Psychologists get surprising insights into their patients’ sleeplessness when they monitor them regularly.

By Sree Roy

In his decades as a sleep psychologist, Thomas K. Speer, PhD, DABSM, FAASM, has found that a patient’s self-reported sleep complaint is frequently only part of the story.

Recently a woman with narcolepsy arrived for help with “insomnia and anxiety.” Speer prescribed seven nights of a Wesper Lab home sleep test (HST). The patch-based HST includes a skin temperature sensor. Surprisingly, “every night, her skin temperature would go up,” Speer says. She’d begin around 95 degrees Fahrenheit each night, but her skin would rise above 101 degrees. “That’s almost febrile,” Speer says. “I had never heard of this.”

A literature search revealed evidence that the hypocretin deficiency in narcolepsy affects skin temperature regulation inversely to that of people without narcolepsy. “So some of their wakenings are due to temperature changes,” Speer says. “Increased temperature can be associated with awakenings, including extended ones, and then to insomnia.” 

Since the patient’s insomnia was likely not due to anxiety but to temperature, Speer customized her treatment plan. She cools or warms her body as needed. When she feels sleepy in the middle of the workday, she drinks cold water to lower her core temperature (and raise her skin temperature). 

The patient continues to use HST to track sleep and temperature. “We’ve been doing this for a month so far, and she says she does better in the afternoons now,” Speer says.

Gandis Mazeika, MD, FAASM, CEO at Sound Sleep Health, also uses longitudinal objective monitoring to guide treatment decisions for patients with insomnia. He employs Advanced Brain Monitoring’s Sleep Profiler, a forehead-worn electroencephalogram-based system that assesses sleep architecture and continuity.

Many people with insomnia experience circadian misalignment, he’s found. Their data shows features such as long REM sleep latencies and a delay in heart rate dipping. “That completely changes the treatment plan,” Mazeika says. “You’re not necessarily putting them through sleep restriction paradigms and talking about maladaptive thoughts and behaviors. You’re talking more about phototherapy, melatonin, adjusting their sleep timing, and discussions with their employer as to whether they might be able to start and finish work a little later.”

As these two sleep specialists illustrate, remote monitoring for insomnia is worth considering. Just as sleep medicine has learned with obstructive sleep apnea (OSA) remote patient monitoring, daily objective (or even self-reported) monitoring for insomnia can influence health outcomes too. “With the emergence of new diagnostic modalities like home polysomnography with wireless devices and advanced analysis techniques, I believe a more targeted approach can be implemented for treatment of insomnia—perhaps similar to what we currently see with phenotypization for OSA,” says Marcel Braun, PhD,  MBA, vice president of market development at Onera Health, which also makes a patch-based HST system.

Why has remote monitoring adoption been slower for insomnia than OSA? “Insomnia therapy is typically behavioral or pharmaceutical, so there is no therapy device automatically generating data,” notes Steve Olson, vice president of market development (US) at sleep software as a service developer SleepImage, which also makes fingertip- and ring-based HST devices.

Mazeika adds, “It’s also a little different because it’s not like wearing the [sleep monitor] fixes the insomnia, right? This is something that you may opt to do. But the link between the treatment and the monitoring is not as robust in insomnia as it is with sleep apnea.”

Still, for those patients who opt into remote monitoring for insomnia, there’s potentially a wealth of insights to be gained. “We’ve found it to be like opening the curtains to this whole narrative in between the visits—in terms of how fragile our patients’ sleep is,” Mazeika says. “We want to see how resilient they are over time. If they catch a cold or travel across time zones, can they get back into the groove? It’s very revealing.”

Insomnia Patient Education and Accountability

No matter the treatment plan, sleep physicians find that sharing remote monitoring data with the patient, such as nightly hypograms, leads to better buy-in. “Between the more precise diagnostic capability, the additional data you get, as well as the ability to share the visual with the patient, it seems to improve outcomes,” Mazeika says.

Sleep psychologist Anne Germain, PhD, says, “I tried all the apps for cognitive behavioral therapy for insomnia [CBT-I], and the one thing that was annoying to me is people would come back and say, ‘It didn’t work.’ But I wouldn’t have any details of how they used it: Was it three days or three weeks?” Wanting a way to supervise treatment in near-real time, Germain launched NOCTEM Health, where she now sells software so other practitioners can remotely monitor their insomnia patients.

Speer uses NOCTEM’s COAST software as a communication portal to check in with insomnia patients. “It makes them participate with their sleep schedule and answer questions for me. When they start falling off answering their questions in the morning, I nudge them to do it again. Then I find out they’re either doing great or not doing so well,” he says.

How to Collect Data from Insomnia Patients

Mazeika too had negative experiences with CBT-I apps, so he created his own online form, where patients report their sleep and sleep intention data each morning. “Intention” covers when the person tried to fall asleep and how much effort they expended. The form also asks for the timing and size of their evening meal, physical activity and stress levels, and medication/supplement intake.

Objective data is another option. The evolution of HST from “sleep lab in a box” concepts to wearable recorders with cloud-based access has paved the way for a new paradigm, says Troy Pridgeon, vice president of US sales at SleepImage. “Rendering rich landscapes of high-density data points and therefore a much more focused vision of a patient’s true sleep patterns….the analysis and capabilities made available for longer periods of testing at reasonable cost will change sleep testing to a more democratic, routine, and systemically important vital sign in the future,” he says.

Consumer wearables with healthcare-friendly platforms for simple metrics like resting heart rate data also have potential. Mazeika is considering Fitbits for Sound Sleep Health patients. “Every wearable will tell you resting heart rate, and it is a leading indicator of physiological stress,” he says. For example, when a person is starting to get sick, their resting heart rate increases. “This is quite relevant in the management of individuals with long-term sleep disturbance,” he says. “They come to us and say, ‘I’m really tired,’ and now we would have the ability to say, ‘I noticed your resting heart rate trended up about three weeks ago, and it stayed up. Is there something you’re aware of that you could share about what’s going on?’”

For sleep physicians who want to implement objective remote monitoring for insomnia patients,  Solveig Magnusdottir, MD, MSc, MBA, chief medical officer at SleepImage, says the device should be cleared by the US Food and Drug Administration to evaluate sleep, not just sleep apnea. “When looking at individuals with insomnia, evaluating wake after sleep onset and arousals is as important as sleep timing and sleep duration,” she says.

With machine learning and artificial intelligence, analysis of sleep data can go much deeper than manual assessments, by using, for example, spectral analysis or detection of micro-arousals, Braun says. This may lead to a much-improved understanding of insomnia in the future,” he says.

Frequency of Remote Data Collection

While therapy devices for OSA patients usually auto-report data nightly, remote monitoring for insomnia takes some effort. This means the use cases for daily monitoring are likely fewer. “One could argue that in individuals for whom there is a certain fragility to their sleep, long-term monitoring could be beneficial,” Mazeika says.

He sees greater utility in monitoring pre- and post-intervention and in the weeks leading up to a visit. Sleep physicians “have been asked to assume the role of managing a lot of Schedule II medications” like stimulants, he says. “It seems reasonable that you would want to have some objective evidence that the stimulant is not harming the patient and that it is actually benefiting the patient,” Mazeika says.

The same could be said for certain individuals who are on chronic hypnotic medication. “Every sleep clinic has people who come every X number of months for their prescription. There’s a certain liability associated with that,” Mazeika says. “So, ideally, you’d have objective evidence that what you’re doing is not harming the patient and that it’s acting in the patient’s best interest (going beyond the patient’s word)…You would have something that shows, for example, that the patient’s sleep efficiency is better than before.”

Getting Paid for Remote Monitoring for Insomnia

Like many other aspects of medicine, the uncertainty surrounding third-party reimbursement is a deterrent to implementing remote monitoring for insomnia. Sleep practitioners should consult their legal and billing advisors before initiating claims to payors, but in general, there are Current Procedural Terminology (CPT) codes for which practitioners have been reimbursed.

The final 2022 Medicare Physician Fee Schedule, released on Nov 2, 2021, created a family of CPT codes for remote therapeutic monitoring (RTM). “It mirrors the RPM [remote patient/physiological monitoring] codes,” Germain says. “The RPM codes came out in 2019. The RTM codes are lagging two years behind but have been following the same trajectory in terms of adoption by clinicians and payors for coverage.”

A difference is the RTM codes—98975, 98976, 98977, 98978, 98980, and 98981—accept subjective patient-reported data. “The RTM can be based on the self-report that people are already doing (monitoring through sleep diaries)” using software with an FDA determination as the “device,” Germain says. Optionally, clinicians can add physiological or objective parameters using a physical device. 

Another coding option is CPT 96156, designated for health behavior assessment and intervention procedures.

Of course, with or without remote monitoring, many sleep psychologists run cash-pay practices. “Depending on your price point and how much time you spend, you could better help patients,” Speer says. “I have yet to have any patients complain about the cost, which is unusual in the sleep field.”

Ultimately, if more practices can be paid for remote monitoring of insomnia, whether via outsourcing software or service or monitoring CBT-I and other therapies in-house, it could be “tremendously helpful to our patients,” Germain says. “And it will achieve something we’ve tried to do for a long time: embed a psychologist in every clinic.”

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