The Impact of Telehealth on Patient Experiences in Sleep Medicine

Lucas Donovan, MD, MS

With the onset of the COVID-19 pandemic, health care providers initiated the use of telehealth to continue to deliver medical services to patients when stay-at-home and quarantine orders prevented in-person clinical visits. In the field of sleep medicine, the use of telehealth was also employed, and it continues to be developed and adapted amidst the ongoing the pandemic. 

Lucas M. Donovan, MD, MS, spoke with NeurologyLive on a recent study, which evaluated patients’ experiences using telehealth to receive sleep care, recruiting participants from June 2019 to May 2020. Donovan, who is an assistant professor in the division of pulmonary, critical care, and sleep medicine at the University of Washington, and core investigator at the Seattle-Denver Health Services Research & Development Center of Innovation, Veterans Affairs Puget Sound Health Care System, Seattle Division, discussed key findings, with participants reporting both positive and negative experiences with in-clinic video, home-based-video, or telephone telehealth encounters.

Donovan provided insight on the role of telehealth in overcoming barriers to care, particularly geographic divisions for patients in rural areas and avoidance of crowds, which could be anxiety-inducing for this patient population. He further noted that telehealth is not a panacea, and in-person treatment will still be necessary for physical exams and other evaluations, depending on patients’ needs and preferences. Looking forward, Donovan emphasized the need to establish equitable access to care via telehealth, while also striking a balance between in-person settings and developing innovative methods to administer care remotely. 

NeurologyLive: Can you provide an overview of the study? What were the key findings?

Lucas Donovan, MD, MS: The aim of the study was just a spectrum [of] patients’ experiences with sleep medicine telehealth encounters and their perceptions of how these telehealth encounters impacted their care. We conducted interviews among 35 VA patients with recent sleep medicine telehealth encounters—these encounters either incurred through in person clinical visits, where they were in a clinic and with a specialist from another facility, or remote visits where the veteran patient was having a teleconference with a provider from their home or having a telephone encounter with a provider from their home. 

Through these interviews, we identified 5 overall themes. One was improved access to care. Patients appreciated telehealth is providing access to sleep care in a timely and convenient manner. Two, security and privacy—patients describe how home health/telehealth afforded them greater feelings of safety and security, due to the avoidance of anxiety provoking triggers such as crowds. Some patients also noted a potential loss of privacy with telehealth. Third was personalization of care. Patients described experiences with telehealth that either improved or hindered their ability to communicate their needs. Fourth was patient empowerment. Patients described how telehealth empower them to actually manage their own sleep disorders, and then fifth was unmet needs. Patients recognized specific areas where telehealth did not meet their needs, including the need for tangible services, such as mask fittings for CPAP [continuous positive airway pressure].

Were any of the findings surprising in any way?

Going into these interviews, I expected the patients would discuss how telehealth encounters were either just the same or perhaps slightly worse than in-person. And while many patients did find that telehealth encounters mimicked in-person care, or had slight technical downsides, other veterans expressed how telehealth was actually superior in facilitating good communication with providers. They felt that their providers had fewer distractions over telehealth and were able to answer their questions in a way that felt like it was less pressure—patients felt like there was less pressure with health, and they could speak their mind more freely, particularly when the encounter was over the telephone.

What was the importance of telehealth following the COVID-19 pandemic? What is going well, and what might need improvement?

I think telehealth is playing an enormous role in helping us overcome barriers to communication between patients and providers. Telehealth helps patients overcome geographic, as well as scheduling barriers. Patients don't need to take to drive a long distance and spend all that all that time in the car, or a waiting room, for a 30-minute appointment. In that way, telehealth has played a huge role in helping us reach rural veterans, rural patients, and those with busy schedules due to work or family obligations. 

It's clear that telehealth by itself is not a panacea. Patients in our study highlighted that they still needed tangible services that could not be delivered by telehealth—some patients or a sample noted that they had all their questions answered by the provider over telehealth, but even though their questions were answered, they still had difficulty accessing the services that were typically needed, particularly those services that were delivered in person, such as mask fittings of CPAP devices. Patients also felt concerned about the lack of a physical exam, and they were wondering what information could be missed. 

We also know need to make sure that we have equitable delivery of telehealth. There has been some concern over a digital divide and that we are missing those who do not have access to technology. This includes those who may have lower incomes and resources and may not be able to afford a smartphone or a computer to do a telehealth encounter at home. Also, it could include those who are older or have less experience with technology. The VA is starting to approach this issue directly through home-based clinical video telehealth where the VA will send veterans tablets and provide training if they do not have the equipment. Long term, we need to make sure that these efforts are effective and that we deliver telehealth equitably.

How did telehealth impact patient care during the pandemic? Do you foresee its continued use in years to come?

In sleep medicine, I honestly did not see a major impact to care during the pandemic. From my perspective, as a sleep physician, I have not seen a change in the care of that I'm able to deliver through telehealth, versus that which I was able to deliver in-person. The only changes [are] that I'm able to see more patients through telehealth, I have fewer no-shows in my clinic, and virtually all the visits are able to start on time. 

The only negative issues related to the pandemic that I've experienced were related to a lack of in-person sleep testing, as we had to avoid in laboratory testing for a while, particularly at the beginning of the pandemic. Since then, we've been able to safely reopen our sleep labs. However, the majority of patients with suspected obstructive sleep apnea, or OSA, can be effectively managed at home [with] home sleep apnea tests and auto-titrating CPAP.

In the years to come, I see us continuing to utilize telehealth for most of our patients in sleep medicine, but we should maintain at least a proportion of our clinic grids available for in-person consultation based on patients’ needs and preferences. At our center, we currently maintain about a third of our clinic grids for in-person care, and that seems to be working well. Over time, I anticipate that the proportion of in-person visits will need to be fine-tuned for different centers, based on their capabilities and the patient's needs.

What does the clinical community need to know about these findings both in the field of sleep medicine, as well as general neurology?

Our main takeaway from this study is that patients who experienced telehealth encounters in sleep medicine really tend to appreciate it. I think the main action item that we appreciate from this study is that we do need to pay attention to the areas where telehealth does not meet patients’ needs. For instance, we need to understand where the physical exam is absolutely necessary and identify those patients who need who need to be seen in-person. What we can do is we can consider the ways to accomplish the tasks that we typically do in person, such as CPAP mask-fittings, and find ways to do those remotely, and so I would like to see innovation in that field. 

With regard to general neurology, I'm not a neurologist, so I'm hesitant to make any comments that would be relevant to the wider field of neurology, since I'm a pulmonologist. I do think that adaptations will be necessary for the neurologic exam, in particular, and that will be a really important consideration as to how to do the neurologic exam remotely, but I will leave the specifics to the card-carrying neurologists.

Transcript edited for clarity.

REFERENCE

Donovan LM, Mog AC, Blanchard KN, et al. Patient experiences with telehealth in sleep medicine: a qualitative evaluation. J Clin Sleep Med. 2021;17(8):1645–1651. doi:10.5664/jcsm.9266