Key Resources and Best Practices for Sleep Labs Amid COVID-19 Pandemic

(Last updated: 4/28/2020)

In light of the COVID-19 pandemic, sleep labs are facing a variety of new challenges and many unanswered questions. Given the view EnsoData’s team has across the sleep community, we thought it would be helpful to highlight resources to help answer some of the recurring questions that we are hearing.

One of the best places to start is the American Academy of Sleep Medicine. AASM has been updating its COVID-19 FAQ and COVID-19 mitigation (new REOPENING update on 4/27/20) pages regularly.

What we’re hearing and seeing:

Our data and conversations across the over 300 sleep centers we work with indicate that sleep testing across the U.S. fell below 40% of “typical” volume near the end of March.

While in-lab testing remained at COVID-period lows, we noticed a rebound in home sleep testing after ~2 weeks. Since that time, the indicators we’ve been tracking have indicated a gradual  and steady growth in home sleep testing. Last week (April 20) was the first week we saw an uptick in in-lab testing. We believe this is an indicator that some centers are reopening in light of relaxed lockdown guidelines in some states or locales.

The three most commonly asked questions we’re hearing:

There are not yet any definitive answers on this. However there are some strong indicators from influential people like Seema Verma (CMS Administrator) that CMS (and commercial payors who tend to follow) will not return to pre-COVID policies. Here’s her quote from a March 28 Wall Street Journal interview.

“I think the genie’s out of the bottle on this one. I think it’s fair to say that the advent of telehealth has been just completely accelerated, that it’s taken this crisis to push us to a new frontier, but there’s absolutely no going back.”

It’s safe to say that investment you made in telehealth as a result of the COVID crisis will not have been made in vain.

Most sleep centers we’ve spoken to have continued (and some have significantly increased) sending HSAT units through mail delivery to reduce patient contact, while others are still suspending services for a limited time. Decisions have been made on a case-by-case basis (read more here).

We work with a number of organizations that support sleep practices and labs that don’t have a robust “virtual HSAT program”. Please get in touch with us if you’d like to learn more about them.

CMS finalized on an interim basis that the agency will not enforce the clinical indications for coverage across respiratory, home anticoagulation management and infusion pump NCDs and LCDs (including articles) allowing for maximum flexibility for practitioners to care for their patients. This policy includes NCD 240.4 Continuous Positive Airway Pressure for Obstructive Sleep Apnea. During the COVID-19 emergency, Medicare will cover CPAP devices based on the clinician’s assessment of the patient. However, once the public health emergency is over, CMS will return to enforcement of the clinical indications for coverage.

AASM held a webinar April 28 on COVID related policy and legislative action. During the webinar, Dr. David Introcaso, a health policy advisor to the US House of Representatives, stated his interpretation was that CPAP prescriptions during the waiver period would not revert to previous requirements for coverage once the COVID interim period ends. However, he did acknowledge potential for variability across payers and even Medicare Administrative Contractors (MACs), suggesting sleep centers contact their payer or MAC representative to confirm the latest.

Telemedicine Capabilities and Resources:

On March 17, CMS expanded payments for telehealth services during the COVID-19 Emergency. The key highlights are:

  1. In all areas (not just rural), established Medicare patients in their home may have a brief communication service with practitioners via telehealth mediums
  2. In all types of locations including the patient’s home, and in all areas (not just rural), established Medicare patients may have non-face-to-face patient-initiated communications with their doctors without going to the doctor’s office by using online patient portals.
  3. HHS Office for Civil Rights (OCR) will exercise enforcement discretion and waive penalties for HIPAA violations against health care providers that serve patients in good faith through everyday communications technologies, such as FaceTime or Skype

Learn more about the CMS Telehealth Expansion here.

Prior to the announcement, we heard a few customers with existing telemedicine programs tell us they plan to shift to remote visits if clinically appropriate and if insurance allows. Others told us this emergency will be the catalyst for starting one. If your sleep lab has closed, or you are seeing a decrease in volume, this may be the perfect time to explore how to incorporate a telemedicine program.

We’ve assembled some information and resources available to all the AASM accredited labs about how to get started with telemedicine.

  • How to start a sleep telemedicine program
  • Developing a workflow plan
  • Understanding hardware and software needs
  • Business aspects of telemedicine
  • Regulatory, Legal, and Ethical Considerations in the Implementation of Telemedicine

The full AASM Telemedicine Implementation Guide can be found here.

Sleep labs can get access to a telemedicine portal called sleepTM here. AASM accredited labs have access to sleepTM for free. Other telehealth options are:

  • Signal: A free app that offers encoded messaging and video systems, Signal is safe and easy to use. You can find step-by-step instructions for conducting your first session with the Signal app here.
  • VSee: Any app that satisfies the guidelines put forth by the National Institute of Standards and Technology is certainly appealing. VSee also enjoys widespread use in numerous government agencies, furthering its reputation as a safe and secure option.
  • While it doesn’t have a security level sufficient to meet the National Institute of Standards and Technology, still has plenty to like. Small businesses and solo practices can use the base version for free, while larger practices can take advantage of the perks available in the paid alternative.

COVID-19, a time to improve patient outcomes?

During the COVID-19 emergency, many patients will be at home and taking special notice of their health for a number of weeks. We’ve heard a number of groups suggest they will seize this opportunity by ramping up phone or text-based CPAP adherence programs. A randomized trial published in 2015 indicated the potential benefits of a phone-coaching program.

“[Our] study shows that Sleep Apnea/Hypopnea Syndrome (SAHS) patients who benefit from phone coaching are statistically more compliant to CPAP than a standard support group is. A simple phone coaching procedure based on knowledge of the disease and reinforcement messages about treatment benefits helps to improve CPAP adherence in SAHS patients.”

Sedkaoui et al. BMC Pulmonary Medicine (2015) 15:102

Another study on this topic is linked here:

A telehealth program for CPAP adherence reduces labor and yields similar adherence and efficacy when compared to standard of care

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