Sleep-Record Outsourcing No Yawning Matter – Chad Doucette

Looming Shortages of Registered Sleep Technologists Fuels a New Business Model that is Being Adopted by Sleep Labs Worldwide

Sleep disorders are like an epidemic sweeping across North America. According to Stanford University Center of Excellence for the Diagnosis and Treatment of Sleep Disorders, obstructive sleep apnea tops the list with an estimated 30 million Americans being afflicted. An estimated 12 million Americans twitch and kick their way through the night with restless legs syndrome and roughly 14 percent of Americans are afflicted with chronic insomnia. Nightmares, night terrors, sleepwalking, head banging and grinding teeth round out a partial list of growing sleep problems called parasomnias.

All this adds up to a sleepy if not cranky population. Fatigue is the most common problem that can lead to higher absenteeism, higher worker’s compensation, increased errors, diminished productivity and a host of costly workforce productivity issues. All this is putting tremendous pressure on sleep facilities. As the number of people dreaming of getting a good night’s sleep increases, more sleep facilities face mounting backlogs of patient’s sleep studies that need to be analyzed. Not surprisingly the pent-up demand for sleep tests is fueling a brand new red-hot trend in sleep medicine: Sleep-record outsourcing. An increasing number of leading hospitals and private sleep facilities are turning to this innovative business practice as a quick cure for staffing shortages, or as a long-term substitute for costly operational expenses. The benefits of record outsourcing are compelling:

  • Increased profitability
  • Heightened efficiency and productivity
  • Reduced overhead costs
  • Restored work/life balance for employees
  • Raise revenue by increasing the number of patients you can assess/treat
  • Improved patient services due to faster turnaround of completed sleep studies
  • Alleviates staff shortages during peak volume periods
  • Gain access to industry experts

In addition to these and other benefits, most sleep laboratories and hospitals will be motivated to incorporate sleep record outsourcing into their business practice as a proactive measure to deal with a looming staff crisis.

Easing Sleep Medicine’s Impending Staffing Shortage

In recent years, demand has outstripped the supply of registered sleep technologists. Lack of qualified staff has left many sleep laboratories working short staffed, many of them working excessive hours of overtime and being frequently called back to work after having completed their shift. Vacant positions are not filled or, in the case of many rural health districts, they are temporarily filled by laboratory aides or other department staff who cannot completely score patient’s studies. Shortages of technologist have also led to longer turn-around times for test results with staff feeling overwhelmed by the workload. In addition, a significant number of technologists will be eligible to retire in the next several years.

In response to this tsunami sized labor crisis, the numbers of scoring companies is expected to increase significantly over the next few years. Until recently the sleep industry has been slow to adopt outsourcing. However, the laws of supply and demand coupled with the proven benefits and cost effectiveness of outsourcing are widely expected to make this a normal if not preferred business practice to account for future growth and the onslaught of employee shortages.

“Who is Scoring My Sleep Studies?”

The sleep record scoring industry is a relatively new and innovative concept. Until recently, the only viable option available to sleep labs and hospitals was to use freelance technologists to score sleep studies on the side. Although this helped to ease some of the workload, a single technologist can only be stretched so far. Factor in concerns over HIPPA compliance and liability insurance coverage, and the single technologist option becomes a short term, stopgap measure at best. Over the past few years we have seen the emergence of some very reputable, value driven companies who place quality at the heart of their organization. As with any industry growth surge, we have seen some companies offering scoring services at very low rates with questionable quality controls and unregistered technologists performing the work. While the benefits of outsourcing are attractive, the key question that a facility should ask when thinking about outsourcing is “Who is scoring my sleep studies?”

Selecting a company that only uses registered technologists to manually score the entire study is a key factor for a successful outsourcing partnership. Scoring companies that do not hire registered technologists as scorers are not ensuring quality control or recognizing the importance of the RPSGT credentials. Cutting corners to save a few dollars by signing on companies whose studies are scored by unregistered technologists can place the quality and reputation of your facility in jeopardy. It is imperative that a standard be set in the outsourcing industry-one that ensures that only registered technologists perform the scoring of the entire sleep study. With the upcoming changes in AASM scoring criteria; this only solidifies the fact that hiring a reputable scoring company who keeps abreast with the changes in the industry and only uses registered technologists be mandatory.

Some sleep labs have considered an offshore option with the actual scoring being conducted in countries as far away as India. This method is tempting because of its cost effectiveness, but caution should be observed: it is critical to ensure these facilities are following the same internal standards established by your facility when it comes to HIPPA and patient security as well as the practice of hiring only registered technologists.

The concept of computer generated scoring has also emerged as a topic of debate. While this option is currently available, its adoption by the industry has not been widely accepted. Many sleep disorder laboratories have different protocols and procedures in conjunction with scoring to R&K standards and medical directors often have diverse perspectives regarding scoring of sleep studies. These factors can undermine the effectiveness of computer generated scoring and may make it difficult for this practice to find a solid home in the sleep medicine industry at this time. While we cannot discount advances in technology, the role of a registered sleep technologist cannot be easily replaced by a computer. As time progresses and continued advancement in technology occurs we may see automatic scoring becoming more of a reality that complements rather than replaces manual scoring of sleep studies.

Here is the bottom line: will your studies be scored by a registered technologist? If the answer is yes, then be sure to and ask for copies of the technologist’s certifications.

How to Make the Best Choice

Finding the right sleep record scoring company can be the difference between the success and failure of your sleep laboratory. How do you know which sleep scoring company is the best? One sure way is to assess the company’s industry reputation or ask for recommendations. Both are valid approaches and both mean you have to do your homework while establishing standards for your investigation to ensure you find the best company for the job.

Price is another consideration. Sleep laboratories, like the majority of healthcare departments, typically have limited budgets. However price needs to be considered in the context of quality, reliability and efficiency. Choosing the vendor with the cheapest service offering can be a shortsighted view that ultimately costs the sleep laboratory more money due to quality issues. More importantly, it can also damage the lab’s reputation.

Here is another important tip when selecting a scoring vendor: find out whether a team of registered technologists will change or will you have a select number specifically assigned to your account. The ability to select a scoring service that does not have a revolving number of technologists scoring on your account will allow your medical directors to become familiar with the scoring technologists while helping to ensure greater continuity and quality in the services provided. It takes time for new resources to ramp up and understand your expectations, so having a dedicated team is far more desirable.

Remember: when it comes to outsourcing, you are the customer. Be as diligent selecting a vendor as you want your referring physicians and patients to be with you. Your patients expect the best when it comes to the service you provide. Do not cut corners by aligning yourself with a company that does not put quality first. As the outsourcing industry continues to grow we can expect to see the emergence of industry standards that will mandate the use of registered technologists to score patient studies.

Outsourcing as a Long-Term Strategy

One thing is certain: sleep record scoring companies and the concept of outsourcing by sleep laboratories worldwide is here to stay. Staffing issues and the growing demand for sleep studies are forcing sleep laboratories worldwide to adopt this as the business model of choice. More sleep labs are “waking up” to the important benefits of outsourcing their studies – and in so doing they have been able to cut costs, free up internal resources and increase productivity. When hiring a scoring company, ensure you are working with qualified, registered technologists to ensure quality and to safeguard your own reputation. And finally, a reputable scoring company will act as an invaluable virtual extension of your team – and in so doing give you more reasons to sleep soundly knowing that your patients’ sleep studies are being analyzed by professional, knowledgeable resources. Pleasant dreams!

Chad Doucette
V.P. Sales and Marketing
Sleep Strategies Inc
Ottawa, Ontario

Should Sleep Labs Embrace Unattended Studies? – David Barone

Most sleep labs utilize polysomnography (PSG) as their sole methodology to diagnose nocturnal breathing disorders. Ambulatory tests (a.k.a. “home studies” or “unattended sleep studies”) are offered by various service providers and health networks as an alternative to rule-out sleep apnea or to confirm the presence and severity of the disease in patients presenting with indicative symptoms. Though hundreds of thousands of patients have been successfully diagnosed using unattended testing, many sleep labs shy away from such studies either out of fear that they may negatively affect the labs’ operations, or concerns that such studies may not provide adequate clinical outcomes.

Successful campaigns by the medical community and organizations like the American Academy of Sleep Medicine, the National Institute of Health and the National Sleep Foundation have contributed to increased awareness among the general public and healthcare practitioners, and to a growing demand for sleep services. With growing understanding of the significant prevalence of sleep apnea and its implications for other morbidities and patients’ quality of life, more physicians now actively screen their patients suspected of sleep apnea and refer them to sleep labs to establish definitive diagnosis and initiate treatments. The growing interest in sleep disorders, coupled with the introduction in recent years of new technologies designed specifically to diagnose sleep apnea in an unattended setting have stimulated an active debate about the role of alternative clinical pathways to the management of these patients. The issue received further urgency following a 2006 report by the Institute of Medicine which sta ted that ”polysomnography, the ‘gold standard’ procedure for the diagnosis of most sleep disorders, is not readily available for everyone who needs it.” The authors of the report stated that “access to portable diagnostic screening procedures and streamlining initiation of treatment would clearly be advantageous” and recommended that “the rationale application of technology needs to be coupled with a reexamination of the role of diagnostic testing in case identification and disease management, clarifying optimal use of objective physiological monitoring data, including data obtained from portable monitors, in clinical diagnosis and management algorithms.”1

A review sponsored by the American Thoracic Society, the American College of Chest Physicians and the American Academy of Sleep Medicine published in 2004 concluded that “given the available data, the use of portable devices was not recommended for general screening.”2 Other reports, some published more recently, reached different conclusions, suggesting that ambulatory studies, when properly utilized and operated by skilled professionals, may indeed add to the arsenal of diagnostic options available to practitioners. The Minneapolis-based Institute for Clinical Systems Improvement (ICSI) has recognized the importance of this issue, and in its 2006 guidelines3 stated that “in patients with a high pretest probability of obstructive sleep apnea (OSA), unattended portable recording for the assessment of obstructive sleep apnea is an acceptable alternative to standard polysomnogram in the following situations: (i) patients with severe clinical symptoms that are indicative of a diagnosis of obstructive sleep apnea and when initiation of treatment is urgent and standard polysomnography is not readily available; (ii) for patients unable to be studied in the sleep laboratory, and (iii) for follow-up studies when diagnosis has been established by standard polysomnography and therapy has been initiated.” The guidelines also state that “employment of portable monitoring as a second-best option is not likely to result in harm to patients with a high pretest probability of OSA, and may result in less risk than leaving the condition undiagnosed.”

While this debate will undoubtedly be further pursued by clinicians, researchers and health policy makers, it is apparent that clinical needs, shifts in healthcare environment and continuing technological developments will most likely lead to growing acceptance of simpler diagnostic options, requiring all sleep labs to assess their current service models and determine how to respond to the shifting landscape.

Studies published in recent years confirmed the performance and efficacy of home studies in the clinical diagnosis and management of sleep apnea. These studies documented acceptable sensitivity and specificity of tests, a high degree of patient acceptance and low failure rates, as well as comparable outcomes to PSG, achieved at considerably lower costs. 4,5,6 The NIH-sponsored Sleep Health Study7 and other studies demonstrated that even EEG measurements are feasible in the home environment. Yet, the inherent complexity associated with such recordings limited its use in the home setting, raising concerns by sleep specialists as to whether that lack of information about the patient’s sleep architecture and actual sleep time affect the analysis of disease severity. New devices using advanced technologies can now provide significant information about sleep, including determination of actual REM sleep, sleep time and sleep fragmentation, without measuring EEG. One of the more noticeable examples is the Watch -PAT, developed by Itamar Medical Ltd., which incorporates a sensor able to monitor minute changes in peripheral arterial vasomotion caused by apnea events. Coupled with a built-in actigraphy, the Watch-PAT provides a reliable and accurate determination of sleep, wake and REM states, and together with measures of heart rate and saturated blood oxygen, generates an accurate assessment of indices based on actual sleep time.8 Multiple studies validated the reliability of the device, its ability to recognize sleep and wake states, and its accurate measurement of apneic events when used either in the lab or at the patient’s home.9 The Watch-PAT points to the direction taken by other participants in the medical technology industry, responding to providers’ needs by developing a new generation of simple-to-use and patient-friendly devices. Such devices leverage advanced sensing, electronic and software technologies to provide a greater amount of clinically relevant and reliable information, the flexibility to ope rate cost-effectively in multiple points-of-service and lowering costs.

In-spite of the availability of new technologies offering alternatives to PSG and many publications evidencing their performance, the majority of patients suffering from sleep disorders are still sent to sleep labs, as referring physicians and patients recognize the medical expertise and broader resources available through these venues. Yet, a growing number of sleep labs are shifting their views from seeing home tests as a threat to patient care and at times, even to their own operations, to realizing that such technologies actually represent an opportunity to enhance and expand their services by rationally integrating PSG and portable tests. Some examples of how portable technologies are benefiting providers of sleep services and patients alike include:

Reducing waiting time. Many labs struggle with the growing demand for services that extends waiting time for patients suspected of sleep apnea to weeks and even months, frustrating patients and referring physicians alike. Any sleep lab faced with increasingly longer wait times can in a relatively short period of time, reduce it by qualifying patients who can be tested at home, applying its own clinical criteria for which patients are most suitable for such tests.

Addressing special needs. It is well-established that many patients referred to sleep labs fail to schedule a study, either because they are intimidated by the experience or simply consider spending an entire night in an outside testing facility too inconvenient. Other patients may have special medical or physical needs that limit their ability to undergo a study in a sleep lab, or given the choice, they simply prefer a test done in the privacy of their homes. Without an alternative to the in-lab PSG, many of these patients remain untreated. The home study route enables providers to offer to many of these patients a clinically acceptable solution, which, when appropriate, can be followed by an in-home APAP study, rather than leaving these patients untreated.

Responding to an immediate need. Most sleep labs schedule their patients weeks in advance and thus, when a situation requiring quick turnaround time arises (e.g. out-of-town patients, high risk cases, etc.), the unexpected need can be addressed with an at-home study rather than a shuffling of the schedule.

Supporting inpatient studies. Hospital-based sleep labs are requested from time-to-time to assess an inpatient located in an ICU, a CCU or another ward. The growing awareness of the prevalence of sleep apnea among CHF, diabetics and geriatric patients, which are prone to frequent hospitalizations, is leading to a surge in the need for in-hospital services. The ability to set up a sleep study for patients within minutes and without interfering with other support systems favors the use of the smaller portable devices. Furthermore, the auto-analysis software available with some of the newer portable systems provides diagnostic results within minutes after the data is complete, enabling the hospital’s staff to expeditiously incorporate the results into the ongoing care decisions.

Conducting follow-up studies. Many patients undergoing either positive pressure or oral appliance therapies require periodic testing to confirm the need for continuing intervention, or to determine an adjustment in treatment parameters. Presently, due to the over-extension of sleep labs and the reluctance of many patients to come to the lab for additional studies, many of them are under-managed following initial intervention. Employing a home study for an annual evaluation, or otherwise, when medically indicated, may optimally address such needs.

Evaluating pre-operative patients. Recognizing sleep apnea prior to surgical procedures may reduce the risk of post-operative complications for patients with this disease. Recently published guidelines by the American Society of Anesthesiologists,10 as well as proposed guidelines by JHACO11 to institute pre-op sleep apnea screening are expected to fuel a significant increase in the case loads involving such patients, which in many instances cannot be accommodated by existing sleep lab facilities. Rather than ignoring these clinical cases or losing such patients to other services, labs may offer the required quick turnaround service by offering a simplified home study, which will be adequate for most of these cases.

Pediatric testing. There is a growing body of literature pointing to the prevalence of sleep apnea among children, often diagnosed and treated inappropriately. Undiagnosed sleep apnea has been associated with behavior, cognitive and learning deficiencies among this population. Since most of these patients require an assessment of breathing disorders, home studies are most conducive clinically and operationally considering the inconvenience and often, parental participation, when conducting the test in a hospital-based facility.

Expanding outreach programs to referring physicians. Cardiologists, family practice physicians, otolaryngologists, bariatric surgeons and other specialists are gaining appreciation of the importance of testing patients for sleep breathing disorders. Sleep labs offering also home studies are able to respond to physicians requesting a simpler test for some of their patients, while still contributing their medical expertise and when appropriate, conducting subsequent diagnostic and treatment services.

An alternative to fixed-bed satellites. A growing number of labs are setting satellite operations, consisting of smaller labs, distant to the main facility. While these facilities enable the organization to capture additional referrals, they do carry a financial cost associated with setup and operation and at times, stretch an already thin staff. This challenge is especially acute in rural areas, as low population density cannot justify a sleep lab staffed by qualified technicians in each locale. Conducting a home test, at least for the initial diagnosis of such patients, is often the most clinically and financially prudent approach.

Employee screening. Some labs have already instituted or are considering expansion of their programs to the employer market, offering screening and diagnostic services to commercial drivers, shift workers, first responders and other employees engaged in critical tasks. Portable and user-friendly systems are an ideal technology and in most instances, the only practical solution for this emerging market.

After shunning home studies for a long time and viewing them as a competitive threat, a growing number of sleep labs are integrating home studies for some of the applications outlined above or other which suit their evolving needs. Adding portable studies to a sleep lab can be accomplished in most instances relatively quickly and with a minimal investment. Other than the acquisition cost of the devices themselves, there are little other up-front costs. Operational hurdles are minimal, since training sleep technologists on such devices is accomplished in a relatively short time, as this highly trained staff is already familiar with patient education, test preparation and data analysis, and with automatic or otherwise simplified scoring, existing staff is in most instances able to absorb the incremental home studies without additional headcount.

As more experience is gained, sleep labs will find out that home studies are not a threat to quality patient care, but rather an important modality that when properly utilized, augments the lab’s current services. Well-managed programs offering both PSG and home testing can gain tangible operational and marketing advantages, strengthen sleep labs’ competitive positions within their respective markets, improve their financial results and most important, enhance and expand quality patient care.

David Barone, MSc, MBA,
Principal, Boston MedTech Advisors, Boston, MA.


1. Institute of Medicine. Sleep Disorders and Sleep Deprivation, An Unmet Public Health Problem. April 2006.
2. Chesson et al. Practice Parameters for the Use of Portable Monitoring Devices in the Investigation of Suspected Obstructive Sleep Apnea in Adults. Sleep 2003; 26:907–913.
3. Pittman et al. Using a Wrist-Worm Device Based on Peripheral Arterial Tonometry to Diagnose Obstructive Sleep Apnea: In-Laboratory and Ambulatory Validation. Sleep 2004; 27:923–933.
4. Westbrook et al. Description and Validation of the Apnea Risk Evaluation System: A Novel Method to Diagnose Sleep Apnea-Hypopnea in the Home. Chest 2005; 128:2166–2175.
5. Townsend et al. Assessing Efficacy, Outcomes, and Cost Savings for Patients with Obstructive Sleep Apnea Using Two Diagnostic and Treatment Strategies. Sleep Diagnostic and Therapy, 2007: 1.
6. Iber et al. Polysomnography Performed in the Unattended Home Versus the Attended Laboratory Setting-Sleep Heart Health Study Methodology. Sleep 2004; 27:536–540.
7. Bar et al. Evaluation of a portable device based on arterial peripheral tonometry (PAT) for unattended home sleep studies. Chest, 2003; 123:695–703.
8. Herscovici et al. Detecting REM Sleep from the Finer: Automatic REM Sleep Algorithm based on Peripheral Arterial Tone (PAT) and Actigraphy. Physiol. Meas. 2006; 27:1–12
9. Pittman et al. Follow-Up Assessment of CPAP Efficacy in Patients with Obstructive Sleep Apnea using an Ambulatory Device Based on Peripheral Arterial Tonometry. Sleep and Breathing, 2006; 10:123–131.
10. Practice Guidelines for the Perioperative Management of Patients with Obstructive Sleep Apnea: A Report by the American Society of Anesthesiologists Task Force on Perioperative Management of Patients with Obstructive Sleep Apnea. Anesthesiology 2006; 104:1081–1093.
11. The Joint Commission on Accreditation of Healthcare Organizations. Potential 2008 National Patient Safety Goals and Requirements. December 4, 2006.

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