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

April 04, 2021

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

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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.