The Future of Virtual Care Services: A Payor's Perspective.

Whereas majority of telemedicine services today are focused on minor acute clinical ailments, the true potential of virtual care models lies in their ability to improve access to chronic condition care for medically complex individuals. Virtual models focused on chronic condition management will require continuity of care and the availability of in-person evaluations when necessary. Such services are more likely to be delivered by community-based primary care and specialty physicians, rather than vendor-administered, which is the most common model today. Both Center for Medicare and Medicaid Services regulations as well as state mandates have been increasingly more favorable toward the reimbursement of virtual services, and as a consequence, we expect to see continued growth in the availability of reimbursement of these services. As reimbursement becomes more liberal, we will soon reach an inflection point where these services are available as a covered benefit for substantial proportions of individuals, and we will see more physicians offer these services to their patients more frequently. As providers gear up to offer these services, there are important operational, logistic, and clinical elements of care models to consider. Consumers, in contrast, will need guidance on the appropriate use of the virtual care delivery channel. We are at an important inflection point in the evolution of virtual care, and are excited about its prospects.

Impact of Direct to Consumer Store-and-Forward Teledermatology on Access to Care, Satisfaction, Utilization, and Costs in a Commercial Health Plan Population.

PURPOSE: Store-and-forward teledermatology can improve access to dermatology by enabling asynchronous consults. This study assesses it on access, satisfaction, utilization, and costs in a commercial health plan setting. METHODOLOGY: In this prospective observational study with matched control, 47,411 individuals were provided access to teledermatology services staffed by board-certified, licensed dermatologists for 6 months. Two hundred forty-three individuals used the service. One hundred fifty-two participants successfully matched to similar users of in-person services for comparison. Average number of dermatology-related visits and dermatology-related costs in 30, 60, and 90 days postvisit, most frequent diagnoses, time to consult, patient satisfaction, and number of procedures were measured. RESULTS: Average time to consult for the teledermatology group was 16.31 h. Patient satisfaction was 4.38/5. Total dermatology utilization in the postvisit period for the teledermatology and the control groups respectively was 9 and 21 visits at 30 days (p = 0.074), 15 and 46 visits at 60 days (p = 0.005), and 26 and 74 at 90 days (p = 0.001). The dermatology-related spend for the teledermatology and control groups, respectively, was $59 and $113 on the day of the initial consult (p < 0.01), $70 and $202 for 30 days (p = 0.03), $78 and $ 221 for 60 days (p = 0.02), and $86 and $307 for 90 days (p = 0.08) following initial visit. Total number of procedures conducted in the control group at the index visit was 26. In the postvisit period, the total number of procedures in the study and control groups, respectively, were 5 and 15 at 30 days (p = 0.053), 10 and 26 at 60 days (p = 0.088), and 14 and 32 at 90 days (p = 0.082). CONCLUSIONS: Teledermatology services are accessible within hours and associated with high patient satisfaction. There is no evident increased utilization or costs postvisit.

Assessing the Impact of Medication Adherence on Long-Term Cardiovascular Outcomes.

BACKGROUND: Although guideline-recommended therapies reduce major adverse cardiovascular events (MACE) in patients after myocardial infarction (MI) or those with atherosclerotic disease (ATH), adherence is poor. OBJECTIVES: The goal of this study was to determine the association between medication adherence levels and long-term MACE in these patients. METHODS: We queried the claims database of a large health insurer for patients hospitalized for MI or with ATH. The primary outcome measure was a composite of all-cause death, MI, stroke, or coronary revascularization. Using proportion of days covered for statins and angiotensin-converting enzyme inhibitors, patients were stratified as fully adherent (≥80%), partially adherent (≥40% to ≤79%), or nonadherent (<40%). Per-patient annual direct medical (ADM) costs were estimated by using unit costs from 2 national files. RESULTS: Data were analyzed for 4,015 post-MI patients and 12,976 patients with ATH. In the post-MI cohort, the fully adherent group had a significantly lower rate of MACE than the nonadherent (18.9% vs. 26.3%; hazard ratio [HR]: 0.73; p = 0.0004) and partially adherent (18.9% vs. 24.7%; HR: 0.81; p = 0.02) groups at 2 years. The fully adherent group had reduced per-patient ADM costs for MI hospitalizations of $369 and $440 compared with the partially adherent and nonadherent groups, respectively. In the ATH cohort, the fully adherent group had a significantly lower rate of MACE than the nonadherent (8.42% vs. 17.17%; HR: 0.56; p < 0.0001) and the partially adherent (8.42% vs. 12.18%; HR: 0.76; p < 0.0001) groups at 2 years. The fully adherent group had reduced per-patient ADM costs for MI hospitalizations of $371 and $907 compared with the partially adherent and nonadherent groups. CONCLUSIONS: Full adherence to guideline-recommended therapies was associated with a lower rate of MACE and cost savings, with a threshold effect at >80% adherence in the post-MI population; at least a 40% level of long-term adherence needs to be maintained to continue to accrue benefit. Novel approaches to improve adherence may significantly reduce cardiovascular events.

Artefactual spikes in electrocardiography: a worthwhile introspection.

Electrical devices, which have become an integral part of our daily life, may influence the electrical recording of the heart. These disturbances from external sources outside of the heart's own activity produce changes in the electrocardiography (ECG) of the patient, simulating rhythmic disturbances of the heart. Understanding these disturbances is essential in order to better interprete the ECG. Common sources of electrical interferences include external devices, such as alternating current and improper earthing, and surgical procedures like diathermy. We report a case of electrical interference in a patient's ECG due to an inserted bladder stimulator. This case report highlights the importance of precise identification of artefacts in the interpretation of ECG, as well as prompt localisation and elimination of the source of interference.

Semantic interoperability of Health Risk Assessments.

The health insurance and benefits industry has administered Health Risk Assessments (HRAs) at an increasing rate. These are used to collect data on modifiable health risk factors for wellness and disease management programs. However, there is significant variability in the semantics of these assessments, making it difficult to compare data sets from the output of 2 different HRAs. There is also an increasing need to exchange this data with Health Information Exchanges and Electronic Medical Records. To standardize the data and concepts from these tools, we outline a process to determine presence of certain common elements of modifiable health risk extracted from these surveys. This information is coded using concept identifiers, which allows cross-survey comparison and analysis. We propose that using LOINC codes or other universal coding schema may allow semantic interoperability of a variety of HRA tools across the industry, research, and clinical settings.