Telemedicine for Dental Sleep Medicine
Concert pianist and Director of BlueSleep® Music, Magdalena Bachevska meets her piano student for a lesson in her New York City studio. The student, however, is getting ready at his piano in Sydney Australia. The next day she visits Yamaha Artist Services at their Fifth Avenue showroom, and sits at a piano that is actually being played by a student in Hamamatsu, Japan. The instrument in front of Magdalena reproduces, in the minutest detail, each movement of the keys and pedals, produced in real time by a pianist on a different continent. I marvel at this amazing technology, and I wonder, why we aren’t using it in telemedicine?
Twenty years ago, my colleagues and I published the first articles on “Tele-Otolaryngology”, technology that would allow us to diagnose cancers of the throat and life threatening ear infections from halfway around the globe (Telemedicine Applications in Otolaryngology. C Heneghan, AP Sclafani, J Stern, et al. Aug 1999. IEEE Engineering in Medicine and Biology). All this was accomplished using real time endoscopic images from our video NasoPharyngoLaryngoscopes (NPL) and otoscopy system transmitted through the internet from the mid-1990s … infinitely slower and costlier than internet speeds on our mobile devices today.
Fast forward 25 years later …why has piano technique and interpretation benefited from internet technology more than medicine?, and diagnosing and treating a disorder of global epidemic proportions (obstructive sleep apnea)?, why isn’t telemedicine used routinely today? Existing technology can enable us to help the 50-100 million undiagnosed sleep apnea patients in the US who have no easy access to sleep specialists. Ironically, the barriers to the adoption of telemedicine in 1996 were: cost, reimbursement, state licensure issues, malpractice coverage across states … they are the same today.
The opinion of at least one health care business attorney is: “it’s the Wild West out there for telemedicine” … which I’m not sure how to interpret …but my impression is that despite the many laws, regulations, associations, and special interest groups, telemedicine is moving forward thanks to the Silicon Valley and Silicon Alley capital invested in digital healthcare startups and especially telemedicine startups. That’s a good thing. Otherwise another generation could go by without realizing any benefits from internet technology other than distractions like Facebook, Instagram, and PokemonGo …
At BlueSleep, we’re done waiting and are launching a telemedicine service designed especially for dentists offering OAT to their patients – SleepAXIS. The service eliminates the barriers confronting dentists and their patients suspected of having sleep apnea: no more sleep centers, no more waiting rooms, no more insurance forms.
Here’s how it works:
You’re having a discussion with your patient in the dental chair about snoring, poor quality sleep, witnessed apneic episodes, daytime sleepiness, and/or co-morbid conditions such as hypertension, diabetes, heart disease and stroke. The patient has manifested interest in getting better sleep and treating the snoring, but also has a fear of sleep labs and CPAP.
“Good news Julia, I can arrange for you to have an evaluation by a board certified sleep specialist from the BlueSleep Center in the comfort of your own home, after work or on the weekend. Once you’ve had the video consultation, the doctor will likely arrange for you to have a home sleep study. You can pick up the equipment from our office or we can arrange for it to be delivered with setup instructions. Don’t worry, it’s simple.”
“You’ll have a follow-up telemedicine visit with the BlueSleep Sleep specialist to go over the results of your study. The doctor will explain the results, and have a discussion about sleep apnea, snoring, and other sleep disorders that may be affecting the quality of your sleep, and your daytime functioning. Assuming that there are no contraindications to treatment with an oral appliance, the doctor will write the prescription for the treatment, and I will fabricate and titrate the device. There will be constant communication between the sleep doctor and me to make sure you are getting the best sleep care possible. Once your oral appliance has been fitted and adjusted, and you’ve used it for some time, another home sleep test will be done at the recommendation of the sleep doctor and me to make sure the appliance is working.”
“It’s really easy, and in case the oral appliance is not solving your sleep problem, you’ll have a sleep doctor you can consult on-line without ever having to leave your home.” Imagine having this conversation with your patients.
BlueSleep is currently offering telemedicine sleep consultations to dentists and their patients in NY, FL, GA, NC, with plans for rapid expansion into other states. Telemedicine is one of the most cost effective ways to help increase diagnosis and treatment of obstructive sleep apnea. The only downside is that a full NPL exam cannot be performed. That being said, the vast majority of sleep patients are not seen by Otolaryngologists, and do not get an upper airway evaluation in the office. The cost of setting up a telemedicine program varies in each state and requires careful evaluation by health care business attorneys, discussions with malpractice carriers, selection of appropriate patient and provider groups, and constant review of policies and procedures. The telemedicine landscape is moving very rapidly.
For the dental practices that have home sleep testing technology in their office, it’s even easier for the patient to be diagnosed. Most health plans require the proper work up of the patient before a home sleep study is performed and covered. This can cause major delays in diagnosis, and in many cases is a permanent roadblock to diagnosis as many sleep specialists still recommend in-center polysomnography.
If the consultation is done in the dental office, then the dental staff can help capture vital signs, and some parts of the physical exam such as neck size, Mallampati score and tonsil grading. Presumably the dentist will provide the information on protrusive range of motion of the mandible, classification of the bite, and other important information about the oral exam. An extensive patient questionnaire standardizes the information obtained in the history of present illness, past medical history, social history, etc. The EHR used by the sleep telemedicine provider for telemedicine patients is the same one used for in-office patients, and the same format of letter is sent to the referring dentists and the patient’s PCP. All that is required in the dentists’ office or the patients’ home is a camera equipped computer connected to the internet.
From a technical standpoint, the patient is set up for the visits via the EHR portal, or EHR app with alternative back up video conferencing and telephony in case of internet connectivity problems. The advantages of conducting the evaluation in the dental office is assisting the patient with the setup of the consult, obtaining real time vital signs and pieces of the physical exam, and being available to discuss the case in real time with the sleep specialist – a good learning experience. Also as a general rule, up to 90% of patients referred from one doctor to another, never follow through. Having patients come back to the dental office for the televisit is like having the sleep specialist “in your office”, as we do at BlueSleep … a truly comprehensive model for the diagnosis and treatment of sleep apnea and snoring. An added benefit is that BlueSleep sleep specialists are also trained in evaluation and treatment of the entire upper airway including the nose, nasopharynx, and sinuses – another critical piece of the the evaluation and management of obstructive sleep apnea patients.
BlueSleep also has an affiliates program where dental sleep specialists can do a mini-residency at the BlueSleep center to learn and observe all aspects of the comprehensive diagnosis and treatment including: in-office upper airway endoscopy, HST, OAT fabrication and titration, in-office RFA of the tongue base and palate, CPAP set ups, and compliance. BlueSleep dental affiliates can join the BlueSleep network of dental sleep specialists around the world, who benefit from the telemedicine service for diagnosis and treatment for their patients, and also from referrals from patients seeking treatment of sleep apnea and snoring with OAT.
If we can move piano keys from halfway across the globe, and visualize laryngeal tumors using telemedicine technology, diagnosing and treating sleep apnea is simple in comparison! Telemedicine for sleep apnea is a critical step toward truly comprehensive model for the treatment of obstructive sleep apnea on a large scale.
Jordan Stern, MD is the Founder and Director of BlueSleep (jstern@BlueSleep.com). He is a best selling author, head and neck surgeon, and he is board certified in Otolaryngology and Sleep Medicine.
Magdalena Bachevska, DMA is Director of the Music Performance Program at Columbia University and appears in solo recitals and as a soloist with leading orchestras of the world.
More information at: www.bluesleepcenters.com. The SleepAXIS telemedicine service by BlueSleep is currently available in NY, FL, GA, MA, NC, and expanding rapidly.