by Emerson M. Wickwire, PhD, ABPP, CBSM

Leveraging the Internet to improve patient care

2012-09 04-01

In the larger health care universe, advances in health care information technology (HIT) are driving massive systemic change. Health care systems and individual medical practices are transitioning to electronic medical records systems. Internet-based technologies increasingly facilitate patient education, communication, and even behavior change. In the near future, these and other innovations in HIT will revolutionize the ways that sleep patients are screened and triaged, assessed and diagnosed, treated, and provided ongoing care.

For adaptive professionals and forward-thinking sleep medicine organizations, these changes bring excitement and provide ripe opportunity. By leveraging the Internet to educate, communicate, change behavior, and track outcomes, sleep professionals can provide better sleep health care. Maximizing performance in each of these areas will help position your organization to excel in the emerging, changed landscape of sleep medicine in the 21st century. To excel, sleep medicine professionals should familiarize themselves with current trends, assess how well they are leveraging HIT and formulate an overall technology strategy in their organization.


1. Increased access to sleep medicine education.
It is well-documented that few physicians are adequately trained in sleep during medical school. Fortunately, in recent years, numerous efforts have been made to increase availability of sleep medicine education, including efforts to educate primary care physicians in sleep, train nurse practitioners, and increase sleep medicine education at the graduate and CME levels.

2012-09 04-02

Emerson M. Wickwire, PhD, ABPP, CBSM

Internet-based education and elearning technologies are accelerating the dissemination of basic instruction and best practices in sleep medicine. Currently, online learning opportunities include formal coursework and certification programs, specialty webinars, and free general sleep education for non-sleep specialists. (For an example of the latter, see a project I spearheaded with an outstanding faculty: [removed][/removed] Many RPSGT and BRPT training programs also have been at the forefront of online education. In the future, online education will enable more widespread education of doctoral and mid-level providers as well as technologists, regarding best practices in screening, assessment, and treatment of sleep disorders.

2. Increased access to sleep medicine care.
In the United States, the demand for sleep medicine services far exceeds the available supply of sleep-trained providers. Based on current prevalence estimates of sleep disorders relative to the number of board-certified sleep physicians, each sleep specialist would need to provide ongoing care to more than 10,000 sleep patients per year to meet the current clinical need! (This estimate does not account for the imbalance between the roughly 45 million people with insomnia and 200 certified behavioral sleep specialists.)

Internet-based technologies will increase access to care in three important ways. First, as has been reported elsewhere, Internet screening can facilitate increased confidentiality and treatment acceptance for patients whose livelihood could be impacted by a sleep disorder diagnosis.1 In light of recent regulatory initiatives at the national and local levels, the importance of a patient-friendly, effective screening, diagnostic, and treatment chain cannot be overstated. Second, telemedicine approaches will increasingly enable providers to treat patients who may be located thousands of miles away, thereby increasing access to specialty care. For example, in the trucking industry, it is not uncommon for a sleep physician to interview a driver via videoconference to facilitate a more effective review of the results of a remotely interpreted PSG. Such processes can improve patient buy-in and treatment outcomes, thereby improving cost-effectiveness of sleep care. The third way that Internet-based technologies will increase access to care is via partially or fully automated interventions such as online cognitive behavioral therapy (CBT) and digital coaching via Web and mobile interface.

3. Improved patient education regarding diagnostic and treatment processes.
The Internet can be used to increase public awareness regarding sleep disorders and sleep health in general and can be used to educate patients and improve care. Specifically, there are at least three critical “sensitive periods” when patient education and understanding are paramount to ensure long-term success: prior to diagnostic testing, during the transition to treatment, and following acclimation to therapy. Further, as patients are asked to complete increasingly complicated steps to facilitate their own diagnosis and treatment (eg, self-hookup to home sleep testing or HST), efficient and effective means of communication will become even more important.

A robust patient portal can facilitate patient education at each stage in the treatment process. For example, prior to diagnostic testing, patients can read printable handouts, view instructional videos, and review FAQs. Patients will arrive better prepared, familiar with the process, and knowing what to expect. During the transition to treatment, patients can receive instruction on equipment maintenance and adjusting to PAP. Once patients have made the transition to PAP, they can be monitored remotely to ensure optimal response to therapy between office follow-up visits.

4. Improved communication between patient, sleep provider, and DME equipment provider.
One of the greatest needs to improve sleep medicine care is to improve communication between the patient, provider, and durable medical equipment (DME) supplier. Indeed, one of the most frequent complaints we hear from new patients is the lack of available support and ongoing communication from past DME providers. Currently, an undue burden falls on sleep patients, who frequently report feeling they act as “middle man” between physician and DME.

A HIPAA-secure online patient portal could enable the sleep provider, patient, and DME provider to view all therapy data real-time and communicate for technical trouble-shooting, prescription adjustments, and reordering of supplies.

5. Easier tracking of patient outcome data.
Very few sleep centers have an organized system for tracking patient data. To achieve and maintain AASM accreditation, centers must maintain a log of tests performed, final diagnoses, and so on. But even among AASM Centers of Distinction, there is no requirement for the systematic tracking of patient outcomes. A major reason is practical: in the absence of an electronic data gathering system, tracking of outcomes requires labor-intensive data entry. Yet reporting program-wide outcome measures such as PAP adherence, sleepiness, and so on will become increasingly important as payor scrutiny increases.

A robust patient portal can aggregate patient data real-time, without duplicated efforts of redundancy. This data can include both self-report measures such as validated questionnaires completed during assessment, post-treatment, and so on, as well as objective data such as PAP adherence and physiologic measurements.


These big-picture trends have already begun to impact training programs, hospital systems, sleep centers, physician practices, DME providers, payors, and patients in both subtle and overt ways. More important, each sleep medicine organization—including yours—will soon be faced with choices regarding whether, how, and when to expand its use of health care information technology. Sleep medicine organizations will need to determine how best to do the following:

  1. Identify, educate, and attract potential patients;
  2. Unidirectionally communicate with potential patients, current patients, and referring providers;
  3. Bidirectionally communicate with current patients including use of online treatment tools;
  4. Gather, analyze, and report data; and
  5. Share information with other health care entities (eg, DME) and integrate with electronic medical record systems.

Where do you stand in relation to each of these key opportunities?


How well are you leveraging available health care information technologies? The above self-assessment should further concretize what these sea changes in the sleep medicine universe mean for you. For each area, rate your organization’s performance. Then use your assessment results to stimulate dialogue among your team regarding use of currently available technologies.


Having completed the self-assessment, your initial reaction may be despair. However, despair can be a powerful catalyst for taking action. Your first step should be to clarify your vision for the future of your organization. This will require consideration of external forces in the field at large, your micro universe, and your organizational aspirations. Where do you want to be in 1 year? 2 years? 5 years?

A recent editorial reviewed the macro-level implications of the shift toward HST/APAP technologies on the sleep medicine field, and highlighted several needs that can be met by leveraging health care information technologies.2 The author employed Jon Kotter’s seminal framework on organizational change management to outline a top-down approach to changing the way sleep medicine is practiced in the United States.3 Yet each sleep medicine entity also exists within a micro universe and faces unique challenges and opportunities, making top-down change difficult.4 This means the burden falls on you. You cannot afford to wait for others to chart your course. You must clearly define your objectives, develop a strategic approach, and determine which tactics will maximize your chances of success. Finally, you must identify those specific technology solutions that will best suit your needs.


The need for sleep medicine services has never been greater, and the future of sleep medicine is bright. But to thrive in the coming years, sleep medicine organizations and sleep medicine providers will be required to embrace pending changes, adopt new approaches, and broaden their perspectives regarding their roles in a new health care landscape. Beyond well-known advances in sleep diagnostics and therapeutics, rapid developments in health information technology will become staples of comprehensive sleep medicine care. Internet-based sleep-specific technologies will be at the forefront of this revolution.

A subsequent article will review in detail specific Internet-based solutions, the pertinent evidence base, and practical applications. I also will present a case study of our approach to leveraging online tools to improve patient care and grow our comprehensive sleep program here at Pulmonary Disease and Critical Care Associates, as well as describe other projects where I have played a consultative role. In the meantime, for the field at large and your organization in particular, the time to clarify a vision for the future is now. Strive to clearly define, then implement, the strategies, tactics, and technologies that will help make your vision a reality.

Emerson M. Wickwire, PhD, ABPP, CBSM, is sleep medicine program director at Pulmonary Disease and Critical Care Associates in Columbia, Md, and assistant professor, part-time, at Johns Hopkins School of Medicine. He serves on the Education Committees of the American Academy of Sleep Medicine and the National Sleep Foundation. He encourages questions and can be reached at [email protected].

  1. Smith B, Phillips BA. Truckers drive their own assessment for obstructive sleep apnea: a collaborative approach to online self-assessment for obstructive sleep apnea. J Clin Sleep Med. 2011;7(3):241-5.
  2. Pack AI. Sleep medicine: strategies for change. J Clin Sleep Med. 2011;7(6):577-9.
  3. Kotter JP. Leading change—why transformation efforts fail. Harvard Business Review. 2007;1:1-9.
  4. Collop N, Fleishman SA. The future of sleep medicine: will you be a part of it? J Clin Sleep Med. 2011;7(6):581-2.