5/1/2013

IncorporatingTelehealth and
CommunicationsTechnologyinto
SleepMedicinePractice
May 4, 2013
Samuel T. Kuna, MD
Center for Sleep and Circadian Neurobiology
University of Pennsylvania and
Pulmonary, Critical Care & Sleep Section
Philadelphia VAMC

Telehealth definition and promises

to patients and practitioners
Telehealth the delivery of healthcare services at
a distance, using any communication modality that
allows the physical separation of provider and
patient while communicating about health issues.

Increase access to healthcare information

Increase access to care
Decrease cost of care (reduce hospitalizations, ER visits)
Improve healthcare for medically underserved populations
Increase access to specialty services
Enhance health literacy
Expand the healthcare workforce through virtual
education and training

The VA telehealth program

About one-half of all veterans live more than 25
miles from a VA hospital. Over one-third of all
veterans live 25 miles or more from a VA clinic.
Some form of telehealth care was delivered to
380,000 veterans in FY11 and to 480,000
veterans in FY12.
It is projected that the number will rise to
820,000 or about 15% of the veteran population
in FY13.

5/1/2013

VA telehealth modalities
Clinical Video (Real Time) Telehealth
Exchanging health services or education live via
videoconference
Home Telehealth
Transmission of medical data for diagnosis or
disease management
Store and Forward Telehealth
Acquires and stores clinical information (e.g. data,
image, sound, video, etc.) that is then forwarded to
(or retrieved by) another site for clinical evaluation

Clinical video telehealth

encounters

VA clinical video telehealth encounters

FY2008 - 2012

Fiscal Year

VA telehealth resources
Established 3 telehealth training centers that
develop and provide standardized training and
resource materials nationwide
Conducts biannual VISN reviews for integration of
telehealth standards with JCAHO requirements for
hospitial- and home-based care
Uses its national databases to generate reports
and analyses for metrics of performance of
telehealth programs at the levels of the local VA
medical center, the VISN and nationwide
Fomrs mational contracts and contract support for
telehealth technologies

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Telehealth personnel at each VAMC

Facility Telehealth Coordinator (FTC) supports
creation and operation of telehealth programs at
the local VAMC and integrate activities with the
regional VISN office
Telehealth Clinical Technicians (TCTs) trained
to use the telehealth technology and equipment,
schedule patient appointments, and provide
customer service. The TCTs are the main point of
contact with patients
Practitioners, as well as all staff engaged in
telehealth need to take telehealth-specific training
in the VAs online educational system

Veterans Integrated Service Network

(VISN 04)

VISN 4 Eastern Regional Sleep Center

referral sources
Wilmington
VAMC

Willow Grove
CBOC

PVAMC
Sleep
Center

Gloucester
CBOC

Coatesville
VAMC

Fort Dix
CBOC

Camden
CBOC

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Current clinical pathway for OSA

management at the Philadelphia VAMC
Initial Evaluation

Home sleep
study - DVD

In-lab PSG
NonOSA

Diagnostic
PSG

Split PSG

AutoCPAP
treatment

CPAP
treatment

NonOSA

AutoCPAP
treatment

Clinic FU

Long-term
FU

Telehealth pathway for management of

OSA at the Philadelphia VAMC
Video
Teleconference

Initial Evaluation

Home sleep
study - DVD

In-lab PSG
Diagnostic
PSG

Split PSG

AutoCPAP
treatment

CPAP
treatment

Wirelessmodem
datatransmission

AutoCPAP
treatment

Clinic FU

Telehealth pathway for management of

veterans with chronic insomnia
Referral of veteran
with chronic insomnia
In-person (1:1)
Clinic evaluation

ViTel (Group)
Clinic evaluation

In-person (1:1)
Cognitive Behavioral
Therapy for Insomnia
(CBT-I) Program

ViTel (Group)
Cognitive Behavioral
Therapy for Insomnia
(CBT-I) Program

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Video teleconferencing of CBT-I to

veterans with PTSD and chronic insomnia
Veterans with PTSD
and chronic insomnia

Group CBT-I
by video
teleconferencing

Group CBT-I
by in-person
delivery

Group in-person
non-active
intervention

2 weeks

2 weeks

2 weeks

q 3 months

q 3 months

q 3 months

Remote Monitoring of PAP Adherence

Internet
DME provider
Sleep lab
Patient
Home

Data Center
Patient compliance data is uploaded to
a secure, HIPAA-compliant website
using the devices integrated wired
modem

Once uploaded, patient adherence

data can be viewed, assessed and
monitored by the healthcare team

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Modem transmission of PAP data

Impact of modem-based monitoring on

PAP adherence in patients with OSA
Patients with OSA (AHI > 15) prescribed autoPAP were
randomized to standard care or telephone contact in
the first month based on modem-transmitted PAP data
Outcomes: PAP adherence after 3 mo, subjective sleep
quality, and side effects

Fox et al. Sleep 35: 477-81, 2012

Impact of modem-based monitoring on

PAP adherence in patients with OSA

Fox et al. Sleep 35: 477-81, 2012

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A cautionary message from telecardiology

Two large multicenter RCTs of telemonitoring for
patients with heart failure (Tele-HF, n=1653; and
TIM-HF, n=710) showed no effect on rehospitalization and death. In TIM-HF, 14% of those
assigned to the intervention group would not
use the system at all, and nearly half of those
who did lost interest over time.
Chaudhry et al. Telemonitoring in patients with heart failure. N Engl J
Med. 2010;363:23012309.
Koehler et al. Impact of remote telemedical management on
mortality and hospitalizations in ambulatory patients with chronic
heart failure: the telemedical interventional monitoring in heart failure
study. Circulation. 2011;123:18731880.

Essential components of a
home monitoring program
Measure
physiological
information
Reassessment
and follow-up

Timely intervention
by contacting the
patient

Transmission
of data

Processing of
data by qualified
personnel

Toward a Tobacco Free Future

Effective July 1, 2013, the University of Pennsylvania
Health System will cease hiring tobacco users in our
efforts to improve the overall health of our workforce
while reducing health care benefit costs.
The new policy will not impact the employment of
current UPHS employees who are tobacco users.
Employees will be required to complete an
attestation regarding their use of tobacco products.
Employees who are not actively enrolled in a
smoking cessation program or using nicotine
replacement therapy can expect to pay a higher
premium for their health care benefit.

5/1/2013

Behaviors that were once seen as exclusively

private often have profound societal effects. As a
result, many stakeholders are trying to change
unhealthy behaviors through mechanisms as
varied as legislative requirements for calorie
labeling in some restaurants, bans on the sale of
large servings of sugar-sweetened beverages, and
Affordable Care Act provisions allowing employers
to provide rewards or penalties worth up to 50% of
employees' health insurance premiums on the
basis of health assessments, including smoking
status. Tele-technologies will enable automated
hovering. Tele-technologies with an engagement
strategy informed by behavioral economics will be
used to hover over patients. Asch et al. NEJM 367; 1-3: 2012

Using telehealth technologies to

change healthcare behavior

Empowerment

Providing patients with

their health information to
promote self-management
and greater understanding
and participation in their
healthcare

VAAdmissionandDischargesummaries
VAAllergiesandImmunizations
VAAppointments(futureandpast)
VADemographics,VitalSigns,ProblemList
VAEKG,LaboratoryResults,PathologyReports
VAProgressNotes
VARadiologyReports
VAWellnessReminders
VAPrescriptionRefill
DepartmentofDefense(DoD)MilitaryServiceInformation

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Websites for patients on PAP therapy

Mobile app and web-based systems providing
patients with personalized feedback allowing them
to take an active role in their sleep apnea therapy.
These portals will allow patients to:
View equipment guides and educational
videos about sleep apnea
Monitor the progress of custom
goals set by the patient
Receive feedback on treatment
Troubleshoot common problems

Changing Healthcare Behavior

Transportation industries
are mandating sleep testing
of their drivers and annual
recertification of drivers
with OSA

Mandates

Current mandates are driven by

concerns about cost and justified
by concerns for public safety

Changing Healthcare Behavior

Empowerment

Mandates

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Changing Healthcare Behavior

Empowerment

Incentives/
Disincentives

Mandates

CMS beneficiaries required to use PAP treatment

for at least 4 hr/day over 70% of days in a one
month period in the first 90 days of treatment

Teletechnologies will enable

automated hovering

Empowerment

Incentives/
Disincentives

Mandates

Telehealth technologies

Emerging and future tele-technologies

Mobile phones are bridging the digital divide
Implantable and surface sensors relaying
physiological information via bluetooth technology
Medical sensors (BP cuffs, peak flow meters,
glucometers, etc.) that are embedded with 3G
mobile chips enabling each sensor to have its own
point of connectivity with the cellular network (or
that send the data to a wireless home health hub)
Biodegradable tablets that monitor medication
adherence via wireless transmission
Technologies identifying the individual wearing the
monitor

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5/1/2013

Current challenges to telehealth

Identify the patient populations that benefit from
telehealth management
Determine the organizations (hospitals, employers,
or insurers) that should deploy the technologies
Develop effective strategies to promote patient
engagement and motivation
Provide reimbursement for telehealth
Develop tools that enable a provider to scan large
data sets at a population level and at a moments
notice, drill into an individuals information to
enable just-in-time decision making
Protect patient privacy and security

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