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					                                   THE FUTURE OF THE ACADEMIC SLEEP CENTER

                                                   Michael Grandner, PhD

The pace of change seemingly increases every year, and those best able to anticipate those changes will best be able to
appreciate the advantages of being in a leadership position. Regarding the Academic Sleep Center, there are several
domains that will dictate the direction of change in the near future: (1) patient populations, (2) communications and
information technology, (3) assessment and treatment modalities, (4) integration of research into clinical practice, and (5)
policies guided by the field, the industry and the government.

                                                     Patient Populations

The big picture: The Academic Sleep Center (ASC) will be at the forefront of guiding the changes in public and physician
knowledge and appreciation of sleep and sleep disorders. ASC faculty will be the driving force behind publishing the
data, reviews and editorials that will continue to legitimize sleep as an important aspect of health. Additionally, faculty
and staff of the ASC will engage in meaningful outreach programs to develop collaborative relationships with other
health care providers, personally educating them and consulting with them in matters of sleep. This will increase
physician knowledge and appreciation of the importance of sleep and lead to increased referrals to sleep disorders centers
for assessment and treatment. Concurrently, ASC faculty will also be leading the drive to better educate the community
about sleep. As sleep becomes more of a recognized aspect of the public health, we can better understand sleep in our
communities. Eventually, we will develop population-based interventions that aim to educate the public about healthy
sleep and options for treatment, as well as promote population-level interventions in individuals and governing bodies.
This dual approach will change the makeup of the patient population seen by the ASC in three ways: (1) many will be
more informed about sleep as a result of outreach programs, (2) many will still be uninformed about sleep but may come
anyway due to increased referrals, (3) a more demographically-diverse (e.g., age, SES, race/ethnicity) group of patients
will present to the clinic, and (4) a more diagnostically-diverse (e.g., apnea cases with comorbidities, insomnia, other sleep
disorders) group of patients will present to the clinic.

What this means: The ASC of the future will need to adapt to changes in two domains (1) the role of the ASC in outreach
programs and (2) adapting the ASC to accommodate a changing patient base. Regarding outreach, the ASC will have to
build on existing relationships and cultivate new partnerships with other health providers. Attending rounds, serving as
consultants, giving talks and workshops, and developing strategies for motivating referrals will all be important. These
outreach efforts will be supported by the growing sleep literature, and key reviews/editorials written by ASC faculty that
summarize the findings for those outside of the sleep field and keep sleep in the minds of practitioners. In the
community, the ASC will partner with local organizations to create and distribute educational materials, give talks and
workshops, and even offer some limited assessment/treatment options in communities. While lower SES communities
might be a prime target for intervention, even high-SES communities may be interested in learning more about the
importance of sleep for health and options for improving sleep. Outreach will also involve interface with governing
bodies to promote legislation that not only facilitates the functioning of the sleep centers (e.g., licensure/certification
issues), but promotes sleep awareness in the population (e.g., public awareness campaigns).

Regarding adapting to a changing population, the ASC will need to be better equipped to handle sleep issues across the
lifespan, including old age (as our society is aging) and perhaps even adolescents and children (and families). Sleep is a
particular concern in these groups, and they may require different treatment for optimal success. Also, culturally-
competent interventions need to be more of a priority in the sleep field, which often takes a one-size-fits-all approach.
Accumulating data suggests that inclusion of spouses and families in treatment may be an important factor. Also, other
factors, such as the nature and frequency of follow-ups, how the clinician interacts (especially nonverbally) with the
patient, and better sensitivity to language barriers will begin to be adopted. The ASC will lead the way in this regard, and
demonstrate the importance of these considerations with improved outcomes.

                                      Communications and Information Technology

The big picture: The ASC will utilize changes in technology to optimally innovate and communicate. Although it is
difficult to foresee what will be possible in even 5 years, projections based on current trends are possible. There are
several domains in which the ASC will be able to harness technology to lead the way.

First, the growing role of electronic medical record systems will come to include more than just a digital filing cabinet.
Electronic medical records will be able to organize progress notes and reports, as well as clinical data for a patient. It will
be able to track data across time, and integrate into system-wide databases that will collect data for research. It will be
accessible remotely. Patient records may be automatically tagged based on lab or report values, or alerts can be ‘pushed’
to certain charts. For example, participants who are eligible for research studies might be automatically tagged in the
system, with the consent form on screen and immediately accessible to print at the press of the button. Or patients taking
certain medications may be tagged for clinicians to specifically inquire about sleep-related effects.

Second, the integration of telemedicine into the clinical role of the ASC will grow. This will take place on a number of
levels. On the population level, the ASC will be the thought leader regarding information about sleep disorders.
Concurrent with the outreach goals mentioned above, the ASC will utilize technology (e.g., websites, social networking,
apps) to place sleep medicine knowledge in the hands of the public. On the patient level, simple follow-up appointments
will be conducted by phone or email more frequently than office visits can be scheduled.

Third, better remote compliance monitoring will improve outcomes. Already, CPAP machines have smart cards that
record compliance. In the future, devices will wirelessly transmit usage data, so that inconsistencies in usage can be
detected immediately and addressed quickly. Other devices will also begin to utilize this approach. Actigraphs may
eventually broadcast data as well, and online sleep diaries will allow for more close surveillance of patients.

Fourth, internet-based communication systems will replace traditional conference calls and improve collaboration. The
expense associated with conference calls will be dramatically reduced by taking advantage of existing VoIP technology
for phone calls, especially those involving international participants.

Fifth, the home institution of the ASC will need to have protocols and protections in place for cloud computing. Most data
will be stored remotely, accessible from any terminal, or the web. This will not only allow for instant access to clinical and
research data, reports, drafts, and records but will afford the benefits of portability and collaboration. Thus, sleep studies
can be scored remotely at one location, verified remotely at another, and accessed by the clinician in clinic with the
patient. Or research data can be entered at one location, scored at another, and organized, analyzed and interpreted at
another, to be written up by authors that can access the data anywhere.

What this means: All medical records will be electronic. All paper-based reports and communications will be scanned
(and analyzed for Optical Character Recognition). Records will be accessible remotely and will integrate with system-
wide databases. A system will automatically send alerts to the clinician seeing a patient under certain circumstances,
based on certain criteria. If, for example, this patient is eligible for a research study, the consent form and/or screening
forms will be sent and will need to be completed by the clinician before progressing to writing a note. This will ensure
recruitment, even with ‘busy’ clinicians.

The ASC website should be the first stop for someone who is interested in learning about sleep from a source that is not a
drug company. The website will be loaded with consumer-friendly information and ways of getting questions answered
(without necessarily making an appointment – perhaps a blog or even a place to ask sleep questions). The ASC will
embrace telemedicine, especially for follow-ups, which may occur via phone or email. Patients who experience difficulty
getting to clinic will be able to consult with physicians and other providers by email, phone or (in more complex
situations) webcam.

Remote monitoring of CPAP compliance will trigger intervention based on non-compliance. Other protocols to utilize
remote access to devices and online sleep diaries to track patients will be implemented as technology comes on line.
Conference calls will utilize low-cost VoIP technology. Additionally, technologies such as shared calendars (e.g., Google
Calendar) for scheduling within the organization, Doodle for scheduling across organizations, TimeBridge for sharing
information during meetings, Google Wave for group-access project management, etc. will be implemented. Lectures will
be webcast for remote access, and select talks will be recorded as podcasts or archived lectures. Finally, the information
infrastructure of the ASC will integrate a cloud computing framework, allowing access to data from any location, whether
for clinical or research purposes. Some data may need to be restricted, but in general, remote access to data will
dramatically increase efficiency and collaboration.

                                             Assessment and Treatment Modalities

The big picture: The ASC of the future will be at the forefront in integrating current knowledge about assessment and
treatment. Regarding assessment, home-based sleep studies for routine screening of sleep apnea will replace the in-lab
study as the standard of practice. In-lab studies will still be used for cases that are either unclear or somehow complex.
The ASC will develop an infrastructure for home studies – not as a supplementary service but as a core service of the
Center. Also, routine intake assessment will be more complex. Blood samples will be routinely collected, for future
research studies. Some questionnaire data will assess a number of social, medical and psychological variables with the
dual purpose of better characterizing, understanding and diagnosing patients and gathering data for research. Finally, as
suggested earlier, many assessments may be conducted online, including sleep diaries. Regarding treatment, behavioral
sleep medicine will be better integrated into the ASC. Not only will an insomnia clinic be available to treat what is
probably the most prevalent sleep disorder, behavioral sleep medicine specialists will be available to assist in the
treatment of circadian rhythm disturbances, parasomnias and improve CPAP compliance. Also, treatment approaches
will be culturally competent. Clinicians will be trained in culturally-sensitive treatment, including ways of involving the
family and using appropriate nonverbal communication. Another way in which treatment delivery will change is the
increased adoption of a model of satellite offices in communities. The central location of the ASC will serve as the primary
location for key faculty, as well as the primary location for assessment and treatment. However, satellite offices will
increase in utility for routine screening and outpatient treatment; their roles will grow to accommodate home-based
studies, specialty care for special populations, behavioral sleep medicine, and eventually in-lab sleep studies. Since all
data will be shared across sites, there will be no walls or lapses in communication. Electronic records, telemedicine and
teleconferencing, and cloud computing will integrate these various sites.

What this means: Blood samples will be routinely taken at intake (provided consent is given), along with select
questionnaires. Also, as home-based studies become the standard tool of sleep apnea screening (with in-lab studies only
being used in cases where the clinical situations are especially complex or treatment is ineffective), a core function of the
ASC will be to administer and score home-based studies. An infrastructure will be put in place to house and coordinate
this effort. Behavioral sleep medicine will become an important part of the ASC – a true insomnia treatment program will
be accompanied by a CPAP compliance program. This will be implemented through the use of a hierarchy of Nurse-
Practitioners delivering most therapy, supervised by Psychologists who oversee the program and see the more difficult
cases. Clinicians will be trained on providing culturally-sensitive interventions, and to be aware of cross-cultural
differences in not only vulnerability, adherence, etc., but in fundamental aspects of communication, relationship with
healthcare, and goals of treatment. Sensitivity to the needs of the community becomes part of the reason for building
satellite facilities in the community to facilitate access.
                                       Integration of Research into Clinical Practice

The big picture: With the advent of new technology, the changing face of clinical and research training, and the financial
realities of a changing society, the integration of research into the ASC will be a core feature of its functioning. Research
operations will continue to operate parallel to clinical activity, but there will be several key areas where the clinical
operations will be a valuable tool for research. Several areas were already described above (i.e., push notification of
eligible patients, routine collection of blood and other data, integration with database systems). In addition, clinical trials
research programs will be better integrated into the clinical operations, with staff specifically tasked to achieve this,
overseen by the clinic supervisors who interface with the PIs. Also, there will be a system in place to track and organize
clinical data for ease of clinical case series studies. With all of these integrated systems, multicenter trials, which will
become more standard, will be more feasible. This will also help in the pursuit of comparative effectiveness research
studies, which will become more valuable in the future. The communication between the ASC and a basic science sibling
program will increase. As focus on translational medicine grows, more interface between these entities will become
crucial. Ideally, they will share much information, to allow for flow of ideas and hypotheses that can be tested
experimentally at any level of the bench-to-bedside spectrum. This approach will only grow, and as more people from the
basic science side interact and collaborate with clinical scientists, fruitful translational research programs can be
successfully developed.

What this means: Staff (and possibly faculty) will need to be involved to coordinate the integrated research components.
Additionally, clinical scientists will need to be trained on how these information systems work, so that they can explore
the wealth of clinical data available online and in databases to address research questions. Increased collaboration with
basic science will expand beyond case conferences and lectures and will grow to include other ways of connecting busy
faculty – even if it takes insistence from senior faculty. Grant applications will be reviewed with an eye towards
collaboration within domains of the ASC. Publications will include co-authors who can round out a paper (e.g., a clinical
paper can include a basic scientist to help bring a biological perspective and a basic science paper can include a clinical
scientist who can bring an applied perspective).

                    Policies Guided by the Sleep Field, the Healthcare Industry and the Government

The big picture: The changing nature of healthcare and sleep medicine will have an impact on the ASC. Reimbursement
will depend more and more on AASM accreditation and board certification. This will require that many (if not all)
intermediate and senior physicians be ABSM certified. Within the next several years, CBSM certification for behavioral
sleep medicine practitioners (doctoral- and masters-level) will be necessary. Further down the road, Psychologists will be
able to obtain their own board certification, through a Behavioral Sleep Medicine exam administered by the American
Board of Professional Psychology. While this is still about 10 years away from availability, it will be useful to anticipate.
Also at issue will be licensure/certification of sleep technicians. Currently, there is no certification in the state of PA, but
this is coming within the next few years. There is now debate whether this will instead include licensure, but at this time
this option does not seem likely.

The ASC will also be guided by policies within the healthcare industry. As reimbursement for visits and assessments will
likely decline, these will need to be shorter and more effective. In addition to streamlining processes using electronic
record systems, there are several ways this can be done. In addition, as mental health parity becomes more of a reality,
reimbursement for behavioral sleep medicine providers will become easier.

At the policy level, there will be several important issues in the next 5 years or so. The issue of licensure/certification for
sleep technologists was discussed above. In addition, tighter regulations on healthcare providers will require more
oversight, which would be facilitated with an integrated electronic records system. Also, the ASC will position itself as a
local leader in terms of outreach to governmental bodies (mentioned above). The ASC will make itself available for
consultation and advocate for changes that it sees as important. As most policy movement begins at the local level, the
ASC is in a prime position to utilize its status as thought leader on sleep-related issues to bring about policy change at the
local and state level.

What this means: An infrastructure for taking board and certification exams should be put in place to ensure that
everyone passes. Patients should be able to make and confirm appointments online, and complete all forms ahead of time.
They should also be able to submit questions for their doctor to address at their next visit – so even if they forget, a
notification will come up in their record. Also, this will help reduce hand-on-the-door questions that the clinician did not
pace the session for but may take up time. Telemedicine approaches (described above) may also reduce effort needed for
routine follow-ups. Finally, the ASC can position itself to become involved with relevant legislation at the local and state
level, using scientific data to back up claims and make recommendations.

                                                         Summary

To maintain a position of leadership, the ASC of the future will utilize its particular strengths to become a respected
thought leader in the field and the community, integrate research into practice, streamline procedures, and take
advantage of new technology. To do this, the ASC will engage in significant outreach into the healthcare community and
the community at large through cooperation and collaboration with other providers, seeding electronic media resources,
advising public policy and developing a presence in the local community. The ASC will collect blood and other data
routinely, integrate clinical trials (especially multicenter and/or comparative trials) and link clinical data to dynamic
research databases, all in an effort to leverage its ability to produce quality research data. The ASC will create an
infrastructure to make sure its faculty and staff are as well-trained as possible, with the aim of maximizing credentials (for
their value as a training tool and for reimbursement/accreditation) and being able to successfully communicate and care
for the members of the community who come for treatment. An integrated electronic records system can effectively
streamline many tasks, including those peripheral to treatment, including assessment, recruitment for research and
collaboration with satellite sites. Home-based studies and remote monitoring of patients will become more the norm, and
behavioral sleep medicine will grow as a sub-specialty. Telemedicine will increasingly be utilized. All (or most) records
will be backed up to the cloud, accessible anywhere. The ASC will serve as a model healthcare and research facility,
combining the talents of many varied practitioners across disciplines, who appreciate the translational approach to health
science, in an organization that maximally appreciates and makes use of its place in the professional and lay community.
                                                      Suite 201 in 2015

                                                   Indira Gurubhagavatula

What will change?

The most dramatic change in five years will be an increased reliance on unattended sleep studies in sleep diagnosis. The
first-line tools in sleep apnea diagnosis will be unattended studies, followed by partially-attended ones or (rarely) fully
attended ones in the laboratory for patients with special needs, such as fully blind amputee-paraplegics. The cost of
unattended studies will decrease because of high volume, whereas costs of in-lab studies may paradoxically rise.

What does this mean?

        It depends on how it is set up, and who retains privileges for specific functions. These functions include: 1)
deciding who gets a study, 2) setting patients up for the study, 3) generating reports, 4) dispensing CPAP, and 5) provide
ongoing disease management services.

1) Sleep apnea awareness will grow and an ever-larger base of providers will decide who gets a study rather than just
   sleep physicians. This includes more PCP’s, including physician extenders and nurse practitioners; ENT;
   endocrinology; anesthesia; cardiology; and many others. The great result is that many more patients can be served.

2) A critical part of what happens will be the Academy. They will likely try to follow the model that neurologists have
   created for EEG’s, and cardiologists have created for ECHOs: though anyone can order the study, only someone
   board certified in sleep medicine can interpret the study.


    If we retain responsibility for setting up studies, we would set up a ‚PSG dispensary‛ where patients make appointments
    to borrow the diagnostic devices. Because parking will become even more of a headache than it is now, most would
    elect to have the equipment mailed to them, with an online, comprehensive demonstration of how to apply it. A
    webcam connection can be used to communicate with a live assistant for help with the set up if problems arise. If the
    live assistant is not available, a YouTube video could suffice, or a message board connection with another patient
    going through the same thing. In some cases, (say after several failed studies), an exceptional patient may present for
    in-person training. (The wild card in all this: what if Walmart sets up a competing dispensary? No worries. Their
    reputation will continue to sully because of scandals about underage or criminal live-assistants, while Penn’s will
    continue to blossom).

3) Automated report generation will become more refined, but the need for oversight, quality control, and clinical
   correlation will continue. Computer glitches, faulty leads, misapplications, and other errors will happen because the
   people putting the devices on in the home are still new to the procedure. Though most studies at the VA make the
   diagnosis, the general population of patients in PCP pools will have far more negative studies. And for lack of a
   better term, ‚idiot-proof‛ sleep studies will continue to remain a dream. Our physician staff may be required to
   proofread the reports for quality control – this would be (most likely) for every patient, since a missed diagnosis
   could be dangerous. If volume increases enough, we may train physician extenders to do this. We would then make
   a recommendation for an in-lab study, an in-person clinical evaluation, and/or no further work up.
4) Dispensing PAP would be done the usual way, with DME providers. Eventually, though not likely in just five years,
   we would bypass steps 1-3 to come right to this step. This is particularly so for special groups like commercial
   drivers, who will resist being labeled with apnea till their last (apneic) breath, but may consider wearing PAP blindly
   ‚just in case.‛ Special breeds of PAP devices (and diagnostics) may need to be developed that have bio-sensors to
   periodically ascertain patient identity, so that we know it is the patient and not their English bulldog who is wearing
   the device.
5) Provision of management services: for straightforward patients, this will go back to the PCP. However, the majority
   will not be straightforward, particularly in the first year of treatment. They will have mask issues, insomnia issues,
   other co-morbidities like RLS or poor sleep hygiene, and a litany of complaints against PAP and its general
   unsexiness. The sleep provider will get these patients. This leads to interesting scenarios in management, and a
   possible niche for additional sleep studies!


    Are PAP downloads good measures of ongoing cardiovascular risk? Probably not. They do not measure residual
    arousals or residual disease burden during hours slept without wearing PAP, even in a patient who wears PAP for 5
    hours/night every night. In management of apnea, the role of the Sleep Center will be to assess ongoing threat of
    cardiovascular disease and sleepiness from untreated sleep apnea, and untreated sleep apnea can exist in a seemingly
    compliant patient!

    This might require additional unattended sleep studies at home, while the subject is wearing PAP, which include
    oximetry and EEG -- maybe 24-hour EEG -- to assess arousal frequency. From this assessment, the sleep specialist
    will work to reduce risk with targeted interventions. Sleep Centers will be heavily supported by nursing and
    respiratory therapy personnel to provide these interventions, as well as behavioral sleep medicine specialists who
    address insomnia.

What about research?

Of course, all these management novelties will mean that the research will burgeon. With less expensive, more
streamlined ways to diagnose apnea, more research dollars can be directed towards other areas, like genetics studies,
biomarkers, and so forth. We will move toward validation of clinical pathways, assessment of outcomes, and risk
prediction models for adverse outcomes of apnea. We will look at other roles for sleep studies in ongoing disease
management and not just in initial diagnosis, and work with industry to design sleek new monitors – maybe even
disposable ones, and those with built-in bio-identification systems.

The Bottom Line: What should Penn do?

As we have been, we will continue to be outstanding in whatever we do, with our traditional multidisciplinary approach,
and this is will continue to attract outstanding fellows, faculty, and staff to Penn. But the bottom line is, the early bird
gets the C. elegans. So we start partnering with PCPs and other providers, and set up streamlined pathways for steps 1-3,
designating point-people to lead various aspects of this program. We set up research questions in parallel with clinical
practice. If we start from the ground, the only way to go is up.