Industry Voices—Embracing the changing landscape of medicine

Seema Khosla

When I was a kid, I remember watching the Jetsons and thinking that this was how my adult life was going to be: push a button and get lunch, have a robot to take care of the household chores, and simply click the television remote to see a doctor. It seemed very convenient and logical.

As I went through medical school, residency, and training, I never thought about the Jetsons nor how medicine would continue to evolve after my training. It wasn’t until I moved to North Dakota that I started to recognize how many barriers there were for rural families to obtain medical care.

Over the years, I have met with some patients who have had sleep complaints for decades; however, they always thought they would get it taken care of once they retired. There wasn’t a sense of urgency and they weren’t distressed enough to justify driving over 100 miles for an evaluation. They weren’t willing to commit to driving for a consultation, driving back for testing and then again for follow-up.

The need for tele-sleep medicine

Too many patients in rural communities are without access to sleep medicine.

Untreated sleep disorders are associated with heightened risks for many medical complications such as hypertension, heart disease, stroke, Type 2 diabetes and depression. Effectively treating a sleep disorder is essential to reduce daytime sleepiness and mend impaired cognitive functioning, both of which can lead to workplace accidents and drowsy driving.

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Millions of people in the United States suffer from a sleep disorder, including nearly 30 million adults who have sleep apnea, according to the Journal of Clinical Sleep Medicine. The demand for access to specialized care for sleep-related problems continues to grow, and unfortunately, there are only so many board-certified sleep medicine physicians.

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Telemedicine for sleep disorders is an ideal pairing, as many patient visits can be conducted by utilizing a secure system, without sacrificing quality of care.

Recognizing that telemedicine can expand patient access to quality sleep health care, the American Academy of Sleep Medicine has developed and launched a telemedicine system to encourage more sleep physicians to offer video visits. The system was the first telemedicine platform to be custom-designed and built by a medical society.

Getting to know telemedicine

We started doing telemedicine many years ago, and I had to be thoughtful about incorporating it into my practice. It came down to one fundamental question: was there something I needed to touch or see that I couldn’t accomplish via telemedicine? I couldn’t come up with anything.

Sleep medicine is a subspecialty that relies on the patient’s history as well as objective testing. The physical examination is helpful, but decision-making relies on clinical history more than anything else.

Technology has also advanced and allows the use of examination extenders, like oral cameras or electronic stethoscopes. We obtain clinical information and then perform sleep testing to obtain evidence of a sleep disorder.

Technology is changing the delivery of services across almost every aspect of healthcare. We are able to remotely monitor pacemakers, blood pressure, and glucose measurements, for example. Patients also go online to research their medications and symptoms.

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Telemedicine is not a new type of medicine but simply another method of delivery. The practice of medicine is the same: if a patient is seen in person with concerns of obstructive sleep apnea, they will be referred for testing. The same protocols apply to our telemedicine patients.

We see patients with all sleep disorders: narcolepsy, idiopathic hypersomnia, insomnia, circadian rhythm disorders, restless legs syndrome, and sleep-disordered breathing. The content of the virtual visit is identical to one that is performed in person.

Our payers reimburse for telemedicine and reimbursement is identical to an in-person visit.

Telemedicine saves our patients time and also saves me time, as I do not need to drive to an outreach clinic. This has allowed our clinic to run more efficiently by utilizing physician time to see patients.

Getting comfortable with telemedicine

Use of mobile technology has become routine in our daily lives, as 77% of Americans use a smartphone and 50% use a tablet, according to the Pew Research Center. I initially assumed that my telemedicine patients would be millennials, since they were the most adept and comfortable with technology. However, we found a bimodal distribution of the average telemedicine patient age. The millennials certainly gravitated toward virtual visits, but Medicare-aged patients were also quite pleased with the virtual visit.

Once I grew comfortable with the technology, I became more nimble in my clinical work and was able to problem-solve on the fly using the resources at my fingertips. There was a learning curve, however, regarding patient communication.

I learned to look for body language cues to let me know that the patient was listening, or if they simply didn’t understand what we were discussing. I would then change how I phrased things in order to ensure that my patient understood the process as well as the disorder and treatment.

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I believe this introspective exercise has translated into my in-person visits as well. It has made me more perceptive of visual cues and has made me focus on the message I want to deliver.

We clinicians need to decide how to utilize this technology in a patient-centric manner before nonclinicians make those decisions for us. It is merely another tool in the tool belt to allow us to improve access for our patients.

It is our choice to advocate for our patients who do not have access to good medical care and to help bridge the gaps in care by utilizing technology that has been around for more than three decades.

The Jetsons really were visionaries: I routinely order lunch via an app on my phone and watch the Roomba vacuum my floors. It is time to embrace telemedicine.

Seema Khosla, M.D., is the medical director of the North Dakota Center for Sleep in Fargo, North Dakota, a division of Precision Diagnostic Services.