Barry G. Fields, MD, MSEd, on Sleep Telemedicine

Telemedicine is a great way to see many patients in disperse locations over a short period of time. For sleep medicine specifically, it allows providers to check in with patients between sleep studies to ensure their regimen is working.

At Sleep Medicine Trends 2019, Barry G. Fields, MD, MSEd—who is an assistant professor of medicine at Emory University School of Medicine and a sleep physician at the Atlanta VA Medical Center—gave attendees an update about sleep telemedicine in 2019. Here are his answers to our burning questions.

PULMONOLOGY CONSULTANT: What types of telemedicine are used in sleep medicine? How are they used, or in which patient populations is it indicated?

Barry Fields: In its broadest sense, “telemedicine” involves utilizing any form of electronic communication to support a patient’s health. One form of telemedicine has been employed for over a century—telephone calls between patient and provider. Newer forms of telemedicine generally fall into 2 categories: synchronous and asynchronous. Examples of asynchronous telemedicine utilized in sleep medicine include store-and-forward technologies. Sleep providers may view sleep testing results and positive airway pressure (PAP) machine downloads far removed from their patients in both time and location.

Synchronous telemedicine usually involves clinical video telehealth (CVT). These real-time interactions between patient and provider allow a high-quality audio and video experience designed to emulate traditional, in-person visits.

Telemedicine can be used in any population with access to the technology required; even many geriatric patients now have apps on their phone allowing them to participate in CVT anywhere.

PULM CON: Where is the field now in terms of using telemedicine for sleep disorder diagnoses and treatment? Has telemedicine improved diagnosis and treatment of these disorders?

BF: Providers may perform initial evaluations and follow-up visits, gathering information to inform their medical decision making. Indeed, comprehensive patient management pathways can now incorporate both synchronous and asynchronous telemedicine to better serve patients, from initial evaluation and sleep study interpretation to ordering treatment and adherence monitoring.

It is difficult to quantify how much telemedicine has improved access to diagnosis and treatment of sleep disorders, but we do know that patient demand for these services far exceeds provider supply. This is especially the case for patients who are homebound, live in rural areas, or live in places with a low sleep provider to patient ratio (even in some urban areas). Research shows that the quality of sleep care provided through telemedicine can be noninferior to that provided through in-person visits.

PULM CON: How has the use of telemedicine changed over the years in sleep medicine?

BF: Sleep telemedicine has transitioned from simply calling patients over the telephone to incorporating different telemedicine modalities into care pathways using CVT and modem technology.

Patient location during CVT appointments is now transitioning from a local clinic (a center-to-center model) to the patient’s home or location of their choice (center-to-home model) through the use of smartphone video apps. Bringing sleep medicine into the patient’s home recalls yesteryear’s “house call,” albeit in virtual form.

PULM CON: What did you think about telemedicine the first time you used it? Can you describe your first experience?

BF: I first used CVT during my sleep medicine fellowship training at the Philadelphia VA Medical Center. A patient at a distant clinic in Southern New Jersey appeared on the large, flat-screen television in the VA sleep Center. While the mode of health care delivery initially felt foreign, it soon felt more and more like a natural extension of the care we provide in the clinic. Perhaps my early days with telemedicine were notable for how not notable it quickly felt. I learned that, while some adjustments should be considered, most of what is accomplished during an in-person visit can be accomplished via telemedicine. Telemedicine is simply a tool to deliver care, and a more frequently utilized one at that.

PULM CON: What else should sleep specialists know about telemedicine in 2019?

BF: Anyone practicing sleep telemedicine should consider the major challenges that remain in reimbursement paradigms. Although no one should consider utilizing telemedicine primarily for its income potential, financial solvency is a linchpin of any successful clinical program. As of this writing, Medicare still has very strict rules about which type of visits qualify for reimbursement. Some states still do not require private insurers to pay the same for a telemedicine visit as for an in-person visit; they do not have “parity laws.” Sleep telemedicine’s viability will remain limited in locations with unequal payment for telemedicine and in-person visits.

Sleep medicine providers should also ensure that their malpractice insurance covers telemedicine and that they are licensed in the patient’s state if it differs from their own. More details about telemedicine implementation in sleep medicine practices can be found on the American Academy of Sleep Medicine (AASM) website: https://aasm.org/download-the-sleep-telemedicine-implementation-guide-a-free-resource-from-aasm/.