John S. Barbieri

The Reliability of Teledermatology to Triage Inpatient Dermatology Consultations

IMPORTANCE Many hospitals do not have inpatient dermatologic consultative services, and most have reduced availability of services during off-hours. Dermatologists based in outpatient settings can find it challenging to determine the urgency with which they need to evaluate inpatients when consultations are requested. Teledermatology may provide a valuable mechanism for dermatologists to triage inpatient consultations and increase efficiency, thereby expanding access to specialized care for hospitalized patients. OBJECTIVE To evaluate whether a store-and-forward teledermatology system is reliable for the initial triage of inpatient dermatology consultations. DESIGN, SETTING, AND PARTICIPANTS Prospective study of 50 consenting adult patients, hospitalized for any indication, for whom an inpatient dermatology consultation was requested between September 1, 2012, and April 31, 2013, at the Hospital of the University of Pennsylvania, an academic medical center. The participants were evaluated separately by both an in-person dermatologist and 2 independent teledermatologists. MAIN OUTCOMES AND MEASURES The primary study outcomes were the initial triage and decision to biopsy concordance between in-person and teledermatology evaluations. RESULTS Triage decisions were as follows: if the in-person dermatologist recommended the patient be seen the same day, the teledermatologist agreed in 90% of the consultations. If the in-person dermatologist recommended a biopsy, the teledermatologist agreed in 95% of cases on average. When the teledermatologist did not choose the same course of action, there was substantial diagnostic agreement between the teledermatologist and the in-person dermatologist. The Kendall τ rank correlation coefficients for initial triage concordance between the in-person dermatologist and teledermatologists were 0.41 and 0.48. The Cohen κ coefficients for decision to biopsy concordance were 0.35 and 0.61. The teledermatologists were able to triage 60% of consultations to be seen the next day or later. The teledermatologists were able to triage, on average, 10% of patients to be seen as outpatients after discharge. CONCLUSIONS AND RELEVANCE Teledermatology is reliable for the triage of inpatient dermatology consultations and has the potential to improve efficiency.

The accuracy of mobile teleradiology in the evaluation of chest X-rays:

We assessed the diagnostic accuracy of digital photographs of plain film chest X-rays (CXRs) obtained using a mobile phone. The study was a randomized, non-inferiority trial, in which physical plain film CXRs viewed on a light box were compared with digital photographs of plain film CXRs. CXRs were selected from a database of radiology studies to show common pathologies found in Botswana associated with pneumonia, lung carcinoma, tuberculosis, pneumothorax and interstitial disease, as well as normal findings. The pre-selected diagnoses were subsequently verified by a second radiologist. Seven radiologists were randomized to review 75 plain film CXRs on light boxes before viewing 75 digital photographs, or vice versa. Their responses were considered correct if they matched the pre-defined diagnosis. For both modalities, the correct diagnosis was provided in 79% of cases; for plain film CXRs, the correct diagnosis was provided in 82% of cases and for digital photographs the correct diagnosis was provided in 76% of cases. The difference in diagnostic accuracy was −5.7% (95% CI: −10.8% to −0.5%), which confirmed non-inferiority (P < 0.001) for the primary outcome of diagnostic accuracy. A subgroup analysis demonstrated non-inferiority for lung carcinoma and pneumonia images, although non-inferiority was not achieved for pneumothorax, tuberculosis, interstitial disease or normal images. The study demonstrates that digital photographs of CXRs obtained via a mobile phone equipped with a digital camera are non-inferior to plain film CXRs.

Future considerations for clinical dermatology in the setting of 21st century American policy reform: Accountable Care Organizations

An Accountable Care Organization (ACO) is a network of providers that collaborates to manage care and is financially incentivized to realize cost savings while also optimizing standards of care. Since its introduction as part of the 2010 Patient Protection and Affordable Care Act, ACOs have grown to include 16% of Medicare beneficiaries and currently represent Medicares largest payment initiative. Although ACOs are still in the pilot phase with multiple structural models being assessed, incentives are being introduced to encourage specialist participation, and dermatologists will have the opportunity to influence both the cost savings and quality standard aspects of these organizations. In this article, part of a health care policy series targeted to dermatologists, we review what an ACO is, its relevance to dermatologists, and essential factors to consider when joining and negotiating with an ACO.

Future considerations for clinical dermatology in the setting of 21st century American policy reform: The Medicare Access and Children's Health Insurance Program Reauthorization Act and Alternative Payment Models in dermatology

With the introduction of the Medicare Access and Childrens Health Insurance Program Reauthorization Act, clinicians who are not eligible for an exemption must choose to participate in 1 of 2 new reimbursement models: the Merit-based Incentive Payment System or Alternative Payment Models (APMs). Although most dermatologists are expected to default into the Merit-based Incentive Payment System, some may have an interest in exploring APMs, which have associated financial incentives. However, for dermatologists interested in the APM pathway, there are currently no options other than joining a qualifying Accountable Care Organization, which make up only a small subset of Accountable Care Organizations overall. As a result, additional APMs relevant to dermatologists are needed to allow those interested in the APMs to explore this pathway. Fortunately, the Medicare Access and Childrens Health Insurance Program Reauthorization Act establishes a process for new APMs to be approved and the creation of bundled payments for skin diseases may represent an opportunity to increase the number of APMs available to dermatologists. In this article, we will provide a detailed review of APMs under the Medicare Access and Childrens Health Insurance Program Reauthorization Act and discuss the development and introduction of APMs as they pertain to dermatology.

Future considerations for clinical dermatology in the setting of 21st century American policy reform: The Medicare Access and Children's Health Insurance Program Reauthorization Act and the Merit-based Incentive Payment System

As the implementation of the Medicare Access and Childrens Health Insurance Program Reauthorization Act begins, many dermatologists who provide Medicare Part B services will be subject to the reporting requirements of the Merit-based Incentive Payment System (MIPS). Clinicians subject to MIPS will receive a composite score based on performance across 4 categories: quality, advancing care information, improvement activities, and cost. Depending on their overall MIPS score, clinicians will be eligible for a positive or negative payment adjustment. Quality will replace the Physician Quality Reporting System and clinicians will report on 6 measures from a list of over 250 options. Advancing care information will replace meaningful use and will assess clinicians on activities related to integration of electronic health record technology into their practice. Improvement activities will require clinicians to attest to completion of activities focused on improvements in care coordination, beneficiary engagement, and patient safety. Finally, cost will be determined automatically from Medicare claims data. In this article, we will provide a detailed review of the Medicare Access and Childrens Health Insurance Program Reauthorization Act with a focus on MIPS and briefly discuss the potential implications for dermatologists.

Physician spending and risk of malpractice claims: what about the effects of socioeconomic status?

Jena and colleagues’ evaluation of the association between physician spending and malpractice claims found that higher spending is associated with fewer claims.1 However, although they examined several potential confounders, including age, sex, race, diagnosis related group, and comorbid conditions, they did not include socioeconomic status (SES). Previous work has shown that, although there is a perception among physicians that patients of lower SES are more likely …

Commentary: Future considerations for clinical dermatology in the setting of 21st century American policy reform: The Medicare Access and CHIP Reauthorization Act of 2015

The American Medical Association and over 750 national and state-based physician and specialty organizations have gone on record in support of H.R. 2, the “Medicare Access and CHIP Reauthorization Act.” Many physicians have questions about the major provisions of the legislation, and others have been disturbed by incomplete or incorrect interpretations of the bill’s legislative language. Below are responses to frequently asked questions about the major provisions of H.R. 2 that will affect Medicare physician payments; following these FAQs are Myth-Fact clarifications to incorrect interpretations of the bill that have been widely circulated.

Introducing the Group for Research of Policy Dynamics in Dermatology: “Future considerations for clinical dermatology in the setting of 21st century American policy reform” manuscript series

O n June 25, 2015, the US Supreme Court upheld the constitutionality of tax credits for purchasing health insurance on federal exchanges, thereby effectively securing health care coverage for an estimated 6.4 million lowand middle-income individuals. On the surface, the ruling provided critical stabilization of insurance markets and ensured that health insurance would be accessible for millions of otherwise uninsured Americans. However, the tacit ramification of the Supreme Court’s decision was the solidification and preservation of the Patient Protection and Affordable Care Act (ACA) for the foreseeable future. Most of us are likely familiar with the ACA jargon: the individual mandate, ban on insurance exclusions for pre-existing conditions, removal of annual dollar and lifetime limits, integration of health systems, and reimbursements rooted in quality outcomes and cost-savings. However, some of the provisions of health care reform either have not yet taken effect or are in such stages of infancy that many health care providers still have not felt the full impact of reform. This may seem unfathomable to those who are already reeling from the sweeping changes that have occurred in health care delivery. Although some individuals, across the political ideology spectrum, continue to advocate for the repeal and replacement of the ACA, it should be noted that proposed replacements or alternatives to ACA include many of the same cost-containment

Trends in prescribing behavior of systemic agents used in the treatment of acne among dermatologists and nondermatologists: A retrospective analysis, 2004-2013

Background: Despite recommendations to limit the use of oral antibiotics and increasing support for hormonal agents in the treatment of acne, it is unclear whether there have been any significant changes in practice patterns. Objective: To characterize changes in prescribing behavior for systemic agents in the treatment of acne in the United States between 2004 and 2013. Methods: We conducted a retrospective analysis using the OptumInsight Clinformatics DataMart (Optum, Eden Prairie, MN). Results: The number of courses of spironolactone prescribed per 100 female patients being managed for acne by dermatologists and nondermatologists increased from 2.08 to 8.13 and from 1.43 to 4.09, respectively. The median duration of therapy with oral antibiotics was 126 and 129 days among patients managed by dermatologists and nondermatologists, respectively, and did not change significantly over the study period. Limitations: The OptumInsight Clinformatics DataMart lacks information on acne severity and clinical outcomes. Conclusions: Additional work to identify patients who would benefit most from alternative therapies such as spironolactone, oral contraceptives, or isotretinoin represents a potential opportunity to improve the care of patients with acne.

Uptake and impact of a clinical diagnostic decision support tool at an academic medical center

Abstract Background: Use of differential diagnosis (DDX) generators may reduce the incidence of misdiagnosis-related harm, but there is a paucity of research examining the use and impact of such systems in real-world settings. Methods: In September 2012, the DDX generator VisualDx was made available across our entire academic healthcare system. We examined the use of VisualDx by month for the 18 months following its introduction. In addition, we compared the number of inpatient dermatology consults requested per month at the flagship hospital of our healthcare system for the 12 months before versus 18 months after VisualDx introduction. Results: Across our entire academic healthcare system, there were a median of 474 (interquartile range 390–544) unique VisualDx sessions per month. VisualDx was accessed most frequently through mobile devices (35%) and the inpatient electronic health record (34%). Prior to VisualDx introduction, there was a non-significant increase in the number of inpatient dermatology consultations requested per month at the flagship hospital of our healthcare system (1.0 per month, 95% CI –2.5–4.6, p=0.54), which remained 1.0 consults per month (95% CI –0.9–2.9, p=0.27) following its introduction (p=0.99 comparing post- versus pre-introduction rates). Conclusions: The DDX generator VisualDx was regularly used, primarily on mobile devices and inpatient workstations, and was not associated with a change in inpatient dermatology consultation requests. Given the interest in DDX generators, it will be important to evaluate further the impact of such tools on the quality and value of care delivered.