Dennis Hwang

American Academy of Sleep Medicine (AASM) position paper for the use of telemedicine for the diagnosis and treatment of sleep disorders

The American Academy of Sleep Medicines (AASM) Taskforce on Sleep Telemedicine supports telemedicine as a means of advancing patient health by improving access to the expertise of Board-Certified Sleep Medicine Specialists. However, such access improvement needs to be anchored in attention to quality and value in diagnosing and treating sleep disorders. Telemedicine is also useful to promote professionalism through patient care coordination and communication between other specialties and sleep medicine. Many of the principles and key concepts adopted here are based on U.S. industry standards, with special consideration given to the body of work by the American Telemedicine Association (http://www.americantelemed.org/), and abide by standards endorsed by the American Medical Association (http://www.ama-assn.org/). Practitioners who wish to integrate sleep telemedicine into their practice should have a clear understanding of the salient issues, key terminology, and the following recommendations from the AASM. The Taskforce recommends the following: • Clinical care standards for telemedicine services should mirror those of live office visits, including all aspects of diagnosis and treatment decisions as would be reasonably expected in traditional office-based encounters. • Clinical judgment should be exercised when determining the scope and extent of telemedicine applications in the diagnosis and treatment of specific patients and sleep disorders. • Live Interactive Telemedicine for sleep disorders, if utilized in a manner consistent with the principles outlined in this document, should be recognized and reimbursed in a manner competitive or comparable with traditional in-person visits. • Roles, expectations, and responsibilities of providers involved in the delivery of sleep telemedicine should be defined, including those at originating sites and distant sites. • The practice of telemedicine should aim to promote a care model in which sleep specialists, patients, primary care providers, and other members of the healthcare team aim to improve the value of healthcare delivery in a coordinated fashion. • Appropriate technical standards should be upheld throughout the telemedicine care delivery process, at both the originating and distant sites, and specifically meet the standards set forth by the Health Insurance Portability and Accountability Act (HIPAA). • Methods that aim to improve the utility of telemedicine exist and should be explored, including the utilization of patient presenters, local resources and providers, adjunct testing, and add-on technologies. • Quality Assurance processes should be in place for telemedicine care delivery models that aim to capture process measures, patient outcomes, and patient/provider experiences with the model(s) employed. • Time for data management, quality processes, and other aspects of care delivery related to telemedicine encounters should be recognized in value-based care delivery models. • The use of telemedicine services and its equipment should adhere to strict professional and ethical standards so as not to violate the intent of the telemedicine interaction while aiming to improve overall patient access, quality, and/or value of care. • When billing for telemedicine services, it is recommended that patients, providers, and others rendering services understand payor reimbursements, and that there be financial transparency throughout the process. • Telemedicine utilization for sleep medicine is likely to rapidly expand, as are broader telehealth applications in general; further research into the impact and outcomes of these are needed. This document serves as a resource by defining issues and terminology and explaining recommendations. However, it is not intended to supersede regulatory or credentialing recommendations and guidelines. It is intended to support and be consistent with professional and ethical standards of the profession.

Monitoring Progress and Adherence with Positive Airway Pressure Therapy for Obstructive Sleep Apnea: The Roles of Telemedicine and Mobile Health Applications.

Technology is changing the way health care is delivered and how patients are approaching their own health. Given the challenge within sleep medicine of optimizing adherence to continuous positive airway pressure (CPAP) therapy in patients with obstructive sleep apnea (OSA), implementation of telemedicine-based mechanisms is a critical component toward developing a comprehensive and cost-effective solution for OSA management. Key elements include the use of electronic messaging, remote monitoring, automated care mechanisms, and patient self-management platforms. Current practical sleep-related telemedicine platforms include Web-based educational programs, automated CPAP follow-up platforms that promote self-management, and peer-based patient-driven Internet support forums.

Effect of Telemedicine Education and Telemonitoring on CPAP Adherence: The Tele-OSA Randomized Trial

Rationale: Automated telemedicine interventions could potentially improve adherence to continuous positive airway pressure (CPAP) therapy. Objectives: Examining the effects of telemedicine‐delivered obstructive sleep apnea (OSA) education and CPAP telemonitoring with automated patient feedback messaging on CPAP adherence. Methods: This four‐arm, randomized, factorial design clinical trial enrolled 1,455 patients (51.0% women; age, 49.1 ± 12.5 yr [mean ± SD]) referred for suspected OSA. Nine hundred and fifty‐six underwent home sleep apnea testing, and 556 were prescribed CPAP. Two telemedicine interventions were implemented: 1) web‐based OSA education (Tel‐Ed) and 2) CPAP telemonitoring with automated patient feedback (Tel‐TM). Patients were randomized to 1) usual care, 2) Tel‐Ed added, 3) Tel‐TM added, or 4) Tel‐Ed and Tel‐TM added (Tel‐both). Measurements and Main Results: The primary endpoint was 90‐day CPAP usage. Secondary endpoints included attendance to OSA evaluation, and change in Epworth Sleepiness Scale score. CPAP average daily use at 90 days was 3.8 ± 2.5, 4.0 ± 2.4, 4.4 ± 2.2, and 4.8 ± 2.3 hours in usual care, Tel‐Ed, Tel‐TM, and Tel‐both groups. Usage was significantly higher in the Tel‐TM and Tel‐both groups versus usual care (P = 0.0002 for both) but not for Tel‐Ed (P = 0.10). Medicare adherence rates were 53.5, 61.0, 65.6, and 73.2% in usual care, Tel‐Ed, Tel‐TM, and Tel‐both groups (Tel‐both vs. usual care, P = 0.001; Tel‐TM vs. usual care, P = 0.003; Tel‐Ed vs. usual care, P = 0.07), respectively. Telemedicine education improved clinic attendance compared with no telemedicine education (show rate, 68.5 vs. 62.7%; P = 0.02). Conclusions: The use of CPAP telemonitoring with automated feedback messaging improved 90‐day adherence in patients with OSA. Telemedicine‐based education did not significantly improve CPAP adherence but did increase clinic attendance for OSA evaluation. Clinical trial registered with www.clinicaltrials.gov (NCT02279901).

Does remote monitoring change OSA management and CPAP adherence

It is increasingly recognized that the high prevalence of obstructive sleep apnoea (OSA), and its associated cardio‐metabolic morbidities make OSA a burden for society. Continuous positive airway pressure (CPAP), the gold standard treatment, needs to be used for more than 4 h/night to be effective, but suffers from relatively poor adherence. Furthermore, CPAP is likely to be more effective if combined with lifestyle changes. Thus, the remote telemonitoring (TM) of OSA patients in terms of CPAP use, signalling of device problems, following disease progression, detection of acute events and monitoring of daily physical activity is an attractive option. In the present review, we aim to summarize the recent scientific data on remote TM of OSA patients, and whether it meets expectations. We also look at how patient education and follow‐up via telemedicine is used to improve adherence and we discuss the influence of the profile of the healthcare provider. Then, we consider how TM might be extended to encompass the patients cardio‐metabolic health in general. Lastly, we explore how TM and the deluge of data it potentially generates could be combined with electronic health records in providing personalized care and multi‐disease management to OSA patients.

Consumer sleep technology: An American academy of sleep medicine position statement

ABSTRACT Consumer sleep technologies (CSTs) are widespread applications and devices that purport to measure and even improve sleep. Sleep clinicians may frequently encounter CST in practice and, despite lack of validation against gold standard polysomnography, familiarity with these devices has become a patient expectation. This American Academy of Sleep Medicine position statement details the disadvantages and potential benefits of CSTs and provides guidance when approaching patient-generated health data from CSTs in a clinical setting. Given the lack of validation and United States Food and Drug Administration (FDA) clearance, CSTs cannot be utilized for the diagnosis and/or treatment of sleep disorders at this time. However, CSTs may be utilized to enhance the patient-clinician interaction when presented in the context of an appropriate clinical evaluation. The ubiquitous nature of CSTs may further sleep research and practice. However, future validation, access to raw data and algorithms, and FDA oversight are needed.

Monitoring Progress and Adherence with PAP Therapy for OSA: the Roles of Telemedicine and Mobile Health Applications

Purpose of ReviewGiven the challenge of optimizing continuous positive airway pressure (CPAP) therapy adherence in patients with obstructive sleep apnea (OSA), this paper discusses implementation of telemedicine-based mechanisms and other health-related technologies in order to develop a comprehensive and cost-effective solution for OSA management.Recent FindingsTechnology is changing every aspect of health care by empowering patients while changing the approach of providers and the health system of delivering care. Key elements include the use of electronic messaging, remote monitoring, automated care mechanisms, and patient self-management platforms. Follow-up care mechanisms involving automated remote monitoring and direct patient messaging have been proven to improve therapy adherence. Additional sleep-related telemedicine platforms that can be practically adopted include the use of web-based educational programs, patient applications that promote self-management, and peer-based patient-driven platforms.SummaryThis paper discusses sleep-related telemedicine mechanisms that can be used to improve CPAP adherence and discusses emerging trends within the health information technology ecosystem, including electronic health record integration and their potential impact on OSA and clinical outcomes.

The Affordable Care Act and the Future of Sleep Medicine

The Affordable Care Act (ACA), signed into law in 2010, embodies changes in the health-care system that have evolved in response to escalating health-care cost in conjunction with suboptimal outcomes when comparing life expectancy with other western countries. The primary paradigm shift is a change in emphasis away from rewarding performance of medical services to achieving optimal clinical outcomes with the goal of providing care that is cost-effective. Sleep medicine mimics the challenges that have affected the greater system as a whole, as it has been a field that has been driven by polysomnography testing and diagnosis. In responding to the challenges of the health-care system, there has been an increasing emphasis on out-of-center testing for the evaluation of sleep-disordered breathing. However, for sleep medicine to thrive in the future landscape, a much more robust change is necessary. Developing a model of care that provides a concrete infrastructure balancing diagnostic testing with robust follow-up care is necessary. Unfortunately, follow-up care is not only costly, but there is also an insufficient number of sleep specialists to effectively care for the population of sleep disorders. In order to address these challenges, sleep medicine will likely need to embrace team-based care with the use of allied health providers as physician extenders and the use of technology that includes automated care mechanisms that enhance population management, continuous disease management, and self-directed care mechanisms. We also recognize that the identity of sleep medicine needs to expand beyond care of obstructive sleep apnea but into new areas of focus that improve the relevance of sleep medicine for patients and for other medical specialties by collaborating on interdepartmental disease management.