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B. G. Fields and I. M. Rosen
the Remote Veteran Apnea Management Platform (REVAMP). REVAMP has been
designed with input from veterans and clinicians throughout the VA system, under
the direction of the VA Ofce of Connected Care and the Ofce of Rural Health.
Now available at over 50 VA medical centers, REVAMP provides users with the 7
core elements of internet-based portals above. Veterans are offered REVAMP access
upon their initial referral to the sleep center. They complete several validated sleep
screening questionnaires, and sleep clinicians utilize those responses to help guide
patients to their next stage of testing. Patients started on PAP can view their nightto- night PAP machine adherence and efcacy data through REVAMP, where they
can also complete follow-up questionnaires, access educational materials, and send
a message to their provider. Clinicians access REVAMP through a designated
provider- facing portal. There, they can view all pertinent data, offer the patient additional questionnaires to complete, and incorporate all patient- and PAP-machine
entered data into a comprehensive clinic note [85].
Leverage Telemedicine (Point D)
Of course, some patients cannot access such tools independently due to lack of
internet connectivity and physical challenges. Healthcare models should always
account for these situations, offering patients as diverse an array of modalities as
possible (e.g., telephone visits, clinical video telehealth, or in-person visits) [72]. As
noted above, potential strategies to improve patient access to sleep care include better training for primary care providers and specialists, bringing more BCSMPs
through the training pipeline, and promoting the development of sleep teams.
Nevertheless, the AASM asserts “None of these solutions has more immediate
potential to overcome these challenges than telemedicine, which can dramatically
increase sleep medicine accessibility and clinical efcacy” [36].
Terminology
Sharing a common language is important when considering telemed-
icine’s impact on future sleep medicine paradigms. According to the Health
Resources and Services Administration, “telehealth” is a broad term implying “the
use of electronic information and telecommunication technologies to support and
promote long-distance clinical health care [86], patient and professional healthrelated education, public health and health administration.” In contrast, “telemedicine” specically refers to patient-provider interactions. The Federation of State
Medical Boards denes telemedicine as “the practice of medicine using electronic
communication, information technology, or other means between a physician in one
location, and a patient in another location, with or without an intervening health
care provider” [87]. Since the focus of this chapter is on patient care, we favor the
term “sleep telemedicine.” Sleep telemedicine can be categorized as either synchronous or asynchronous, a key distinction with implications described below. (See
Feasibility section). Asynchronous telemedicine includes patient-provider messaging through a secure email-style system and store-and-forward technologies such as
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the patient- and provider-facing online platforms now available from most PAP
machine manufacturers. Figure4.1 illustrates another use for asynchronous telemedicine: provider-to-provider interaction (Point E). As shown, there can be many
decision points for non-BCSMPs once screening and initial work-up are complete.
Collaboration with a BCSMP or team member through secure email systems,
portals, or a common electronic medical record (EMR) can be crucial to streamlined
patient management. For example, the VA health care system has employed
provider- to-provider asynchronous telemedicine through its use of “e-consults.”
Non-BCSMPs place relatively straightforward clinical questions directly into the
EMR; BCSMPs and their team members may answer those questions and guide
further work-up. Therefore, many veterans may begin their work-up and treatment
without waiting for, or traveling to, the sleep center [72].
As opposed to asynchronous telemedicine, synchronous telemedicine is realtime communication between patients and providers. Telephone calls are one example, as are the audio-visual interactions used for Clinical Video Telehealth (CVT).
CVT visits are currently accepted for initial visits, ongoing patient follow-up, and
encounter reimbursement, and they closely emulate a traditional in-person visit.
Long the CVT standard, Center-to-Center (C2C) telemedicine implies a provider (at
a distant site) and a patient (at an originating site) are both in clinical locations.
Emerging CVT modalities include Center-to-Home (C2H) telemedicine where the
patient is in a non-clinical location and Out-of-Center (OOC) telemedicine where
both patient and provider are at non-clinical locations. C2H and OOC telemedicine
provide progressive levels of patient-centered exibility but also come with their
own complexities since distant-site providers are more reliant on originating site
patients’ technical savviness and troubleshooting.
Feasibility of Communication via Telemedicine Represented by Point D in
Figs. 4.1 and 4.2, telemedicine can be employed for many initial and follow-up
encounters. Sleep patients’ receptiveness to telemedicine has been demonstrated for
at least the past decade [88]. Nevertheless, questions persist as to how feasible it really
is to include telemedicine in future sleep care models. The COVID-19 pandemic
brought with it a rapid migration to telemedicine [89], forcing many sleep providers
to reckon with several aspects of its feasibility presently and moving forward: technology, privacy and security, reimbursement, licensing, and clinical outcomes.
Sleep telemedicine (specically CVT) is technically feasible, and CVT visits
have been conducted for more than a decade. Various platforms allow real-time
audiovisual communication and several of them also offer tele-stethoscope and portable camera options; these physical exam tools are typically utilized only for C2C
telemedicine. The AASM recommends up-to-date software with a minimum connection speed of 384kbps and 640×480 video resolution transmitted at 30 frames
per second [90]. Sleep telemedicine is also feasible from a privacy and security
perspective, with the AASM making further recommendations that any CVT platform be patched with the latest security updates, encrypted, and only accessible by
authorized users [90].
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B. G. Fields and I. M. Rosen
Financial feasibility has long been an impediment to sleep telemedicine’s proliferation, though changes just before and during the Covid-19 pandemic have been
quite impactful. Most states now have “parity laws” that require private insurers to
reimburse providers the same for a telemedicine visit as for an in-person visit.
States’ Medicaid reimbursement has also become more favorable toward telemedicine, but knowing terminology is key; “telemedicine” is typically limited to CVTstyle visits whether seeking private or Medicaid reimbursement. Researching
guidelines at both the distant and the originating site is key to understanding whether
reimbursement can occur [91]. Federal reimbursement from the Centers for
Medicare and Medicaid Services (CMS) has also been fraught with complexity.
Prior to the Covid-19 pandemic, C2C sleep telemedicine reimbursement was available only for the most rural originating sites, and it was not available at all for C2H
or OOC sleep telemedicine models. The Covid-19-associated public health emergency loosened those restrictions at least temporarily. The CMS website should be
consulted for the latest guidance [92].
Sleep telemedicine’s feasibility from a licensing perspective has also been complex. Providers must generally be licensed in the patient’s state (originating site) for
them to practice. The Federation of State Medical Boards has developed an Interstate
Medical Licensure Compact that now includes most states. The Compact allows a
physician in one state to have licensure facilitated in another state as long as both
states are part of the Compact. Additional strategies to facilitate interstate medical
licensing, and even to develop a unied national medical license, have been proposed [93]. Further progress in this area will continue to lower the hurdles toward
telemedicine’s wider adoption.
The most important measure of sleep telemedicine’s feasibility may come
through the lens of clinical outcomes. That is, can we maintain the same level of
clinical care in the Fig.4.1 model, or any model, using sleep telemedicine? Previous
work has suggested that OSA patients’ functional outcomes, PAP adherence, and
satisfaction do not differ when assessed and followed through telemedicine (CVT)
versus traditional in-person care [94, 95]. Those ndings, especially in light of the
AASM’s OSA Quality Measures, [96] suggest that sleep telemedicine for OSA is
feasible from a clinical outcomes perspective assuming the other elements of feasibility above are fullled (adequate technology, etc.). Similar results have emerged
recently from insomnia research. Cognitive behavioral therapy for insomnia (CBTI) provided through CVT produces similar improvements in Insomnia Severity
Index as CBT-I provided in-person [97]. CVT-based treatment outcome studies in
other sleep disorders remain lacking.
Special Considerations
oping eld. Though its utilization appears more and more essential to the future of
sleep telemedicine paradigms (Figs.4.1 and 4.2, Point D), its deployment remains
complex. Providers should consider carefully not only the feasibility issues above,
but also specic laws and regulations pertaining to their specic state(s) of practice.
As of the writing of this chapter, there has been no successful litigation of a sleep
provider simply due to the use of telemedicine. However, standards of care should
Sleep telemedicine is still a relatively nascent and devel-
4 The Future ofSleep Medicine: APatient-Centered Model ofCare
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be upheld, and it is up to that provider to ensure that all applicable rules are followed
(e.g., interstate medication prescribing, licensing). The AASM provides a “checklist” of regulatory issues to aid new and more experienced sleep telemedicine providers [98].
A discussion of sleep telemedicine must also address technology the patient
brings to the visit. Wearable consumer sleep technologies will undoubtedly play an
increasing role in sleep medicine as newer devices become more advanced and fulll the broad denition of asynchronous, store-and-forward sleep telemedicine.
Though their accuracy and reliability in data reporting has long been suspect, current device algorithms more closely mimic established tools such as home sleep
apnea testing (HSAT) and actigraphy [99]. Indeed, the evolution of sleep medicine
may rely increasingly upon the most patient-centered data of all: that which these
patients collect themselves in their natural environment. It will be up to the provider,
whether BCSMP or non-BCSMP, to integrate that information with evolving clinical guidelines to devise collaborative sleep disorder management plans.
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Putting It All Together
Ideally, given the importance of sleep health and how ubiquitous sleep complaints
are, a patient should be able to access sleep medical care in a way that is patientcentered. Care should be convenient, timely, and evidenced based. We propose a
model of care that starts with the identication of a patient who has a sleep complaint (Fig.4.1, Point A–C). This identication could be based on provider inquiry
and/or patient self-screening. Articial intelligence would also leverage information
in the electronic health record, and chart nudges would prompt formal screening
questionnaires and/or provider inquiry to the patient. If a patient is determined to
have a high pretest probability for obstructive sleep apnea with or without comorbid
insomnia, the involved provider would order a home sleep apnea test and place a
referral for CBT-I, if appropriate (Fig.4.1, Point D). If the HSAT was positive for
OSA, the ordering provider would initiate treatment with CPAP and follow the
patient to ensure symptom improvement as well as ongoing adherence to CPAP as
part of routine care. If the patient is not responsive to usual therapy, a referral would
be made to a sleep medicine specialty team (Fig.4.1, Point E). The guidelines for
and facilitation of such a referral should be predetermined, similar to how a provider
would refer a patient with difculty to control diabetes or hypertension would be
referred to an endocrinologist or cardiologist, respectively. Importantly, patients
with concern or high risk for sleep-disordered breathing that is not straightforwad
OSA should be referred to a sleep medicine provider directly to expedite evaluation
and treatment.
Alternatively, if a patient is noted to have insomnia or another sleep disorder that
the engaged provider is comfortable diagnosing treating (e.g., restless leg syndrome),
a treatment plan can be initiated by the non-sleep specialist, as appropriate (Fig.4.1,
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B. G. Fields and I. M. Rosen
Point E; Fig.4.2, Point D). Again, if the patient is not responsive to usual therapy or
if the provider is not comfortable or feels uncertain with any aspect of diagnosis or
treatment, a referral would be made to a sleep medicine specialty team (Fig.4.1,
Point E; Fig.4.2, Point D). A patient who has a sleep complaint but who does not
screen positive for a sleep disorder should be evaluated for the appropriate non-sleep
disorders related to their complaint (e.g., mood disturbance, thyroid disease, asthma).
If no obvious cause is determined and ongoing concerns about sleep remain, a referral to a sleep medicine physician could be considered. (Fig.4.1, Point F).
The model we propose identies several areas for future development. These fall
under the categories of telemedicine, education, industry partners, and guidelines.
Leveraging telemedicine to facilitate patient identication, screening and provider
response is critical. Non-sleep provider education along with easy access to treatment guidelines and pathways is vitally important as well. All primary care providers (e.g., internal medicine, family medicine, pediatrics, OB/GYN, and general
surgery) and relevant specialties (e.g., cardiology, pulmonary, and ENT) should
have ACGME and ABMS mandates to learn about basic sleep disorders as part of
their training. Similarly, advanced practice providers should be expected to learn
this as part of their specialty training. Providers who have already completed their
training could be encouraged to learn about important sleep disorders via statemandated licensure requirements, maintenance of certication, CME, and/or CNE
offerings. Additionally, we believe industry should be called upon to leverage articial intelligence to facilitate initial patient identication (i.e., EHR vendors) as well
as those who would benet from stepped up care. For example, PAP vendors could
create a dashboard that alerts a provider to all patients in their panel who are not
adherent to PAP or whose PAP is not effectively treating their sleep apnea, as
opposed to requiring a provider to log into a specic patient’s PAP data.
Last but not least, we enthusiastically support the development of national guidelines to further articulate the collaboration between sleep medicine specialists and
non-sleep trained providers. Such guidelines should have input from a diverse set of
applicable stakeholders, inclusive of patients, relevant industry and business partners, leaders from appropriate professional organizations familiar with clinical
guideline development, and sleep and non-sleep providers. Insurers and self-insured
businesses should be called upon to work together as stakeholders to test these
guidelines and demonstrate value. Once such collaborative guidelines are outlined,
adjustments can be made locally between the spoke and hub providers, as needed,
to further facilitate access to patient-centered sleep care.
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