Running head STRATEGIC MARKETING MODULE 1 CASE .docx

Running head: STRATEGIC MARKETING MODULE 1 CASE
1
STRATEGIC MARKETING MODULE 1 CASE 2
Trident University International
Student Name
Strategic Marketing Module 1 Case
MKT501: Strategic Marketing
Professor’s Name
Date of Submission
Strategic Marketing Module 1 Case
This is your 2-3 sentence introduction. No heading is
required. Remember to always indent the first line of a
paragraph (use the tab key). The margins, font size, spacing,
and font type (bold or plain) are set in APA format. While you
may change the names of the headings and subheadings, do not
change the font or style of font. This introduction should

provide a quick overview of the topic discussed.
Industry
Research your product/service’s industry with regard to
mark-ups and contribution margins. Describe the industry.
Industry Markups and Contribution Margins
Discuss the margins and markups on goods or services. Discuss
other economic factors that affect the mark-ups
Supporting Prices and Margins
What marketing techniques can companies use to support the
pricing schemes that support their margins?
Conclusion
This is your 2-3 sentence conclusion. Remember this is the last
thing your reader will hear.
References
This listing should be in alphabetical order. Below are a few
examples of reference list entries. The following list needs to be
removed before you submit the paper.
Journal in online library(be sure that you give the specific
library database for journal articles that you have retrieved from
the library, e.g., Proquest, EBSCO – Academic Search
Complete, EBSCO – Business Source Complete, IBISWorld,
etc.):
Last name, Initials. (yyyy of journal volume). Title of article.
Title of Journal,volume
number,(issue number), pages. Retrieved from [insert name of
library database]
Example:
Borgerson, J. L., Schroeder, J. E., Escudero Magnusson, M., &
Magnusson, F. (2009).

Corporate communication, ethics, and operational identity: A
case study of Benetton. Business Ethics: A European Review,
18(3), 209-223. Retrieved from Proquest.
Book in online library:
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from [insert name of library
database]
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Johnson, R. A. (2009). Helping really fat dogs. Retrieved from
EBSCO eBook Collection.
Newspaper in online library:
Author last name, first initial. (YYYY, MM DD). Name of
article. Title of Newspaper,
pages. Retrieved from [name of library database].
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Dee, J. (2007, December 23). A toy maker’s conscience. New
York Times Magazine, 34-39.
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Websites
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Author. (Year [use n.d. if not given]). Article or page title.
Larger Publication Title. Retrieved from https://urladdress
Example:
Shiva, V. (2006, February 12). Bioethics: A third world issue.

Nativeweb. Retrieved
from https://www.nativeweb.org/pages/legal/shiva.html
APA end reference for a website – with no author:
Title of article. (Year [use n.d. if not given]). Website Title.
Retrieved from
https://www.website-name/ABCDEFG-12345
Example:
Media giants. (2014). Frontline: The Merchants of Cool.
Retrieved from
https://www.pbs.org/wgbh/pages/frontline/shows/cool/giants/
Rubic_Print_FormatCourse CodeClass CodeAssignment
TitleTotal PointsNRS-433VNRS-433V-O502Rough Draft
Qualitative Research Critique and Ethical
Considerations200.0CriteriaPercentage1: Unsatisfactory
(0.00%)2: Less Than Satisfactory (75.00%)3: Satisfactory
(83.00%)4: Good (94.00%)5: Excellent
(100.00%)CommentsPoints EarnedContent75.0%Qualitative
Studies5.0%Only one article is presented. Neither of the articles
presented use qualitative research.Two articles are presented.
Of the articles presented, only one article is based on
qualitative research.N/AN/ATwo articles are presented. Both
articles are based on qualitative research.Background of
Study10.0%Background of study, including problem,
significance to nursing, purpose, objective, and research
questions, is incomplete.Background of study, including
problem, significance to nursing, purpose, objective, and
research questions, is included but lacks relevant details and
explanation.Background of study, including problem,

questions, is partially complete and includes some relevant
details and explanation.Background of study, including
problem, significance to nursing, purpose, objective, and
research questions, is complete and includes relevant details and
explanation.Background of study, including problem,
questions, is thorough with substantial relevant details and
extensive explanation.Article Support of Nursing Practice
Issue15.0%Discussion on how articles support the PICOT
question is incomplete.A summary of how articles support the
PICOT question is presented. It is unclear how the articles can
be used to answer the proposed PICOT question. Significant
information and detail are required.A general discussion on how
articles support the PICOT question is presented. The articles
demonstrate general support in answering the proposed PICOT
question. It is unclear how the interventions and comparison
groups in the articles compare to those identified in the PICOT
question. Some rational or information is needed.A discussion
on how articles support the PICOT question is presented. The
articles demonstrate support in answering the proposed PICOT
question. The interventions and comparison groups in the
articles compare to those identified in the PICOT question.
Minor detail or rational is needed for clarity or support.A clear
discussion on how articles support the PICOT question is
presented. The articles demonstrate strong support in answering
the proposed PICOT question. The interventions and
comparison groups in the articles strongly compare to those
identified in the PICOT question.Method of
Study15.0%Discussion on the method of study for each article
is omitted. The comparison of study methods is omitted or
incomplete.A partial summary of the method of study for each
article is presented. The comparison of study methods is
incomplete. A benefit and a limitation of each method are
omitted or incomplete. There are significant inaccuracies.A
general discussion on the method of study for each article is

presented. The comparison of study methods is summarized. A
benefit and a limitation of each method are summarized. There
some inaccuracies or partial omissions. More information is
needed.A discussion on the method of study for each article is
presented. The comparison of study methods is generally
described. A benefit and a limitation of each method are
presented. There minor are inaccuracies. Some detail is required
for accuracy or clarity.A thorough discussion on the method of
study for each article is presented. The comparison of study
methods is described in detail. A benefit and a limitation of
each method are presented. The discussion demonstrates a solid
understanding of research methods.Results of
Study15.0%Discussion of study results, including findings and
implications for nursing practice, is incomplete.A summary of
the study results includes findings and implications for nursing
practice but lacks relevant details and explanation. There are
some omissions or inaccuracies.Discussion of study results,
including findings and implications for nursing practice, is
generally presented. Overall, the discussion includes some
relevant details and explanation.Discussion of study results,
including findings and implications for nursing practice, is
complete and includes relevant details and
explanation.Discussion of study results, including findings and
implications for nursing practice, is thorough with substantial
relevant details and extensive explanation.Ethical
Considerations15.0%Discussion of ethical considerations when
conducting nursing research is incomplete. A discussion on
ethical considerations of the two articles presented in the essay
is incomplete.Discussion of ethical considerations when
conducting nursing research is included but lacks relevant
details and explanation. A discussion on ethical considerations
of the two articles used in the essay is summarized but there are
significant inaccuracies or omissions.Discussion of ethical
considerations when conducting nursing research is partially
complete and includes some relevant details and explanation. A
discussion on ethical considerations of the two articles used in

the essay is discussed but there are some inaccuracies, or some
information is needed.Discussion of ethical considerations when
conducting nursing research is complete and includes relevant
details and explanation. A discussion on ethical considerations
of the two articles used in the essay is presented; some detail in
needed for accuracy or clarity.Discussion of ethical
considerations associated with the conduct of nursing research
is thorough with substantial relevant details and extensive
explanation. A detailed discussion on ethical considerations of
the two articles used in the essay is presented.Organization and
Effectiveness15.0%Thesis Development and Purpose5.0%Paper
lacks any discernible overall purpose or organizing claim.Thesis
is insufficiently developed or vague. Purpose is not clear.Thesis
is apparent and appropriate to purpose.Thesis is clear and
forecasts the development of the paper. Thesis is descriptive
and reflective of the arguments and appropriate to the
purpose.Thesis is comprehensive and contains the essence of the
paper. Thesis statement makes the purpose of the paper
clear.Argument Logic and Construction5.0%Statement of
purpose is not justified by the conclusion. The conclusion does
not support the claim made. Argument is incoherent and uses
noncredible sources.Sufficient justification of claims is lacking.
Argument lacks consistent unity. There are obvious flaws in the
logic. Some sources have questionable credibility.Argument is
orderly, but may have a few inconsistencies. The argument
presents minimal justification of claims. Argument logically,
but not thoroughly, supports the purpose. Sources used are
credible. Introduction and conclusion bracket the
thesis.Argument shows logical progressions. Techniques of
argumentation are evident. There is a smooth progression of
claims from introduction to conclusion. Most sources are
authoritative.Argument is clear and convincing and presents a
persuasive claim in a distinctive and compelling manner. All
sources are authoritative.Mechanics of Writing (includes
spelling, punctuation, grammar, language use)5.0%Surface
errors are pervasive enough that they impede communication of

meaning. Inappropriate word choice or sentence construction is
used.Frequent and repetitive mechanical errors distract the
reader. Inconsistencies in language choice (register), sentence
structure, or word choice are present.Some mechanical errors or
typos are present, but they are not overly distracting to the
reader. Correct sentence structure and audience-appropriate
language are used.Prose is largely free of mechanical errors,
although a few may be present. A variety of sentence structures
and effective figures of speech are used.Writer is clearly in
command of standard, written, academic
English.Format10.0%Paper Format (use of appropriate style for
the major and assignment)5.0%Template is not used
appropriately or documentation format is rarely followed
correctly.Template is used, but some elements are missing or
mistaken; lack of control with formatting is apparent.Template
is used, and formatting is correct, although some minor errors
may be present.Template is fully used; There are virtually no
errors in formatting style.All format elements are
correct.Documentation of Sources (citations, footnotes,
references, bibliography, etc., as appropriate to assignment and
style)5.0%Sources are not documented.Documentation of
sources is inconsistent or incorrect, as appropriate to
assignment and style, with numerous formatting errors.Sources
are documented, as appropriate to assignment and style,
although some formatting errors may be present.Sources are
documented, as appropriate to assignment and style, and format
is mostly correct.Sources are completely and correctly
documented, as appropriate to assignment and style, and format
is free of error.Total Weightage100%
Article
Type 1 diabetes self-management:
developing a web-based telemedicine

application
Haleh Ayatollahi, PhD
1
,
Mostafa Hasannezhad, MSc
1
,
Hedieh Saneei Fard, MD2,
Mehran Kamkar Haghighi, MSc
1
Abstract
Background: Self-management skills are essential for patients
with diabetes mellitus to minimise the risks of compli-
cations from their condition. The aim of this research was to
develop a web-based application for self-management of type
1 diabetes, suitable for use by patients, their carers and
physicians. Method: The study was comprised of two phases,
the
first being analysis of the kind of information and capabilities
required by potential users of the system. Based on the
results derived from the first phase of the study, the system
prototype was designed and then evaluated using the ‘think
aloud’ method and a standard questionnaire. The application
was designed for use by patients, their carers and physicians.
Patients could enter the level of blood glucose, insulin and
activities on a daily basis, and physicians were able to supervise
a
patient’s health status from a distance. Results: Users were
generally satisfied with the final version of the system. People
with a wide range of literacy skills were able to use the system
effectively. Conclusion: Patients or their carers could use

the web-based application as a log book by entering the level of
blood glucose and insulin doses on a regular basis, and as an
educational resource to improve self-management skills.
Physicians could use the system at any time convenient to them
to
support patients by giving medical advice. Further research is
needed to report the effectiveness of the system in practice.
Keywords (MeSH)
type 1 diabetes mellitus; chronic disease; disease management;
self-management; telemedicine; Iran; health information
management
Background
Diabetes mellitus is a condition that occurs when the pan-
creas is unable to produce sufficient levels of the glucose
regulating hormone insulin, or when the body’s cells cannot
accurately respond to it (Smeltzer et al. 2008; Shrivastava,
Shrivastava & Ramasamy 2013). Globally, diabetes is one of
the most prevalent endocrine diseases, which causes about 4
million deaths annually. In the USA, the cost of healthcare
for a patient without diabetes is about 2,560 USD annually,
while for a patient with diabetes, it is about 11,744 USD
(Harmel & Mathur 2004; Pazhoohi & Khoshniyyat 2010).
The World Health Organization (WHO) and the Amer-

ican Diabetes Association (ADA) have classified diabetes
into four groups: type 1, type 2, gestational diabetes mellitus
(GDM) and diabetes due to other causes. Type 1 diabetes or
insulin dependent diabetes, which comprises 10% to 15% of
total cases of diabetes, is an autoimmune disease where the
body destroys the insulin-producing cells, and eventually no
insulin is produced. Patients with this type of diabetes must
be provided with subcutaneous insulin injections, and the
number of patients hospitalised due to type 1 diabetes is
5.3 times more than patients who are hospitalized due to
other diseases (Ragnar 2006; Smeltzer et al. 2008).
As diabetes is a lifelong disease, it is necessary to train
diabetic patients in self-management techniques to mini-
mise its probable risks (Bodenheimer et al. 2002). Clearly,
people with diabetes have differing levels of knowledge,
social support, self-efficiency, motivation, disease cer-
tainty, and individual capabilities for self-management
activities (McDonald et al. 2004; Sousa et al. 2005). Con-

sequently, they have different information needs for man-
aging their illness, and such information must be provided
1 Department of Health Information Management, Iran
University of
Medical Sciences, Tehran, Iran
2
Paediatric Endocrinology & Metabolism, Imam Hossein
Hospital, Shahid
Beheshti University of Medical Sciences, Tehran, Iran
Accepted for publication August 26, 2015.
Corresponding author:
Haleh Ayatollahi, Department of Health Information
Management, Iran
University of Medical Sciences, Tehran, Iran.
Email: [email protected]
Health Information Management Journal
2016, Vol. 45(1) 16–26
ª The Author(s) 2016
Reprints and permission:
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DOI: 10.1177/1833358316639456
himj.sagepub.com
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by an expert as effectively as possible. For example, insulin
injections, a healthy eating style tailored for diabetics and
physical activities are important for managing diabetes and
patients must learn how to maintain a balance between
these factors (Bodenheimer et al. 2002). Increases in blood
glucose level may cause a number of complications; there-
fore, a patient with diabetes must learn how to control the
level of blood glucose through adjusting insulin dosage
(Mulcahy et al. 2003).
It is critical that patients with diabetes, particularly type 1
diabetes, have access to continuous healthcare services (Sim-
mons et al. 2007). However, in developing countries financial
and human resources are limited (Debussche et al. 2009) and
only 50% of patients with diabetes are referred to hospitals
and healthcare centres to receive these services. Face-to-face
education plans and training for self-management, designed
to empower patients in managing their illness, are often insuf-

ficient in meeting these requirements (Simmons et al 2007;
Debussche et al 2009). Furthermore, due, for example, to
remote distance or transportation costs, it can be impossible
for some patients to attend hospitals and have continuous
access to healthcare services. The use of information technol-
ogy and provision of online training has been suggested as a
method of regular and continuous education (Zaali 2006).
The Internet has become a powerful medium for teaching the
elements of a healthy lifestyle as well as improving patients’
knowledge about their disease. It is expected that an appro-
priate online application would facilitate the process of care
and improve the self-sufficiency of patients or their families
in the management of the disease (Izquierdo et al. 2003;
Wantland et al. 2004).
The literature review showed that many studies have
been undertaken to investigate the benefits of the Internet
as an information resource for patients with diabetes
(Wantland et al. 2004; McMahon et al. 2005; Lee et al.

2007; Moore et al. 2008; Roek et al. 2009). Some of these
benefits are: providing patients with recommendations,
reminders, educational information and online support;
improving communications between patients and health-
care providers; and empowering patients to be able to man-
age their disease (Izquierdo et al. 2003; Wantland et al.
2004; Moore et al. 2008; Silk et al. 2008). Some studies
showed that while the annual cost of traditional treatment
for a patient with diabetes is between 300 and 1000 USD,
managing these patients using web-based applications is
about 50 USD per each patient (Zaali 2006). Nevertheless,
most people who are using the Internet as an information
resource still prefer face-to-face communication with their
healthcare providers (Jennings et al. 2009).
Most studies published in this area have focused on web-
based diabetes self-management education programs (Chau
et al. 2012; Yu, Parsons, Mamdani et al. 2014); designing a
recommender system and an e-learning course for patients

with diabetes (Hidalgo et al. 2014); designing a dialogue-
based application to improve knowledge of patients with
diabetes about their illness (Weymann et al. 2013; Wey-
mann, Härter & Dirmaier 2013); and the use of mobile
phones in recording health data and communicating with
healthcare providers (Frøisland, Arsand & Skårderud 2012;
Nes et al. 2012). Few studies have presented an interactive
web-based application for diabetes self-management as a
telemedicine approach to support patients (Yu, Parsons,
Hall et al. 2014; Siminerio et al. 2014). It should be empha-
sised that although the use of the latest technology in
empowering self-management is valuable, in many devel-
oping countries telemedicine and even simple web-based
applications are still new and require more attention. How-
ever, in most of these countries the Internet is available to
different age groups (children and adolescents) and can
provide them with high level of support for self-
management at a very low cost (Debussche et al. 2009).

Currently, in Iran, there are about seven million patients
with diabetes and among them about 500,000 suffer from type
1 diabetes. The age range of patients with diabetes is 10 to15
years less than the age range of similar patients in the devel-
oped countries (Pazhoohi & Khoshniyyat 2010). According
to the latest report issued by the Ministry of Health, 700
million USD dollars should be spent to manage the disease
and to treat the patients annually. This is a huge amount of
money in which indirect costs have not been included (Este-
qamati 2004). Web-based interventions have the potential to
improve diabetes care and self-management (Yu, Parsons,
Hall et al. 2014) and the technological features can help
patients to receive online support (Zhou et al. 2014). As
patients demand access to personalised healthcare, web appli-
cations should be designed to meet users’ specific needs (Nij-
land et al. 2011), and to achieve this, end-users must be
involved in the design process (McCurdie et al. 2012). More-
over, there are a number of individual and context-specific

factors that influence the use of the system and simply adopt-
ing the existing systems might not be a desirable approach
(Fichman, Kohi & Krishnan 2011). Therefore, the researchers
intended to design a web-based application to support patients
with type 1 diabetes. This was the first time that such an
application had been developed in this country. It is expected
that by using such an application, many direct and indirect
benefits, such as improving the health status of patients with
diabetes and saving costs, can be gained.
Method
This study was completed in 2013 and consisted of two
main phases. Initially, a survey study was undertaken to
determine what kind of information and capabilities are
required by the users of the application. In the second
phase, the application was developed based on the results
derived from the first phase, and the initial usability testing
was conducted. The setting of the research was the endo-
crine clinic in a teaching hospital.

Participants
The initial plan was to develop an application that could be
used by both groups of users, namely patients and their
endocrinologists. In the first phase of the study, Group 1
included 30 participants (7 patients with type 1 diabetes,
and 23 parents who took care of their children with type 1
diabetes). The parents of patients under 15 years of age
Ayatollahi et al. 17
were asked to take part in the study. Group 2 included 15
endocrinologists, paediatric endocrinologists and their fel-
lows who worked in different teaching hospitals. The
method of convenience sampling was used to select
patients and endocrinologists.
The endocrine clinic was responsible for implementing
diabetes screening programs and more than 100 patients
were visited monthly by the endocrinologists in this clinic.
In the second phase of the study, 15 system users (5 endo-

crinologists, 5 patients and 5 parents), who were interested
in taking part in the usability testing of the website, were
invited to attend the clinic and evaluate the usability of the
application.
Data collection instrument
To determine the information needs of the users, a ques-
tionnaire called ‘Information Needs Assessment Question-
naire-INAQ’ was designed based on the criteria suggested
by the American Diabetes Association (ADA) (Nes et al.
2012), Iranian Diabetes Association (IDA) (Delavari 2004;
Pazhoohi & Khoshniyyat 2010), and by reviewing other
related materials (Lee et al. 2007; Jennings et al. 2009;
Nordfeldt et al. 2013). The questionnaire included 32
closed questions and was divided into four main parts:
required data elements related to patient’s demographic
information; clinical information; physician’s supervision;
and required system capabilities. There were two possible
answers for each question; ‘necessary’ or ‘unnecessary’. At

the end of each part, there was an open-ended question that
asked the participants to suggest further data elements or
system capabilities that might not have been considered in
the questionnaire. The content and the face validity of the
questionnaire were checked by the experts. The reliability
was confirmed using a statistical test (KR-20 ¼ 0.74).
In order to collect data, the questionnaires were given to
a nurse who worked in the endocrine clinic. As she was
responsible for taking a clinical summary of patients, she
could easily identify patients with type 1 diabetes. She
asked patients or their parents to complete the question-
naire. The participants were also asked whether they were
interested in taking part in the second phase of the study.
The same questionnaire was distributed among the endo-
crinologists by the researcher (MH) who attended the clinic
personally to ask physicians to complete the questionnaire.
As the number of endocrinologists was limited in the clinic,
they referred the researcher (MH) to their colleagues who
were working in other teaching hospitals.

The usability of the system and users’ satisfaction with
the interface was evaluated using the standard Question-
naire for User Interaction Satisfaction (QUIS) version 5.5
provided by the University of Maryland (Alexandru 2010).
The 9-point Likert scale questionnaire included five parts
(27 questions), overall reaction to the software (6 ques-
tions), screen design and layout (4 questions), terminology
and systems information (6 questions), learning (6 ques-
tions), and system capabilities (5 questions). The question-
naire was translated and its face validity was checked.
According to the literature, the reliability of the
questionnaire was (a ¼ 0.94) (Alexandru 2010). This ques-
tionnaire was completed by 15 users (patients, parents and
physicians) who were invited to attend the clinic and use
the prototype of the system.
Data analysis
Initially, the data collected in the survey study were ana-
lysed as follows. To decide which data elements should be

included in the application, a rule was set by the research-
ers. According to this rule, the data elements selected as
‘necessary’ by at least 60% of the participants (both
patients and endocrinologists) were considered important
to be included in the application. To analyse the data col-
lected from the usability testing, the Likert scale was
divided into three levels: ‘weak’ (1-3), ‘average’ (4-6) and
‘good’ (7-9). Mean values were calculated for different
parts of the questionnaire, and were reported for patients,
parents and physicians separately. The final results were
reported based on the three levels mentioned above.
System design and usability testing
The prototype of the system was designed using ASP. NET
programming language. To evaluate the usability of the
system, the ‘think aloud’ method was used initially. This
is a cheap, robust, flexible, convincing and easy to learn
method in which participants are asked to use the system
while verbalising their thoughts as they move through the

interface (Nielsen 2012). This method has also been used in
other studies to evaluate the usability of a system (Qiu &
Yu 2007). In this research, the prototype of the system was
run on a personal computer (PC) in a private room in the
clinic. One of the researchers (MH) initially introduced the
system to 5 participants (3 patients and 2 physicians). He
explained the study objectives to the participants and col-
lected their informed consent. The participants were asked
to perform the experimental tasks while verbalising what-
ever they saw, did, and felt when performing these tasks.
During each session, MH took field notes about the parti-
cipants’ performance and comments. All sessions were
audio-recorded and the duration of each session was about
30 minutes. The participants’ comments were applied to the
final version of the system. Similar to the previous stage,
the final version of the system was run on a PC in the clinic.
Then, a number of users (5 patients, 5 parents, 5 physicians)
were asked to work with the system and evaluate it using a

standard questionnaire (QUIS). Generally, the website was
refined in a number of cycles to confirm the requirements
of users. A research flow diagram is presented in Figure 1.
Ethics approval
Ethics approval was obtained from the university research
ethics committee. Participation was voluntary and the
respondents could opt out of any phases of the study at any
time. All participants were fully informed about the project
and signed a written consent form before taking part in the
study. Patients’ and physicians’ identities were kept
18 Health Information Management Journal 45(1)
confidential throughout the process of data collection and
system usage.
Results
Participants’ demographic information
In total, 7 patients and 23 parents took part in the study. The
age range of patients was between 15 and 30 years, and

most of them were female (n ¼ 4, 57%). The age range of
parents, who took care of children aged under 15 years with
type 1 diabetes, was between 20 and 50 years, and the
highest frequency was related to mothers (n ¼ 18,
78.3%). Most of the endocrinologists who took part in this
study were men (n ¼ 9, 60%) and their age range was
between 31 and 58 years.
Required data elements and system capabilities
After data analysis, the data elements identified as ‘neces-
sary’ by at least 60% of the participants were selected to be
included in the application. For example, regarding blood
glucose control, all items were found necessary to be
included in the website (Table 1).
Interestingly, items, such as the contact number of a
patient’s relatives, patient’s address, place of birth, mar-
riage status, father’s name, and the identification number
were not found necessary by most of the participants. Table
2 shows the required data elements and capabilities of the
website found necessary by at least 60% of the participants.
Prototype

The prototype of the system was designed in accordance
with the results of the first phase. The method of prototyp-
ing has some advantages, such as reducing the time and the
cost of the design process, preparing an initial version of
the system for making modifications with low cost, higher
efficiency in the final version, and more compatibility with
the users’ requirements.
As the users of the application were patients or their
parents and endocrinologists, the system was designed for
both groups. The system was stand alone and all informa-
tion must be entered manually. At the time of the study,
there was no link between this system and other health
information systems, for example clinic health records.
However, apart from receiving advice from the endocrinol-
ogists, patients could use it as a diabetic patient’s logbook.
The first page of the system was a login page and included a
general description about the system, rules and regulations,
and some information about national diabetes associations.

New users had to click and complete a registration form
which included their name, surname, date of birth, sex,
telephone number, email address, username and password.
When completing the registration form, the type of user
was specified. After logging into the system, the user could
see the relevant pages based on the type of the user deter-
mined in the previous step.
Features for patients
The final version of the system included eight links for
patients: recording new data; editing profile; reading edu-
cational materials and information about how to manage
diabetes; viewing changes in the level of blood glucose and
insulin in a table and a graph; contacting the endocrinolo-
gists; contacting the website administrator; and changing a
password. To record new data, patients could choose a date
Development of
the website
Literature review and designing a
questionnaire for requirements

analysis
Requirements analysis
Patients (n=7)
Parents (n=23)
Physicians (n=15)
Designing the system prototype
Evaluation of the website using the
‘think aloud’ method
Patients (n=3), Physicians (n=2)
Evaluation of the website using the
usability testing method
Patients (n=5), Parents (n=5),
Physicians (n=5)
Website refinement
Website refinement
Planning to introduce
the website to other
endocrinology clinics
Figure 1. The research flow diagram.

to enter the level of blood glucose, insulin, and their activ-
ities manually. The level of blood glucose and activities
could be reported five times a day and the insulin rates
(NPH and regular) could be reported twice a day (Figure 2).
The educational material was developed based on the
needs assessment study conducted in the first phase. This
part was intentionally provided in a simple form, so that
children or adolescents with a low level of literacy could
understand it. To make it attractive, animations and images
were used in different parts, which included some informa-
tion about diabetes, how to control the level of blood glu-
cose, insulin types and the method of injection, a healthy
diet, diabetes complications, and suggested exercises and
activities.
Features for endocrinologists
For endocrinologists, the system included five links: view-
ing a list of patients who had updated their records or con-
tacted their physician; viewing patients’ blood glucose,

insulin rate and activities in a table along with full infor-
mation about the patient (Figure 3); viewing the graphs of
changes in blood glucose and insulin rate (Figure 4); pre-
scribing and medical advice; and changing a password.
Physicians could first log into the system whenever it
was convenient for them, and would see a list of their
patients, identifying those who had entered their recent
data. Next to the patient’s name, there was a link to show
further information and changes in the blood glucose, insu-
lin rate and activities in a table and a graph. Finally, phy-
sicians could see and answer questions asked by patients. In
addition, physicians could also be informed about new
messages via their email. Therefore, the system helped
them to monitor patients’ health status without visiting
them in the clinic, and they could supervise their patients
from a distance.
Usability testing
To ensure the system worked as intended and met users’

requirements, the usability of the system was tested using
the ‘think aloud’ method and a standard questionnaire
(QUIS). According to Lyles, Sarkar and Osborn (2014),
technology-delivered diabetes education and support inter-
ventions should be evaluated using standard usability test-
ing. To evaluate the usability of the initial design, the
prototype of the system was run on a PC in the clinic and
5 participants (3 patients and 2 physicians) were asked to
Table 1. Required data elements for blood glucose control.
Diabetes
self-management Questionnaire items Respondents Necessary %
Unnecessary %
Mean (%)
Necessary
Mean (%)
Unnecessary
Blood glucose
control
Recording blood glucose level Physicians (n ¼ 15) 15 (100) 0
100 0
Patients (n ¼ 7) 7 (100) 0
Parents (n ¼ 23) 23 (100) 0

Training on blood glucose
monitoring
Physicians (n ¼ 15) 15 (100) 0 98.5 1.5
Patients (n ¼ 7) 7 (100) 0
Parents (n ¼ 23) 22 (95.6) 1 (4.4)
Training on the use of a
glucometer
Physicians (n ¼ 15) 14 (93.3) 1 (6.7) 97.8 2.2
Patients (n ¼ 7) 7 (100) 0
Parents (n ¼ 23) 23 (100) 0
Table 2. Required data elements and features for the website.
Data group Data elements
Patient’s demographic information First name, last name, age,
sex, height, weight and contact number
Patient’s clinical information Last HbA1C hemoglobin, total
daily insulin injections, blood glucose test frequency (daily),
hypoglycemia episodes (weekly), hypoglycemic convulsion
frequency (monthly), number
of hospitalization, number of emergency visits (every 6
months), number of specialist
visits (in 6 months)
Diabetes self-
management
Blood glucose (BG) level Recording BG levels (five times a
day), training on BG monitoring and the use of a Glucometer
Insulin injection Time and the amount of insulin injection,
Insulin titration information, information about

different types of insulin, required actions in insulin overdose
Nutrition Nutritional information, necessary information about
the food components
Diabetes complications Information about controlling
hypo/hyperglycemic episodes, information about diabetic
convulsion, caring for foot, eye, kidney and other organs
Activity The amount of patient’s daily activities, type of
activities
Other required
information
Information about diabetes-related scientific associations,
endocrinology and metabolism
institutes and related clinics
Physicians’ supervision Checking BG values, BG testing
schedule for each patient, insulin injection dosing,
supervising patient’s diet, recommendations and medical
advices for patients
Required capabilities of the system Displaying date/time of data
entry, recording time of BG testing, displaying a graph of
insulin and BG level changes, displaying the patient’s previous
data (BG, insulin and
activity rate), tele-consultation with physician via e-mail
Figure 2. Features for patients – Reporting blood glucose,
insulin rate and activities.

Figure 3. Features for endocrinologists – Demonstration of
patients’ blood glucose, insulin rate and the amount of activities
in a table.
work with the system and explain their points of view. This
‘think aloud’ method helps the system designer to modify
the prototype based on the users’ needs and make it more
efficient. In this study, the verbal expression of users’
thoughts was recorded using a digital voice recorder and
each person used the system for about 30 minutes. For
example, patients suggested that the system should be able
to give a message registering successful data entry. They
were also interested in viewing a graph of changes in their
blood glucose and insulin rate, and wanted to know how to
contact the system administrator when they had a question
or suggestion about the system. Physicians suggested that
all messages sent by patients should include time and date,
and if a patient had just asked a question, it should be

highlighted in the list of patients. It is also important for
users to be able to change their passwords. Having modi-
fied the system based on the users’ perspectives, 15 users
were invited to attend another session in the clinic to work
with the system and to evaluate its usability using a stan-
dard questionnaire. In each session, only one participant
attended. The results of the usability testing of, and users’
satisfaction with, the system are presented in Table 3.
According to the results, the mean values for patients,
parents and physicians were between 7 and 9 in different
areas of assessment, indicating that the users were rela-
tively satisfied with the system. From the physicians’ point
of view, ‘terminology and system information’ (8.40 +
0.89), and from parents’ and patients’ point of view ‘overall
reaction to the software’ had the highest mean values. The
Figure 4. Features for endocrinologists – Changes in a patient’s
blood glucose.
Table 3. Usability testing of, and users’ satisfaction with, type 1
diabetes self-management website.
Mean + SD

Assessment areas
Mean + SD
(5 physicians)
Mean + SD
(5 patients)
Mean + SD
(5 parents)
Overall reaction to
the software
8.20 + 0.83 8.40 + 0.89 8.00 + 1.00
Screen design and
layout
7.90 + 1.07 8.20 + 0.83 7.80 + 0.83
Terminology and
system information
8.40 + 0.89 7.40 + 0.54 7.80 + 0.83
Learning 7.80 + 0.83 7.20 + 0.83 7.60 + 1.14
System capabilities 7.60 + 1.14 8.00 + 1.00 7.80 + 0.83
lowest mean values were related to the system capabilities
(7.60 + 1.14) from physicians’ perspectives and the sys-

tem learnability (7.20 + 0.83) from patients’ and parents’
perspectives (7.60 + 1.14).
Discussion
The use of the Internet and web-based systems have many
advantages for patients and healthcare providers. These
systems can help patients to receive online education and
to ask questions, for example, by sending emails. Health-
care providers can also use web-based systems to obtain
information about patients’ health status and to set proper
care plans for them without any concerns about distance
and time limit (Lee at al. 2007). Another benefit of such an
intervention is to increase patient engagement, which in
turn can help to improve quality of care, especially primary
care (Dubenske et al. 2010). In diabetes, like many other
chronic diseases, many problems faced by patients can
potentially be prevented by an organised care plan, educa-
tion, and timely supervision (Hee-Sung 2007). As a result, a
web-based application can be a useful tool to control their
health status in a timely manner (Wantland 2004; Montori

et al. 2004). In a study conducted by Lee et al. (2007), a
web-based self-management education system was devel-
oped and its effectiveness was evaluated. Their study
showed that web-based education could help patients to
control their blood glucose level and could improve their
diabetes self-management skills. Lee et al. (2007) also
introduced this type of education as the best tool for pro-
viding continuing care.
Generally, self-management of diabetes is influenced by
a number of individual, social, and clinical factors and each
individual may have unique requirements and challenges to
the appropriate management of their own care. Therefore,
personalised self-management interventions are needed to
meet different individuals’ requirements (Cassimatis,
Kavanagh & Smith 2014). While in some studies theoreti-
cal frameworks of self-care and self-efficacy have been
used to design a website for self-management (Yu, Parsons,
Hall et al. 2014), in the current study, users’ requirements

were initially investigated in order to be able to design a
useful system. The results of the first phase showed that
most of the data elements suggested by the national and
international diabetes associations were found necessary by
the users (patients, parents and physicians) and recom-
mended to be included in the system. Similarly, the per-
spectives of patients, parents, and physicians showed close
correspondence regarding the required capabilities of the
system.
According to Dougherty et al. (2014), telemedicine can
be used effectively to promote the health status of adoles-
cents with diabetes. In the current study, the researchers
aimed to develop a telemedicine application for patients
and physicians to be able to communicate electronically.
Therefore, the system features were not limited to educa-
tional resources. In a similar study, Jennings et al. (2009)
developed a virtual clinic to facilitate self-management of
diabetes for patients who used an insulin pump. Using this

system, patients were able to communicate with diabetes
specialists who were not necessarily their own physicians.
In addition, the communication sessions were conducted
via the site’s asynchronous discussion forums. However,
in the current study, users were able to consult their own
physicians. As the website was password protected, each
physician was able to review their own patients’ informa-
tion, and as a result, patients’ privacy and information con-
fidentiality were respected.
As noted previously, only information related to type 1
diabetes could be entered into the system and there was no
link between this system and other patient heath records;
therefore, it cannot be considered as a personal health
record (PHR). The PHR is owned, controlled, and managed
by the patients and is not limited to operating systems or
devices. Moreover, the interoperability of data between
diverse systems is one of the main characteristics of PHR
(Kahn, Aulakh & Bosworth 2009). As a result, apart from

being a telemedicine application, the system designed in
this study can be considered an electronic logbook to help
patients with type 1 diabetes to keep an online record of
their health status.
The literature review indicated that in some studies
related to the use of web-based systems for diabetes self-
management, the systems were not evaluated by the users
(Roek et al. 2009; Ko et al. 2010; Lyles, Sarkar & Osborn
2014). However, in the current study the system was eval-
uated by patients, parents and physicians. Findings indi-
cated that most users were satisfied with the system and
the overall reaction was quite positive, which showed it had
been accepted in the initial stage. Similarly, Lee et al.
(2007) used a questionnaire to evaluate users’ satisfaction
with their system. These researchers found that 45% of
users were satisfied with the interface of the system, 40%
of users were neutral and 15% had negative views.
According to Debussche et al. (2009), providing educa-

tion to enable patients to self-manage their disease is still a
challenge in some developing countries, and in particular,
more field study is needed to address the continued require-
ments and demands of individuals with chronic diseases
like diabetes (Shrivastava, Shrivastava & Ramasamy
2013). It is possible to introduce web-based systems to
those countries which have affordable internet access. In
developing countries, due to the shortage of specialists and
healthcare resources in different geographical areas,
patients have to be in a long waiting list to visit a physician.
The resulting delay in receiving treatment or obtaining
advice from a physician could affect a patients’ condition
(Debussche et al 2009). However, the use of web-based
systems can facilitate access to healthcare services at the
point of need. Furthermore, the accessibility of information
about the patients’ blood glucose, insulin, and physical
activities can help physicians to make better decisions
regarding the patient’s condition.

Implementing such systems in developing countries
might engender some challenges (Alajmi, Almansour &
Househ_2013). For example, it might be difficult to con-
vince specialists and patients to use the system as a replace-
ment for a face-to-face consultation if, for example, the
specialists are busy visiting patients and may not be able to
spend time using the system (Khanal et al. 2015). It seems
that receiving adequate support from the national diabetes
associations can help to introduce the system’s benefits,
and this would facilitate the process of system implemen-
tation and usage. At the time of this study, it was not clear
to what extent the system will be adopted by patients and
their physicians. Therefore, after introducing the system to
other clinics, further research is needed to investigate users’
attitudes and the likelihood of usage in a bigger sample
size.

Limitations
Although it was the first time in this country that such a
web-based system was designed to support patients with
diabetes, the current study had some limitations. First, the
number of patients and physicians recruited in the study
was limited. As the researchers aimed to develop a new
system, rather than to extrapolate the results to a larger
population, it seems that using such a small group of parti-
cipants does not necessarily influence the system design
process. In fact, the main aim of recruitment was to involve
a number of potential users to be able to design a useful
system specifically for them.
Due to the time and resource constraints, the researchers
focused on providing a system specifically for patients with
type 1 diabetes. As paediatric patients with type 1 diabetes
and their parents might be less experienced in regard to
self-management activities, the system was designed to
be as simple as possible in order to support this group of

users in particular. However, the application could be
expanded by adding more relevant information for other
types of diabetes. The system could also be improved by
adding more information about patients’ diet and calorie
intake.
In terms of the usability testing, the application needs to
be evaluated on a larger scale (by patients, parents and
physicians) to show how usable it is from users’ perspec-
tives more generally. In this case, the researchers would
require an opportunity to improve the system by introdu-
cing it to other clinics or diabetes associations. In addition,
the clinical effectiveness of this system was not evaluated
in this study due to resource restrictions. Conducting pre/
post-implementation studies would help to evaluate the
impact of the system on the health status of patients with
type 1 diabetes.
Conclusion
Although a large part of caring for those with chronic dis-

eases such as diabetes is undertaken by the patients them-
selves or their carers, the use of information technology is
recommended as an effective tool to facilitate patients’
access to their health information and to improve their
self-management skills. The application designed in the
current study was an example of a web-based system that
could be easily be made available by connecting to the
Internet. For example, patients or their carers could use it
as a log book by entering the level of blood glucose and
insulin doses on a regular basis. They could also learn more
about the disease and self-management skills by reading
the educational part of the system. Physicians could use
the system at any time convenient to them to support
patients by giving medical advice. The significance of this
research was the simplicity and the transparency of the
system developed in terms of the contents, meaning that
it was useable even by children and others who were able to
use the Internet yet had low literacy skills. Moreover, the

use of the Internet made it available and affordable to dif-
ferent age groups, thus system developers and users might
not be faced by major financial or technical obstacles in
setting up such a scheme. Further research is needed to
evaluate the usability of the system and to report its effec-
tiveness in terms of improving self-management activities.
Funding
The author(s) disclosed receipt of the following financial
support
for the research, authorship, and/or publication of this article:
This
work was supported by Iran University of Medical Sciences
[Grant Number 592]. The authors declare that they have no con-
flict of interest.
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Copyright of Health Information Management Journal is the
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ELECTRONIC VISIT PROGRAM DESCRIPTIVE RESEARCH
REPORTS
AM J HEALTH-SYST PHARM | VOLUME 75 | NUMBER 12 |
JUNE 15, 2018 901
Implementation and evaluation of a pharmacist-led
electronic visit program for diabetes and anticoagulation
care in a patient-centered medical home
Emily M. Hawes, Pharm.D., BCPS,
CPP, Department of Family Medicine,
UNC School of Medicine, Chapel Hill, NC,
and UNC Eshelman School of Pharmacy,
Chapel Hill, NC.
Erika Lambert, Pharm.D., CPP, BCPS,
UNC Medical Center, Chapel Hill, NC,
and UNC Eshelman School of Pharmacy,
Chapel Hill, NC.
Alfred Reid, M.A., Department of Family
Medicine, UNC School of Medicine,

Chapel Hill, NC.
Gretchen Tong, Pharm.D., CPP, UNC
Family Medicine Center, Chapel Hill, NC,
and Department of Family Medicine, UNC
School of Medicine, Chapel Hill, NC.
Mark Gwynne, D.O., UNC Health
Alliance, Chapel Hill, NC, and Department
of Family Medicine, UNC School of
Medicine, Chapel Hill, NC.
Address correspondence to Dr. Hawes
([email protected]).
Copyright © 2018, American Society of
Health-System Pharmacists, Inc. All rights
reserved. 1079-2082/18/0602-0901.
DOI 10.2146/ajhp170174
Purpose. Results of a study evaluating quality-of-care,
financial, and pa-
tient satisfaction outcomes of pharmacist-conducted telehealth
visits for
diabetes management and warfarin monitoring are reported.
Methods. A retrospective pre–post study was conducted to
determine
the impact of an electronic visit (e-visit) program targeting 2
groups of
outpatients: adults with uncontrolled diabetes and warfarin-
treated
adults performing patient self-testing (PST) for monitoring of
International
Normalized Ratio (INR) values.

Results. A total of 36 patients participated in the e-visit
program during
the 2-year study period. Among warfarin-treated patients, the
percentage
of INR values in the desired range increased relative to
preenrollment val-
ues (from 62.5% to 72.7%, p = 0.07), and the frequency of
extreme INR
values (values of <1.5 or >5.0) decreased (from 4.8% to 0.01%,
p = 0.01);
the margin per patient was $300 during the first year and $191
annually
thereafter. In the diabetes group, a decrease from baseline in
glycosylated
hemoglobin values of 3.4 percentage points was observed at 5.7
months
after enrollment (p < 0.001), with significant improvements in
frequencies
of statin use, aspirin use, and blood pressure control; the margin
was $100
per patient. The overall median patient satisfaction survey score
was 39
of 40.
Conclusion. An online e-visit model for warfarin monitoring
was an effi-
cient, safe, and cost-effective method for implementing PST.
Pharmacist-
led management of diabetes through e-visits, often in
combination with
in-person visits, generated revenue while significantly
improving clinical
outcomes.
Keywords: anticoagulation, diabetes, electronic visits, patient

self-testing,
pharmacist, telemedicine, warfarin
Am J Health-Syst Pharm. 2018; 75:901-10
Telemedicine, defined as “use of electronic information and
com-
munication technologies to provide
and support health care when dis-
tance separates participants,” has
introduced novel ways for patients
and providers to interact.1 It encom-
passes exchange of medical infor-
mation via electronic communica-
tion (e.g., live videoconferencing,
store-and-forward imaging, Internet
communication).
Given its potential to yield time and
cost savings, telemedicine technology
has the capability to grow beyond ini-
tial implementations providing access
to remote locations.2,3 Patient portals
within the electronic medical record
(EMR) are an example of telemedicine
technology that has increased patient
access to medical records through se-
cure, online portals. Patients can view
laboratory results, request medica-
tion refills or appointments, and seek
mailto:emily_hawes%40med.unc.edu?subject=
DESCRIPTIVE RESEARCH REPORTS ELECTRONIC VISIT
PROGRAM

902 AM J HEALTH-SYST PHARM | VOLUME 75 | NUMBER
12 | JUNE 15, 2018
medical advice on a platform that is
efficient and convenient.
Electronic visits (e-visits), or com-
munication between patients and
providers through a secured electron-
ic channel, are gaining popularity for
nonurgent medical services, including
chronic disease management. E-visits
do not require that a patient travel to
a site to interact with a medical pro-
vider in person or through clinical
video technology (CVT) and can occur
anywhere with a computer and In-
ternet access. In current e-visit mod-
els, patients complete a standardized
questionnaire, and providers respond
within 12–24 hours with instructions
that may include prescriptions or re-
ferrals.4,5 E-visits offer an alternative
to telephone consultations, which
are frequently nonreimbursable, and
in-office visits. E-visits often cost less
than office visits and entail minimal
to no indirect cost to patients.6,7 Data
on e-visits are limited, and most perti-
nent studies we identified focused on
e-visits conducted by physicians and
advanced provider practitioners not
including pharmacists.4-8
Pharmacist-managed anticoagula-

tion services have been demonstrated
to yield positive outcomes with re-
spect to safety, effectiveness, and cost
savings. Several studies have indicated
that pharmacist-led anticoagulation
services in a variety of settings, in-
cluding services provided via CVT, can
achieve significantly better control of
International Normalized Ratio (INR)
values than can be achieved with usu-
al care.9-16 In recent years, increased
attention has surrounded the concept
of patient self-testing (PST) for anti-
coagulation monitoring. Compared
with standard laboratory monitoring,
home INR monitoring has been shown
to enhance quality of life and patient
satisfaction, improve INR control, and
reduce mortality and thromboembo-
lism occurrence, with no increased
risk of major bleeding events.17-32
Several studies have shown that
pharmacist care improves glycosylated
hemoglobin (HbA
1c
) control, blood
pressure control, and adherence to
KEY POINTS
• Results of a pre–post study
indicated that a pharmacist-led
electronic visit (e-visit) pro-

gram for patients with diabetes
and warfarin-treated patients
conducting patient self-testing
(PST) resulted in significant
improvements in International
Normalized Ratio and glycosyl-
ated hemoglobin values, a posi-
tive financial margin, and highly
satisfied patients.
• An e-visit model can be a safe,
efficient, and cost-effective
method for implementing PST
and an effective follow-up alter-
native to in-person visits or tele-
phone consultations in diabetes
management.
• The study was the first to
evaluate chronic disease man-
agement through pharmacist-
conducted e-visits.
primary prevention therapies and has
cost benefits.33-38 Additionally, diabetes
management with various telemedi-
cine interventions has been shown
to yield significant improvements in
HbA
1c
control relative to usual care, but
the evaluated analyses did not include
services conducted by pharmacists.39,40

In North Carolina, clinical phar-
macist practitioners (CPPs) have a
long history of providing direct pa-
tient care for chronic disease state
management by initiating, changing,
or discontinuing pharmacotherapy,
ordering laboratory tests, and billing
for services. CPPs have the skill set
to offer anticoagulation and diabetes
management services as an e-visit.41
Many anticoagulation clinics do not
routinely provide home INR manage-
ment services to patients due to the
high time burden and low reimburse-
ment rates.42-44 However, a systematic
online INR monitoring program in-
volving e-visits by a CPP may be a so-
lution for providing quality warfarin
management in a more cost-effective
manner. Likewise, offering e-visits
as a follow-up option for interested
patients with uncontrolled diabetes
may be efficient, convenient, and ef-
fective in enhancing diabetes control.
Thus, a CPP-led e-visit program was
implemented for warfarin-treated pa-
tients conducting PST and for patients
with uncontrolled diabetes at a family
medicine center (FMC). To our knowl-
edge, there is no literature evaluating
e-visits conducted by pharmacists for
chronic disease state management.
The objective of the study described
here was to evaluate the impact of a
pharmacist-led e-visit program for an-

ticoagulation and diabetes manage-
ment on clinical outcomes, financial
outcomes, and patient satisfaction.
Methods
Practice setting. A pre–post
retrospective and observational
study was conducted at the FMC, a
physician-owned academic medical
center that is part of a large health
system in North Carolina. The FMC
annually serves approximately 19,000
patients through 56,000 visits. The
FMC is recognized as a National Com-
mittee for Quality Assurance level
3 patient-centered medical home
(PCMH) that provides full-scope pri-
mary care. A CPP is a licensed phar-
macist who has met specific criteria
specified by the North Carolina Medi-
cal Board and North Carolina Board
of Pharmacy and is authorized to pro-
vide drug therapy management under
the supervision of a licensed physi-
cian. A CPP’s scope of care is specific
to each practice site and guided by
a protocol outlining disease states
for which the CPP can prescribe and
disease-specific drug therapy.41 Within
the FMC, 2 CPPs provide direct pa-
tient care through in-person visits in
the pharmacotherapy clinic. Patients
are referred to the pharmacotherapy
clinic by FMC practitioners for en-
hanced management of a variety of

chronic diseases. The FMC uses an
REPORTS
JUNE 15, 2018 903
Epic EMR and the MyChart patient
portal (both from Epic Systems Corpo-
ration, Verona, WI). MyChart provides
patients access to their medical rec-
ords and enables secure 2-way mes-
saging between patients and provid-
ers. The MyChart messaging feature
is the mode of secure communication
used for e-visits between patients and
CPPs. An Epic smartphone applica-
tion is also available for download.
Program development and de-
scription. Anticoagulation. Prior to
2014, individual primary care provid-
ers (PCPs) at the FMC had provided
home INR management on a case-by-
case basis, but this practice was dis-
couraged by clinic administrators due
to low clinic revenue, a high time bur-
den, and logistic issues. For example,
there were instances when patients
with home INR monitoring devices
had out-of-range INRs but their PCP
was unavailable, requiring that on-
call physicians address those situa-

tions. Furthermore, PCPs attempted
to use Current Procedural Terminol-
ogy (CPT) code G0250 for billing,
but this yielded approximately $9 in
reimbursement per encounter and
required evaluation and documenta-
tion of 4 INR test results.45 In response
to frequent patient requests for home
INR warfarin management, the phar-
macotherapy clinic run by CPPs began
exploring options to make the process
more efficient, safe, and cost-effective.
Hence, the decision was made to pi-
lot test an online e-visit monitoring
model.
In 2014, the pharmacotherapy
clinic began offering the current CPP-
managed online home INR monitor-
ing program on a rolling basis to pa-
tients who were eligible for PST and
agreed to the program’s expectations.
Patients whose condition was stable,
who were adherent to warfarin ther-
apy for at least 3 months, who were
emotionally, mentally, physically,
and financially able to perform PST,
and who had MyChart access were
eligible. Once approved, the home
monitoring device and supplies were
shipped to the FMC, and a CPP con-
ducted initial in-person training on
use of the device, the CoaguChek XS
system (Roche Diagnostics, Indianap-
olis, IN). The training included dem-

onstration of use and care of the INR
monitor, collection of a blood sample,
education regarding the process of
reporting home INR test results, and
documentation of the patient’s abil-
ity to perform testing. Once training
was completed, the CPP billed for ser-
vices using CPT code G0248. Ongoing
testing supplies were provided to the
patient by the manufacturer of the
CoaguChek XS system. Subsequent
visits were conducted through Epic’s
MyChart messaging portal. Every 2
weeks on a predetermined day, the
patient checked his or her INR, sub-
mitted the result online or by phone to
Roche, and electronically sent a com-
pleted questionnaire (modified from
Bussey and Bussey18) and INR data in
a MyChart message to the CPP by 1
p.m. The CPP scheduled an afternoon
pharmacotherapy clinic appointment
(a 30-minute session) weekly to com-
plete the PST e-visits. Via MyChart
messaging, the CPP then responded to
the patient with a management plan,
including warfarin dosing and lifestyle
adjustments, and provided education,
ordered laboratory tests, and/or sent
prescriptions to the pharmacy. The
CPP also reviewed the Roche Coagu-
Chek Link Portal website to confirm
that the patient had reported the INR
data. Any patient with a home INR
of >4.5 was required to visit the FMC
for venipuncture INR verification and

evaluation by a CPP or another pro-
vider. CPPs submitted reimbursement
claims via “incident-to” billing (i.e.,
billing for services provided incident
to, or in conjunction with, those pro-
vided by the supervising physician)
using CPT code 99444 for 1 electronic
encounter each month, as agreed
upon during enrollment.
Diabetes. In January 2015, the
e-visit program was expanded to in-
clude CPP-conducted diabetes man-
agement for interested patients. Pa-
tients were recruited during CPP visits
in the pharmacotherapy clinic, by re-
ferral from FMC providers, or through
EMR reporting to identify patients
with an HbA
1c
concentration of >9%.
Patients were eligible for participation
if they needed pharmacist-enhanced
diabetes care, received primary care at
the FMC, and agreed to online evalu-
ation visits (billed using CPT code
99444) and use of MyChart. Eligible
patients were initially enrolled by the
CPP during a telephone encounter or
ideally during an in-person visit in the
pharmacotherapy clinic to establish
a relationship, to allow assessment
of health literacy and understanding

of diabetes, and to provide baseline
disease state education. Patients who
needed additional follow-up were
given the option of in-person visits,
e-visits, or a combination based on
patient preference. Insurance cover-
age and expected copayment were
evaluated prior to patient enrollment
and communicated to the patient. On
a predetermined date or based on pa-
tient inquiry, the CPP sent the patient
an individualized questionnaire to
answer via MyChart. The CPP often
responded with additional questions,
resulting in back-and-forth messages
between the patient and the CPP be-
fore the conclusion of the encounter.
Some patients receiving insulin used
the “glucose flowsheet” available in
Epic to report blood glucose read-
ings and insulin dosing in a chart for-
mat. At the end of the encounter, the
CPP provided a management plan
including medication adjustments
and lifestyle modifications, provided
education, ordered laboratory tests,
sent prescriptions, and developed a
follow-up strategy. After the patient
indicated understanding and agree-
ment, the CPP wrote a note, complet-
ed the encounter, and billed for the
e-visit. One CPP conducted e-visits
for both anticoagulation and diabetes
management.
Study design. The study, ap-

proved by the university’s institutional
review board, was a single-center,
retrospective, observational pre–post
study including a patient satisfaction
survey. Patients were included if they
PROGRAM
12 | JUNE 15, 2018
were at least 18 years of age, received
primary care at the FMC, and par-
ticipated in at least 1 pharmacist-led
e-visit via MyChart from 2014 through
2016. All patients were asked to partic-
ipate in a survey evaluating satisfac-
tion with the e-visit program over the
phone or through a MyChart message.
Statistical analysis. Categorical
variables were represented as frequen-
cies and percentages, and continuous
variables were expressed as mean
± S.D. or median with interquartile
range (IQR) values. For calculating the
statistical significance of postimple-
mentation versus preimplementation
data, nominal variables were analyzed
via chi-square testing, and continu-
ous values were analyzed using ei-
ther a paired Student’s t test for nor-

mally distributed data or Wilcoxon’s
matched-pairs signed rank test for
non-normally distributed data. The a
priori level of significance was <0.05.
Assumptions used in the financial
analysis appear in the appendix.
Outcomes. The primary objective
of the study was to assess the effect of
a pharmacist-led e-visit program on
clinical outcomes, financial indica-
tors, and patient satisfaction. For the
anticoagulation group, the primary
outcome was the difference in the
proportions of visits associated with
an INR value in the target range of
2.0–3.0 before and after enrollment.
For the diabetes group, the primary
outcome was the difference in mean
HbA
1c
values before and after enroll-
ment. The secondary endpoint for
the anticoagulation group was the
difference in the occurrence of ex-
treme INRs (values of <1.5 and >5.0)
before and after enrollment and the
frequency of adverse events, defined
as recurrent embolization or bleed-
ing requiring medical intervention,
in the postenrollment phase. Second-
ary endpoints for the diabetes group
included changes in the proportions

of patients who had HbA
1c
values of
<8% and <7%, had controlled blood
pressure, and were taking aspirin or
statin therapy (if indicated), as well
as antidiabetic medication utilization
and frequency of hypoglycemia, in
the postenrollment phase. Additional
outcomes for both groups included
numbers and types of visits, time spent
by the CPP on e-visits, reimbursement
outcomes, and patient-reported sat-
isfaction with the e-visit program. As-
sumptions for our financial analysis
included overhead costs, with calcula-
tions based on average values in our
practice and Medicare rates for ap-
propriate billing codes at the time of
the study. A modified version of the
Satisfaction with Pharmacist (SWiP)
scale was used to assess patient sat-
isfaction with the e-visit program
and was administered by a pharmacy
resident.46 The survey consisted of 7
questions that were modified from the
SWiP scale for use in the study along
with 3 additional questions specific
to the e-visit program. The maximum
score of 40 indicated the highest level
of satisfaction.
Results

A total of 36 patients participated
in e-visits. Nine patients were en-
rolled for warfarin management, and
29 were enrolled for diabetes man-
agement. Two patients were enrolled
for both anticoagulation and diabe-
tes management. Demographic and
outcomes data for enrolled patients
are summarized in Tables 1 and 2. We
found no relationship between any
Table 1. Baseline Patient Demographicsa
Variable Value
Diabetes group (n = 29)
Mean ± S.D. age (yr) 52.1 ± 7.8
No. (%) women 19 (66)
Race, no. (%)
Black or African-American 24 (83)
White or Caucasian 5 (17)
Mean ± S.D. HbA
1c
concentration (%) 10.9 ± 1.9
No. (%) with controlled blood pressureb 15 (52)
No. (%) receiving aspirinc 18 (86)

No. (%) receiving statind 23 (82)
Anticoagulation group (n = 9)
Mean ± S.D. age (yr) 54.3 ± 12.1
No. (%) women 5 (56)
Race, no. (%)
Black or African-American 0
White or Caucasian 9 (100)
Indication for anticoagulation with warfarin, no. (%)
Atrial fibrillation 2 (22)
Aortic valve replacement 2 (22)
Venous thromboembolism 5 (56)
Fraction (%) encounters associated with target INR 65/104 (63)
aHbA
1c
= glycosylated hemoglobin, INR = International Normalized
Ratio.
bDefined as blood pressure values of <140/90 mm Hg in
accordance with 2017 American
Diabetes Association (ADA) guidelines.
cOnly 21 patients met 2017 ADA guideline criteria for aspirin
therapy for primary or second-
ary prevention or did not have a contraindication.

dOut of 28 patients, 1 patient had a contraindication to statin
therapy.
REPORTS
JUNE 15, 2018 905
evaluated outcome and patient age or
sex, overall number of visits, or pro-
portion of encounters conducted via
e-visits.
Anticoagulation program. The
mean duration of e-visit participation
for anticoagulation patients was 10.4
months (median, 12 months; range,
4–16 months). Seven of the 9 patients
were still receiving INR management
via e-visits with a CPP at the time of
data collection for the study. Two pa-
tients discontinued due to relocating
out of state. Prior to enrollment, pa-
tients were receiving warfarin man-
agement via in-person clinic visits
with a CPP. INR control improved after
e-visit participation (Table 2). Fur-
thermore, no patients experienced an
adverse event related to recurrent em-
bolism or bleeding requiring medical
intervention while managed through

e-visits.
Diabetes program. The median
length of patient participation in the
diabetes e-visit program was 4 months
(range, 1–12 months). The majority of
patients (n = 27) were enrolled during
in-person visits, while 2 patients were
enrolled by telephone. After enroll-
ment, 19 patients (66%) participated
in only e-visits, while the others had
a combination of visit types. HbA
1c
was measured at a mean ± S.D. of 5.7
± 4.5 months after enrollment (me-
dian, 4 months; range, 1–19 months;
IQR, 2.5–8.5 months). The mean HbA
1c
value significantly decreased after
participation (Table 2). After enroll-
ment, 20 patients (69%) achieved an
HbA
1c
value of <8%; of those patients,
9 (45%) achieved an HbA
1c
value of

<7%. E-visit participation increased
the percentage of patients with con-
trolled blood pressure, as well as the
percentage receiving statin and aspir-
in therapy when indicated. The inten-
sity of statin therapy also improved,
with an increase in use of moderate-
to high-intensity doses and a decrease
in use of low-intensity doses.
There was no significant change
in the mean number of antidiabetic
agents prescribed (2.0 before enroll-
ment versus 2.1 after enrollment);
however, there were differences in
the types of antidiabetic agents used
(Table 2). Most patients who were
treated with metformin or basal insu-
lin were maintained on those thera-
Table 2. Primary and Secondary Outcomes Before and After
Program Initiationa
Variable Before Program After Program p
Anticoagulation group (n = 9)
Fraction (%) INR values of 2.0–3.0 65/104 (63) 144/198 (73)
0.07
Fraction (%) INR values of <1.5 or >5.0 5/104 (5) 1/198 (0.5)
0.01
Diabetes group (n = 29)

Mean ± S.D. HbA
1c
concentration (%) 10.9 ± 1.9 7.5 ± 1.0 <0.0001
No. (%) patients with HbA
1c
concentration of <8% 1 (3) 20 (69) <0.0001
No. (%) patients with HbA
1c
concentration of <7% 0 9 (31) 0.0002
No. (%) patients with controlled blood pressure 15 (52) 27 (93)
<0.001
No. (%) patients receiving aspirin 18 (86) 21 (100) 0.07
No. (%) patients receiving statin therapyb 23 (82) 28 (100) 0.06
Low-intensity 3 (13) 0 0.23
Moderate-intensity 10 (44) 16 (57) 0.19
High-intensity 10 (44) 12 (44) 0.79
Mean ± S.D. no. antidiabetic agents per patient 2.0 ± 0.8 2.1 ±
0.6 0.59
No. (%) patients receiving antidiabetic agent
Metformin 24 (83) 25 (86) >0.99
Sulfonylurea 13 (45) 4 (14) 0.2

DPP-IV inhibitor 2 (7) 2 (7) >0.99
Basal insulin 13 (45) 12 (41) >0.99
Bolus insulin 2 (7) 3 (10) >0.99
Mixed insulin 0 3 (10) 0.24
GLP-1 agonist 1 (3) 12 (41) <0.0001
aINR = International Normalized Ratio, HbA
1c
= glycosylated hemoglobin, DPP-IV = dipeptidyl peptidase 4,
GLP-1 = glucagon-like peptide 1.
bAll enrolled patients were prescribed or switched to a
moderate- or high-intensity statin therapy, as recommended by
the 2013 American College
of Cardiology–American Heart Association guidelines.
PROGRAM
12 | JUNE 15, 2018
pies. Fewer patients remained on
a sulfonylurea, and more patients
were initiated on a glucagon-like
peptide-1 (GLP-1) receptor agonist
during enrollment. Five patients
(17%) reported at least 1 episode of
hypoglycemia during e-visit partici-

pation, but none required emergent
medical attention.
Two patients receiving diabetes
care through e-visits had uncon-
trolled gout prior to enrollment. By
initiating and adjusting allopurinol
therapy, the CPP reduced gout flares
by gradually decreasing uric acid con-
centrations to a target range (from 9.3
to 5.4 mg/dL and from 9.9 to 4.9 mg/
dL in the 2 patients, respectively).
Encounters, clinical time, and
billing. The CPP reported that pa-
tient care responsibilities (including
MyChart messaging with the patient,
billing, sending prescriptions, and
note documentation) for each e-visit
were completed in 5–10 minutes for
warfarin e-visits and 10–20 minutes for
diabetes e-visits. Traditional in-person
pharmacotherapy clinic appointments
are allotted a 30-minute time frame.
Each week the CPP blocked out 30
minutes to conduct a single pharma-
cotherapy session covering an aver-
age of 4.5 home INR monitoring pa-
tients, which equated to 6.7 minutes
per e-visit.
Services were provided and
incident-to billing was conducted in
conjunction with a supervising phy-
Table 3. Financial Outcomes

Anticoagulation Program
Variable Year 1
After Year
1
Diabetes
Program
Clinical pharmacist
practitioner time (hr/mo)
2.1 plus 13.5 for
initial training
sessions
2.1 38
No. patients/mo 9 9 29
Median revenue per patient ($) 44/mo 28/mo 43/mo (172 total)
Cost of care per patient ($) 19/mo 12/mo 18/mo (72 total)
Margin per patient ($)a 25/mo 16/mo 25/mo (100 total)
aBased on a total of 2.4 e-visits and 1.4 in-person visits over a
4-month duration.
sician, who cosigned the encounter
documents. Reimbursement rates were
similar to the published North Caro-
lina Medicare Fee Schedule rates.45
Table 3 summarizes the findings of the
financial analysis.

At the time of data collection, the 9
patients in the anticoagulation group
had participated in a total of 198 elec-
tronic encounters from 2014 through
2016. The patients were enrolled on
a rolling basis. CPT code G0248 was
billed for each patient once after train-
ing and documentation. E-visits were
billed once monthly, representing 48%
of all electronic encounters during the
study period and resulting in billing of
12 e-visits per patient using CPT code
99444 annually.
In the diabetes group, at the time
of data collection patients had par-
ticipated in a total of 69 e-visits and
41 in-person visits after enrolling, for
a mean of 2.4 e-visits (range, 1–13 vis-
its) and a mean of 1.4 in-person vis-
its (range, 0–4 visits) with a CPP. All
e-visits were billed using CPT code
99444, and the in-person visits were
billed according to the level of ser-
vice (codes 99211–99214, with code
99213 typically used). With the use
of code 99213 reimbursement rates
for in-person visits and code 99444
rates for e-visits, the total revenue for
managing the 29 patients was close to
$5,000.
All study patients were insured. Al-
though coverage for e-visits varied by
insurance carrier, patients were more

commonly covered by private insur-
ance companies versus government-
funded insurance (e.g., Tricare, North
Carolina Medicaid, Medicare Part A
or Part B, federal employee plans). All
study patients had insurance plans
that covered CPT code 99444, which
included the following plans: BCBS
Blue Options/PPO/ADV, BCBS Blue
Care HMO, BCBS Blue Value, Cov-
entry Wellpath–Coventry Healthcare,
Humana Medicare Adv, North Caro-
lina State Health Plan, UMR, Unicare
Commercial–Unicare Medicare Supp,
United Healthcare, and United Health-
care Medicare Adv.
Patient satisfaction. Nineteen
patients (53%) participated in the vol-
untary survey (Table 4). The median
score was 39 out of 40 points, indicat-
ing a high level of satisfaction. Patients
reported the highest level of satisfac-
tion in response to the questions relat-
ed to the e-visit practice model (ques-
tions 8–10).
Discussion
The goal of the study was to evalu-
ate the impact of a pharmacist-led
e-visit program on clinical outcomes,
financial indicators, and patient satis-
faction. CPP use of e-visit telemedicine
technologies to deliver care resulted in
significantly improved INR and HbA

1c
control for patients who participated
in anticoagulation and diabetes man-
agement, respectively. The program
improved clinical care quality and
financially resulted in a net positive
margin, and patients reported high
levels of satisfaction. To our knowl-
edge, ours was the first study to evalu-
ate chronic disease management by a
pharmacist through e-visits.
Most studies addressing a phar-
macist’s role in direct chronic disease
management within a PCMH using
telemedicine were conducted within
the Department of Veterans Affairs
healthcare system and involved the
use of live CVT.16,47-49 Our study ex-
panded on previous findings regard-
ing real-time telehealth technology
by including a novel e-visit model,
REPORTS
JUNE 15, 2018 907
with nonurgent secure messaging, in
a PCMH at a physician-owned aca-

demic FMC.16,47
No patients in the warfarin PST
group experienced an embolic or
bleeding event, and the percentage
of extreme INR values significantly
decreased after program enrollment.
Prior to e-visit participation, warfarin
therapy was managed in the CPP-led
pharmacotherapy clinic. After pro-
gram implementation, the percent-
age of INRs within the target range
increased, albeit nonsignificantly, by
about 10%. This finding was consis-
tent with those of other studies com-
paring standard in-person antico-
agulation management via PST with
Internet-based feedback.17,23-29 In our
study the prescribed INR monitoring
frequency was every 2 weeks, which
varied from the intervals in most PST
studies, which involved weekly moni-
toring. This frequency was set to re-
duce providers’ time burden and limit
out-of-pocket costs that patients in-
cur with increased testing frequency.
Of note, the quality of warfarin man-
agement in our study was like that in
studies in which PST occurred more
frequently.17-19,24,26,28,30-32 Despite dem-
onstrated effectiveness, PST is often
not implemented due to high pro-
vider time demands and limited rev-
enue.42-44 By using e-visit billing and
systematic online secure messaging,
the provider time was decreased to a

mean of 14 minutes monthly, yielding
a return of almost $30 for that time in
addition to improved quality.
In the diabetes management
group, our study demonstrated a sig-
nificant mean HbA
1c
reduction of 3.4%
through use of e-visits conducted by
a CPP. This finding was consistent
with findings in previously published
analyses evaluating diabetes man-
agement with various telemedicine
technologies; however, in our study a
CPP directed care.39,40 Only 9 patients
(31%) had achieved a target HbA
1c
value of <7% at the time of data col-
lection. Of note, HbA
1c
was measured
less than 3 months after enrollment
in 7 patients. Our findings are con-
sistent with results reported with
pharmacist-conducted diabetes man-
agement via CVT.46 E-visits are argu-
ably even more convenient than CVT

given that they can occur wherever
Internet access or smartphone con-
nectivity is available, at a time that is
convenient for the patient, and with-
out travel to a clinic. Most e-visits oc-
curred after an initial in-person visit;
therefore, these e-visits were an effec-
tive follow-up alternative to in-person
visits and nonreimbursable telephone
consultations.50
In the diabetes group, significantly
more patients achieved preventive
care targets, including blood pres-
sure control, statin use, and aspirin
therapy, specified in accordance with
guideline recommendations.51,52 Pa-
tients were maintained on a mean of
2 antidiabetic medications, a figure
essentially unchanged from baseline
despite improving glycemic control.
This finding highlighted the observa-
tion that medication burden did not
increase and thus did not contribute
to a reduction in patient adherence.
After enrollment, fewer patients were
maintained on a sulfonylurea, and
more patients were initiated on GLP-1
receptor agonists, which pose a low-
er risk of hypoglycemia and weight
gain.53 Although weight loss has been
reported by patients receiving GLP-1
agonists,54-56 it was not measured or
documented in our study. The low
frequency of patients experiencing

hypoglycemia at any point after en-
rollment (n = 5) and the lack of reports
of severe hypoglycemia reinforce our
stance that e-visits may be a safe al-
ternative to in-person visits. Of note,
prestudy reports of hypoglycemia
were not collected.
Within a PCMH, clinical and finan-
cial outcomes and patient satisfac-
tion are important indicators of the
quality of services. Patient satisfaction
is positively correlated with health
outcomes, safety, and adherence to
medications and preventive care mea-
sures.57 Of the patients who responded
to the survey, all indicated high levels
Table 4. Patient Satisfaction Survey Results (n = 19)a
Survey Item
Median
Score (IQR)
1. My pharmacist advises me on the proper use of my
medicines.
4 (4–4)
2. My pharmacist advises me on the adverse (side) effects of my
medicines. 4 (4–4)
3. I have confidence in my pharmacist. 4 (4–4)

4. My pharmacist is available to answer my questions. 4 (3–4)
5. My pharmacist helps me with the arrangements necessary to
obtain my medicines and supplies. 4 (3–4)
6. My pharmacist is aware of my treatment-related needs. 4 (3–
4)
7. My pharmacist responds to my treatment-related needs. 4 (3–
4)
8. How comfortable did you feel in communicating with
someone by MyChart messaging? 4 (4–4)
9. How convenient was the MyChart messaging? 4 (4–4)
10. Was the lack of physical presence of the provider
acceptable? 4 (4–4)
Total score (maximum = 40) 39 (34–40)
aQuestions 1–7 were modified from the Satisfaction with
Pharmacist scale.46 Questions
8–10 were specific to the e-visit program. Scores indicated
response to survey statements or
questions: 0 = not at all, 1 = a little bit, 2 = somewhat, 3 = quite
a bit, 4 = very much. IQR =
interquartile range.
PROGRAM
12 | JUNE 15, 2018

of satisfaction (Table 4). Only part of
the SWiP survey (questions 1–7) has
been validated46; however, it was im-
portant to receive feedback about
the e-visit service. A similar modified
SWiP survey was used by Maxwell and
colleagues.47 In our study, the highest
levels of satisfaction were related to
questions 8–10, which were specific
to the e-visit model. Patients felt com-
fortable communicating with a CPP
through MyChart messaging, found
the service convenient, and accepted
the lack of a physical CPP presence.
Patient satisfaction with pharmacist-
led services in the study was consis-
tent with satisfaction levels reported
in studies of other pharmacist-led
services for chronic disease manage-
ment.47,58-60 More than half of the pa-
tients responded to the patient satis-
faction survey, which was higher than
the FMC’s average rate of response to
patient surveys (e.g., less than 10%
for Press Ganey surveys [Press Ganey
Associates, Inc., South Bend, IN]).
The study was not without limi-
tations. The small patient sample
limited the external validity of the
findings. However, it is notable that
a statistically significant difference
in outcomes was found despite the
small sample size. Given require-
ments regarding patient access to and

use of MyChart, competency in us-
ing a home INR device or glucometer,
and insurance coverage for e-visits,
participating patients may have had
higher-than-typical levels of health
literacy and access to care. The strict
inclusion criteria likely contributed
to a small sample size. In addition,
our patient population was young
relative to populations in similar stud-
ies.47 Based on the above points, the
study results cannot be generalized to
a broad chronic disease population.
Since the study, insurance coverage
for e-visits may have expanded to in-
clude more carriers. Patients were in-
volved in varying levels of care prior to
enrollment. Anticoagulation patients
were managed by a CPP for at least
3 months before enrollment. Given
that many patients with diabetes par-
ticipated in e-visits and in-person
visits, it is difficult to strictly assess
the impact of e-visits alone. All INR
values required manual reporting to
the monitoring device manufacturer.
Using a wirelessly connected moni-
tor could reduce reporting errors. The
same home testing device was used by
all enrolled anticoagulation patients
to improve monitoring efficiency, ac-
curacy, and consistency for the CPP.
While direct revenue from CPP bill-
ing was collected, further analysis
to evaluate the economic impact of

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