Editor’s intro: Telemedicine can have many future applications, such as addressing dentist/doctor interaction, follow-up consultations, and expanding the clinician’s reach. Read more about this promising technology in this article by Dr. Jagdeep Bijwadia and Kyle Miko.
by Jagdeep Bijwadia, MD, MBA, DABSM, and Kyle Miko, CRT/CSE
Telemedicine is becoming an increasingly important part of healthcare. The Department of Health and Human Services estimated that in 2018, 60% of all health care facilities were using some form of telemedicine.
Trends like increasing commercial payer acceptance of telemedicine, continuing technological advances, and growth of consumerism in healthcare all indicate that telemedicine offerings will expand significantly in the years to come. Patients increasingly expect real-time access to healthcare in the same way they receive other commercially available services. You probably expect the same thing for your personal health care – it’s time to provide it for your patients!
American Academy of Sleep Medicine has stated that it supports efforts to expand telemedicine and is committed to increasing the adoption of this technology to improve patient access. Their recent position paper details the key features, standards, and processes for a sleep specialist.
Dental Sleep medicine as a field is uniquely positioned to take advantage of the new telehealth technology. Obstructive sleep apnea is a significant health issue with an estimated 80% of patients remaining undiagnosed. Dentists are uniquely positioned to identify patients who are at risk for obstructive sleep apnea but there are some significant barriers that prevent patients from getting to oral appliance therapy in an efficient and cost-effective manner. The lack of availability of sleep physicians in some areas, the high cost, requirement for numerous visits, and time involved in the diagnosis and treatment of obstructive sleep apnea remain challenging. Although predicting individual response remains a challenge, oral appliances are an extremely effective, patient-preferred option for the treatment of sleep apnea, often as a first line option.
The typical patient who is identified at risk for sleep apnea by a dentist is referred to a sleep physician’s office for consultation and diagnosis. Appointments can often take several days or even weeks for that initial consult. Further delays occur with the sleep testing process, especially if polysomnography is pursued. A trip back to the physician for discussion adds another layer of complexity before a prescription for treatment can be completed. Communication back to the dentist can be sub-optimal given the disparate communication platforms that dentists and physicians use. Patients are lost at various steps on this pathway and vital opportunities to impact health are missed. As patients go through the complex pathway, costs escalate with every step, and the chances that the patient will ‘give up’ increase.
Telemedicine can potentially help address many of the barriers that face dentists and physicians in getting patients to oral appliance treatment. Using a telemedicine platform allows a patient who is identified as at risk for obstructive sleep apnea to be diagnosed and treated efficiently.
Technology and services exist today that allow a patient identified as at high risk for obstructive sleep apnea to be scheduled for a virtual consult right at the dentist’s check out desk. Consultation is completed either while the patient is in the dentist’s office or within just a few days in the comfort of the patient’s own home via a secure, HIPAA compliant, web-based platform. Prior to the consult, they register and fill out some medical information in preparation for the visit. The visit itself is carried out on any mobile device and is a real-time video link. The physician or nurse practitioner performing the consult can review the medical notes and document their visit. The video interface allows the clinician to do a comprehensive review and answer any of the patient’s questions as well as educate them about diagnostic and treatment options. A brief physical exam can be performed for findings like facial structural abnormalities, retrognathia, and Mallampati scores. If the patient is physically in the dental office, vital signs and even electronic stethoscopes may be used for more complex patients.
At the end of the visit, ordering a home sleep test allows a diagnosis to proceed in a cost-effective manner for most patients, unless there are reasons to pursue more in-depth testing. Several companies perform home sleep tests by mailing the equipment to the patient and having it returned in a prepaid package. Once interpreted by board-certified sleep physicians, the study can be reviewed by the consulting clinician and an order for an oral appliance can be generated to the referring dentist.
There are several important advantages of using the telemedicine and home sleep testing model. From a dentist’s perspective, it makes the referral process efficient since the scheduling for the telemedicine visit can be done right at the time of checkout. Consultations and sleep study reports should be available to review as they are completed on the telemedicine platform. This allows for easy communication between the dentist and the physician. Documentation for claims submission is immediately accessible online rather than having to track down various pieces of information from other offices. Many dentists currently collaborate with home testing companies that generate sleep test reports and who even provide prescriptions for patients that the physician group has never interacted with. Using telemedicine and collaborating with physicians allows accurate diagnosis and importantly the ability to consider sleep disorders other than OSA that are often responsible for the patient’s symptoms.
For the physician, telemedicine expands their reach and allows them to selectively schedule the more complex patients requiring additional care to their offices. While at home telemedicine consultation is not yet reimbursed by insurers, telemedicine visits completed in a clinical setting like a dental office are usually covered by the patient’s insurer. Home sleep testing is also covered benefit when sleep apnea is clinically suspected and the study has been ordered after appropriate clinical evaluation.
For the patients, telemedicine reduces the time spent traveling back and forth to various offices and sleep centers and is also much less expensive. Patients who are not located close to a sleep specialist can have increased access to high-quality specialty consultations.
As you choose a telemedicine partner, look for a group that specializes in sleep medicine and that is experienced and understands the nuances of dental sleep medicine. Ask questions about the telemedicine platform, making sure it is HIPAA secure and that it allows you access to your patient’s data. Seamless integration with home sleep testing with a company that in the patient’s insurance network is helpful so that the dentist does not have to coordinate and have the expense of two separate services and also minimizes the patients out of pocket expenses. The ability to provide follow up consultations on request and offer advice after efficacy testing allows the partnership to work across the continuum of care. Availability of physician appointments, state licensure, turnaround times for home testing and cost are all important considerations.
Telemedicine may be an ideal option for dentists who are starting out in the field of dental sleep and would like to get patients they identify on to treatment efficiently and safely. It is also a useful option for dentists who have established sleep practice but whose patients travel long distances or want a less expensive but high-quality path to treatment. It is important to note that Medicare does not currently allow reimbursement for oral appliances with telemedicine consultations and still requires a face to face visit.
Telemedicine is ideal for dentist-physician collaboration but in the future may have many other applications in dental sleep medicine. Experienced clinicians mentoring and even supervising other dentists in real time is likely to help increase availability and expertise in dental sleep, allowing patients increased access to care. Other advances in technology and new uses will doubtless surface in the next years making this an exciting time to be in the field.
Read more about the effect that telemedicine can have on future dental sleep medicine practices in his article, “Medicare DME/Telemedicine: Friend or Foe? Part 3.“
- 1. Office of Health Policy, Office of the Assistant Secretary for Planning and Evaluation. Report to Congress: E-health and telemedicine. Washington, DC: Department of Health and Human Services, August 12, 2016
- Telehealth. Tuckson RV, Edmunds M, Hodgkins ML. N Engl J Med. 2017 Oct 19;377(16):1585-1592.
- American Academy of Sleep Medicine (AASM) Position Paper for the Use of Telemedicine for the Diagnosis and Treatment of Sleep Disorders. Singh J, Badr MS, Diebert W, Epstein L, Hwang D, Karres V, Khosla S, Mims KN, Shamim-Uzzaman A, Kirsch D, Heald JL, McCann K. J Clin Sleep Med. 2015 Oct 15;11(10):1187-98