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A d h e ren c e wi t h Po s i t i v e
A i r w a y P re s s u re T h e r a p y fo r
O b s t r u c t i v e Sl e e p A p n e a
The Roles of Telemedicine and Mobile
Health Applications
Dennis Hwang, MD
KEYWORDS
CPAP adherence CPAP follow-up Telemedicine Self-management Patient engagement
Mobile health applications Wearable sensors Electronic health records
KEY POINTS
Telemedicine and its integration into the overall health technology ecosystem is a critical component of the evolving solution for obstructive sleep apnea management and continuous positive
airway pressure (CPAP) adherence.
Current strategies that can be practically implemented include the use of Web-education, adoption
of automated and self-management CPAP follow-up platforms, and providing patients information
regarding online support groups.
The future holds unlimited possibilities, from the expansion of mobile health applications and wearable sensors to electronic health record integration that can streamline end-to-end comprehensive
care and provide advanced analytics to enhance disease management and facilitate population
health management.
patients approach their health are already substantially evolving. From the widespread adoption
of electronic health records (EHRs), to the ubiquitous nature of smartphone and health applications, to the increasing proliferation of wearable
devices, it is clear that medicine must figure how
to embrace technology and use it to the benefit
of medical providers, the global health system,
and ultimately for patients.
Disclosure Statement: The author has received recent research support from the American Sleep Medicine
Foundation (ASMF; Physician Scientist Training Award and Strategic Research grant 104SR13) and Itamar Medical Ltd. The author has previously received research support from the National Institutes of Health (grant 1
T32 HL072752) and Ventus Medical, Inc. ASMF supported the research presented on Fig. 1. The other sponsors
do not represent a conflict of interest.
Sleep Medicine, Southern California Permanente Medical Group, Kaiser Permanente Fontana Sleep Disorders
Center, 9961 Sierra Avenue, Fontana, CA 92335, USA
E-mail address: Dennis.x.hwang@kp.org
Sleep Med Clin - (2016) -http://dx.doi.org/10.1016/j.jsmc.2016.01.008
1556-407X/16/$ see front matter 2016 Elsevier Inc. All rights reserved.
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sleep.theclinics.com
INTRODUCTION
Hwang
It is well documented that a major challenge for
sleep specialists is optimizing adherence of patients with obstructive sleep apnea (OSA) to
continuous positive airway pressure (CPAP) therapy. Literature generally reports that only half of
patients remain adherent to CPAP 3 months after
initiating therapy.2 Efforts to improve adherence
through advances in CPAP technology have not
proven fruitful, whereas psychosocial interventions are often labor intensive and modest in effect. Given the impact of OSA on a persons
overall well-being and on the public health system,
it is imperative to successfully answer the
following question: How can technology be a solution to the problem of CPAP adherence? The goal
of this article is to explore sleep medicines
approach toward addressing this issue. The
author provides a general overview of healthrelated technologies while clarifying the scope of
telemedicine, discusses current and emerging
sleep medicine telemedicine platforms, and understands the evolution of the health information
technology (health IT) ecosystem and its anticipated impact on sleep medicine.
OVERVIEW OF TELEMEDICINE
Definitions
Telemedicine is key to improving our ability to care
for patients with OSA. However, there is confusion
regarding the meaning of telemedicine, and clarifying its definition and purview is necessary to
create a framework for the overall discussion
within this article. There are 2 basic types of telemedicine, synchronous and asynchronous. Synchronous refers to mechanisms in which medical
care is delivered in real-time, and this includes
video visits, which are often incorrectly used synonymously with telemedicine. Video visits may
be useful for sleep medicine for several reasons:
1. Limits travel time for frequently sleepy patients
2. Expands the geographic area, particularly
remote areas, in which a sleep specialist can
provide care
3. Enhances CPAP education and troubleshooting over a simple telephone call because
of the ability to visually assess and demonstrate
mask fit and equipment use
In the authors sleep center, the use of video
visits has expanded from sleep physicians to respiratory therapists (to provide CPAP troubleshooting); both patient and provider experience
has been overwhelmingly positive. The American
Academy of Sleep Medicine has recognized the
value of expanding video visits within this field. It
convened a task force that published a position
paper aimed at assisting sleep specialists in incorporating video visit capabilities into their practice:
American Academy of Sleep Medicine (AASM)
Position Paper for the Use of Telemedicine for
the Diagnosis and Treatment of Sleep Disorders.3
The limitation of synchronous telemedicine,
however, is that it still requires face-to-face
provider time. The American Telemedicine Association states that the 3 primary goals of telemedicine are to (1) improve access to care, (2)
improve quality of care, and (3) improve efficiency
or cost-effectiveness of care.4 Although video
visits can improve access and quality of care, its
impact on care efficiency is modest at best.
Rather, in order to do so, it requires the adoption
of elements that largely fall under the purview of
asynchronous telemedicine.
Asynchronous Telemedicine
Overview
Asynchronous telemedicine, also called storeand-forward, indicates that the encounter between patients and provider does not occur in
real-time. Examples of this include the following:
Electronic messaging: the use of e-mail and
text messaging to communicate with patients
or deliver medical information
Remote monitoring: (1) accessing stored patient data from a medical test and reviewing at
a later time from a remote location (eg, sleep
physicians
accessing
polysomnography
[PSG] data for interpretation) and (2) accessing
patient-collected data from end-user devices,
including wireless access of data from patients
home medical devices (eg, Glucometers,
sphygmomanometer, CPAP devices) or data
from personal mobile devices (eg, smartphones, tablets) that often have installed health
applications or are linked to a wearable sensor
Automated care mechanisms and selfmanagement platforms: (1) platforms that
automate patient feedback based on therapy
adherence and (2) smartphone applications
(often with wearable sensors) that can provide
a continuous system of accountability
These elements are key principles that underpin
the ability of asynchronous mechanisms to improve
the efficiency of care delivery and are evident in the
eventual discussion on sleep telemedicine platforms relevant to OSA management. For now,
each of these principles is further explored.
Electronic messaging
Virtually all patients have access to e-mail and text
messaging. In a research study performed in the
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Hwang
cost-effective solution to delivering these strategies is explored further.
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Hwang
at study completion than at baseline, suggesting
that this surrogate metric may reflect that engagement with MyCPAP improved over time (unlike the
fall-off seen in the study by Kuna and colleagues16
after the first week.)
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Hwang
time to activate only when the person is not in deep
sleep in order to limit postwake grogginess. It
should be noted that a similar application called
Sleep Time was compared with PSG, and the sleep
parameters (sleep efficiency, light sleep, deep
sleep) showed no correlation.24
On the other end of the spectrum, some devices
claim more complex sleep-related functions. One
company produces headphones studded with
sensors and asserts the ability to sense deep sleep
and induce lucid dreaming with the goal of
improving sleep quality.25 Others are emerging
that attempt to evaluate the risk of OSA by
measuring parameters associated with snoring or
integrate more complex signals, such as electroencephalogram, oxygen saturation, and cardiac
signals. But the use of these more advanced wearables is mostly nonvalidated and not as common
as those focused on tracking activity, such as FitBit and similar devices.
Activity trackers
Activity trackers are essentially simple accelerometers that send motion data to a software
application, which then processes the data to
determine wake and sleep periods, similar to
that of traditional sleep actigraphy devices.
Several wrist-worn devices are commercially
available; FitBit and JawBone are 2 of the more
common ones. A recent review of 22 studies evaluating wearable activity trackers concluded that
they were better at measuring physical activity
(specifically number of steps) than measuring
sleep.26 Only 4 studies were available (FitBit and
Jawbone) that compared these trackers with
PSG, and they indicated that these devices
generally overestimate sleep (total sleep time
and sleep efficiency) while underestimating
wake. FitBit does have an ultrasensitive mode
that reverses this and underestimates sleep while
overestimating wake.27
Practical implications
It is important for the sleep specialist to understand
the evidence, albeit limited, regarding wearables.
One 16-year-old patient came into the authors
center for a PSG because her mother thought her
FitBit was reporting a sleep problem. Her PSG
was normal, and her history indicated normal sleep
pattern and daytime vigilance. The mother insisted
that a sleep problem was present, and it was only
the ability to conduct an educated discussion
based on published data that the family was reassured. On the other hand, these devices can
function as a crude screening mechanism. Anecdotal experience also describes patients whose
Peer-Based Follow-up
Peer-based follow-up is another promising
follow-up strategy that has been explored in conditions, such as human immunodeficiency virus,
heart failure, and diabetes.28 Although it does not
represent a new unique technology, it does typically use telecommunications and the Internet to
facilitate this form of self-directed care. Parthsarathy and colleagues29 published a pilot study in 2013
in which 39 patients were randomized into a buddy
system or to usual care. The buddy system involved
matching new CPAP users to an experienced
CPAP user who would effectively act as a mentor
over 3 months. After 2 face-to-face sessions, the
mentor would call the new user weekly for 1 month
and then every 2 weeks. Ninety-one percent of patients found the experience to be satisfactory, and
measures of CPAP adherence were overall better
in patients who were mentored (64% of patients
in the buddy system were considered adherent
compared with 40% in the usual-care group.)
Although feasibility of a buddy system in a standard
sleep center requires further investigation, other
peer-based programs already do exist in the form
of Internet group forums, which can provide peerbased engagement, additional education, and
motivational testimonials. Examples of these online
communities are hosted by the American Sleep Apnea Association, MyApnea.org (which also functions as a patient-driven research platform), and a
ResMed portal called WakeUpToSleep.com.
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Hwang
Fig. 2. End-to-end care integration: EHRs can streamline OSA clinical care pathways through enabling device
integration (sleep devices, follow-up platforms, wearable sensors), facilitating patient-provider interchange
(questionnaires, Web education), and advanced data analytics (screening, population management).
SUMMARY
Telemedicine and its integration into the overall
health technology ecosystem is a critical component of the evolving solution for OSA management
and CPAP adherence. Current strategies that can
be practically implemented include the use of
Web-education, adoption of automated and selfmanagement CPAP follow-up platforms, and
providing patients information regarding online
support groups. The future, however, holds
unlimited possibilities, from the expansion of mobile health applications and wearable sensors to
EHR integration that can streamline end-to-end
comprehensive care and provide advanced analytics to facilitate population health management
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