Telemedicine: Will Sleep Medicine Ride this Wave of the Future?

Telemedicine is emerging as a powerful service delivery platform across the USA and around the world. While there are tremendous opportunities embedded in this advanced technological approach to patient encounters, telemedicine may be especially suited to some fields of healthcare more than others. The most natural use of telemedicine would be any form of telephonic communication, including skype encounters or other forms of videoconferencing, wherein the only goal is to conduct a conversation between patient and doctor. There are many more approaches to telemedicine that involve hospital systems, arranging for specialist care from off-site physicians, but the focus of this blog is on the more basic level of service between a doctor and patient.

As talking heads are the essential requirement for most psychotherapy today, it is no surprise the field of psychology has seen a substantial rise in telemedicine services, and research studies have already been conducted to demonstrate efficacy in this form of care delivery. In thinking about medical fields, psychiatry is probably the next best suited to telemedical services, because so much of the discussion nowadays revolves around monitoring changes in symptoms with subsequent adjustments of psychotropic medications. Still another version of psychological or psychiatric interventions includes web-based approaches such as video lectures or creative interactive programs to help patients treat a diverse array of ailments such as anger management, agoraphobia, depression, and traumatic brain injury.(1)

Sleep medicine may also be well suited to telemedicine services, because although our field requires hands-on activities such as mask fittings for PAP use and sleep studies in a sleep lab, there is a great deal of coaching and educating that sleep professionals must provide to patients. It is conceivable that programs supervised by medical doctors and operated by sleep technologists could vastly expedite communication with patients to trouble-shoot and problem solve issues surrounding PAP equipment, and a related program could be implemented to coach patients on insomnia, again operated by trained sleep technologists and supervised by a psychologist or physician trained or experienced in cognitive-behavior therapies. Such programs have already been attempted.

Unfortunately, at this point in time, there are many barriers to telemedicine services, which also may apply to sleep medicine programmatic efforts. These barriers are not insurmountable, but in the short- and long-term, they will create large hassle factors in trying to streamline programs. The results may be less than optimal until these barriers can be overcome. Briefly, there are two main barriers to discuss.

The financial issue is a large barrier, because very few insurance carriers are up to speed on telemedicine services in ways that easily promote use of this advanced technology. For example, some carriers may have rules requiring in-person visits with patients before they can subsequently make use of telemedicine visits. As you would imagine, this rule completely subverts the purpose if telemedicine were attempting to help someone a long distance away from the provider. Some insurance carriers may not cover such services, and then the individual would need to pay out of pocket. The equipment involved may also represent another financial barrier if patients do not have access to the appropriate computer hardware and software as well as internet speed to successfully engage in a telemedicine encounter. All these obstacles should be fixable, but administratively, it may take quite a long time to prevail upon healthcare systems to embrace this newer approach to care.

Along the same lines, but probably an even larger obstacle, is the licensing issue. State medical boards have a great deal invested in maintaining control over practices within their individual borders. In the past, where radiologists engaged in telemedicine activity to help read imaging studies (e.g. X-rays, CT scans, MRIs, etc.), the physician would secure a license to practice medicine in that individual state. Some radiologists have licenses to practice in 20 different states, because the demand for services has been so high, and apparently the availability of local radiologists was so low.

Now, there is a push for the Interstate Medical Licensure Compact to expedite the capacity for an individual physician to deliver services across state lines. As a novel idea, the compact sounds very interesting, but there have been many concerns that it will prove far too costly, will continue to require individual state licensure, and will markedly increase regulatory burdens on participating physicians. Frankly, I have tried to read pros and cons on this topic during the past year, and I remain fairly confused about how the program would work and whether or not it will prove another regulatory nightmare akin to Obamacare. For more details, here’s a website describing some aspects of the compact and the legislative progress toward enacting the system.

These two areas, financial and licensure, are probably the two greatest barriers to setting up workable telemedicine programs, especially among those hoping to see care delivered across state lines. Another option sure to arise at some point is to avoid the financial aspect altogether by offering non-insurance based services, i.e. paying out of pocket. Actually, this approach might expedite things considerably if the fees charged can be maintained at a reasonably lower level, which is possible because the physician is not burdened by insurance regulations and administrative burdens that always jack up the price of care. But, there is no easy solution to the interstate barrier, because of the ongoing concerns of state medical boards. 

Summing up, these barriers will directly affect sleep medicine professionals as they attempt to expand into this realm. As things stand now, most institutions attempting telemedicine programs stick to within state borders’ patients to avoid any conflicts with state medical boards. Thus, it would seem that a long-term proposition for sleep services crossing state lines is not in our immediate future.

 

References and Additional Reading Material

  1. Norman S. The use of telemedicine in psychiatry. J Psychiatr Ment Health Nurs. 2006 Dec;13(6):771-7.

  2. Bossen AL, Kim H, Williams KN, Steinhoff AE, Strieker M. Emerging roles for telemedicine and smart technologies in dementia care. Smart Homecare Technol Telehealth. 2015;3:49-57. Epub 2015 Mar 22.

  3. Wilson LS, Maeder AJ. Recent Directions in Telemedicine: Review of Trends in Research and Practice. Healthc Inform Res. 2015 Oct;21(4):213-22. doi: 10.4258/hir.2015.21.4.213. Epub 2015 Oct 31.

  4. Merrell RC. Geriatric Telemedicine: Background and Evidence for Telemedicine as a Way to Address the Challenges of Geriatrics. Healthc Inform Res. 2015 Oct;21(4):223-9. doi: 10.4258/hir.2015.21.4.223. Epub 2015 Oct 31.

  5. Downes MJ, Mervin MC, Byrnes JM, Scuffham PA. Telemedicine for general practice: a systematic review protocol. Syst Rev. 2015 Oct 5;4(1):134. doi: 10.1186/s13643-015-0115-2.

Barry Krakow MD

Author

Dr Krakow’s 27 years of sleep research have focused on the complex relationship between physiological and psychological sleep disorders. Dr Krakow currently operates private sleep medical center, Maimonides Sleep Arts & Sciences, Ltd., and serves as Classic SleepCare’s paid Medical Director.



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