A Novel Approach for Generating Sleep Patient Referrals in the Primary Care Practice

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2 A Novel Approach for Generating Sleep Patient Referrals in the Primary Care Practice Most sleep medicine professionals would agree that upwards of 90% of patients with sleep disorders remain undiagnosed and untreated. This is not only sleep apnea but incudes the major syndromes including insomnia, narcolepsy, restless legs, parasomnias and the remaining 80 plus sleep disorders. Why is this still a major problem in healthcare? Why can t primary care physicians, the gatekeepers for our basic healthcare, do a better job screening for sleep disorders? Why can t they at least use one of a number of validated paper sleep questionnaires to screen for sleep disorders? How can I increase my referrals for sleep studies and keep my referral sources loyal? Prevalence of Sleep Disorders in the Primary Care Practice Several publications have documented the prevalence of sleep disorders within a Primary Care Practice (PCP) setting. In 1997 a primary care clinic in Idaho surveyed 1,250 adult patients for sleep disorders over a one year period. The results indicated that 32% suffered from insomnia, 24% with sleep apnea and 29% with RLS. Another more extensive survey was done in 2007 with 1,935 patients from 5 family practice offices in North Carolina. More than 50% reported excessive daytime sleepiness, 33% had insomnia, 33% had sleep apnea and more than 25% had symptoms of RLS. Both these surveys and others indicate that all types of sleep disorders probably exist in a higher prevalence and severity among the primary care patient population when compared to the general population. Most likely this is due to the very nature of medical practice where over 85% of encounters are for chronic and acute disease. This results in an enriched profile for risk factors. These studies also suggest the primary care population has a higher prevalence of insomnia than the general population because of concomitant psychiatric and medical illness. A separate Cleveland cohort study identified 50% of their primary care patient population was obese and/or hypertensive and such patients were more likely to visit their family doctor than healthy adults. Another extensive 1999 worldwide survey conducted in 10 practices located in 10 cites concluded that on any given day 35% of patients in a PCP waiting room have a high pretest probability for sleep apnea. These and other related studies strongly indicate that sleep disorders in general are highly prevalent in the PCP setting. Moreover there is no evidence that more than a very small percentage of patients with sleep disorders are properly diagnosed and treated by primary care physicians.

3 Sleep Disorders not properly screened in the Primary Care Practice The continuing failure to recognize sleep disorders in the PCP practice constitutes a major personal and public health crisis that absolutely must be addressed. The majority of primary care physicians are uneducated on sleep disorders and their practices are too busy to ask patients the appropriate screening questions. Dropping reimbursement for typical office visits also has a negative impact on the amount of time a PCP actually spends with the patient. Compounding this problem is that although there has been an increase in public awareness of certain sleep disorders the majority of patients are not aware of the impact that lack of sleep has on their lives and the comorbidities associated with those disorders. Even if the patient wishes to discuss a sleep related problem it often comes at the end of the consultation when the question of hey Doc can you give me something to help me sleep as the physician is walking out the exam room! So becomes the catch 22 situation that physicians don t ask and patients don t tell. Traditional paper screening methods for Sleep Disorders Although there are a number of surveys and questionnaires available for screening sleep disorders, the majority were designed to screen for Obstructive Sleep Apnea. Below is a list of the more common questionnaires categories broken down between sleep apnea and general sleep disorders. Sleep Apnea Epworth Berlin STOP General Sleep Disorders Mayo Sleep Questionnaire Cleveland Sleep Habits Questionnaire Cleveland Adolescent Sleepiness Questionnaire FOSQ (Functional Outcomes of Sleep Questionnaires) Paper questionnaires are valuable tools for screening patients but their main disadvantage is that a qualified individual must still score them in a timely fashion and make sure the results are reviewed by the attending physician during the patient examination. Within a busy practice where a physician may see an average of 30 patients a day this may not be practical. In addition tracking the results of numerous paper questionnaires becomes a tedious and inefficient process. In our own experience we tried on a number of occasions to implement an Epworth and/or Berlin paper questionnaire into a primary care practice and were met with stiff resistance. Much of this

4 was due to the fact that the physicians themselves did not believe that sleep disorders were really that big of a deal and certainly did not warrant screening of their patients. In the other cases physicians were concerned that a paper questionnaire would take up too much staff time to distribute and score the results. In perspective of the 100 plus medical practices we regularly visited only 1 routinely used a paper questionnaire and that was due to the fact they were contracted by the DOT to screen truck drivers for OSA! Traditional Referral Marketing at the Primary Care Practice Establishing a steady supply of patient referrals is of critical importance for most sleep testing facilities. This requires a constant marketing effort by regularly visiting a number of PCP practices and often includes a lunch and learn session. Typically this means lunch must be supplied to the entire office staff in order to spend a few minutes with the physicians and medical assistants educating them on sleep disorders and selling them on your sleep facility. Any experienced marketing person reading this paper can relate to the effort required to do this on a consistent basis. It s also quite common that many physicians or their medical assistants don t actually direct the referrals to any particular sleep lab. In fact our experience has been that at least 50% of the referring PCP physicians we dealt with did not personally send the referral and did not know which sleep lab it was sent to. This referral pattern could be traced to 2 specific factors: 1) Physicians typically did not want to be associated with any specific sleep lab so they referral split meaning they send patients referrals equality (they thought) among a few sleep labs in town. 2) In many cases it was the front office staff that was directing the referrals often to a single sleep lab where the marketing staff had influenced them with gift cards and other items. Although this is illegal it was highly practiced in our area. If questioned on either of these referral habits the physicians or staff would become defensive and deny this was occurring and if they were pushed you would not be allowed back in the practice. It became obvious that old habits are hard to break and that unless we were willing to incorporate the payola methods there did not seem to be a way to increase our referrals unless we used a different method to help screen and refer patients with sleep disorders. As the medical profession moves towards the integration of Electronic Medical Records the era of paper surveys and questionnaires is drawing to a close. So it would seem that now is the time to move away from traditional paper screening and utilize the technology advancements in Smartphones and Tablets for a more efficient method to screen, refer and track statistics on patients at a high risk for sleep disorders.

5 Using wireless mobile technology to improve patient screening Over the last few years a variety of new generation Smartphones and Tablets have been introduced into the consumer market with a number of advanced features. They are much more reliable, easier to use and provide wireless options to connect to the ever increasing speed of the internet. Along the way thousands of applications or apps have been developed allowing these devices to be used in a number of areas including the healthcare industry. Recent surveys report that over 80% of physicians own a Smartphone and an increasing number use a Tablet in their medical practice. This penetration of mobile technology into the healthcare market provides an excellent opportunity to introduce a more efficient method of screening patients for sleep disorders as they sit in the waiting room of their PCP. So with the popularity of these mobile devices increasing and the ability to wirelessly connect them to the internet, the technology is now available to introduce a Tablet based screening and referral program. Objectives of a Tablet Sleep Screening Questionnaire Include screening questions for all major sleep disorders Include health related questions to catch comorbidities Include the Epworth questionnaire to satisfy insurance requirements Must be easy for office staff to enter patient information Must be easy for the patient to interact with for all age groups Must take less than 5 minutes to complete Provide a simple but detailed sleep profile report with high risk assessments Provide an electronic referral form submitted with a single finger touch Provide statistics of referral patterns and sleep disorder procedures Using such a wireless Tablet questionnaire patients would answer a series of sleep related questions with a single finger touch to the screen. Each question would appear full screen with large touch sensitive buttons and audio feedback making the answer selection an easy task to perform even for elderly patients. Subsequent questions would be displayed automatically only if the preceding question was answered with the option to go back and correct the last answer at any time. The results of the questionnaire would generate a sleep profile report within seconds and display this report on a second wireless Tablet or Smartphone within the practice. This report would indicate if the patient is high risk for any of the major sleep disorders including sleep apnea, insomnia, restless legs syndrome, narcolepsy and parasomnias. It would be designed to be easily understood so the physician could show the patient and discuss the results. A referral form would also be generated that auto populated the indications for a sleep study directly from the results of the questionnaire. Certain comorbidities picked up from the questionnaire would be displayed helping in the decision of what type of service should be

6 prescribed. The attending physician could show the patient the referral form, select the appropriate action and make comments before sending the electronic referral to a specific sleep center with a single finger touch. This application could also provide additional assistance to the physician by not allowing a HST study be prescribed if certain comorbidities were indicated during the questionnaire process. Most important is the fact that this patient screening and report generation and electronic referral process will save a significant amount of physician time, increase the amount of referrals for all the major sleep disorders and eliminate the need for wasteful paper questionnaires. It must however be easy to use by the patients, office and medical staff. This requires minimal setup for each patient by the office staff and easy access to the results by the medical staff. It therefore must be a simple step by step process for all parties involved as follows: Step by Step Process Front desk staff enters basic patient information into the program. Patient is handed the tablet ready to begin the sleep questionnaire. Patient completes the questionnaire with single finger touch answers. Patient is prompted to return the tablet to the front desk staff. Front desk staff sets up the tablet for the next patient with minimal keystrokes. Program automatically calculates the risk factor and generates a sleep profile report. This report is now available for viewing on additional medical staff Tablets or Smartphones. Medical staff can review the report with the patient. High risk patients are recommended for consultation, diagnostic or treatment options. An auto-populated referral form is generated by a single touch. This electronically signed referral is sent to a specific facility with a single finger touch. Testing facility receives the incoming report and referral in pdf formant via . Statistics are available to track referral and sleep disorder numbers.

7 Tracking and quantifying valuable referral statistics Another significant advantage of using this type of application to screen and refer high risk patients is the ability to track and quantify these statistics. This includes the ability to monitor specific referral patterns from individual physicians and their practices. Imagine the marketing person of a busy sleep center simply displaying last week s referral patterns of a particular physicians practice just before they drop by the practice for a follow-up visit. In addition it would also be possible to track the incidence of specific sleep disorders down to the individual referral source or for all the practices using the application. This would be ideal for research work since it would be easy to gain an insight just how many patients are indicating they have symptoms of specific sleep disorders. All these statistics could also be compared to a nationwide database of information gathered from a number of screener applications being used across the country. SleepScreener is a new product that addresses the need to screen and refer patients in a primary care practice. It s easy for both patients and medical staff to use eliminating the need for paper questionnaires. It s also easy to implement in the PCP practice, saves physician time from asking sleep related questions and directs referrals to your lab not your competitor. Features Works on any browser accessible computer Tablet or Smartphone Single finger touch answers for full display size questions Screens for all the major sleep disorders including insomnia Generates an easy to read report with high risk recommendations Generates an auto-populated single touch electronic referral form Prevents prescribing a Home Sleep Study with certain patient comorbidities Provides statistics for tracking referral patterns and much more Authors: Andrea and Michael Clark