1. Rapidly Evolving Models of Care for Patients with OSA Samuel T. Kuna, MD Center for Sleep and Respiratory Neurobiology University of Pennsylvania and Sleep Medicine Section Crpl Michael J Crescenz VAMC Philadelphia, PA

2. Outline Application of emerging telehealth technologies to the diagnosis and management of patients with OSA Recent evidence showing the effectiveness of telemedicine management of patients with OSA Providing patients with web-based access to their PAP results improves adherence Development of a VA-based web platform (REVAMP) that will allow Veterans with OSA to be diagnosed and managed without having to come to a sleep center

3. Veterans Integrated Service Network (VISN 04)

4. AutoPAP treatment In-lab PSG Home sleep study CPAP treatment Clinic FU Initial In-person evaluation Split PSG Non- OSA OSA management at the Crescenz Veterans Affairs Medical Center Diagnostic PSG PSG / HST Long-term FU

5. Telemedicine – the delivery of clinical services at a distance, using communication technologies that allow physical separation of practitioner and patient while evaluating and managing health issues. Telemedicine – definition PractitionerPatient Any communication modality that allows the physical separation of patient and practitioner Teleconsultation

6. Clinical Video (Real Time) Telehealth Exchanging health services or education live via videoconference Home Telehealth Transmission of medical data for diagnosis or disease management Store and Forward Telehealth Acquires and stores clinical information (e.g. data, image, sound, video, etc.) that is then forwarded to (or retrieved by) another site for clinical evaluation Telehealth modalities

7. Increase access to healthcare information Increase access to care (primary and specialty services) Decrease cost of care (reduce hospitalizations, ER visits) Improve healthcare for medically underserved populations Standardize care Expand the healthcare workforce through “virtual” education and training Anticipated promises of telehealth/ telemedicine to patients and practitioners

8. AutoCPAP treatment In-lab PSG Home sleep study CPAP treatment Clinic FU Split PSG Application of telehealth technologies for diagnosis and management of OSA Diagnostic PSG Video Teleconference Store and forward of wireless data Store and forward Phone or video teleconference Initial In-person or video teleconference evaluation PSG / HST

10. Video teleconferencing program to deliver cognitive behavioral therapy for insomnia

11. This is where we are going!

12. AutoCPAP treatment In-lab PSG Home sleep study - DVD CPAP treatment Clinic FU Split PSG Telemedicine pathway for remote management of OSA Diagnostic PSG Video Teleconference Wireless modem data transmission Store and forward Phone or video teleconference Initial In-person or video teleconference evaluation PSG / HST

13. Some monitors used for home testing

14. Portable testing is just one part of an ambulatory clinical pathway for the chronic management of OSA patients! HST

15. AutoCPAP treatment In-lab PSG Home sleep study - DVD CPAP treatment Clinic FU Split PSG Telemedicine pathway for remote management of OSA Diagnostic PSG Video Teleconference Wireless modem data transmission Store and forward Phone or video teleconference Initial In-person or video teleconference evaluation PSG / HST

16. Wireless modem transmission of PAP data Home PAP unit Manufacturer’s website

17. Event detection by PAP machine Berry et al. Sleep 2012; 30:361-7 Difference AHI AED – AHI PSG Average AHI AED and AHI PSG Apnea-Hypopnea Index

18. PAP with wireless modem at home PAP data sent to manufacturer server MANAGEMENT ACTIONS PAP data entered into EMR (CPRS) Data sent to patient via Secure Messaging Review data with patient during clinic visit Adjust PAP settings Phone follow-up Authorize home visit by DME therapist Provider reviews data on website STOREFORWARD Wireless modem transmission of PAP data

19. The amount of data can be overwhelming!

20. Impact of modem-based monitoring on PAP adherence in patients with OSA Patients with OSA (AHI > 15) prescribed autoPAP were randomized to standard care or telephone contact in the first month based on modem-transmitted PAP data Outcomes: PAP adherence after 3 mo, subjective sleep quality, and side effects Fox et al. Sleep 35: 477-81, 2012

21. Sharing wireless PAP data with the patient Home PAP unit Manufacturer’s website Patient website Patient

22. Websites for patients on PAP therapy Mobile app and web-based systems providing patients with personalized feedback allowing them to take an active role in their sleep apnea therapy. These portals will allow patients to: –View equipment guides and educational videos about sleep apnea –Patients set custom goals and monitor their progress –Receive feedback on treatment –Troubleshoot common problems

23. 195 patients with newly diagnosed OSA (AHI ≥ 15) Randomized (n=139) Usual care ( n=53 ) 3 month Visit (n=52) Web-based access + $$ incentive (n=40) Web-based access (n=46) 3 month Visit (n=45) 3 month Visit (n=39) Does giving patients access to their PAP data improve treatment use? Kuna ST et al. Sleep 2015; 38: 1229-36

24. Total (n=136) Usual care (n=52) Web only (n=45) Web+$$ (n=39)P-value First week5.6 (2.9)4.7 (3.3)6.3 (2.5)5.9 (2.5)< 0.0001 3 months4.5 (3.2)3.8 (3.3)5.0 (3.2)4.8 (3.0)< 0.0001 Mean (SD) daily hours of PAP use in first week and over 3 months Increased PAP use in the Web Only and Web+Financial Incentive ($$) groups compared to Usual Care group at one week and 3 months Kuna ST et al. Sleep 2015; 38: 1229-36

25. 12345 67 Weeks 2.0 3.0 4.0 6.0 7.0 Mean (SD) hours of use per week over 3 months Average hours of use per week 5.0 89101112 Web only Web + $$ Usual care 12345 2.0 3.0 4.0 6.0 7.0 Mean (SD) hours of use per week over 3 months Average use per week (hr) 5.0 Kuna ST et al. Sleep 2015; 38: 1229-36

26. Days Percentage of subjects Web only Web + FI Percentage of patients accessing the website each day to view their PAP data Kuna ST et al. Sleep 2015; 38: 1229-36

27. Web-based access - Lessons learned Patients’ web-based access to PAP adherence improves average daily hours of PAP use over the first 3 months of treatment Addition of a financial incentive in the first week of PAP treatment to web-based access to PAP results does not result in improved use compared to web-based access alone While web-based access to PAP results improves long term PAP adherence, it does not prevent the gradual decline in adherence over time Additional strategies are needed to help patients sustain their initial pattern of adherence Kuna ST et al. Sleep 2015; 38: 1229-36

28. Phone enrollment (N=60) Video tele- conference (N=28) Home sleep test (N=28) APAP ordered (N=19) OSA negative (N=9) 1-mo and 3-mo video teleconference FU (N=14) In-person visit (N=28) Home sleep test (N=27) APAP ordered (N=21) OSA negative (N=4) 1-mo and 3-mo In- person FU (N=20) Video teleconference vs in-person care: Protocol Fields B et al. Sleep (in press)

29. Variable In-Person Care (n=19) Telemedicine Care (n=15) P Value FOSQ 0.89 ± 0.592.57 ± 0.690.067 CES-D -4.31 ± 1.73-6.51 ± 2.030.413 ESS -3.56 ± 1.13-4.22 ± 1.310.702 SF-12, physical 2.08 ± 1.540.86 ± 1.830.611 SF-12, mental 0.73 ± 1.789.26 ± 2.090.003 Working Alliance Index (WAI) 1.70 ± 1.505.93 ± 1.770.074 Client Satisfaction (CSQ-8) 0.013 ± 0.48-0.31 ± 0.570.665 Video teleconference vs in-person care: Functional outcomes and satisfaction Fields B et al. Sleep (in press)

30. PAP adherence variable In-person (mean ± SE; N = 20) Telemedicine (mean ± SE; N = 16) P value % days with device usage 54 ± 865 ± 80.493 % days ≥ 4 hours 39 ± 847 ± 90.493 Use, hours (all days) 2.9 ± 0.63.7 ± 0.60.301 Use, hours (days used) 4.5 ± 0.55.1 ± 0.50.426 Video teleconference vs in-person care: PAP adherence Fields B et al. Sleep (in press)

31. Isetta V, et al. Thorax (in press) Baseline visit CPAP titration and training Control group (70) Standard CPAP follow-up Face-to-face visits at month 1 and 3 Extra contacts by phone Telemedicine group (69) CPAP follow-up at distance Televisits at month 1 and 3 Extra contacts by e-mail Web tool support At 6 months: CPAP adherence, QoL, cost effectiveness 139 included in ITT analysis 123 included in PP analysis Cost-effectiveness of telemedicine management of sleep apnea

32. Isetta V, et al. Thorax (in press)

33. Cost-effectiveness of telemedicine management of sleep apnea Isetta V, et al. Thorax (in press)

34. A personalized, interactive website for Veterans with OSA that promotes self-management by providing feedback on test results, PAP treatment, and response to treatment Remote Veteran Apnea Management Portal Increase access to care for Veterans with OSA Standardize care across the Veterans Health Administration Obtain patient centered outcomes and PAP data Improve cost effectiveness of OSA management Goals of REVAMP

35. Wireless modem transmission of PAP data Manufacturers’ websites REVAMP website Patient Practitioner

36. Features of REVAMP’s patient portal Intake and follow-up questionnaires to evaluate patients and track clinical outcomes Videos and educational materials Frequently Asked Questions for self-management Graphical displays of PAP results Secure messaging Sends reminder text and e-mail messages to the patient

37. Features of REVAMP’s practitioner portal Create new patient accounts Select tasks to be completed by patient Monitor patient’s completed and upcoming tasks Review patient’s questionnaire responses Questionnaire responses autofill progress notes Interface with VA electronic medical record

38. Electronic Medical Record Wireless PAP Data Standardized history and sleep study collection Patient centered outcomes REVAMP provides standardized, patient outcome based management of OSA

40. Time to Leap Into Telemedicine?

41. Barriers to implementing telemedicine into routine practice Telemedicine Parity Law Partial Parity Law Proposal Parity Bill No Parity legislative Activity

42. Sleep telemedicine – a promising but unproven future Provides a scalable, cost effective alternative to in- laboratory management of patients with OSA Web-based applications will increase patient access to care, improve PAP adherence and promote patient self-management The combination of clinical video teleconferencing, home sleep testing and wireless transmission of PAP data will allow patients with OSA to obtain care without coming to a sleep center

43. Rapidly Evolving Models of Care for Patients with OSA Samuel T. Kuna, MD Center for Sleep and Respiratory Neurobiology University of Pennsylvania and Sleep Medicine Section Crpl Michael J Crescenz VAMC Philadelphia, PA

44. 14/15 participants mentioned “convenience” of telemedicine. 14/15 participants had no prior exposure to telehealth visits. 15/15 agreed: “The quality and content of telehealth visits are comparable to in-person visits.” 1/15 was concerned about confidentiality (“who is getting the information”) Video teleconference vs in-person OSA management: End of study phone calls Fields B et al. Sleep (in press)

45. Well, I don’t think it was really any different. I mean, like I said, he was right there. We were talking face-to-face over the video. The only difference between talking over the video versus talking to a doctor actually in the office is, you know, they are there, in the office. I don’t think it [in-person visit] would’ve made any difference. It was more convenient for me to do it this way than for me to have driven all the way to the hospital. It was much more convenient for me. I think it’s just a great idea and a great study all the way around. With the fact that they can, you know, monitor your sleep patterns remotely with the wireless router. And you wouldn’t have to go to the clinic, you know, every six months, once a year, they can do it right from the house. [I] would have been more comfortable actually being in a room with the doctor…the video visit was OK, too. More things may have come to mind [in-person]…being it [telehealth visit] was more convenient, it was worth that little bit I might have missed discussing, you know. Video teleconference vs in-person management: End of study phone calls Fields B et al. Sleep (in press)