Outsourcing sleep scoring helps many laboratories be more efficient and flexible, but a lack of industry standards concerns some.

For sleep center managers, staffing can be one of the biggest challenges. As the demand for sleep-disorder testing grows, so does the demand for qualified technologists to administer the testing, and this can create a real bind. For example, in the small community of Dover-Foxcroft, Me, Kim Havea, RRT, director of cardiopulmonary services at the Mayo Regional Hospital Sleep Disorders Center, had to find a way to efficiently score just a small number of studies a day without an RPSGT on staff. In the San Francisco Bay area, Mehran Farid, MD, medical director and CEO of the Peninsula Sleep Center in Burlingame, needed to provide quality scoring while also controlling costs in an area where chief technologist salaries tend to match the high cost of living. For both, the solution was outsourcing a portion of their sleep studies, a trend that some see as encouraging and others see as possibly troubling because of the lack of independent national standards in outsourcing services.

Companies providing outsourcing for sleep studies say their services relieve sleep facilities of the costs of salaries and benefits for skilled technologists, while giving timely turnaround at affordable rates. Each scored study is typically returned in 12 to 72 hours and runs between $50 and $150. Most outsourcing companies employ contracted scoring technicians that are experienced RPSGTs and are adept at handling all brands of sleep software. However, some sleep laboratories forgo large outsourcing companies and simply find local technicians seeking extra income. Neither of these solutions is regulated by any guidelines from accrediting sleep medicine associations.

Choosing Outsourcing
Farid, a board-certified physician in sleep medicine and pulmonary diseases, considered the staffing needs of the four-bed facility and the typically high salary and benefits paid for a chief technologist in his area. Instead of hiring one chief technologist to provide all of the aspects of the operation, in addition to local scoring, he hired four part-time RPSGTs and gave most of the scoring responsibilities to outsourcers. The part-time technologists assist him and three other pulmonary physicians and score approximately 30% of the studies. The business model has helped him cut costs while still maintaining a turnaround and reporting of the study 48 hours after the test is completed. Farid also likes being able to transfer more of the scoring workload to the outsourcing company as needed.

Another case where outsourcing seems to work well is for small or rural sleep clinics that find it difficult to justify the expense of hiring a full-time RPSGT to score a small number of daily sleep studies. One such center is Kim Havea’s two-bed facility in a small community an hour from Bangor, Me. Havea says, “When you’re a little place like us, it would cost quite a bit of money to have another tech here to just score a couple of studies full time in the day.” Instead, the center employs a technician to stage the test during acquisition. The data is then uploaded via a secured server to Sleep Strategies, an outsourcing company located in Toronto. Sleep Strategies gives Havea different turnaround options, from 24 hours to 72 hours, depending on the urgency.

Choosing to Invest in Recruitment and Training
While outsourcing can be a boon to some facilities, for others it is not the right option. Robert Lindsey, RPSGT, director of neuromedical services for Memorial Health Care System in Chattanooga, Tenn, considered outsourcing. In the end, he decided to develop an in-house long-term training program to up the number of full-time RPSGTs at his facility. Today Memorial Health Care System’s sleep laboratory has 14 beds and 15 sleep technicians.

Much of the reasoning for Lindsey’s decision was because of the way Lindsey’s center scores its studies. While some sleep laboratories train their technicians to stage their studies during acquisition, then review and score sometime after the test, Lindsey’s technicians use the method that takes advantage of the “look-back” feature of most Microsoft Windows-based acquisition software. Utilizing the look-back feature, each technologist stages and scores two patients per night during data acquisition, and then reviews and finishes the scoring before leaving the next morning. Typically, the night technologist stays a half hour to an hour after the patient has left the laboratory. Consequently, an outsourcer is an unnecessary expense, even for a sudden increase in the number of studies. “We’d rather pay inside people and know that we’ve got a strong team,” Lindsey says.

Similarly, Kendal White, RPSGT, director of sleep disorders at the Diagnostic Center for Sleep Disorders, decided to recruit and train, rather than consider outsourcing. White’s 10-bed sleep laboratory, also located in Chattanooga, uses the look-back feature as well.

“An hour’s worth of sleep scoring takes less than 5 minutes to score,” White says. “So if the tech, just once an hour, sat down for 5 minutes, they could have everything that happened in the previous hour staged, scored, and ready.”

White allows that his beginning technicians may have to stay later into the morning to finish scoring, but that their efficiency improves over time.

Outsourcing and Quality Control
The American Academy of Sleep Medicine (AASM), the Board of Registered Polysomnographic Technologists (BRPT), and the Association of Polysomnographic Technologists (APT) all lack requirements that sleep studies be scored directly after acquiring the data. Many AASM-accredited sleep laboratories accurately score sleep studies long after acquisition. However, it is the quality of the scoring that most concerns sleep specialists.

Farid’s Peninsula Sleep Center, which is AASM-accredited, has three measures of quality control. First, before sending the study to the outsourcer, Farid personally reviews the data for any indication that would require immediate attention. When the scoring is returned from the outsourcing company 48 hours later, Farid compares his initial notes with the outsourcer’s report. Second, the scored data will be screened again by one of his four part-time technologists to ensure proper tagging of the events. As a third quality control, Farid personally scores at least 1% of all the studies himself, and then matches his scoring against the outsourcer’s scoring. These checks have revealed minor discrepancies.

“Sometimes you have to change the events tagging when it arrives,” Farid says. “On the occasion that it has significance, we have given the outsourcing company feedback, and they have improved the tagging.” He also notes that the outsourcing company scores according to Peninsula’s protocols and that they use the same software.

Roger Godbout, RPSGT, director of the Sleep Disorders Clinic for Children & Adolescents in Montreal, and a BRPT board member, uses outsourcers at the Rivière-des-Prairies Hospital, a research and clinical sleep laboratory also in Montreal. Aside from checking references and confirming that his outsourcer is a Technologiste en Électrophysiologie Médicale, the Quebec equivalent of being an RPSGT, Godbout also gives his outsourcers a quality-control study mixed with real cases. As with Farid’s quality checks, the results of these quality-control tests are generally positive, but sometimes requires the outsourcer to make a few adjustments.

Outsourcing and the Nuances of Sleep
Because diagnosing sleep disorders can be highly nuanced, opinion does vary, however, on whether even the best quality-control program for the outsourcing of sleep scoring can compete with direct observation and scoring. White says, “If you have a possibility that a patient has sleep apnea, or you’re looking for signs of narcolepsy or central nervous system hypersomnolence, the night tech is going to know what the RDI [respiratory distress index] is in the morning. He’ll know what the sleep architecture looked like during the night.”

Lindsey agrees. “They [night technicians] have seen the morphology, they’ve seen the amplitude of that person’s brain waves, and they’ve seen the patient that night, one-on-one, in real time. Things look a lot different the next day. It’s a little intangible, but there is an advantage,” says Lindsey.

Standards and Security
Godbout is more concerned about the lack of standards for outsourcing sleep scoring. “There are many possibilities for disaster,” he says. “There are no guidelines, so you have to rely on your own way of doing things. I can imagine somebody hiring someone, training [that person] for a week or so, then taking over these files and doing something with it.”

As for protecting privacy, most outsourcing companies use secure servers that protect patient privacy and comply with the standards of the Health Insurance Portability and Accountability Act (HIPAA), as well as screen their technologists.

The AASM and the APT elected not to comment regarding the outsourcing of sleep scoring. Though not speaking for the BRPT, Godbout is personally in favor of the AASM, APT, and the BRPT cooperating in developing some guidelines. “We have to apply some rules,” he says. “We have to be sure that the job is well done, that it’s done by someone who is accredited somehow, that the person has continuing education hours, and that the person’s education level is optimal.”

Tor Valenza is a staff writer for Sleep Review. He can be reached at [email protected].