Any health care that takes place between a patient and a clinician who are not in the same physical location could be considered telemedicine. In a sense, many sleep doctors have been practicing telemedicine for a long time by reading sleep studies remotely through virtual private networks (VPNs). Recently, there has been an explosion in the field and telemedicine has made major inroads in several medical specialties, including stroke, urgent care, dermatology, ophthalmology, and psychiatry, among others. There are a few different models of telemedicine and some new terminology to describe them:
Synchronous: the patient and provider interact at the same time.
Asynchronous: data is obtained from the patient and accessed at another time by a provider. An example would be a patient emailing a picture of a suspicious mole to his dermatologist with the dermatologist accessing the image from a secure server at his convenience.
Telepresenter: a healthcare paraprofessional, such as a medical assistant or nurse, who facilitates a telemedicine encounter where the patient is located.
Direct-to-consumer telemedicine: the patient and provider interact directly without intermediaries.
There may be room here for a healthy debate on the topic, but my answer is unequivocally "yes." The diagnostic bible of sleep medicine is the International Classification of Sleep Disorders - Third Edition (ICSD-3). This book details the formal criteria necessary to make sleep disorder diagnoses and is consistent in delineating that the diagnosis can be made from a patient's history in conjunction with sleep studies, although not all sleep disorders require a sleep study. This information can be readily obtained through telemedicine.
There are many advantages, including decreased cost of care and convenience to patients and providers. At a minimum, patients may only need a computer or smartphone, and an Internet connection to have a telemedicine evaluation. This may save patients from having to take time off from work and commuting to their doctor's office. In some regions of the country that are underserved by sleep medicine, this could save a patient several hours of travel to the nearest sleep clinic. Also, there is risk involved, for the patient and from a public health standpoint, to having excessively sleepy people driving this much.
From a provider's standpoint, telemedicine allows us more flexibility in where and when we provide patient care. It is also a novel platform for increasing access to health care and has tremendous potential for improving population health outcomes.
Physical examination is generally limited to observation. Biometric data, such as BMI and neck circumference, is provided by the patient and the clinician is not able to validate it objectively. However, telepresenters, when available, can help this situation by taking vital signs and assisting with the physical examination. Additionally, there is an increasing array of data-transmitting telemedicine examination devices, such as stethoscopes and otoscopes, that are entering the marketplace and allowing more robust physical examinations.
Another drawback to telemedicine is that, by definition, telemedicine does not allow "laying of hands" by the provider, preventing the physical connection that many doctors argue enhances the therapeutic patient-doctor relationship. There are also theoretical privacy risks such as your protected health information (PHI) becoming exposed over an unsecured network. It is important for your telemedicine provider to use a platform that conforms to HIPAA requirements.
In the majority of states, telemedicine services have been determined to be equivalent to traditional healthcare services. There has been a rapid proliferation of "parity" laws in states requiring insurance companies to reimburse telemedicine and traditional services equally. You can learn more at americantelemed.org.
Telemedicine providers can prescribe medication and electronically send prescriptions to your pharmacy. Diagnostic testing, including sleep studies and laboratory tests, can also be ordered.
Currently, Texas and Arkansas have been given "F" ratings by the American Telemedicine Association for restrictions placed on providers while Georgia has been given a "C" rating. These states have enacted legislation that essentially makes it impossible to practice telemedicine. If you live in one of these states, let your state congress know that it is time to change these statutes and catch up with the rest of the country.
Joseph Krainin, M.D. is the founder of Singular Sleep, a company that offers virtual, online sleep medicine consultations.
© 2020 American Sleep Association.