, the only physician shortage was the failure to obtain one physician for RGC (who needed to be replaced due to recent retirement), Defs.’ Tr. Br. 7, and additional physician hours for the dialysis unit. (Hutchinson Dep. 23.) He explained that this shortage was due to the fact that the hiring was to be done by Dr. Deon Middlebrook (the nephrologist who provides hours at the dialysis unit and who works for CMS as an independent contractor with his physician employees). (Hutchinson Dep. 17, 23-26.) More particularly, he explained that the unfilled physician hours were due to the fact that one of Dr. Middlebrook’s physician hires dropped out after he attended CMS orientation. (Id.) According to Dr. Hutchinson, Dr. Middlebrook is still attempting to hire for those hours. (Id.) Defendants’ briefing admits that the dialysis unit is understaffed, but argues that the under-staffing does not jeopardize patient health and asks for an opportunity to present supporting testimony at hearing in January. (Defs.’ Tr. Br. 8.) Defendants’ briefing does not explicitly comment on the absence of nurse staffing, presumably because Plaintiffs’ motion had specifically requested additional physician staffing only. (See Defs.’ Tr. Br. 5-6.) 66. Defendants have submitted the De Bene Esse Deposition of Barbara Hladki on the subject of their hiring plans. According to her testimony, she has received tentative administrative approval for two additional LPNs and a third position (either a nurse or pharmacy technician) for JMF. (Hladki De Bene Esse Dep. at 33-34.) Hladki speculated that the “spending plan” would be approved in committee the next week and then she would be authorized to seek the new staff in January. (Id.) Hladki explained that it would take another two weeks to one month to fill the positions, but she did not explain in her answer why past openings had not been readily filled. (Id.) Indeed, defense counsel in the briefing accuses the Court and the media of making these positions difficult to fill, and says that one-half of recent applicants have cancelled interviews. (Defs.’ Tr. Br. 7.) As of November 2, 2006, JMF had five nursing vacancies out of 13 allocated positions. (Hladki De Bene Esse Dep. 36.) RGC had one vacancy out of seven allocated positions. (Id. at 37.) Parnall had one vacancy out of seven allocated positions. (Id.) 67. Interestingly, the testimony of Dr. Hutchinson and Barbara Hladki assumed the staffing of JMF was adequate even if not compliant with the Court-ordered Plan. The Plan set the minimum staff levels for JMF at four physicians and one mid-level provider. (Plan at 20.) This staffing was in addition to other additional staff for other parts of the Hadix facilities, including new staffing of the dialysis unit. (Plan at 19-20.) Defendants admit that they have not complied with this requirement— having employed only three physicians and one physician’s assistant. (Defs.’ Resp., Dkt. No. 2219, at 10.) They deem this as a sufficiently good-faith response even though no permission to deviate from the Plan was ever sought or extended. I. Workers Without Computers 68. One important side alley discussed during the recent hearing involves the implementation of the SERAPIS system— which was a requirement of the Preliminary Injunction. As specified above, the Preliminary Injunction required the expansion of SERAPIS to lab reports, the pharmacy and DWH, but did not provide an exact deadline for completion. This requirement was not an idle one. Since a landmark report of the Institute of Medicine of the National Academy of Sciences, the medical profession generally has recognized that an electronic medical record is the preferred method of recording keeping for health care in order to reduce errors associated with handwriting, prevent medication errors, expedite service and facilitate stable and remote access to patient records. See Institute of Medicine, The Computer-Based Patient Record: An Essential Technology for Health Care (National Academy Press 1991); see also Institute of Medicine, To Err is Human: Building a Safer Health System (National Academy Press 2000) (discussing cost in lives of medical error and strategies for prevention). As Dr. Cohen put it in his testimony, “You have to ... do it, otherwise you end up with the charts which are unreadable and have bad effects.” (T.T., vol. Ill, at 586.) Another huge advantage of the technology is that it allows one to rapidly search a patient record for pertinent information. (Pramsteller De Bene Esse Dep. 13.) 69. Furthermore, it appears that Defendants agree that the expansion of SER-APIS or a SERAPIS compatible system to all parts of the Hadix facilities, including records for in-patient care at C-Unit and DWH, is an important goal which must be met soon. (See Greifinger T.T., vol. Ill, 468-71.) It is possible to use SERAPIS for all ambulatory care, lab studies and prescriptions, but the system is not configured for in-patient care at C-Unit or DWH because it does