Sleep Medicine for the 21st Century: Leverage the Cloud to Improve Patient Care

In the larger healthcare universe, advances in healthcare information technology (HIT) are driving massive systemic change. Healthcare systems and individual medical practices are transitioning to electronic medical records systems. Internet-based technologies increasingly facilitate patient education, communication, and even behavior change. In the near future, these and other innovations in HIT will revolutionize the ways that sleep patients are screened and triaged, assessed and diagnosed, treated and provided ongoing care. For adaptive professionals and forward-thinking sleep medicine organizations, these changes bring excitement and provide ripe opportunity. The purpose of the current article is to suggest practical ways to provide better sleep health care by leveraging the Internet to educate, communicate, change behavior, and track outcomes. Maximizing performance in each of these areas will help position your organization to excel in the emerging, changed landscape of sleep medicine in the 21st century. Following a review of current trends, I will provide a self-assessment to gauge your organization’s current status. Finally, I will suggest several key questions to consider in formulating an overall technology strategy in your organization.

Top 5 ways the internet is changing sleep medicine

1. Increased access to sleep medicine education. It is well-documented that few physicians are adequately trained in sleep during medical school. Fortunately, in recent years numerous efforts have been made to increase availability of sleep medicine education, including efforts to educate primary care physicians in sleep, train nurse practitioners, and increase sleep medicine education at the graduate and CME levels.
   
   
   Internet-based education and elearning technologies are accelerating the dissemination of basic instruction and best practices in sleep medicine. Currently, online learning opportunities include formal coursework and certification programs, specialty webinars, and free general sleep education for non-sleep specialists. (For an example of the latter, see a project I spearheaded with an outstanding faculty: www.quantiamd.com/sleep). Many RPSGT and BRPT training programs have also been at the forefront of online education. In the future, online education will enable more widespread education of doctoral and mid-level providers as well as technologists, regarding best practices in screening, assessment, and treatment of sleep disorders.
2. Increased access to sleep medicine care. In the US, the demand for sleep medicine services far exceeds available supply of sleep-trained providers. Based on current prevalence estimates of sleep disorders relative to the number of board-certified sleep physicians, each sleep specialist would need to provide ongoing care to over 10,000 sleep patients per year to meet the current clinical need! (This estimate does not account for the imbalance between the roughly 45 million people with insomnia and 200 certified behavioral sleep specialists.)
   
   Internet and cloud-based technologies will increase access to care in three important ways. First, as has been reported elsewhere, internet screening can facilitate increased confidentiality and treatment acceptance for patients whose livelihood could be impacted by a sleep disorder diagnosis (1). In light of recent regulatory initiatives at the national and local levels, the importance of a patient-friendly, effective screening, diagnostic, and treatment chain cannot be overstated. Second, telemedicine approaches will increasingly enable providers to treat patients who may be located thousands of miles away, thereby increasing access to specialty care. For example, in the trucking industry it is not uncommon for a sleep physician to interview a driver via videoconference, to facilitate a more effective review of the results of a remotely interpreted PSG. Such processes can improve patient buy-in and treatment outcomes, thereby improving cost effectiveness of sleep care. The third way that Internet-based technologies will increase access to care is via partially or fully automated interventions such as online CBT and digital coaching via web and mobile interface. A future article will consider the applications and limitations of these technologies in detail.
3. Improved patient education regarding diagnostic and treatment processes. In addition to increasing public awareness regarding sleep disorders and sleep health in general, the Internet can be used to educate patients and improve care. Specifically, there are at least three critical “sensitive periods” where patient education and understanding is paramount to ensure long-term success: prior to diagnostic testing, during the transition to treatment, and following acclimation to therapy. Further, as patients are asked to complete increasingly complicated steps to facilitate their own diagnosis and treatment (eg, self hookup to HST), efficient and effective means of communication will become even more important.
   
   
   A robust patient portal can facilitate patient education at each stage in the treatment process. For example, prior to diagnostic testing patients can read printable handouts, view instructional videos, and review FAQs. Patients will arrive better prepared, familiar with the process, and knowing what to expect. During the transition to treatment, patients can receive instruction on equipment maintenance and adjusting to PAP. Once patients have made the transition to PAP, they can be monitored remotely to ensure optimal response to therapy between office follow-up visits.
4. Improved communication between patient, sleep provider, and DME equipment provider. One of the greatest needs to improve sleep medicine care is to improve communication between patient, provider, and DME supplier. Indeed, one of the most frequent complaints we hear from new patients is the lack of available support and ongoing communication from past DME providers. Currently, an undue burden falls on sleep patients, who frequently report feeling they act as “middle man” between physician and DME.
   
   
   A HIPPA-secure online patient portal could enable sleep provider, patient, and DME provider to all view all therapy data real-time and communicate for technical trouble-shooting, prescription adjustments, and reordering of supplies.
5. Easier tracking of patient outcome data. Very few sleep centers have an organized system for tracking patient data. To achieve and maintain AASM accreditation, centers must maintain a log of tests performed, final diagnoses, and so on. But even among AASM Centers of Distinction there is no requirement for the systematic tracking of patient outcomes. A major reason is practical: in absence of an electronic data gathering system, tracking of outcomes requires labor-intensive data entry. Yet reporting program-wide outcome measures such as PAP adherence, sleepiness, and so on, will not only become increasingly important as payor scrutiny increases.
   
   
   A robust patient portal can aggregate patient data real-time, without duplicated efforts of redundancy. This data can include both self-report measures such as validated questionnaires completed during assessment, post treatment, and so on, as well as objective data such as PAP adherence and physiologic measurements.

Why these changes matter to you now

These big-picture trends have already begun to impact training programs, hospital systems, sleep centers, physician practices, DME providers, payors, and patients in both subtle and overt ways. More important, each sleep medicine organization—including yours—will soon be faced with choices regarding whether, how, and when to expand its use of healthcare information technology. For most organizations, the key decision points will involve five primary functions of increasing technical complexity:

1. Identification, education, and attraction of potential patients
2. Unidirectional communication with potential patients, current patients, and referring providers
3. Bidirectional communication with current patients including use of online treatment tools
4. Data gathering, analysis, and reporting
5. Sharing of information with other healthcare entities (eg, DME) and integration with electronic medical record systems.

Where do you stand in relation to each of these key opportunities?

Self-assessment: How well are you leveraging available technologies

The following self-assessment should further concretize what these sea changes in the sleep medicine universe mean for you. For each area, rate your performance as non-existent, acceptable, distinct, or world-class. Then use your assessment results to stimulate dialogue among your team regarding use of currently available technologies. PDF link here and need a good title

Practical suggestions—before you invest in technology

Having completed the self-assessment, your initial reaction may be despair. Or you might be tempted to jump to Google or the Sleep Review advertiser’s index and begin to research available tools. Either of these reactions would be a mistake. Your first step should be to clarify your vision for the future of your organization. This will require consideration of external forces in the field at large, your micro universe, and your organizational aspirations. Where do you want to be in 1 year? 2 years? 5 years? A recent editorial in an academic journal reviewed the macro-level implications of the shift toward HST/APAP technologies on the sleep medicine field, and highlighted ways healthcare information technology (2). The author employed Jon Kotter’s seminal framework on organizational change management to outline a top-down approach to changing the way sleep medicine is practices in the United States (3). Yet each sleep medicine entity exists within a micro universe and faces unique challenges and opportunities, making top-down change difficult (4). This means the burden falls on you. You cannot afford to wait for others to chart your course. You must clearly define your objectives, develop a strategic approach, and determine which tactics will maximize your chances of success. Finally, you must identify those specific technology solutions that will best suit your needs.

Where to go form here

The need for sleep medicine services has never been greater, and the future of sleep medicine is bright. But to thrive in the coming years, sleep medicine organizations and sleep medicine providers will be required to embrace pending changes, adopt new approaches, and broaden their perspectives regarding their roles in a new healthcare landscape. Beyond well-known advances in sleep diagnostics and therapeutics, rapid developments in health information technology will become staples of comprehensive sleep medicine care. Cloud-based sleep-specific technologies will be at the forefront of this revolution. For the field at large and your organization in particular, the time to clarify a vision for the future is now. Strive to clearly define then implement the strategies, tactics, and technologies that will help make your vision a reality.

References

1. Smith B; Phillips BA. Truckers drive their own assessment for obstructive sleep apnea: a collaborative approach to online self-assessment for obstructive sleep apnea. J Clin Sleep Med 2011;7(3):241-245.
2. Pack, AI. Sleep medicine: strategies for change. J Clin Sleep Med. 2011 Dec 15;7(6):577-9.
3. Kotter, JP. Leading change–why transformation efforts fail. Harv Bus Rev. 2007 1;1–9.
4. Collop N, Fleishman SA. The future of sleep medicine: will you be a part of it? J Clin Sleep Med. 2011 Dec 15;7(6):581-2.