2015 singh telemedicine for sleep disorders
DESCRIPTION
telemedicineTRANSCRIPT
Telemedicine for
Sleep Disorders
Jaspal Singh, MD MHA MHS
1. I do not have any relationships with any entities , health care goods or services consumed by, or used on,
patients,
2. I have the following relationships with entities , health care goods or services consumed by, or used on,
patients.
Type of Potential Conflict Details of Potential Conflict
Grant/Research Support
Consultant
Speakers’ Bureaus
Financial support
Other
3. The material presented in this lecture has no relationship with any of these potential conflicts,
4. This talk presents material that is related to one or more of these potential conflicts, and the following objective references are provided as support for this lecture:
1.
2.
3.
• Clinician in a large complex organization
– Not an IT expert
• Like Technology when it makes life better
– Has to be easy to use
• Regularly do Tele-ICU
• My organization has not embraced sleep
telemedicine yet
• To illustrate the need for telemedicine
protocols in sleep
• To review the AASM Protocol in Sleep
Telemedicine
• To develop strategies and dialogue
regarding optimizal utilization of sleep
telemedicine applications
• 66 yo male seen for annual physical
• Elevated BMI, neck circumference and
has a new diagnosis of hypertension.
• He is referred to you for a sleep evaluation
and lives 200 miles away.
• Sleepy, ESS 14, Near-accidents when
driving
• Can you treat with Telemedicine tools?
• You will only evaluate and treat that patient
if he drives 200 miles to see you in person
• AND you are willing to sit as a passenger
• You are willing to consider Telemedicine
applications
• Similar scenarios are not uncommon
• Telemedicine is far less about the
technology, and far more about trying to
find ways to care for the patient
• American Telemedicine Association
– Key resources
• American Medical Association
– Endorses use
• AASM Document to serve as a resource
• Background
• Promote Sleep Telemedicine
– Quality, Access, Value
• Safwan Badr
• Wendy Diebert
• Lawrence Epstein
• Dennis Hwang
• Valerie Karres
• Seema Khosla
• Nicole Mims
• Affifa Shamim-Uzzaman
• Jaspal Singh
• Douglas Kirsch
• Sherene Thomas
• Jon Heald
• Kathleen McCann
• Steve Van Hout
• Jerome Barrett
• Sleep is Getting
Respect
– Disorders
– Affects comorbidities
– Public health impact
• Too few trained
providerswww.aamc.org
http://www.ncsl.org/research/health/primary-care-workforce.aspx
• Additional workforce?
– Board-certified sleep physicians
– Primary care and others to do sleep
– Nurse Practitioners / Physician Assistants
• Re-design key elements of patient flow?
• Telemedicine Tools and Applications?
• Balance pressures to Cut Costs
• Means to increase Access
• Increasing demand
– Patient-driven
– Payor-driven
• Quality
– What can/should be done this way?
• Telehealth – exchange of medical information to
improve a patient’s health status
• Teleconferencing -- information from central
location to multiple remote sites
• Teleconsultation -- Telephone or video
interaction between clinicians
• Telemonitoring -- Remote collection and
transmission of data
• Telemedicine -- a legal patient/clinician
encounter using electronic communication
Electronic Health Record
Lab DataDiagnostics
“I recommend…”
Questionnaires? • Asynchronous in • Time• Space
• Remote Interpretation
• Store-and-Forward• Define Patient-
provider Relationship!
• Reimbursement challenges
• Function as a live visit– Same standards
• Real-time
• Terms– Originating Site
patient
– Distant Site provider
– Patient Presenter
• Document, Bill
• Quality Assurance
Mirror the Live Visit! Domains covered
• Initial Consultation
• Diagnostic Testing
• Interpretation of tests
• Follow-up of visits
• Therapeutic
Recommendations
• Monitoring of therapies
• 66 yo male seen for annual physical
• Elevated BMI, neck circumference and
has a new diagnosis of hypertension.
• He is referred to you for a sleep evaluation
and lives 200 miles away.
• Some near-accidents when driving
• Can you treat him through Telemedicine
tools (live interactive)?
• What tools you always need
– For decision-making
– For legal/regulatory/billing
• What might you need
– Clinical variability
– Unanticipated problems
• Local Resources in Existence– Sleep labs and therapists
– PCP’s, specialists
– Labs, radiographs, cardiac testing
• Augment Technology– Electronic Tools / peripherals
– Downloads
• Create your own local resources– Nurse Practitioners / ACP’s
– Local clinics
• More intense follow up.
• PAP follow-up
• Psychostimulant and hypnotic usage
– Suspected abuse of prescription drugs
• Risk of injury from sleep disorder
• Occupational / Commercial vehicle operator
• Pediatric disorders
• Surgery for sleep-disordered breathing
• High Medical Complexity patients with concomitant sleep disorders
• Mirror the live process as much as
possible
• Patient-centered Outcomes
• Patient Experience
• Overall Provider Experience
• Technical ease, reliability, safety
• Compliance with HIPPA requirements
• Function under the same
standards as the Physicians
• Live-interactive in real-time
can function as direct
supervision
• Asynchronous supervision for
generalized supervision
• QA process of their
performance
• Not violate intent
– Improve overall access, quality, value
• Potential Financial conflicts
– Even perception of COI to be addressed
• Establishing the Physician-Patient Relationship
– Informed consent
• Knowledge of technology expected
• Backup systems in place
• HIPPA compliance
• Malpractice insurance
• Bandwidth
• Resolution
• Software
• Diagnostic Equipment
• Safety
• Privacy
• Clinical judgment on what you can /
cannot accomplish with telemedicine
• Managing patient expectations
• Often difficult to teach
• Dr. K is a board-certified sleep specialist who wishes to support rural primary care providers
• Establishes a sleep telemedicine clinic– In sleep lab
– Patient presenter sleep tech or LPN
– Interprets sleep studies
– Documents, bills for live interactive visits• Rural location, meets Medicare definition
– Provides additional support
• Follow – up Visits via Telemedicine, data…
• Technical ease
• Patient-provider relationships
– Informed consent, other providers
• Documentation and Communication
• Care coordination
– HME (who signs the CMN’s?)
• Quality Assurance
• Direct billing
– Medicare in certain regions
– Some insurers!
• Non-billable and non-reimbursed time and
effort
– e.g. E-ICU work is often paid by the hospital
• This is changing weekly!
• Obesity-Hypoventilation
• Insomnia
• Medicare PAP
• Narcolepsy
– E-prescribe not allowed
• Multiple Disorders
• 66 yo male seen for annual physical
• Elevated BMI, neck circumference and
has a new diagnosis of hypertension.
• He is referred to you for a sleep evaluation
and lives 200 miles away. What are some
issues to consider when evaluating his
candidacy for a remote visit?
• Can he be evaluated for OSA treatment?
• What are the regulations regarding the scripting of PAP?
• What are the elements of the physical examination that must be performed in order to determine the next step in his care?
• What are the reimbursement requirements for a new Medicare patient?
• How will follow-up care be provided regarding CPAP compliance?
• CPAP Adherence
clinic
• Virtual, direct-to-
consumer
• Initial consultation for
OSA
• Sleep hygiene,
insomnia, early CBT
• Work : Reimbursement ratio worse than
previously?
• Direct billing?
• Indirect revenue streams?
• Access to patients, studies, etc.
– But have to give patients clear options
• If we (sleep providers) don’t do it,
someone probably will!
• Huge area of growth
in venture capital
• Position statement and recommendations are meant to serve as a guide
• Check with local, state, and other regulatory agencies
• Try to mirror the live visit as much as possible
• Informed consent, Quality assurance processes
• AASM endorses use of sleep telemedicine as long as care meets AASM recommendations
• Start simply (?PAP follow-up?)
• Do my homework
• Develop clear algorithm
• Simple tools, protected
• Measure all I can on how this is
working
• See if I got paid after billing
• Keep at it
