New Era for Diagnostic Sleep Center DMEPOS Accreditation

The accreditation simplification movement that is sweeping through healthcare evaluation circles today has had a profound impact on all sectors of our healthcare delivery system. Indeed, in many important ways, the focus has shifted from a monolithic, one size fits all approach to accreditation, to more nuanced customizable programs that help healthcare providers alter their everyday business operations to meet specific healthcare sector patient care quality measures.

In recent years, as a way of urging these reforms forward, the Centers for Medicare and Medicaid Services (CMS) has adopted plain language, product-line and service specific, accreditation quality standards for the durable medical equipment, prosthetics, orthotics, supplies (DMEPOS) industry.

Indeed, no sector of our healthcare delivery system has felt the effects of accreditation simplification more acutely than the DMEPOS industry. Competition between the various CMS “deemed” private sector accreditation organizations has not only helped streamline and simplify the accreditation process, it has effectively lowered implementation times and all associated costs across the board. This is especially true for sleep center DMEPOS accreditation; bringing benefits to both provider organizations and patients alike.

Let there be no misunderstanding, sleep center DMEPOS accreditation is not the same as the accreditation process for a diagnostic sleep center facility. Whereas facility-wide accreditation looks at the entire organizational structure and the daily operations that are needed to conduct successful sleep studies, sleep center DMEPOS accreditation is much more narrowly focused on the activities surrounding patient set-up and usage of a limited number of product types; most notably CPAP and Bi-PAP devices.

What follows are some caveats that I believe should be closely adhered to in order to assure that sleep DMEPOS accreditation becomes synonymous with the exemplary care that every patient deserves:

1. Medicare’s DMEPOS Supplier Standards as well as product specific accreditation quality standards must be met in order to maintain a facility’s Medicare billing privileges.
2. Written policies for sleep center DMEPOS need to be understandable to all staff members; not just administrators and compliance officers.
3. Policies and Procedures should reflect an operations perspective when addressing specific business functions such as: Administration, Human Resources, Equipment Management etc. By formulating policies according to the functions and tasks of the DMEPOS department it makes it easier for the staff to utilize it as a true resource.
4. Comprehensive instruction on Plans of Care and the close monitoring of product use compliance through diligent follow-up procedures brings with it many patient care benefits.
5. Patient care services are best evaluated by experienced sleep professionals. These professionals must be properly credentialed, and participate in a continuous education regimen.
6. Sleep DMEPOS staff should be able to demonstrate a thorough knowledge of the full range of products as well as their set-up and delivery requirements.
7. As experts in Equipment Management- sleep DMEPOS professionals add value to the patient’s plan of care goals.
8. CPAP/ Bi-PAP devices have built-in compliance monitoring functions that are designed to track compliance and give feedback to the sleep physician.
9. Sleep DMEPOS equipment experts often do the most thorough job of product instruction.
10. Sleep DMEPOS departments should demonstrate expertize in staff training in the exercise of universal precautions to prevent cross-contamination from blood or other bodily fluids.
11. Cleaning, storage and maintenance of equipment is critically important as an infection control measure. E.g. Using appropriate disinfection techniques. Proper hand washing.
12. Patient follow-up is an integral part of the DMEPOS accreditation process and is a special area of interest during the accreditation on-site evaluation or survey visit.
13. Inventory tracking is an important component of the accreditation process as a measure of recovery readiness in the event of a product recall. (A good inventory tracking mechanism also helps maintain profitability by preventing thief or product “shrinkage”.)
14. Medical Record reviews are an important aspect of the sleep DMEPOS accreditation process. During an on-site evaluation/ survey while looking at patient records we want to see documentation of all patient interactions that transpired as well as the LCD/insurance requirements of the billing provider.

Moving Forward

New rulings by CMS are happening all of the time and they often change what is required of sleep professionals; to the point where keeping up with the ever-evolving world of government regulatory matters becomes a critical business function. Case in point, Medicare Part B now requires that beneficiaries return to their doctor for a CPAP compliance (usage) test 60 days after set-up, but before 90 days from the dispensing date.

Another rapidly evolving arena that is affecting diagnostic sleep center business models is the status of home sleep studies. Now that home testing is CMS reimbursable, patient safety and the appropriateness of the sleep study device being used in a home environment must be taken into account.

Given the general leveling effect that CMS’ product-line and service specific quality standards have brought to the DMEPOS accreditation world, it is easier than ever for diagnostic sleep centers to meet these nettlesome challenges. Much of the credit for these advancements should also go to the emergence of the new era of healthcare accreditation simplification. Sleep DMEPOS professionals can bank on it.

Sandra C. Canally, RN is the Founder and President of The Compliance Team, Inc., a CMS approved accreditation organization with deeming authority for DMEPOS. In addition, her firm offers a full line-up of proprietary Exemplary Provider™ accreditation programs including ones for: Diagnostic Sleep Center, Infusion/ Specialty/ and LTC Pharmacy, Critical Access Hospital, Rural Health Clinic, Physician Practice/ Medical Home, Long Term Care, Home Health/ Hospice Agency, Private Duty Homecare, Ocularist/ Anaplastologist.

Reflections From The ABSM Information Session At SLEEP 2011

 This is a reprint of a letter recently published at By Cindy Altman, RPSGT, R.EEG/EP T., President-Elect, BRPT .

What are your thoughts?:

Did the AAST have prior knowledge of the AASM/ABSM decision to develop a credentialing exam that by design is easier to pass? Did the AAST ask the AASM/ABSM to develope such an exam and credential?

Did/Are certain members of te AAST Board of Directors (present or past) participating in the development of such a credentialing process while serving on the AAST Board of Directors? If they are/did, are you OK with that?

Has sufficient information been released to the professional sleep community by either the AAST/AASM/ABSM to support the claims made about the pass rate of the RPSGT exam or the skills sets of the new RPSGT’s?

If you are an RPSGT, are you yourself planning on supporting the new credential by paying the ABSM $25 to be grandfathered in to the new credential?

Do you think that this is all meaningless and that an influx of newly credential sleeptechs will have no impact on your current salary or employment opportunites?

By Cindy Altman, RPSGT, R.EEG/EP T.
President-Elect, BRPT

“I recently attended an American Board of Sleep Medicine (ABSM) technologist examination information
session at the American Association of Sleep Technologists (AAST) program in Minneapolis. Most
technologists went to lunch, but a hundred or so were present.

Dr. Richard Rosenberg gave the presentation. Dr. Nathaniel Watson was also there. He was introduced
as president of the ABSM and he sat next to Dr. Rosenberg on the stage but really didn’t say much.

Dr. Rosenberg is a full-time American Academy of Sleep Medicine (AASM) employee, and Dr. Watson
is on the AASM board of directors. How can the ABSM be “an independent, nonprofit, self-designated
board” separate from undue influence by the AASM? The relationship between the two groups is not

On several occasions Dr. Rosenberg let the audience know that he trained in sleep with Dr.
Rechtschaffen, and he serves on the Committee for Accreditation of Polysomnographic Technologists
Education (CoA PSG). He talked of all the good the AASM has done for sleep technologists and
education. He forgot to mention the role that the AAST and the Board of Registered Polysomnographic
Technologists (BRPT) played in advancing technologists’ professional status, or in the formation and
continued support of the CoA PSG.

Dr. Rosenberg said there was absolutely no financial motivation, as rumors implied, behind the
development of the new technologist exam. He said the ABSM simply wants to offer a technologist
examination that is relevant for all “stakeholders.” And they want a pass rate that is higher than the
RPSGT exam…for the good of the profession. In other words, for the good of the physicians who employ
the techs who are unable to pass the RPSGT exam. After all, he implies, the problem in passing the
RPSGT exam is with the exam itself, and not the individuals or educational pathways.

To them, it doesn’t matter that the BRPT works with a well-respected professional testing company,
or that the BRPT uses best practices for developing, maintaining, reviewing, delivering, and scoring
the RPSGT examination. Or that it uses a geographically and professionally diverse group of Subject
Matter Experts. Or that at every step along the way, the RPSGT examination is checked for validity
and relevance not only by the professionals in the field, but by professionals in the testing community.
What matters is that the ABSM believes it has produced a better technologist exam that will result in a
higher pass rate. After all, the ABSM knows “some psychometricians” who help with the exam. What
matters is that the ABSM will do what the AASM asks.

Dr. Rosenberg said the ABSM would apply for NCCA accreditation for the technologist examination.
He fumbled with the terms and relationship between the Institute for Credentialing Excellence
(ICE), the National Commission for Certifying Agencies (NCCA), and the National Organization for Competency Assurance (NOCA), which is now ICE. I hope he gets these organizations straight for his
next presentation.

Dr. Rosenberg blamed the RPSGT exam pass rate on “stifling” the development of formal sleep
technology education programs across the country. He based this on a conversation with a dean at a
school in the Chicago area. Dr. Rosenberg talked about the dissatisfaction physician’s have with the
RPSGT credential, yet he has no data to support that. The AASM is certainly capable of surveying a
large number of people and institutions to determine the extent of this dissatisfaction…if they were

Dr. Rosenberg repeatedly referred to outdated RPSGT exam pass rates and did not discuss the
difference in pass rates based on educational pathway or over time, or compare the pass rates of similar
examinations with multiple pathways. When program directors from two different schools challenged
the assertion that the exam was too difficult for CAAHEP students, Dr. Rosenberg indicated their schools
were the exception, not the norm.

Dr. Rosenberg told us that the RPSGT requirement for AASM sleep center accreditation would still stand.
Yet when asked if he would put that statement in writing, he let the audience know it wouldn’t have any
weight. When asked if the new examination should be viewed as a mid-level credential, with the CPSGT
on the lowest level and the RPSGT on the highest level, he made it clear that the new credential was to
be on equal terms with the RPSGT.

Dr. Rosenberg reminded the audience that the AAST supports the new exam. He let us know AAST’s
immediate past president and current president have been involved in the development of the ABSM
technologist exam. The audience was already aware of AAST’s position to support “all” technologist
examinations—even those not yet developed or evaluated—but it was surprising that AAST leaders
were actually assisting in the exam development. This was news to current AAST board members as
well. Did Dr. Rosenberg let the cat out of the bag?

When it was time for questions and comments at the end of the presentation, not one person stood
up to voice support for the new exam. However, many stood in line to question or comment on the
purpose of it. At times those in attendance clapped enthusiastically in support of the techs or physicians
who challenged the ABSM. Suffice it to say, the new ABSM technologist examination was not well

So why, exactly, is the ABSM getting involved in technologist credentialing? Could it be that the BRPT is
truly an independent organization adhering to best practices in credentialing, and the AASM does not
like that?

The RPSGT is the Gold Standard. Don’t let grandfathering into the new credential confuse you. While
it is “only $25” and you may think that you have nothing to lose, you do. You risk losing the professional
identity that technologists have worked for over 32 years to achieve. As technologists we can stand
united to keep the RPSGT credential strong. Don’t let the AASM divide and conquer. That is really what
this is all about.” 

Alan Hickey

Alan Hickey

Publisher of Sleep Diagnosis and Therapy Journal the Official publication of the American Sleep and Breathing Academy, the Journal is a clinical and technical publication for dental and medical professionals.

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Sleep Training in Bogota, Colombia

In May, 2011 the first course in polysomnography in the city of Bogotá was presented. It was hosted by Sleepvirtual & Priority Health Education. The course gathered the participation of more than 50 attendees, which included doctors and technicians interested in the field of polysomnography. The course had more than 50 attendees, which included doctors and technicians interested in the field of polysomnography.

There was four days of intensive theoretical training starting with the Basic Priciples of Polysomnography, AASM New Scoring Guidelines, Patient Hook-up and Preparation, Digital Polysomnography, Positive Pressure Titration an O2 Therapy, among other points of interest. The program was delivered in spanish.

The four day polysomnography course was awarded 50 continuing education credits, 25 each by the AARC and the AAST. This unpresidented event marked the first time in Colombia’s history that a polysomography course was offered with the approval of this many education credits from American Associations.

In the opinion of the attendees, the course was one of the best offered to sleep professionals in Colombia and has sparked their interest to pursue more educational events geared toward the field of sleep medicine and technology.

“Very good and complete, the course is very well designed and deals with all of theissues from the simple to the complex and helps all the technicians.” – Dr Rafael Lobelo, Pulmonologist

“The course was excellent for deep content & well suited for activities that are performed daily. I hope to go deeper on most issues of polysomnography, thank you very much and I hope to participate again on the next course offered.” – Sandra Rocio Morales, Technical Coordinator in Polysomnography

“It was very good, I learned a lot, I would like to undertake some more practical sesions.” – Jeimy Carolina Gomez, Polysomnographt Technician

Ed Faria, MBA, Sleep virtual’s CEO presents the faculty: Felipe Lerida, CPSGT, Candace Anderson, CPSGT, and Joseph Anderson, RPSGT, RPFT, CRT-NPS, RCP, the Directorof Education for  

The organizers (from left to right): Laura Patino, Felipe Lerida, Paula Velasquez, Joseph Anderson, and Candace Anderson

Plans are currently underway to bring additional educaion throughout Latin America.

Alan Hickey

Alan Hickey

Publisher of Sleep Diagnosis and Therapy Journal the Official publication of the American Sleep and Breathing Academy, the Journal is a clinical and technical publication for dental and medical professionals.

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No Time to Waste

Jonathan Davidson M.D.
Advanced Sleep Disorder Centers
Modesto, CA

Clinicians looking to capitalize on the growing sleep field don’t want to wait when it comes to expansion. Fortunately, there are manufacturers that can help.

California’s Central Valley is world famous for its agricultural production, but Jonathan Davidson, MD, believes the area is also fertile ground for sleep medicine. The owner of Advanced Sleep Disorder Centers has so much faith in the burgeoning sleep market that he intends to double his number of sleep labs in 2011—going from three to six.

The fourth lab opened in January 2011 in Merced, California, a county of more than 200,000 people. His fifth and sixth labs will also be located in Merced (labs are located about 30 to 40 miles apart.)

BScreenShot148 No Time to Wasteoosting locations by 100% in one year is powerful evidence that statistical projections for sleep are beginning to match objective reality. Experts predict that a whopping 90% of sleep apnea sufferers are still undiagnosed. Even if the number turned out to be half that, it would still add up to massive demand.

Florida-based Sleepvirtual USA Inc is helping savvy clinicians get up and running quickly to serve expansion growth in the sleep industry. Despite a terrain filled with large competitors, Sleepvirtual continues to grow as a strong challenger in the realm of PSG diagnostic equipment that allows users to record and score unlimited sleep studies.

The BWII PSG sleep system consists of two hardware pieces and a software program that can be used with PC computers running Windows XP, Vista, or W7. The software provides trace and scoring capabilities that are relied upon by users such as Davidson, who says the unit’s portability (under 10 pounds) and accompanying software features and functionalities make it a potent combination.

Customers appreciate the BWII’s price and value, but technical support and financing are the clinchers. Customers are financed internally, and do not need third party financing to purchase equipment. There are various options for the equip- ment: rent, lease to own or purchase choices, which allows price-conscious purchasers such as Davidson to equip their sleep labs without massive cash outlays.

Ultimately, Sleepvirtual’s sales have mirrored the growth of the industry with 2010 sales 60% higher when compared to 2009. “We expect to double our sales in 2011,” predicts Felipe Lerida, CPSGT, customer service manager for Sleepvirtual, Doral, Fla. “I believe our recent growth was due to greater brand recognition, direct referrals from happy clients, and repeat customer purchases. As word spreads, members of the sleep community have no choice but to notice.”


Seeking to become board certified in sleep medicine? Davidson warns that 2011 marks the last year that physicians can take the board exams without first completing a fellowship. The state boards exams are in November 2011, but there is still time to study.

For board certified physicians who wish to expand or open a new lab, Sleepvirtual’s equipment can be leased (prices vary) to avoid large capital outlay. “As far as training employees,” says Davidson. “The American Association of Sleep Medicine [AASM] has a 14-step training module that works well.”

As a sleep lab owner for the past decade, Davidson particularly likes that Sleepvirtual offers free lifetime technical support every day for as long as he owns the equipment. A live person is always available to answer the phone when he needs them, which is not always the case with larger manufacturers. “We have had problems with reps at major companies,” says Davidson, who opened his first three California sleep labs in Stockton, Sacramento, and Modesto. “At other manufacturers, reps get fired and they can’t replace them. Sleepvirtual is a privately owned company that is more interested in giving you personal service. Acquisition of data is easy, validation is easy, and the way the hardware is designed makes it simple to work with. The electrode headbox is light, and it’s a fraction of the size of its competitors.”

A colleague referred Davidson to Sleepvirtual, who eventually contacted the company to try a 1-month trial product. He liked what he saw and eventually ordered two BWII PSG sleep systems for his Stockton lab, replaced four machines in Modesto, and by the time he outfitted his Sacramento facility he had a dozen Sleepvirtual sleep systems (all of which are subject to free upgrades.)


Lerida knows that many qualified physicians suffer from sticker shock when it comes to start-up expenses. In many ways, the old axiom is true, “you have to spend money to make money.” However, he says that hardware expenses do not have to be so burdensome.

“Physicians must be aware of initial upfront costs and look for solutions to minimize operating and staffing expenses,” says Lerida. “Physicians and lab owners should start off by looking for affordable and reliable equipment. We provide a fully AASM-compliant Type 1 PSG diagnostic system at the most competitive price in the market. We allow customers the option of in-house financing to alleviate additional finance charges that may be incurred by other companies, along with 24/7 free tech support both via telephone and remote internet.”

Too often, physicians assume all services are the same, but Lerida points out that companies vary in regards to length of extended warranty and technical services offered. “Sleepvirtual offers the most cost efficient extended warranty package, unlimited reading and scoring software licenses, and a 24-hour backup guarantee in case of any hardware issues for the life of the equipment,” says Lerida. “When it comes to financing, the Sleepvirtual’s philosophy is one specifically built for cash-strapped labs. Bank financing often takes months to get approved, but at Sleepvirtual internal financing is quicker and just as effective. So far, no customers have been turned down.”


  • Score on the run which allows users to split the screen during the acquisition and start scoring the same study you are recording.
  • Sleep statistic window which automatically gives updates on the AHI and other parameters in real-time.
  • All necessary menus for recording a PSG on the same screen.
  • Montages, filters, sensitivity, and speed of the page adjustments with the quick mouse click and keyboard options.
  • One exam for one file for ease of transferring, copying, and e-mailing (HIPPA Compliant).
  • Exclusive technology allows users to have the system working anywhere when the team moves around to different locations.
  • The system can be used for acquisition in one location, be scored somewhere else and interpreted by the physician in a third place, it can also be archived in a completely different location.


For more information about the BWII PSG sleep system, visit

A Better Picture of Sleep

There are millions of people in North America alone who have an undiagnosed sleep disorder, but how do we identify them? A new entry from the world’s largest sleep diagnostics company aims to fill the preliminary investigation niche that can help identify new patients who may need a full PSG test.

The latest offering from Embla, makers of the familiar REMBrandt™, RemLogic™, and Sandman® PSG systems, is designed to identify the undiagnosed masses who have so far eluded treatment. Dubbed SleepImage™ for its ability to capture a total picture of sleep, CEO David Baker hopes to use the product to fill screening gaps that still persist in modern sleep medicine.

Embla officials contend that sleep is a unique field in the medical industry, because the most extensive test (the PSG) is run first, often without the benefit of screening or preliminary investigation. Every other medical procedure includes some form of triaging the patient starting from a simpler, inexpensive test followed by more extensive and often more expensive tests if necessary.

The protocol for having an in-lab sleep test is so intimidating that an estimated 25% to 30% of individuals who are referred to sleep labs hesitate to get the help they need. The presence of what Baker calls a first-line diagnostic tool can change that, and he believes the FDA-approved SleepImage system fits the bill. “If even half of the 25% to 30% population not wanting a PSG change their minds once they see the actual results of their test, the health and well being of patients would benefit significantly,” contends Baker.

ScreenShot143 A Better Picture of Sleep Motivating Patients to Act

Embla officials believe sleep disorders are significantly under-diagnosed because there are no simple home sleep tests to objectively measure sleep quality that would be equivalent to a thermometer or blood pressure cuff. The thought of spending a night in a sleep clinic is threatening to many patients, and without tangible evidence of the disorder, many patients tend to ignore it.

“Home sleep testing is divided between subjective questionnaires and simple screeners which can indicate whether, for example, an apneic event may have occurred, but that won’t tell you if or how it impacted your sleep,” says Baker. “The real question is: Are you are having good quality sleep or not? We believe we have the only product in the market that offers the answer to this obvious, but overlooked question.”

A big concern about having non-objective testing is that you will often get the wrong answer. “If you ask a commercial driver how he sleeps, he will probably say he sleeps well, because he knows that if he is identified as having sleep apnea, his license could be in jeopardy,” says Baker. “People will answer questionnaires the way they want, and not necessarily the way they should. With SleepImage, you can actually test people and validate how they are actually sleeping.”

ScreenShot144 A Better Picture of Sleep Sleep Quality is Key

Developed by physicians at the Beth Israel Deaconess Medical Center, an affiliate of Harvard Medical School, Cardio Pulmonary Coupling (CPC) technology, in conjunction with the SleepImage M1™ recorder, is able to measure actual sleep quality. According to Baker, CPC is the world’s first clinically validated technology to simply phenotype obstructive sleep apnea, and the more difficult to identify complex sleep apnea, which he says can now be spotted through a home sleep test thanks to SleepImage.

The SleepImage system consists of a small credit card sized sleep screener called the M1™, and a secure web-based software program that allows patient data to be uploaded securely from any Windows®-based PC for review by a clinician. The simple and inexpensive test allows physicians and clinicians of any discipline to evaluate sleep quality. This has never been done before and Embla officials believe it will be a paradigm shift in how sleep will be viewed in the future. It will show the impact of the changes in therapy, medication, sleep hygiene or weight gain/loss over time. There is also value in using the SleepImage system as a screener before surgery to identify patients with high risk of sleep disorders.

Uncovering the Truth

Baker points out that certain PSG or therapy device compliance data can indicate “everything looks fine” when that is far from the truth. SleepImage, he says, uncovers a reality that can shock potential patients into action. “CMS requires that the patient’s sleep disorder is ‘improved’ as a result of the therapy, not simply that they wore the device. A simple measurement of compliance does not address whether patients are sleeping well or that they actually have better quality sleep,” explains Baker. “That’s the paradigm shift between the old way of doing it, which is measuring the events, as opposed to asking whether patients are sleeping well, and answering the question in an objective way.”

The SleepImage system will make its debut at SLEEP 2011 in Minneapolis this year, and is currently being introduced to large sleep operations. A trial of the SleepImage system was done at the National Jewish Hospital in Denver to validate the model of using SleepImage within a sleep facility. Findings should be published soon.

Baker believes that much of the business potential for sleep labs to increase their occupancy starts with that 25% to 30% of patients who were identified, but refused for one reason or another, to take the full PSG test. Faced with the SleepImage data, which objectively measures patient sleep quality, the hope is to convince them to seek treatment in the sleep lab.

David Baker, president and CEO of Embla Systems, is based in Denver. He can be reached at For more information on Embla, visit

Virtual Extension of your Sleep Laboratory

Imagezzzz Virtual Extension of your Sleep LaboratoryNatalie Morin
President & CEO, Sleep Strategies, Inc.

A behind the scenes look at how sleep scoring services aim to form seamless partnerships with clients.

The use of sleep scoring services has gained tremendous momentum as more and more hospitals and sleep labs change their internal operations to incorporate this progressive business practice. Over the course of the last decade the process of scoring sleep studies in-house has increasingly moved out of the laboratory and into the hands of specialized scoring service companies. This reflects not just a desire to cut costs, but a recognition of the value that a third party can provide as part of a strategic concentration of sleep laboratory resources.

By now, most hospital administrators and directors are aware that sleep record outsourcing can deliver more than just labour cost savings. By freeing up staff to work on marketing, community outreach and patient initiatives, sleep record outsourcing allows for the generation of new revenues, increases in productivity and the management of risk that would have been previously unaffordable. However, sleep record outsourcing offers more immediate benefits as well. Sleep scoring firms have the ability to provide rapid turnaround and perhaps the highest level of scoring quality available by registered technologists. Where cost cutting often forces labs to stretch their labour power—simultaneously jeopardizing patient care—most sleep scoring services are exclusively devoted to the sole task of ensuring the meticulous analysis of sleep studies. The level of quality available from a third party specialist is near impossible to achieve in a hospital or lab where there exists multiple duties to which need attending.

With so many benefits to be had by outsourcing sleep scoring, one might inquire as to why it isn’t yet standard practice. According to Chad Doucette, V.P. Sales & Marketing of Sleep Strategies Inc., “Many clients have told us that they were hesitant about the process at first—doubtful that an outside firm could easily integrate with pre-established internal procedures. But once they realized how a little initial diligence results in a seamless long-term relationship, their concerns are usually eased.” This article will familiarize readers with the step-by-step process of aligning with a scoring service. Using one of the industry’s leading scoring companies as a guide, it will show you how Sleep Strategies Inc. has managed to remain at the top of the game by not merely acting as a service provider, but as a virtual extension of their clients’ labs.


When it comes to the decision of whether or not to bring a sleep scoring service on board, scoring is surprisingly not the primary task on the agenda. The first question a sleep facility manager must ask themselves is WHY—why should we consider outsourcing our sleep studies? Begin by comparing your situation to the following statements made by various Sleep Strategies clients before they came on board:

  • “Over the course of the last few months our lab has experienced a number of HR issues. Most importantly, we haven’t been able to find enough registered sleep technologists.”
  • “Hospital administration has slashed our operating budget forcing us to scale back over-time hours.”
  • “We have such a backlog of sleep studies that our patients sometimes have to wait weeks before receiving results.”
  • “We don’t have a devoted quality department.”
  • “We’re looking to expand our facility but don’t know if we can afford additional staff.”

The above are just some of the factors that commonly lead hospitals and labs to outsource their scoring. Whatever your reason, remember that once the decision to hire a scoring service has been made, you are hiring a partner for your sleep lab—one who must be trusted with your business practices and patients. Choose wisely.


Demand for sleep studies has increased so significantly that it’s now surpassing the number of registered sleep technologists available—which means, if you’re not careful in your selection process, you could easily end up with an under-qualified scoring service. Below are five key questions to ask any potential scoring service:

  • Do you have RPGSTs (registered polysomnographic technologists)? This is a must for efficiency and accuracy of test scoring, but don’t assume it’s a given. Establish in advance whether an RPGST will be handling the scoring process in its entirety—not just supervising the process.
  • What about a Quality Assurance Department? A reputable scoring company will have a designated quality-assurance department. This department should have a program which includes: routine review of all scoring technologists, inter-rater reliability and audit reviews as well as scoring guarantees with a policy for re-scoring.
  • Do you perform manual scoring? For the most reliable results, a registered technologist should score sleep studies manually. Automatic software scoring is not as accurate.
  • Do you have Liability and Errors & Omissions Insurance? A sleep-scoring company should carry the same level of insurance as your sleep laboratory. This should include general liability as well as errors & omissions insurance.
  • Is management separate from scoring? In some organizations, the person scoring your studies is the same person managing the company. Favour scoring services with a devoted management team, separate account reps and an RPGST committed solely to the task of scoring your studies.

Remember, qualified institutions will welcome such questions. Aligning yourself with a reputable service will not only enhance productivity and efficiency, but let’s not forget: your reputation too.


Once you’ve decided on your ideal scoring service provider, the question that now remains is: how to get started? While the beginning phases of integrating with an external provider should be treated meticulously, the process need not be painful. “At Sleep Strategies we see ourselves as an extension of a sleep laboratory,” says Natalie Morin, president & CEO, Sleep Strategies Inc., who adds,” when clients are done asking us questions, we make time to ask a few of our own.” What Morin means by this is that for Sleep Strategies, the pre-scoring integration phase begins with the completion of a scoring questionnaire. This allows a lab to convey their expectations to the service provider, who in turn is equipped with the requisite understanding of pre-existing scoring criteria.

While a reputable scoring company will always score studies to meet AASM standards, individual sleep labs will typically have their own nuances or additional scoring criteria that they wish to have upheld. “The scoring questionnaire is the foundation for providing the successful delivery of sleep scoring,” says Doucette, who believes that one-size-fits-all solutions have no place in the world of scoring. “Good doctors and technologists have put years of experience and training into refining their scoring processes,” he adds, “It’s important that we tailor our approach to reinforce, not negate, the nuanced and varied habits of each of our clients.”

Once the scoring questionnaire is completed it is then subject to a detailed review by Sleep Strategies’ Quality Assurance department. Questions and clarifications are often necessary at this phase to ensure the team of registered technologists assigned to a given account fully understands their client’s scoring perimeters, which extend beyond industry standards. “No two sleep labs are the same and no two medical directors are the same. This questionnaire process allows us to adhere to strict standards while still honouring how one lab differs from another in its scoring technique,” Doucette emphasizes.


Delivering patient information over the Internet can be a simple, convenient and cost effective method for data transfer, as long as the method is secure. Provided that the scoring service provider uses a reputable transfer system, electronic methods of information exchange can allow for the delivery of sleep study results in record turnaround times.

“Ensuring that your sleep scoring service has a HIPAA compliant data transfer system is key”, says Morin, who explains that most such well-developed transfer systems are not only reliable, but also easy to install and operate. “Our transfer system is considered one of the most user-friendly systems that exists. Our clients regularly remark on its ease of use and simplicity,” says Doucette. However, what is perhaps even more important than ease of use is having a technical support team on hand to assist clients and ensure that the transfer system runs effectively and securely. “24-hour turnaround times is a lofty goal. We wouldn’t make this promise to our clients if we didn’t have faith in the useability and reliability of our software,” Doucette goes on to say.


The scoring questionnaire has been filled out and the transfer system has been installed to allow for the relay of patient sleep studies. The next step—once again—involves the Quality Assurance department. This time, they’re looking to review clients’ pre-scored, in-house sleep studies. Providing a scoring service with several internally scored “gold standard” studies allows a sleep scoring service provider to compare and cross reference real-life scores with the preferences outlined in the questionnaire results.

In doing so, ambiguities can be identified and resolved before the third-party scoring begins. In this sense, a good scoring service also serves as an external consultant who can identify inconsistencies and make recommendations for improvement. This process simultaneously gives the scoring service an example of a lab or hospital’s unique scoring protocols and procedures. For example, Hypopnea definitions can vary from facility to facility. Many doctors also want to see additional events scored, such as EKG arrhythmias, as opposed to just commenting on them—a good scoring service will have mechanisms to observe these client preferences.


Once the scoring questionnaire and “gold standard” studies have been reviewed and all questions answered, Sleep Strategies asks for several patient sleep studies to be sent for the test scoring phase. This allows the client to assess the sleep scoring company’s approach before signing off on quality and allowing the scoring process to begin.

As is the case with most business partnerships, a service agreement will need to be signed to ensure such issues as patient confidentiality and adherence to process are fulfilled. Any sleep service that does not require clients to sign an agreement should be viewed with suspicion. Service agreements outline turnaround times, pricing structure, cancellation terms and confidentially requirements. For many hospitals the vendor will also need to provide proof of insurance at this phase, as well as a signed business associate’s agreement.

With the paper work out of the way, it’s now time to start the scoring process.


A sleep scoring service is a busy operation. Organizations such as Sleep Strategies score studies for hospitals and sleep labs across the country. “On any given month, Sleep Strategies is scoring thousands of sleep studies. Each sleep lab has their own scoring nuances, turnaround times and expectations. We have some clients that are expanding, others that are going through accreditation and some that are dealing with unexpected growing pains—adapting to the various rhythms of each clients’ operations is a necessary part of our success. Flexibility and timing is everything in this business,” says Morin.

Scoring services are typically made up of various departments, such as a general polysomnography division, a specialized pediatric division and a research division, for example. In order to coordinate the multiple interests competing for attention, a scheduling department may also be necessary. This attention to detail is key so that all contracted scoring deadlines are met. ”Our scheduling department along with our specifically developed and proprietary scheduling software ensures our clients’ sleep studies are scored on-time, every time,” explains Morin.

Constructing a successful scoring service is more than just a matter of employing the best RPSGTs to conduct scoring; it requires a team of professionals from account executives, administrators, clinical directors, quality assurance managers to uphold the level of scoring this sector of sleep medicine has built its reputation on. “The true success of Sleep Strategies lies in the foundational belief that a scoring service is more than just a vendor for a sleep lab. We see ourselves as an extension of each and every one of our sleep labs and hospital partners,” says Morin, who hopes that such partners will continue to recognize the cost savings and efficiencies that come with bringing on a sleep scoring service.

Natalie Morin, President & CEO, Sleep Strategies Inc. proves that incorporating a scoring service as part of an operational business strategy can assist sleep labs and hospitals significantly cut costs and increase productivity.

All About Compliance – Advocate Home Care Products

ScreenShot139 All About Compliance   Advocate Home Care Products

Consistent follow-up, productive partnerships with sleep labs, and high tech monitoring all lead to an overall Medicare CPAP compliance rate of 63% at Advocate (

Earning a high compliance rate for Medicare beneficiaries— a patient population that can be particularly challenging—is no easy task. Illinois-based Advocate is able to hit the lofty percentage thanks to old fashioned human interaction and sophisticated technology.1

The financial stakes are high, because without at least 90 days of objective compliance data, providers do not receive reimbursement from CMS. On the other equally important side of the coin, poor compliance equals unhealthy patients.

Nadia Rallo, CPAP coordinator at Advocate, relies on the ResTraxx Online System from ResMed for wireless compliance monitoring—call it the high-tech portion of the compliance equation. ResTraxx allows Rallo to remotely monitor patients and check on them at a glance, a process that can quickly identify causes of noncompliance.

A function called exception reporting aids in the management of multiple patients by identifying those who fall outside desired thresholds for usage or mask leak. From there, Advocate staff members can focus efforts on those who require intervention. “We also have a system which allows us to enter patients in a database and pull follow-up reminders for the patient,” says Rallo. “As soon as that patient gets set up, I put in a 31-day reminder to follow up, plus a 45-day and a 60-day reminder. Using this with the the ResTraxx system has really made the difference for us.”

If a problem crops up at 31 days, Rallo immediately sends a respiratory therapist to the patient’s home to correct any mask or discomfort issues. “Follow-up is the key with these patients, as is communication with the sleep lab and the therapist,” says Rallo. “Everyone works hand in hand, and it is one big team that is focused on patients.”

As a large scale HME in the Midwest, Advocate Home Care Products maintains that focus requires an unwavering dedication that stretches to sleep lab partners and referral sources. Darrell Swiniuch, respiratory care manager at Advocate, acknowledges that patient challenges are numerous: discomfort, resistance, poor engagement, lack of awareness/education; documentation; unreliability of patient reporting; and rigorous payor requirements all factor in.

By following a model of partnership and communication with sleep labs, along with regular follow-up and exceptional treatment, Advocate has overcome these challenges. The results are improved patient health outcomes, positive impacts for comorbidities, and potential cost savings for payors.

Wireless Monitoring a PriorityScreenShot138 All About Compliance   Advocate Home Care Products

When Swiniuch and Advocate staff members sought to boost compliance, they went on the hunt for better technology. “We needed some type of wireless communication to make it easier, because there is no way we can go out to all the patients’ homes and do these downloads,” says Swiniuch. “There is a great relationship with the patients going to the sleep labs, and when they do their follow-up visits at the labs, the lab technicians can download from the machines. We also needed a system such as ResTraxx to keep an eye on these patients.”

Prior to electronic monitoring, it was difficult to see what patients were doing on a day-to-day basis. It was labor intensive and costly for therapists to visit the home, and often inconvenient for patients to make trips to the doctor’s office. Fortunately, a wireless system of remote monitoring was introduced to boost CPAP compliance, while making the retrieval of data much easier.

When patients receive the technology, Swiniuch reports that there is not much they need to do. “We set up the machine and put the ResTraxx unit on it,” says Swiniuch. “All we have to do is register it to the ResMed site, and from thereon it is just communicating with the machine. We can get the data any time of the day. With all of our sleep labs involved with ResTraxx, we can issue them a pass code for only their patients if they would like to view information online to help with compliance.”

Many ResTraxx users appreciate at-a-glance reports and exception reporting, while Swiniuch prefers the month-to-month information that indicates compliance. “I look at the therapeutic report which provides the number of hours, the AHI, and a report of any mask leak,” he says.

ResTraxx uses AT&T’s GSM network, similar to Blackberry data, and every afternoon information is transmitted from the patient’s bedroom to the cell tower. From there it is encrypted, put into a server, and downloaded into a Web site portal that Advocate can access. “The actual unit is about the same size as a cell phone that fits on the back of a CPAP machine and basically acts as a conduit,” says Rob Suter, territory manager for ResMed, Chicago. “When you plug in the CPAP, it powers up the ResTraxx unit to signal and send information to the cell tower.”

Comfort Equals Compliance

To further support compliance, Advocate takes advantage of clinically validated comfort technologies. Research shows that auto-titrating devices have improved long-term compliance, but getting patients comfortable with treatment is an ongoing challenge. Advocate realized long ago that technology, combined with calling, emailing, and visiting, is the only real way to ensure that patients are using their equipment.

The technology preferred by Advocate is under San Diego- based ResMed’s S8/S9 umbrella. Advocate uses APAP machines with expiratory pressure relief (EPR) technology on the majority of their patients. EPR enhances patient comfort and makes exhaling against fixed pressure easier. ResMed APAP machines have three lines of defense against non-compliance: 1) responding with aggressive pressure increases in the midst of flow limitation to the upper airway, snoring, and apneas; 2) auto-titrating technology that continually adjusts to deliver the lowest therapeutic pressure necessary; and 3) responding to snores and the severity of such events.

Using APAP technology combined with wireless monitoring, plus the excellent follow-up implemented by Advocate, is a direct path toward patient compliance.

It all adds up to what has become a successful marriage of the old school (telephone) and the new school (ResTraxx and S8/S9 technology). Rallo says you can’t have the high tech without the low tech, because that human connection and caring seals the deal. “Most people are very receptive when I call,” says Rallo. “You’ll always have the occasional one or two that don’t want to be bothered but, quite honestly, at the 31st day when I call— especially if they are not doing well—they do not find me intrusive at all. I would say that 99% of them welcome my calls.”


ResMed officials are building their compliance case with clinical trials. One recent trial involved 50 OSA patients using the S9 every night in place of their own CPAP for 4 weeks. The summary of the compliance study showed patient daily usage increased by up to 30 minutes on average with S9 devices. Visit and reference ID number NCT01013207 for more details.


ResTraxx at a Glance

Web-based compliance monitoring allows users to

  • check on patients at a glance;
  • zoom in for more information; and
  • quickly identify causes of noncompliance.

Exception reporting enables you to manage multiple patients while helping to:

  • identify those who fall outside desired thresholds for usage or mask leak;
  • focus efforts only on patients who require intervention; and
  • act as a value differentiator in a competitive market.

ResTraxx can add value to referral business by:

  • providing referral partners with proof of higher patient compliance due to improved patient care;
  • improving productivity and managing patients more efficiently;
  • transferring compliance and efficacy data either daily or historically, for access via Internet;
  • saving time and money by adjusting therapy settings remotely;
  • changing pressure and comfort settings without data cards or home visits;
  • accessing coverage through AT&T’s GSM network; and
  • accessing patients’ information anytime and everywhere.


Case Study
Compliance: From 5% to 73%

The story started a few years ago when a man with Down’s Syndrome came to Advocate via referral for an initial consultation. The man had already tried CPAP and failed due to anxiety and obsessive compulsive disorder. The patient ultimately had a tonsillectomy, which worked for a while. However, after a few years the patient started gaining weight, began snoring again, and became extremely tired at work.

When a primary care physician referred the man back to Advocate for a PSG, the hope was to alleviate his tendency to fall asleep at work. With PSG results showing an AHI of 98, therapy began in April 2010 with a ResMed S8 II AutoSet—with a pressure range of 16 to 20 centimeters of water pressure (CWP), and an EPR setting of 3. The patient, his family, and group-home staff underwent patient education and training on proper equipment use.

In June 2010, Advocate downloaded compliance data and found the patient was only using the machine for more than 4 hours per night 5% of the time. His Epworth score was still high at 17 out of 24, and the patient was still sleepy. Advocate’s respiratory therapist, Tracy Kinlaw, RRT, recommended a bilevel rescue, and the patient was placed on ResMed VPAP, with pressures set at 19 over 15 CWP.

A subsequent download in August 2010 yielded 18% compliance, with an Epworth score of 10. Pressure settings and machine mode were adjusted to VPAPAUTO at 20/10 CWP with pressure support at 4. Yet another download in October 2010 reflected a positive compliance jump to 73%. AHI went down dramatically from 98 to 15, with an Epworth of 7 out of 24, within normal range. In addition, the man lost 14 pounds, reducing his BMI of 42.6 to 39.4.

From treatment initiation and subsequent bilevel rescue, Advocate’s intervention consisted of regular data review, four home visits from respiratory therapists for mask re-fitting and re-instruction, plus cooperation with the family. Aside from the objective measures of significant improvement, Kinlaw’s personal interactions with the patient reflected a positive impact. “When the patient’s family first brought him to visit me, he barely spoke,”says Kinlaw.“He was so quiet and unresponsive, almost like he was falling asleep in his chair. The last time I met with him he was very animated and interactive. He was a completely different person.”


1 Group A: n=55 patients

  • Discontinued therapy—attempts made at therapy but treatment ultimately was discontinued at or before 90 days with a physician’s order or AMA (against medical advice).
  • Group B: n=93 patients: Compliance maintained for a minimum of 3 months, per Medicare standards.

Total n=148 patients over a 4-month period

  • 62.8% (Group A): Overall patient compliance, including those that discontinued therapy early.
  • 90.75%—(Group B): Those patients that accepted and maintained therapy for a minimum of 90 days.

ScreenShot140 All About Compliance   Advocate Home Care ProductsScreenShot141 All About Compliance   Advocate Home Care Products

ResMed Reorganizes its Management Structure and also Announces New Business Unit

ResMed’s new management structure repositions senior executives currently working within ResMed, without adding new executive hires. All the organizations and leaders described below report to the chief executive officer. The new structure combines three existing business units into two, creates a new strategic business unit, and confirms other roles in the existing commercial, manufacturing, logistics, supply and corporate staff areas. JC Kyrillos will lead the new strategic business unit, ResMed Ventures and Initiatives, to focus on opportunities in disease states related to SDB and other market opportunities.

View business units and new appointments on the ResMed website

Source: ResMed