New AASM Guideline on Sleep-Related Telemedicine

Pauline Anderson

October 23, 2015

Clinical care standards for healthcare delivered through telemedicine services, including all aspects of diagnosis and treatment decisions, should mirror those of live office visits, according to a position paper issued by the American Academy of Sleep Medicine (AASM).

The position paper also recommends that appropriate technical standards be upheld, specifically those of the Health Insurance Portability and Accountability Act (HIPAA); that roles, expectations, and responsibilities of providers be defined; and that providers be appropriately remunerated.

Sleep medicine is particularly well suited for telemedicine, Nathaniel Watson, MD, AASM president, and professor, neurology, University of Washington, Seattle, told Medscape Medical News. Home-based sleep tests, including sleep apnea tests, where information obtained from a patient can be uploaded and interpreted by a provider at a later date, are a form of telemedicine technology and are already in use, he said.

Dr Nathaniel Watson

The paper was published in the current issue of the Journal of Clinical Sleep Medicine.

"Grossly Underserviced"

Sleep disturbances affect an estimated 35% to 40% of the adult US population, but there's a substantial shortage of board-certified sleep medicine providers, with parts of the country being "grossly underserviced or not serviced at all," the authors write.

"The geographic distribution of our specialists and the somewhat limited number of them makes the notion of telemedicine an attractive way to reach people who may not otherwise have access to these services," said Dr Watson.

There are about 6000 sleep specialists across the country, but "roughly three times more" are needed to meet the demand, he said.

The demand is growing because of the aging population and because the prevalence of one of the most common sleep disorders — obstructive sleep apnea, which now affects 6% to 12% of those aged 30 to 70 years — is increasing, in part as a result of obesity, Dr Watson said. Sleep disorders in general "are some of the most prevalent disorders known to man," he said.

There's also a shortage of sleep medicine education provided in internship and residency programs in medical schools, said Dr Watson. "Our clinical pipeline needs to grow."

To help fill the specialist gap, experts are seeking more efficient and accessible ways to provide services beyond the traditional office model. Increasingly, telemedicine is meeting that demand by offering tools to deliver cost-effective care while increasing accessibility.

In 2014, the AASM board of directors convened a task force to understand and define the key features, processes, and standards for telemedicine specific to sleep medicine.

According to the position paper, telemedicine applications can generally be divided into two categories: synchronous interactions (patients and providers are separated by distance but interact in real-time using videoconferencing), where the encounter is meant to function as a live office visit, and asynchronous interactions (patients and providers are separated by distance and by time), so key aspects of the clinical encounter are performed at separate times.

E-messaging Increasing

Clinicians are increasingly using e-messaging — through email or online asynchronous technologies — to communicate with patients about such issues as nonurgent ongoing or new symptoms.

Also increasing is use of "self-directed care," which refers to direct access by patients to interactive feedback, coaching, or other sleep-related care mechanisms that don't directly involve interaction with a sleep provider. Examples include online cognitive-behavioral therapy programs and smartphone applications of sleep-wake data.

The task force believes that if used for treatment decisions, "the information from these systems must be easily available to the ordering physician and the time spent on managing data, quality assurance, and other aspects of care delivery should be remunerated as value-based payment schemes are developed."

The paper includes several recommendations regarding patient evaluation, testing, and treatment. For example, providers should perform key elements of the sleep-relevant medical history as if the visit were an in-person visit.

Providers should also perform sleep diagnostics in a manner that is in accordance with standards, clinical practice guidelines, and practice parameters established by the AASM, the paper notes. Home sleep apnea testing devices are to be used when clinically appropriate in a manner consistent with current clinical standards.

Clinicians should interpret sleep studies in accordance with the AASM Manual for the Scoring of Sleep and Associated Events.

As for prescriptions, the task force endorses the use of live interactive telemedicine as a suitable alternative for prescription of sedative hypnotics, stimulant medications, wakefulness-promoting medications, or other controlled substances. However, some states don't allow controlled substances to be prescribed to patients that the provider has not seen in a face-to-face encounter.

If allowed and the provider feels comfortable, it's recommended that there be consistent and clear electronic documentation; providers have an active current license in the state in which the substance is prescribed; and providers adhere to all relevant federal, state, and local guidelines and use clinical judgement regarding the abilities and limitations of telemedicine.

"Figuring out the complexities of billing, of practicing medicine across state lines, where you need a license, those sorts of things I think are important aspects of this, but by no means are they insurmountable," commented Dr Watson.

The AASM already has the HIPAA-compliant "Tell A Sleep Doc" telemedicine software platform. It provides the infrastructure necessary for sleep medicine practices to "get into the telemedicine arena fairly quickly," according to Dr Watson.

This telemedicine platform could be used for provider-to-provider consultations and to deliver educational materials to patients, among other things, he said.

"We view this as the future in many ways, not just for sleep medicine, but for medicine in general. We are excited to be at what we feel is the cutting edge" of this technology, he said.

Dr Epstein has served as a consultant for AIM Specialty Health and eviCore Healthcare and has received salary from Welltrinsic Sleep Network Inc. Study authors Ms McCann and Mr Heald are employees of the AASM. The other authors have disclosed no relevant financial relationships.

J Clin Sleep Med. 2015;11:1187-1198. Abstract

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