Is the Sleep Lab Obsolete? Telehealth and the Future of Sleep Medicine
The "diffusion of innovation" theory holds that there are five stages to the adoption of new technology that conform to a bell-shaped curve as seen below.
There is abundant evidence to suggest that, nationally, telemedicine is moving into the “early majority stage.” An illuminating 2014 report from consulting powerhouse Deloitte concluded that from 2012 to 2014, “eVisits” were predicted to increase 400 percent and result in a savings of over $5 billion dollars when compared to the cost of in-person provider visits. A December 2015 Harris Poll revealed that 64 percent of American adults were willing to have online video doctor visits. Both patients and providers are happy to utilize telehealth as evidenced by a recent survey from the Missouri Telehealth Network showing that both groups reported a 90 percent satisfaction rate with the quality of care received by telemedicine. Telemedicine has made significant inroads in certain fields such as urgent care, stroke care, and psychiatry, but its full potential has yet to be realized.
Sleep medicine in the United States is plagued by several systematic access, logistical, and economic problems. There is a shortage of trained sleep medicine physicians in the country, but these doctors are overrepresented in urban areas, leaving wide swaths of the country underserved. Changes in reimbursement by CMS over the last several years have reduced the number of Independent Diagnostic and Testing Facilities (IDTFs) nationally, and thus, the total number of sleep lab beds. This trend has served to increase the wait time for a sleep study. A 4-8 week wait time for a sleep study is not uncommon and waits are often even longer for clinic appointments with sleep medicine doctors. Sleep apnea is a risk factor for a number of dangerous medical problems, including sudden death, myocardial infarction, stroke, cardiac arrhythmias, type 2 diabetes, and hypertension. In many areas of the country, patients face unacceptably long delays in getting help for sleep apnea.
There is also the inherent risk of sleepy patients commuting to and from appointments. This risk is exacerbated when an already sleepy patient has to depart the sleep lab after a night of foreshortened and poor quality sleep. Cost is another issue in sleep medicine. The recent changes in health care insurance regulation have led to a vast increase in high-deductible plans in the 40-64 age cohort, which is most common when sleep apnea first becomes symptomatic. In this population, out-of-pocket expense for an in-lab sleep study averages $1,000-$2,000 and has been reported as high as $8,000 at certain academic medical centers.
Sleep telemedicine, and specifically comprehensive sleep telehealth clinics, offers an alternative pathway to sleep health care delivery that circumvents the problems discussed above. Conceptually, a sleep telehealth clinic offers 360-degree, total patient care. This is comprised of three interdependent services:
• home sleep apnea testing
• online sleep physician consultations
• dispensing and management of positive airway pressure (PAP) equipment
The most common reason for referral to a sleep center is for sleep apnea evaluation. Testing for this disorder now can be done, for the majority of patients, at home. Home sleep studies are relatively unobtrusive and obviate the majority of patient objections about in-lab studies. A home sleep apnea test is much more cost-effective than an in-lab study and many patients may save hundreds, if not thousands, in out-of-pocket expense. A well-run, efficient, “virtual” sleep center should be able to fulfill home sleep apnea testing orders in a fraction of the time that it takes to get results for an in-lab test.
Online sleep physician video consultations allow the clinician to establish a patient-doctor relationship that state medical boards now recognize as equivalent to in-person meetings. There are major cost savings associated with an online clinic compared with a traditional brick-and-mortar clinic due to overhead reduction. Sleep physicians can review sleep study reports with patients as well as diagnose and treat other sleep disorders, the majority of which are clinical diagnoses, i.e. based on history alone, including insomnia, restless legs syndrome, circadian rhythm disorders and sleepwalking. Electronic prescribing platforms make it easy to get patients the medications that they need.
PAP is the gold-standard treatment for all forms of sleep apnea. An appropriately licensed, comprehensive online sleep center can fulfill the durable medical equipment (DME) needs of its sleep apnea patients. Advantages of the online sleep center dispensing DME include ensuring that the patient receives the most appropriate equipment for his or her condition as recommended by the clinician, rapid troubleshooting of PAP tolerance issues, and seamless monitoring of device compliance and efficacy due to ubiquitous electronic data transfer systems available on PAP machines.
Sleep medicine is a relatively young field and the numerous barriers to care in the current system are perhaps a result of the field's “growing pains.” As primary care physicians and the US population become increasingly aware of the dangers of sleep disorders, comprehensive online sleep telemedicine centers may play an important role in the solution.
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