"Sleep Medicine and Telehealth in the 21st Century: Using Technology to Empower Patients and Physicians" Santosh Vaghela(03.24.2021)

April 04, 2021

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00:22Alright, good afternoon everybody.
00:24I think we're going to get started.
00:26I'm Lauren Tobias and I'd like to welcome you
00:29to our yield sleep seminar this afternoon.
00:32A few brief announcements
00:33before I turn it over to Dr.
00:36Ian Weird to introduce today's speaker,
00:38please. First take a moment to
00:40ensure that you're muted in order to
00:42receive CME credit for attendance,
00:44please see the chat room for instructions.
00:46You can text the unique ID for
00:49this conference until 3:15 PM.
00:51If you're not already registered with
00:53Chelsea and me will need to do that first.
00:55If you have any questions
00:56during the presentation,
00:57please make use of the chat room throughout
01:00the hour and we will invite you to unmute
01:02at the end and ask your questions.
01:04Also, if you so choose.
01:06I have recorded versions of these
01:09lectures available online within two
01:10weeks at the link provided in the chat,
01:13and finally,
01:13please feel free to share announcements
01:15about our weekly lecture series to anyone
01:18else who you think may be interested
01:20or you can can't contact Debbie
01:22Lovejoy to be added to our email list.
01:25So with that I'm going to
01:26turn it over to Doctor.
01:28We're alright.
01:29Hi everyone,
01:30in Ware program director for pulmonary
01:32and Sleep Medicine at New York
01:34Hospital and I have the honor today
01:36to introduce our Speaker Doctor.
01:38Santos Fagella he's one of
01:40our Sleep Medicine fellows,
01:41so before starting his fellowship he
01:43did his internal medicine training at
01:45Waterbury Hospital and then completed
01:47his pulmonary and critical care
01:49training at Norwalk Hospital and Yale,
01:52New Haven for critical care Medicine.
01:54And then I was lucky to convince him
01:56to stay for an extra year of Sleep
01:59Medicine where he's about to finish
02:02up his Sleep Medicine fellowship.
02:04Doctor Miguel almost didn't become a doctor,
02:06he was actually.
02:08An engineer and a paramedic,
02:09and Luckily he was swayed to come
02:11and pursue a medicine career,
02:13and we're very lucky to have him.
02:16Also some good news about Doctor Fagella.
02:18He's welcoming his first child in a
02:21few weeks to and so he's very excited
02:23with his wife to have a daughter
02:26and this is going to be a new life
02:29for him and he's very excited.
02:31Once he finishes his Sleep Medicine training,
02:33he will be off as a pulmonary critical
02:35care and sleep attending in Sarasota Springs.
02:38Beautiful upstate New York with
02:40great weather and act or outdoor
02:42activities and he's going to be being
02:44a great asset to their Medical Group.
02:47So with that I'd like to introduce
02:49Doctor Miguel who will be talking
02:51about Tele Health and talking
02:53about really all the aspects of
02:55Tele Health with a unique twist.
02:56So here we go.
02:58Take it away.
02:59Thanks Doctor Weir.
03:00Hello everyone, good afternoon.
03:02Thanks for joining us
03:03today as Doctor Weir said,
03:04I'll be talking today a little
03:06bit about Sleep Medicine,
03:08Tele medicine and I know we've
03:09been doing a lot of this recently,
03:12so I'm hoping to take a little
03:13bit of A twist that we haven't
03:16yet discussed or seen yet.
03:18And that's talking a little bit about
03:20the evolution of where Tele medicine
03:22is come from to what it is now,
03:24and to also discuss about where we're
03:27going in the future with Tele medicine.
03:30As always,
03:31there's no commercial support
03:32for grand rounds today,
03:34and I don't have any conflicts
03:36of interest to disclose.
03:38We're going to discuss again a few aspects
03:40of Sleep Medicine currently and again,
03:43namely,
03:43we talk a lot about Tele medicine
03:45and the models that we're currently
03:47using in our day-to-day practices.
03:49It's pretty clear that
03:51telemedicine is here to stay,
03:52so I think it's relevant to delve into the
03:55long term implementation of Tele Medicine.
03:57Really, understanding historical
03:59perspective where telemedicine came from.
04:01Talk about some of the models that are in
04:03place right now and talk about the potential
04:06future models that could be implemented.
04:08I want to also discuss,
04:10you know, as we all know how
04:11the pandemic is really shaped.
04:13Telemedicine,
04:14how as it exists right now and
04:16to look at some of the evidence
04:18that exists behind Tele medicine,
04:20you know,
04:20is it really not inferior
04:22to face to face visits?
04:23What aspects of Sleep Medicine can we apply?
04:26Tele medicine to somewhat
04:27confidently on a regular basis?
04:29And then finally I want to end by
04:31talking about some of the current
04:32integrated platforms that exist
04:33just to showcase a little bit.
04:35Technologies are out there.
04:36I would love for this to
04:38be an interactive talk,
04:39so if anyone has any questions or
04:42needs clarification please feel free to
04:44either raise your hand or just jump right in.
04:47So let's just talk about a little bit
04:49of definitions before we get started.
04:51I think a lot of these terms
04:53are used interchangeably.
04:53Tele Medicine and Tele health.
04:55But it's important to separate them out,
04:57because,
04:57again,
04:57we are going to be using them
05:00going forward quite a bit as we
05:01have been for the past year.
05:03Tele Medicine is really what we've
05:05been doing every day for the most part.
05:07It's really a physician or
05:09clinician at one location.
05:10Using telecommunications to
05:11deliver care to patients at a
05:13distance site and that site could
05:14be their home could be an office,
05:16but it's really that one on one
05:18interaction that we're doing.
05:19And delivering medicine to patients.
05:21Tele Health is actually a much broader term.
05:25It uses a broader range of technologies
05:27and services to provide patient care
05:30and improve healthcare delivery,
05:32and it can refer to remote clinical
05:34services as in Tele medicine,
05:37but it can also refer to non
05:40clinical services.
05:40These include clinician training,
05:42administrative meetings,
05:43continuing medical education
05:44and so on and so forth.
05:47So we can consider Tele medicine
05:49as essentially a branch of the.
05:52Broader Tele health term.
05:55When I think about Tele medicine,
05:57I think of it in two ways.
05:59I think of it as a patient
06:02form and a clinician form,
06:04and the overarching themes that I
06:06think about in Tele medicine in terms
06:09of patients are really improvement
06:10of patient access to clinicians,
06:13and more so convenience to patients as well.
06:16I think convenience is starting to
06:18become a major theme in Tele medicine,
06:21and we may see that as a
06:24growing theme going forward.
06:27For clinicians, however,
06:28Tele medicine means a little
06:29bit of a different thing.
06:31Certainly it means improvement
06:33in patient access to clinicians.
06:34We obviously want to be able to have
06:37our patients see us and any modality
06:40that's validated that provides
06:41patients with improved access to
06:43clinicians should be a good thing.
06:45But also, you know,
06:47a theme that's come up and we'll
06:49talk about quite a bit inside
06:51of this talk is reimbursement
06:54legalities regarding Tele medicine.
06:56You'll find the reason that
06:58telemedicine really has been not
07:01quite popular up until recently is
07:03that it's been difficult to have
07:06reimbursement linked to these visits.
07:08It's been very limited and sporadic,
07:10and the law also was quite broad
07:13and vague terms at a state level
07:16when it came to Tele medicine,
07:19and thus these issues weren't really
07:22systematically approached until recently,
07:23so you'll hear me talk a little bit.
07:27About specifically reimbursement
07:28legality a lot when it comes
07:31to the physician side of Tele
07:33health and telemedicine.
07:35So quick history,
07:36lesson,
07:36telemedicine and in many forms and Tele
07:39health have been around for quite awhile.
07:42Pennsylvania,
07:42back in 1940 was really the first time
07:46that we saw the first electronic transfer
07:49of a medical record by a telephone line.
07:52Radiology images were sent about
07:5424 miles between two townships,
07:56and this was thought to be pretty
07:58groundbreaking at the time.
08:00A Canadian doctor then built upon this
08:03technology in the 1950s and created an
08:06entire teleradiology network in Montreal.
08:09These practices became more
08:10widespread within radiology,
08:12and with film becoming prevalent technology,
08:14there were serious plans for video medicine
08:17that were created and actually in 1959,
08:20the University of Nebraska set up a
08:23two way television set up to transmit
08:26information to medical students
08:27across campuses across their campus.
08:30Excuse me.
08:31And then, five years later,
08:33linked it with the state hospital,
08:35performed video consultations.
08:37Remember, this was a 1959 so.
08:39We've had some form of technology
08:43that's developed for quite awhile.
08:46When we think about Tele medicine,
08:48there's really two models that
08:50that we think about.
08:51There's the center to center model
08:53and the center to home model.
08:56Prior to the pandemic of the Center,
08:59the center model was probably
09:01the most prevalent model.
09:02This model uses an originate Ng site,
09:05which is typically a medical
09:07office or clinic where audiovisual
09:08equipment is located.
09:10This baby equipment is
09:11usually very high quality.
09:13Patients are required to
09:14travel to this office,
09:16check in as they normally
09:18would within your office.
09:19Be roomed, they would have their vitals
09:22checked by either an MA or nurse and then
09:25the interaction starts with the AV equipment.
09:28The physician is located generally quite
09:31far from the patient, and there are.
09:35Adjunctive staff available to
09:37introduce additional technologies
09:38to supplement the visit.
09:40You know for physical example for,
09:43for example.
09:45Center to home is something
09:47that I think we're a little bit
09:49more familiar with these days.
09:51This is the model that we're currently using
09:53with the patient uses their own technology,
09:56a laptop or cell phone,
09:58and they access your system from.
10:00Essentially,
10:00wherever they prefer,
10:01you know, be at their home.
10:03In some cases, the car and so on.
10:07So the center center model
10:10is essentially the current.
10:12Or previous gold standard it most closely
10:15approximates a live in clinic visit.
10:17It facilitates workflow and
10:20office coordination that's very
10:22similar to a face to face visit.
10:25Thing also was reimbursed in a more
10:28standard way that we'll talk about.
10:31This allowed for high quality audio
10:34visual equipment to be used and the
10:38technical abilities generally were
10:40much greater or greater in this
10:43modality compared to center home.
10:46Some obvious key disadvantages to this
10:48model are that remote site agreements
10:50are required to participate between your
10:52office or wherever the clinician may be,
10:54and the remote center,
10:55if they were owned independently and there
10:58were higher costs associated with this model.
11:00Equipment was much higher
11:02quality and cost more money.
11:03You had to have personnel
11:05at the clinic to staff it,
11:07and it was less convenient for patients
11:09because they couldn't do the visit from home.
11:12They had to come to the originate Ng site.
11:17This centered a home model is essentially
11:21what we consider the new standard.
11:24Obvious key advantages here to the patient,
11:27because they're using their own technology
11:30without the need for an originating site.
11:33Patients access the technology again from
11:36wherever they are from home from work,
11:39and it facilitates easier communication
11:41between patients and their clinicians.
11:44Key disadvantages to this,
11:46as we've probably all seen,
11:48is that privacy is a little bit more
11:51difficult to monitor and ensure.
11:53Especially if you're not using
11:55definition are not on a hospital
11:58network or office network that secured.
12:01There is the potential inability
12:03to use the tools by the patient.
12:06You know in terms of using their technology.
12:09Signal quality can obviously significantly
12:11vary depending on where the patient is,
12:14what kind of access they have
12:16to Internet and Wi-Fi.
12:18Uhm?
12:19And prior to recently,
12:21insurers and governments were not
12:24very amenable to center to home models
12:27as being a reimbursables service.
12:29So let's take a little bit of time
12:32and talk about how Tele medicine
12:35was prior to the covid pandemic.
12:38In a term it was not great.
12:40I think you can.
12:41We can all agree that Tele medicine was
12:43somewhat limited from our own experience.
12:45Doctor Weir, our program director,
12:47was one of the few clinicians
12:49in our entire network
12:51that was doing Tele medicine prior to covid.
12:54And I think it's important to talk
12:56about what Tele medicine really
12:58was like prior to the pandemic,
13:00because it really does give you a
13:03new appreciation to what we have,
13:05what we've evolved into in the past year.
13:10Tele medicine really all started.
13:14With the VA and veterans Anan
13:17honestly with rural health.
13:20The VA in the early 2000s were
13:22looking for a way to improve access
13:25to rural veterans at that time,
13:27about a little over four and a
13:30half million veterans lived in
13:32rural communities and as a whole,
13:34rural veterans had less access to
13:37health care providers and nurses per
13:39capita in their areas that they lived.
13:42They had lower household incomes and
13:44still do in some cases as much as 50%
13:48or higher or lower annual incomes.
13:50And as a result they either didn't
13:53have access to Internet or they
13:55face very long distances that they
13:57had to drive to access quality
13:59healthcare in urban areas.
14:00So as a result,
14:01the VA created the Office of Connected
14:04Care and this is going to be a little
14:07bit off in terms of timeline timeline,
14:09so I apologize for that.
14:11But what the office of Connected Care
14:14did was work really well with the Office
14:17of Rural Health and the VA organization.
14:20And really worked to try to eliminate
14:22or minimize these barriers that
14:24rural veterans faced in obtaining
14:27the services that they required.
14:29The VA created the first home Tele
14:32Health program back in 2003 and
14:35continually VA research is working
14:38with connected care to conduct
14:40studies that are looking at areas
14:43of need or to test connected care
14:46solutions and targeted interventions
14:48that help improve access to rural
14:51and other veterans who need them.
14:55This is a list from the VA Research
14:57Group on selected accomplishments and
14:59studies that they've done over the years
15:02that help to fill disparities that
15:04exist for rural and other veterans.
15:06Looking at this, I think one of the
15:09things that really struck me the most
15:11is that it's clear that the VA has
15:14taken a patient centered approach
15:16to implementation of Tele medicine,
15:18amongst other technologies.
15:19They really were looking to
15:21improve patient access,
15:22veteran access to clinicians
15:24in areas where it was lacking.
15:27As you'll see, this contrasts quite
15:30a bit to the civilian side of things,
15:33historically speaking.
15:36Since most of us do work on the
15:39civilian side, I think we're going
15:41to spend more time on this,
15:43but it's in my opinion,
15:44was important to at least delve into the VA,
15:48being really the forerunner in patient
15:50centered access to Tele medicine.
15:52On the civilian side of things again,
15:55Tele medicine concepts have
15:57been around for a while,
15:59but the first major push seemed to
16:02have been during the Obama years
16:05with the Affordable Care Act.
16:07If you'll remember,
16:09the ACA was introduced back in 2010,
16:12and the ACA had several large portions to it,
16:15but one of the major goals was to
16:18move away from a fee for service
16:21model and really promote preventative
16:24care and Wellness.
16:25And within this preventative care
16:27and Wellness,
16:28there were some penalties that were
16:30created for hospitals for chronic re
16:33admissions for Medicare patients,
16:35namely for heart failure pneumonia.
16:37Post MI.
16:37And there was also a focus on
16:40connected health and electronic
16:42health records,
16:43so a lot of large hospital networks,
16:46the Kaiser Foundation,
16:48for example on the West Coast.
16:52Took the initial focus for Tele
16:54medicine for them based on the ACA's
16:57edicts to really use telemedicine
16:59to help hospitals lower re admission
17:02rates for patients with heart
17:04failure with pneumonia,
17:05and post MI to allow them to
17:08have connections to doctors and
17:10other health care professionals.
17:12Nurses care managers after discharge.
17:16Again,
17:16compared to how the VA took the
17:19approach of improving access
17:21on the civilian side,
17:23I think it was more focused on costs
17:27and avoidance of repercussions,
17:29and unfortunately the reimbursement
17:31side of things did not correlate
17:34or follow from the government.
17:36So that led to very limited.
17:40By and from hospital groups and from
17:43hospital networks in Tele Medicine.
17:45Some of these things that we saw
17:47in the past few years were that
17:49Medicare would only pay for a limited
17:52amount of Tele medicine services,
17:54and again a very limited circumstance.
17:56In general,
17:57patients had to be in a designated
17:59rural area for the most part,
18:01and they had to leave their home to
18:03go to a center to have a synchronous
18:06communication with with the clinician.
18:09This center to center model
18:11that we discussed.
18:12Remote patient monitoring for chronic
18:15diseases was not covered at any
18:17store and forward services which will
18:19discuss were also not covered except
18:22for in certain states such as Alaska
18:24and Hawaii. As a whole, again,
18:29we're going to talk about reimbursement
18:31quite a bit in the next couple of slides,
18:34because whether we like it or not,
18:37hospitals, an networks and offices have to
18:40be paid for the services that we provide,
18:43and with reimbursement
18:44being extremely limited,
18:45there seems to be there had been
18:48minimal incentive for large networks
18:51to invest in Tele medicine technology.
18:54In 2018, Medicare started paying
18:56for brief communications with
18:57clinicians called virtual checkins.
18:59These were different from the
19:01traditional Medicare Tele health
19:03visits because they were patient,
19:05initiated,
19:05and there were very specific rules
19:08regarding the communication.
19:09The rules were one of them was the
19:12communication could not be related to
19:15a medical visit that occurred in the
19:18past seven days and must not lead to a
19:21medical visit within the next 24 hours.
19:24Additionally,
19:24verbal consent had to have
19:26been obtained for the virtual
19:29check-in for every single visit,
19:31for this was changed in January
19:34of 2020 to allow a clinician to
19:37obtain a single consent for a
19:40years worth of these services.
19:43There were a few exceptions to
19:45these otherwise strict rules.
19:47One of them were dialysis patients
19:49could have their dialysis facilities
19:51and homes qualify as originating
19:53site for Tele Health encounters.
19:56Mobile stroke units could also be
19:58originate Ng sites and specifically.
20:00Individuals with substance abuse
20:02disorders or kerkering mental health
20:04disorders could have their homes made
20:06into an eligible originating site,
20:07although that site would not
20:09qualify for the facility fee.
20:12In 2019,
20:12CMS also added reimbursement for several
20:15other remotely furnished services.
20:17This includes the evaluation of
20:19prerecorded patient information that was
20:21either via video or image technology,
20:23and this was to really determine if an
20:26office visit or service was necessary.
20:29This was only established to this
20:31is only able to establish patients,
20:34excuse me.
20:36Interprofessional Internet consultation
20:37was also reimbursed with this limited
20:40between practitioners that could
20:42independently bill for enm visits,
20:43so this is our E console that we see.
20:49And then E visits were also reimbursed,
20:51and this allowed for patients
20:54to communicate with providers
20:55through online patient portals.
20:58So.
20:58Specifically,
20:59we're seeing that there's quite a few
21:02civilian side Tele medicine issues
21:05that specifically go with Medicare.
21:08There is clearly limited access
21:10to patients pre pandemic.
21:11The Center to center model
21:13was heavily favored,
21:14which limited the patients
21:16ability to see clinicians.
21:17They had to go and travel to the office.
21:21There was a lack of universal uniformity
21:23between payers and at the state level.
21:26That's quite important.
21:27Will discuss.
21:28We had a high cost of AV equipment
21:30and the buy in was quite high
21:33with again limited reimbursement,
21:34so there wasn't much.
21:38And there's a lot at stake for
21:40hospital networks to invest in this
21:41technology that really had very
21:43convoluted rules on reimbursement,
21:45and that were quite limited to begin with.
21:48So we talked a lot about the federal
21:50level with Medicare patients,
21:52but how does this all work at
21:55the state level?
21:57Specifically, as we all know,
21:59Medicare regulates self insured
22:01health plans and Medicare patients.
22:03The federal level.
22:04But Medicaid and private payers are regulated
22:08both at the federal and state level.
22:11The state level is a whole
22:13different conversation.
22:14There are multiple complex
22:15regulatory frameworks that are
22:17at place and state to state.
22:19The rules differ quite a bit,
22:21so telemedicine implementation
22:23is was extremely challenging.
22:24As a result of the different
22:27state to state rules that exist.
22:30What I think is important for all of us
22:33to understand are the so-called parity laws,
22:36and I want to spend a few
22:38minutes talking about this,
22:40with Tele health varying so
22:42much on a state to state level,
22:44the services that providers
22:47are reimbursed for delivering.
22:49Very really on a state to state
22:51level and thus parity laws exist
22:54at certain states to give.
22:56Essentially,
22:56equivalent reimbursement for
22:58analogous services.
22:59So what that means is it allows for
23:02states that have these parity laws to
23:05require private insurance companies
23:08to reimburse providers for care.
23:11DEVOTE delivered remotely via Tele
23:14medicine at the same rate as an
23:18in person or face to face visit.
23:2137 states currently have these laws,
23:24and they address several major issues.
23:26These issues include patient location.
23:28Most of these parity laws prevent
23:31health plans from withholding
23:32reimbursement for telehealth services
23:34based on a patient's location.
23:36This means that patients can do
23:39Tele health appointments in certain
23:41states from their home or office.
23:43They don't need to travel to a
23:46qualified originate Ng site.
23:48Remember that one, the cumbersome,
23:50medical Medicare requirements.
23:51These laws also address reimbursables
23:53services, so.
23:54The states that have these laws to
23:57a certain degree mandate private
24:00payer reimbursement.
24:01At a similar level to the face to face.
24:06Eligible providers are also
24:08specified in parity laws,
24:10so each state determines which licensed
24:12professionals may provide Tele medicine,
24:15so that can be physicians nurse
24:17practitioners PA's in some states,
24:20physical therapists,
24:20other therapists, like psychologists.
24:22And again, that vary state
24:25to state and parity laws,
24:27helping determine that
24:29for the individual state.
24:31The reimbursement levels are also
24:34dictated through each state's parity
24:37laws and then again most states the
24:40majority of private payers will reimburse
24:43it levels equivalent in person visits.
24:46And as always,
24:47there are exceptions to all of these,
24:50and really, you have to look at
24:52your individual states legislation,
24:54specific insurance plans to know
24:56what is considered reimbursables,
24:58who's eligible.
25:00These are the states that currently
25:02have telemedicine parity laws,
25:04and there are two parity laws
25:06that are currently proposed
25:09or are pending at this time.
25:11So to summarize,
25:12pre pandemic telemedicine was extremely
25:14limited access to telemedicine
25:16services has been conducted mainly
25:18using the center center model,
25:20and it was really meant for the
25:23rural or underserved population.
25:24There's a definitions were
25:26extremely limiting.
25:27An established relationship
25:28was required at the state level
25:31for non Medicare patients the
25:33rules changed and it's hard for
25:35clinicians to keep up with that.
25:37Parity laws do try to address
25:40these changes and standardize visit
25:42reimbursement to a certain extent,
25:44but again, it's not.
25:46Available in every state.
25:48So it's been challenging prior
25:50to the pandemic.
25:51As we all know.
25:52Last year though, the pandemic struck
25:55and things changed quite a bit.
25:59In February of 2020,
26:01as we all know,
26:02the CDC issued guidance advising
26:04persons and health care providers
26:06in areas affected by the covid
26:08pandemic to adequately adopt
26:10social distancing practices and,
26:12as a result, a lot of hospitals
26:14shut down elective services,
26:16medical offices limited who they
26:18were seeing a lot of offices,
26:20including our own shut down like our
26:23Sleep Medicine Office, for example,
26:25and this led to patients having.
26:28Limited access to their clinicians and
26:30significant worry about health conditions.
26:33As a result,
26:35the Trump administration.
26:38Started the 1135 Eleven thirty five waiver,
26:41which was the declaration of the
26:44Covid pandemic as a disaster
26:46under the Stafford Act and the
26:49HHS Secretary with taking the
26:51declaration of the Public Health
26:54Emergency was given certain powers,
26:56and these powers allowed the Health
26:59and Human Services Secretary to
27:02temporarily waive or modify certain Medicare,
27:05Medicaid,
27:05and Children's Health Insurance
27:07Program requirements to.
27:09Really ensure sufficient health
27:11care items and services were
27:13available to meet the needs of the
27:15individuals that were enrolled in
27:17these programs in the emergency area.
27:19And given that this was a
27:21nationwide emergency,
27:21that was a very broad area.
27:25It also allowed for providers who gave such
27:28services in good faith to be reimbursed,
27:31exempted from sanctions.
27:32Absent any determination of order of them.
27:35So really,
27:36the 11:35 waiver was the major catalyst
27:40which then led to the CARES Act.
27:44The CARES act of the Coronavirus
27:46aid Relief and Economic Security Act
27:48was passed in March of last year,
27:51March 27th of 2020, and was a very
27:53large bill that had several major
27:56game changing provisions that
27:57help to improve the delivery of
28:00Tele Health to support the social
28:02distancing mandate from the CDC.
28:04There's obviously many sections to this.
28:06I just want to review a few of
28:09the most important ones.
28:11Section 3703 expanded Medicare's Tele
28:13health flexibility, so there was a.
28:15Waiver as there was a requirement
28:17for Medicare,
28:18excuse me that the patient had been seen
28:22by the provider the last three years.
28:25The so called established
28:27patient requirement.
28:27This was removed in section 3703 so new
28:31patients could be seen by Tele Health.
28:34It also removed definitions in Tele health
28:37that allowed providers to use audio only.
28:40Telehealth, so if patients didn't have
28:42access to smartphones or iPads or laptops.
28:45Phone calls could be completed
28:47reimbursed and safe from HIPAA laws,
28:50which obviously is very important.
28:52The HI HHS secretary also had
28:56significantly expanded authority to
28:58waive any other statutory limitations
29:01on Medicare Tele Health Services.
29:04Section 3707 required the HHS to
29:07actually issue clarifying guidance on
29:10encouraging use of telecommunications,
29:12and,
29:13you know,
29:14they were mandated in doing such
29:17part of what they came up with
29:21was providing $200 million.
29:23The Federal Communications Commission
29:25to specifically support health care
29:28providers addressing the coronavirus
29:30by telecommunications services
29:32by using information technology.
29:35And by providing devices to enable the
29:37provision of Tele health services.
29:40And I think one of the most
29:42important parts of the CARES
29:44act that will help immediately,
29:47but will help us in the long term.
29:50Is that $27 billion was earmarked
29:52for the to the HHS for modernization,
29:55and that included modernization
29:57of the workforce of Tele Health.
29:59Access of Tele.
30:00Health infrastructure and what the
30:03government essentially did through
30:04the CARES Act was allow for obviously
30:07short term access to Tele medicine,
30:09but really show that they wanted
30:11to permanently invest long term
30:13in Tele Health and Tele Medicine,
30:15which I think was a really positive
30:18omen for our future,
30:19especially in Sleep Medicine.
30:23Centers for Medicare followed suit as
30:25a result of the CARES Act being passed
30:28and several major provisions that really
30:31were large and conferences were lifted
30:33in terms of the use of Tele medicine.
30:37Geographic barriers were removed.
30:39Patients in all settings could access Tele
30:43medicine from home again from home from work,
30:46not just rural areas or underserved areas,
30:49but really a patient could
30:51access Tele health from anywhere.
30:53Positions could provide these
30:55telemedicine services to new
30:57established Medicare patients,
30:58as we discussed,
30:59the consent could be obtained by anyone,
31:02and it was only required once on
31:05an annual basis physicians.
31:07Could provide Tele health services
31:09from their own home.
31:10They didn't have to go through the office,
31:12although as we all know that
31:14switch quite a bit recently.
31:16And the physician specifically did
31:18not have to update their Medicare
31:20enrollment file with their home address
31:22and physicians license in one state
31:24could provide services to Medicare
31:26beneficiaries in another state.
31:28Although state licensure laws still applied.
31:31Significant technical barriers
31:32were removed any two way face
31:36to face maybe device was valid.
31:39No FaceTime, Skype zoom very popular.
31:44Platforms were used up front,
31:46however you know with HIPAA
31:48obviously needs to be followed.
31:50The Office of Civil Rights specifically
31:53discourage positions from using
31:54other platforms like Facebook,
31:56Twitch, or Tick Tock.
31:58Anything about the public would would face.
32:02And.
32:02Reimbursement was also enhanced
32:04and simplified to to a large
32:07degree as we talked about.
32:10Reimbursement was very challenging
32:11prior to the pandemic and code
32:14selection documentation guidelines
32:15for office visits were all very
32:18similar to face to face visits.
32:20Essentially physicians could bill for the
32:23most part based on time that they spent
32:27with their patients on Tele medicine.
32:29So.
32:30Overall,
32:30how they do I think they did
32:32a pretty good job.
32:34The goal was to improve access
32:36for patients and physicians,
32:37and I think it's a safe assumption to say
32:40that the CARES Act at a really good job.
32:43The CDC published a cross sectional
32:45analysis of Tele Health during the pandemic
32:48from the early aspects in January to March,
32:51and what they addressed were,
32:54you know,
32:54what really were the effects of some of
32:57these changes to help Tele health visits,
33:00and,
33:01although sounds pretty straightforward,
33:03I think they did a nice job in
33:06proving that there really were
33:09unprecedented increases in access.
33:11So to examine the changes in frequency
33:14of the use of Tele health services,
33:17the CDC looked at Deidentified
33:19encounter data from four of the
33:22largest Tele health providers and the
33:25trends in Tele Health were identified
33:28and analyzed again from January.
33:30First,
33:31which is surveillance week one
33:33all the way to the end of April,
33:36which goes up the surveillance
33:38Week 13 and these were compared to
33:42the same weeks the prior year and
33:45during the first quarter of 2020,
33:47the number of Tele Health visit
33:50increased significantly 50% and then
33:52154% increase in visits was noted
33:55in Surveillance Week 13 in 2020
33:58compared to the same period back
34:01in 2019. Early on,
34:03most of these encounters were noted
34:05to be from patients seeking care
34:07for conditions other than COVID-19.
34:09However, the proportion of COVID-19
34:12related encounters significantly increased
34:15in the last three weeks of March.
34:17So this is a bar graph that kind of
34:21looks to discuss that a little bit more.
34:24What we're seeing is that coronavirus
34:26like symptoms are the dark blue
34:29coronavirus related ICD 10.
34:30Coding is the slightly more lighter
34:32blue and then the lightest blue is the
34:35coronavirus related texturing only.
34:37And what we see is during the end
34:39of the surveillance period really
34:41analogous to when the pandemic
34:44really was starting to ramp up.
34:46We do see and.
34:48Increase in visits via Tele medicine
34:51that were related to COVID-19 encounters.
34:56I think what's really interesting
34:57with that graph in comparisons of this
35:00one is that this is a representation
35:02of that increase in access,
35:04again compared to 2019 in the
35:06same surveillance period.
35:07It's a little bit of a busy graph,
35:10so we can just spend a minute looking at it.
35:13What we're seeing is the number of
35:15encounters on the left hand side,
35:17the surveillance week on the X axis,
35:20and on the right hand side.
35:22Y axis is the percentage change
35:24from 2019 to 2020.
35:26The dark line is the percent change
35:29in Tele health encounters from
35:312019 to 2020 and the dotted dashed
35:33line is the percent change in YD
35:36visits during the same time period.
35:38So we can clearly see the 11:35 waivers
35:42go into effect on March 6th of 2020,
35:44and then there is a sharp rise
35:47in Tele health encounters,
35:49and I think what's interesting to see
35:51is there's also a sharp decline as well,
35:54a divergent in the graph away from.
35:57ER visits with the group favoring
36:01Tele health encounters.
36:02During this time period,
36:04most of these Tele health encounters
36:07for adults were aged between 18 and 49.
36:10This was 66% in 2019.
36:13That age group and 69% in 2020,
36:16so really not significantly different.
36:19The majority were females,
36:2163% both in 2019 and 2020.
36:25And.
36:26Again,
36:27in the early pandemic period,
36:29the percentage of Tele health
36:31visits really only increased
36:32slightly compared to the year prior,
36:35but again went up as expected
36:37after the 11:35 waivers and the
36:40CARES Act were initiated.
36:42So overall, really,
36:44the cross sectional analysis shows that.
36:46The government actually did a really
36:48good job in terms of allowing for
36:51better access for patients during
36:53the early stages of the pandemic.
36:55There were substantial increases
36:57in Tele medicine visits that were
37:00made in the first three months.
37:02Compared to the same period in 2019,
37:04Ed visits went down dramatically
37:06during that same period,
37:08which I think we all felt in
37:10our own practices,
37:11and these increases in visits were
37:14directly attributable to the CARES Act.
37:16They helped improve provider
37:18payment for services,
37:19allowance of care for out-of-state
37:21patients was really important.
37:23Authorization for multiple different
37:25types of services and reduced cost
37:28sharing was also all really
37:30important to virtual visits.
37:32Based on executive orders in 2020,
37:35these changes became permanent.
37:37Medicare added,
37:38somewhere along the order of 144
37:41different Tele medicine services that
37:43they added to their permanent list and,
37:46as a result of this, these services
37:49are going to be for the near future.
37:53Here to stay, see Ms has commissioned
37:56a study to look at Tele health,
38:00flexibility and.
38:02Evaluate what was provided during the
38:05public health emergency and to look for
38:08opportunities really to better Tele
38:10health going forward in the future.
38:12I know we're running a little bit on time,
38:15so I'm going to try to go through these
38:17next couple of parts a little bit quickly,
38:20please.
38:20Please jump in if you have any questions.
38:23I want to spend a little bit of time
38:25that we have remaining on what evidence
38:27really is out there in Tele medicine,
38:30and these are all pre pandemic
38:31studies that I'm going to show you
38:34and they're all sleep specific.
38:35So I think this is a really nice
38:37group of papers that have been
38:39published and they look at really
38:41answering some important questions.
38:42Is Tele medicine non inferior to conventional
38:45face or face to face to face care?
38:47Which specific sleep pathologies
38:48benefit from telemedicine encounters?
38:50If any,
38:50do patients like virtual visits
38:52and water patient perceptions of
38:53doctors in the virtual environment?
38:55I think these are all relevant
38:57questions to ask and I think
39:00some of these studies have done a
39:02really good job in answering them.
39:04So I think this is really the low
39:07hanging fruit for Sleep Medicine,
39:09and that's long term management,
39:11obstructive sleep apnea, and using CPAP.
39:14You know,
39:15obviously this represents one of our
39:17most chronic and common patient groups,
39:19and the interaction already is somewhat
39:21remote in nature as we have remote downloads,
39:24pressure changes,
39:24so it was an excellent place to really
39:27start and look at the evidence behind
39:29Tele medicine and real world applicability.
39:31So this is a study from the Blue
39:33Journal that was multicentered
39:35prospective randomized,
39:36and it was a non inferiority trial
39:38that was conducted at 17 sleep
39:40centers in Japan and this is really
39:43used to investigate the.
39:44Effects of Tele medicine of a Tele
39:47medicine intervention on treatment
39:48adherence in long term CPAP users.
39:51Japan's quite a bit different from
39:53us and one of their differences in
39:55treating long term CPAP patients
39:58is that those that are on C pap.
40:00We must undergo at the time of
40:03this study face to face follow up
40:06by physicians regularly,
40:07even if long term.
40:09CPAP adherence has been established.
40:11You know, obviously quite
40:12different from how we do things.
40:15Mostly positions see their patients in
40:17Japan Monthly for therapy management.
40:19Again,
40:19even if they have long term adherence.
40:22So because there's intensive
40:24support required.
40:26The main question of the study was
40:28that would reducing frequency of
40:31visits lead to worsening of adherence,
40:34or could we add junked if
40:36Lee use Tele medicine
40:37to prevent a worsening of
40:40adherence or essentially have no
40:42change in adherence in patients?
40:45So the groups assumption was that
40:47adherence would drop if a time
40:50interval went from one month to longer.
40:52They used three months as
40:54their longer time interval,
40:56and they hypothesize that using
40:58complementary support with telemedicine
40:59will prevent a drop in adherence.
41:01So participants in this study were
41:04randomized to one of three groups,
41:06a Tele medicine group that
41:08followed up every three months,
41:10and there was a monthly and sorry about
41:13follow up was in person every three months.
41:16And there was a monthly Tele medicine
41:18intervention that included coaching.
41:20If required.
41:21A three month group that met every
41:23three months in person and the
41:25Standard Care Group which met once
41:28a month and had regular follow up.
41:30These groups were followed for six
41:32months and they essentially looked at
41:34adherence as the primary endpoint as
41:36well as the change from baseline in
41:39the percentage of days that patients
41:41use CPAP for at least four hours per night.
41:45So additional data that they collected within
41:49this group were baseline and end of study,
41:52Epworth Sleepiness,
41:53scores,
41:54Pittsburgh Sleep Quality Index
41:55and they also looked at patient
41:58satisfaction with the allocated OSA
42:00care which was evaluated through
42:03a multiple choice questionnaire.
42:05And again,
42:06the hypothesis was that the Tele
42:09medicine intervention or the
42:11three month intervention would
42:12be non inferior to the one month.
42:15Group and.
42:19This was again a non inferiority
42:22design study.
42:23So they needed to enroll about
42:26132 patients in this study,
42:29and they assumed the dropout rate around 10%,
42:33so they ended up wanting to recruit
42:37about 150 patients per each group.
42:40What they ended up getting were about
42:43161 patients in the Tele Medicine TM
42:47Group that underwent full analysis
42:50set analysis 166 in the three month group.
42:54And then 156 in the one month group
42:56the per protocol analysis numbers
42:59are listed directly below that.
43:01Anyone with protocol violations were
43:03dropped out from this analysis,
43:05but otherwise anyone who completed
43:08the full protocol for six months
43:11were included in these groups.
43:14Overall, groups were very clinically similar.
43:16A couple of important points that
43:18I'll point out.
43:19The groups are predominantly male
43:21and they were not obese,
43:23but there are overweight.
43:24You can see that BMI is around
43:2727 in all three groups,
43:29and these were pretty seasoned
43:31C Pap veterans.
43:32They the implementation
43:33time was about 29 months,
43:35so they had been on C pap for quite
43:37a bit of time and a majority of
43:41these patients were on auto set.
43:43C.
43:44PAP and the pressure and their
43:46residual hi were pretty similar.
43:48They use pretty standard good
43:51adherence definitions greater
43:52than four hours and 70% and the
43:55baseline Epworth was under 10.
43:57In the PS, Qi was around 5:00 for each group.
44:04And this chart looks at frequency of
44:06telephone coaching in the Tele Medicine
44:08Group and essentially 52 patients.
44:10A telephone in the Tele Medicine Group,
44:13which is about a third
44:15received telephone coaching.
44:16During the study,
44:17the percentage of patients who had
44:19telephone coaching was lower in the
44:22group with good CPAP adherence as
44:24we expected compared to those who
44:26had bad CPAP adherence at baseline.
44:30Uhm? And in terms of results,
44:33we're looking at percent change
44:35in CPAP adherence from baseline to
44:38the end of the six month study.
44:40In the full analysis set.
44:42So again,
44:43we're looking at percent change of
44:45days greater than four hours per night
44:48from the baseline to the end of the study.
44:51They were characterized in three groups.
44:53They either had a less
44:55than negative 5% change,
44:57they had deterioration essentially,
44:58which is in black.
45:00The black bars grey.
45:02Is no change which is greater than
45:05negative 5% to less than 5% or greater
45:09than 5% was an improvement in adherence.
45:13What we're seeing is the telemedicine
45:15group in the first column,
45:16the three month group in the second column,
45:18and the one month group in the third column,
45:20which was the control group.
45:22Deterioration in adherence
45:24is found in 41 patients,
45:26which was about 1/4 of
45:28the telemedicine group.
45:2955 patients was about a third
45:32in the three month group,
45:34and in the one month group 22%
45:37were had declined in adherence.
45:39So overall,
45:40based on their preset in
45:42noninferiority margins,
45:43the Tele Medicine Group had non
45:45inferiority to the one month
45:48group in terms of percentage of
45:50patients who had deterioration and.
45:53Feirense the absolute change was about 3%.
45:57They set a margin of 4%,
45:59whereas the three month Group
46:02did not show Noninferiority.
46:06I'm just going to move ahead a little bit
46:09just because we're crunched for time and
46:12I want to go through a few other studies,
46:15but essentially what these other
46:17graphs are showing are again.
46:19A lot of noninferiority between the
46:21Tele Medicine Group and the one month
46:24Intervention Group and the three month
46:26group essentially showed overall poor
46:28adherence compared to the other two groups.
46:31And then this is just showing the
46:33Epworth and the Pittsburgh Sleep Quality
46:36Index scores that were not different
46:38between any of the other groups.
46:40So overall,
46:41this trial showed that face to
46:43face follow up every three months,
46:45accompanied by monthly.
46:47Tele monitoring was not inferior
46:49to monthly face to face follow-up
46:51in long term CPAP users.
46:52What I thought was really interesting
46:54is the last point over here was this.
46:57There was a simulation of cost effect
47:00analysis that was done separately.
47:02And if only half of the 386 thousand
47:06Japanese CPAP users were managed
47:08by the Tele Health intervention,
47:11again just moving from seeing the
47:14providers once a month every three months
47:17with monthly Tele health intervention,
47:20the cost for management of OSA
47:23would go down about 17 percent,
47:2615.4 to 12.8 billion Japanese yen,
47:29which corresponds to about
47:31140 to $117 million.
47:33And that includes loss productivity time
47:35from not going to work and then gains of
47:39productivity for the clinicians themselves.
47:42So pretty significant,
47:44pretty significant numbers.
47:45I want to go through this
47:47one a little bit faster,
47:49just 'cause again we're running out of time.
47:52This was an article that looked at Tele
47:55Medicine versus face to face delivery of CBT.
47:58I again in a randomized non
48:00inferiority trial design.
48:01This is actually published
48:03in sleep this year,
48:04but this was from data that was collected
48:07in November of 2017 to June of 2019.
48:10As we all know,
48:11CBT CTI is the mainstay of
48:13treatment for chronic insomnia
48:15and this particular article.
48:17Hypothesized looking at ISI
48:20and they hypothesize that ISI.
48:25Done that, the ISI would not
48:28significantly drop the margin that
48:31they use was less than 4 by 4 points.
48:34When CBT was done in a Tele medicine
48:38fashion versus a face to face fashion,
48:42the exact same clinician performed
48:44these visits and they had
48:46independent researchers look at
48:48recordings of the interventions to
48:51make sure that they were similar.
48:56The individuals were standard
48:58insomnia patients that met ICD ICS.
49:02D3 criteria for chronic insomnia.
49:04They excluded those that had other
49:07or inadequately treated sleep
49:10disorders other than insomnia.
49:12Other chronic medical conditions
49:14that could be related to insomnia,
49:17shift work disorder or previously
49:20failed CBT, and the study.
49:23Randomized single site parallel
49:25non inferiority.
49:26Again, not a fair trial between CTI
49:29in person versus Tele medicine.
49:31Participants were block randomized in
49:33a one to one ratio between the face to
49:37face and Tele medicine intervention.
49:39And. We're going to go through
49:43a little bit quickly over here,
49:46but essentially,
49:47randomization was successful and
49:49very similar groups were created
49:51between the telemedicine intervention
49:53in the face to face intervention.
49:56What we're looking at over here.
49:58ISI scores post treatment and at.
50:00Three month follow up,
50:02and that's important because as we know,
50:05insomnia is a disease that
50:07doesn't always go into remission.
50:09In fact,
50:10you know only going to permission
50:12up to about 40%.
50:14So what this is showing is that
50:16the ISI scores post treatment
50:18in three months of follow-up
50:20showed reduction in both groups,
50:228.8% in the telemedicine 8.8 points.
50:25The telemedicine group versus 9.34
50:27points in the face to face group.
50:30But the condition by visit basically.
50:32Where the patient was face to
50:35face or Tele medicine didn't
50:37significantly change the ISI drop, so.
50:40Basically what we're looking at is
50:43that the ISA I dropped was similar
50:46in the Tele Medicine Group versus
50:49the face to face group and the non
50:53inferiority margin for this was not met,
50:56which was four points.
50:58Therefore the conclusion from
51:00this study was CBT done via Tele
51:04medicine versus done via face
51:06to face was non inferior.
51:11Interesting outcomes in this were that
51:13the equivalent post treatment improvements
51:15were also maintained at three months,
51:17and the study looked at therapeutic
51:19alliances and they actually found that
51:22the ratings were quite similar between the
51:24face to face in the telemedicine group,
51:27which was an unexpected finding for them.
51:31I'm I'm going to skip this last one because
51:34I do want to talk a little bit about what.
51:37The limitations are Tele health
51:39studies and I do want to give you
51:41guys some time to ask questions.
51:43The last study was just looking at some
51:46patient perceptions for Tele medicine,
51:47and they found that patient had positive
51:50interactions overall and they actually
51:52felt positively towards positions.
51:54I think some of the limitations
51:56that we have towards Tele medicine
51:57studies are that they may be prone
51:59to significant amounts of bias.
52:01You know these were non inferiority
52:03trials that we looked at.
52:05And as we know there significantly
52:07prone to bias, I think it's difficult,
52:09however, to do the gold standard,
52:11placebo controlled trials in Sleep
52:12Medicine for Tele Health because we
52:14would be depriving our patients of
52:16some of these again gold standard
52:18therapies that we know that work.
52:20See PAP for example CBT.
52:21So these non inferior parties.
52:23Non inferiority trials are really
52:25what we have available to us now.
52:27We think that a lot of these patients
52:29obviously volunteered for these studies.
52:31So is there a self selection bias
52:33for more technically savvy patients?
52:34Although they didn't know what
52:36group they would end in two versus,
52:38you know,
52:39in the pandemic patients don't really
52:40have an act an option to which how
52:43they're going to see their clinician,
52:45whether it be in person or by Tele medicine.
52:49There are definitely limitations where
52:50telemedicine can worsen health care
52:52disparities. Remember telemedicine?
52:54We think. Can improve access.
52:56We want to improve access to clinicians,
52:59but if patients aren't comfortable
53:01technologies or don't have access to it,
53:03you know the the opposite can
53:05happen and disparities can worsen.
53:07An I think more research is really
53:10required and there's quite a
53:12bit that's coming out there.
53:14I think overall the future of
53:17Tele Medicine is quite bright.
53:20I think that specifically for
53:22Sleep Medicine there are potential
53:25applications that already exist,
53:27including start to finish OSA diagnosis.
53:32Low risk,
53:33uncomplicated OSA patients that
53:34can be virtually diagnosed,
53:35treated and monitored in the
53:37future with pretty minimal harm.
53:39I think remote CBT I can improve some
53:41of these gaps that exist out there
53:44in terms of accessing health care
53:46providers that do CBT in the Community.
53:49And there's certainly a convenience
53:51factor that that plays a role to,
53:53you know, empower patients that would.
53:54Otherwise, you know may no show to visits,
53:57or you know,
53:58work jobs and are juggling a really
54:00hard schedule that makes it difficult
54:02for them to come in during visits.
54:04I think that that convenience factor
54:06really does bring in a an alternate
54:08that that they could come and see
54:10their clinicians when they
54:11otherwise wouldn't be able to.
54:15I did a quick clinicaltrials.gov
54:16search and there are a lot of studies
54:18that are out there that I'm looking
54:20at Tele Medicine and Tele health
54:22that are currently recruiting.
54:23Enrolling the field is growing and
54:25I think that we're going to see
54:27a lot of a lot of new positive,
54:29hopefully trials come out there.
54:34So overall, Tele medicine
54:35is here to stay, I think.
54:37Hopefully it leads to better
54:39access for doctors and patients.
54:40Are we seeing a change in
54:42the Sleep Medicine Office?
54:44Yeah, I think we are.
54:45I think we're seeing some validated
54:47work that's already been done for
54:49low risk OSA patients on C pap
54:51in terms of Falcon inherence,
54:53we're seeing non inferiority in CBT.
54:55I. So hopefully you're all
54:58seeing that in your own practices
55:00as we're moving forward.
55:02Here's my references and
55:03I thank you for your time.
55:10Thanks so much Santosh that was great.
55:12What a wonderful overview and just really
55:15wonderful to give the historical kind
55:17of perspective of all the legislation
55:19that's guiding what we're doing now
55:20I want to open it up for questions.
55:23I think we probably just have time for
55:25one question if anyone wants to unmute
55:28themselves I see there is a question
55:30in the chat from Lynelle Schneeberg.
55:33Which says, oh, can we leave the
55:35references page while we do the
55:37Q and I'm putting that up.
55:38Santosh, thanks. Great, thank you.
55:42Yeah, some fantastic articles there.
55:55Do you have a question and I think you
55:57all jump in while waiting for others.
56:00Jump in so so great so you know
56:02you've been doing Tele Tele health
56:04with Tele Medicine as a fellow.
56:07And what do you see as
56:08the as the biggest block,
56:10an obstacle for Tele health to
56:13become more prominent in the future?
56:15You know, I I've
56:17seen in our own experience,
56:19I've seen that the biggest obstacle,
56:21I think, is patients comfort with technology.
56:24I think you know different offices
56:26are using different technologies,
56:27different platforms,
56:28and if patients are not integrated
56:30within the healthcare network and
56:32they're going to see different
56:34positions and different doctors
56:36and they're using different.
56:37Different telehealth platforms.
56:38It's hard to be standardized.
56:40It's hard for them to, really.
56:44Use all these different
56:45products that are out there,
56:47so I think the lack of standardization in
56:49these Tele health platforms is challenging
56:51both for patients but also for clinicians.
56:54In our own practice,
56:55we've switched from early in the
56:57pandemic to using zoom to multiple
56:59different platforms that we've
57:00trialed out and they're all very
57:02different and I think unless you're
57:04able to really get comfortable with
57:06one of your patients are able to get
57:08comfortable with one that's going to
57:10be the biggest challenge going forward.
57:12I think it's just.
57:15Having patients be comfortable
57:17using the technology regularly.
57:22Great, thank you.
57:24It is actually 3:00 o'clock,
57:25so I think we'll wrap up,
57:27but I just want to say before we close that
57:29next week we have another Norwalk Sleep
57:32Medicine fellow giving our conference,
57:34and that's going to be here, a backyard.
57:36She's going to.
57:37Her talk is entitled back to basics,
57:39innovative ways to improve CPAP adherence.
57:41So actually, I'm sorry Ian,
57:42did she change the title of her talks
57:45and I think it may not be different.
57:47I'm sorry.
57:48Yeah, I think she is going to be
57:50a medical education seminar in
57:52Sleep Medicine and looking at.
57:53New innovative ways to teach Sleep
57:55Fellows as well as the new sleep
57:58milestone from the ACG inmates,
58:00I think that's what she decided to talk on.
58:03Wonderful thank you.
58:04Alright, so I look forward to
58:06seeing everybody next week.
58:08Thanks. Take care.
58:09Thank you.
58:11Rachab,
58:12Santosh thanks.