1. VHA Innovation Program
Remote Veteran Apnea
Management Portal (#687)
Project Director: Samuel T. Kuna, MD
Philadelphia VAMC, Station 642, VISN 04
Collaborator: Carl Stepnowsky, PhD
VA San Diego Healthcare System, Station 664, VISN 22
The primary risk factors are being male, older and overweight. The VA is comprised primarily of men. The average age is XXX and over 65% are considered overweight.
Latest prevalence rates of OSA in year old men is 17%. This means the VA is at least 17%. Based on a recent VA publication of the most common chronic conditions in the VA, this would put OSA at #2, behind only hypertension.
Important to point out that there is a distinction between prevalence rate and diagnostic rate. Prevalence rate is the estimated % of a disease in a popuation, while the diagnostic rate is the actual number diagnosed with that disease in a population. The diagnostic rate for OSA in large part reflects the capacity to diagnose. We find that those centers that provide primarily home sleep testing, such as San Diego, have a current diagnostic rate of 22%. They follow a population of 13,000 OSA patients with over 200 new diagnoses each month.
The problem is that no medical center has the staffing required for appropriate OSA diagnosis and management. And no VA medical center will have the staffing required because of the focus other disease conditions, such as PTSD and TBI (report prevalence rates here for comparison purposes).
What has happened within the VA is that each of the 150 Medical Centers have developed their own approach to OSA diagnosis and management, and we have now have great variability in methods of diagnosing OSA and in the methods for starting therapy and managing it over time.
Complicating this is the use of DME’s, some of which are outsourced, and some of which are in-house.

2. Project Background Problem Statement
Obstructive Sleep Apnea (OSA) is a sleep-related breathing disorder that is now recognized as a major public health problem
Patients with OSA are at increased risk of serious medical consequences including motor vehicle accidents, hypertension, heart attacks, strokes and death
High prevalence of OSA in veterans; 17% of middle aged adult males in US are estimated to have moderate to severe OSA
The wide disparity of sleep resources across VHA are unable to meet this patient need
Lack of standardized care – up to 20% of testing is outsourced
Long patient wait times – up to 6 month wait times
Limited access to diagnosis and treatment – up to 80% of patients with OSA are undiagnosed and therefore not treated

3. Top 10 Chronic Conditions in VHA Veterans
Yoon et al, 2008

4. Disparity in VHA Sleep Services
VA Sleep Service Inventory (FY12); 110/150 (73%) sites reported
40 VA Medical Centers not reporting likely have limited programs
All sites could benefit from REVAMP
Management and testing
48%
No management No testing
11%
Management but no testing 14%

5. The Remote Veteran Apnea Management Portal (REVAMP) Solution
A web-based clinical management pathway for veterans with OSA
Validated questionnaires completed online
eliminates paper forms, increases symptom reporting, accesses outcomes
Online videos instructing Veterans how to perform their home sleep test
replaces in-person instruction
Treatment with auto-adjusting positive airway pressure (autoPAP)
eliminates need of additional sleep testing
Wireless transmission of home autoPAP data to REVAMP website
enables patients and providers to monitor treatment results
allows remote pressure changes on home unit
Clinical management by phone calls and video teleconferencing
increases clinical efficiencies; reduces patient travel and lost work hours
Auto-generation of progress notes and integration with CPRS
increases clinical work-flow efficiencies
REVAMP is an interactive website with patient and provider-facing portals that is integrated with CPRS. REVAMP has a number of important features that help to improve the clinical management of OSA:

6. Existing Models versus+ +
Inpatient Diagnostic
$1,680
Home Diagnostic
$990
Wireless Data Transmission
AutoPAP adherence Data
Patient Questionaires
Automated CPRS progress notes
Little Data for Providers / Difficult Data Collection
Lots of Data for Patients and Providers
a meaningful use of technology
I see you’re doing great with the CPAP!
So.. how’s it going with the CPAP?
Anecdotal Promotion of Compliance
Transparent, Meaningful Engagement

7. Execution Status September 2012 Intellica, Corp. selected as vendor
Oct – Feb REVAMP website developed with both provider- and patient-facing portals
Integration with electronic medical record (CPRS)
Integration with ResMed and Philips PAP devices
March – May 2013 Troubleshooting and refinement of website
June 2013 – present Pilot testing
21 enrollees at Philadelphia VAMC and 18 at VA San Diego Healthcare System
Positive patient and provider feedback
September Approval of no-cost extension for continued pilot testing through February 2014
Very ambitious schedule
Obtained integration two different equipment vendors
e.g, Mid-March approved connectivity with ResMed
June, ditto with Philips
BAA with Philips??
Data on number of successful testing;

8. VA Center for Innovations ISB Selection Criteria
Summary Value = 1 * (23+37) = 60
Business Value = 10 + (-7) = 23
Clinical Value = = 37
Criteria
See…
Self-Assigned Score
Compliance
Slide 9 1
Five-Year Net Operational Cost Change
Slide 10 10
Implementation Cost
Slide 11 -7
Clinical Impact (Broadness)
Slide 12
Clinical Impact (Degree)
Slide 13
Business Impact (Broadness)
Slide 14
Business Impact (Degree)
Patient Safety
Slide 15 4
Patient Value
Slide 16
Healthcare Disparity
Slide 17 3

9. Business Case: Compliance
REVAMP is compliant with published guidelines and practice parameter reports from the VHA, the American Academy of Sleep Medicine and the Centers for Medicare and Medicaid Services.
Many VA Medical Centers are unable to achieve these guidelines because of insufficient resources, including staff and equipment
Self-assigned score = 1

10. Business Case: Five-Year Net Operational Cost Change (all figures in millions)
Annual Performance (millions)
Year 1
Year 2
Year 3
Year 4
Year 5
Total
Annual Cost
$3.4
$5.9
$16.4
$10.2
$46.0
Annual Benefit
$1.4
$3.9
$80.0
$228.0
$452.3
$766.0
Annual Net Benefit
($2.1)
($2.0)
$64.1
$217.9
$442.0
$720.0
Self-assigned score = +10

11. Business Case: Implementation Cost
Cost Profile
Year VISN
Year Region
Year 3
Year 4
Year 5
5-Year Total
REVAMP Product (Software) Development
$1,200,000
$1,750,000
$2,500,000
$1,250,000
$7,950,000
CPAP Shipping Services
$750,000
$1,500,000
$6,000,000
$5,000,000
$18,250,000
Purchase of Monitors (For OSA Diagnosis)
$250,000
$500,000
$2,000,000
$3,750,000
Space Leases for Regional Hubs
$100,000
$6,600,000
Telecom Equipment for Phone Consults
$300,000
$2,200,000
Staff Training
$136,400
$457,000
$1,119,400
$275,000
$2,262,800
Other Costs (C&A, Staff Time)
$877,000
$900,000
$1,550,000
$850,000
$5,027,000
Annual Total:
$3,413,400
$5,907,000
$16,369,400
$10,175,000
$46,039,800
Cummulative Costs:
$9,320,400
$25,689,800
$35,864,800
---
Years 1 and 2 are Implementation Phase I
Year 1: VISN-wide implementation
Year 2: Regional Implementation
Years 3+ are National Implementation
5-year Total Cost Projection: $46.0 million
Self-assigned score = -7
Self-assigned score = 1

12. Business Case – Clinical Impact (Broadness)
OSA performance measures published by the American Academy of Sleep Medicine/Nat’l Committee for Quality Assurance include:
Documentation of subjective daytime sleepiness
Documentation of diagnostic apnea-hypopnea index (AHI)
Positive airway pressure (PAP) prescription
Utilization of objective PAP adherence and efficacy data
REVAMP meets and exceeds all of these measures:
Uses self-administered, online questionnaires with automatic scoring for the comprehensive assessment of symptoms
Reports the diagnostic AHI as well as daily AHI from PAP device
Provides patients and practitioners daily access to the PAP data
REVAMP is designed to assess two other important metrics: patient centered outcomes and patient satisfaction
Self-assigned Broadness Factor Score = 10
Standard clinical practice is to look at one sleepiness measure; REVAMP will include battery of questionnaires.
Standard clinical practice is to look at dx AHI; REVAMP will look at nightly AHI for ongoing treatment.
Ditto (4); by both providers and patients.

13. Business Case – Clinical Impact (Degree)
Published research by both Dr. Kuna and Dr. Stepnowsky has shown:
Home sleep testing is a reliable and valid way to increase diagnostic capacity in veterans with OSA without reducing quality
Patient adherence to PAP treatment is increased by at least 33% when patients and practitioners have access to the PAP data and can use that data to inform clinical management
It is expected that REVAMP will positively impact each OSA performance measure.
Self-assigned Degree Factor Score = 10

14. Business Case – Business Impact
REVAMP improves quality of work being performed:
OSA clinical decision-making is better informed
Best practices are standardized to reduce service variability
Clinical data are of higher quality and easier to access and use
Better OSA management reduces organizational risk
REVAMP improves VA staff efficiency and workflow:
Practitioner time for clinical encounters reduced by 50%
Direct costs reduced by 22% compared to current models
REVAMP improves Veteran/Beneficiary’s experience:
Reduces patient wait time, burden of travel, and lost work hours
Provides self-help educational materials
Promotes patient self-management
Self-assigned score = 10 & 10

15. Business Case - Patient Safety
By improving access to diagnosis and treatment, REVAMP offers the potential to reduce mortality and morbidity in veterans with OSA.
Treatment of OSA has been shown to:
Reduce the risk of cardiovascular disease
Reduce blood pressure in patients with OSA and hypertension
Improve daytime alertness (i.e., reduce the risk of motor vehicle & workplace accidents)
Improve depression and mood (and reduces irritability)
Improve quality of life - bed partners sleep better
A 2010 studied conducted by McKinsey and Harvard Medical School estimated an annual per patient cost of $3,000 for each case of unmanaged OSA
Self-assigned score = 4

16. Business Case – Patient Value
REVAMP will benefit veterans with OSA in a number of ways:
Increases patient access to diagnostic testing and treatment
Reduces patient wait times
Reduces veteran travel time and lost work hours
Promotes patient self-management
Self-assigned score = 10

17. Business Case – REVAMP Addresses the Following Healthcare Disparities
Geographical disparities
Veterans in remote and rural areas will have access to diagnostic testing and treatment through REVAMP\
Sleep resource disparities across VHA medical facilities
Veterans at VAMCs without sleep resources will be able to obtain testing and treatment through REVAMP
Healthcare disparities in disabled veterans
Disabled veterans with OSA who are unable to travel to a VA medical facility will have access to care through REVAMP
Racial healthcare disparities
Veterans can access REVAMP using their iPhones, Android phones, and iPads and thereby will reach a majority of veterans
Self-assigned score = 3
Digital divide
Breaking down.
Mobile phones helping to accomplish this fact.

18. Contributors to REVAMP
VA Philadelphia: Samuel Kuna, MD, Barry Fields, MD, Aileen Love, MD, Sue McCloskey, NP, Keith Davies, Diane Richardson, PhD, Carson Clark, Jennifer True, PhD
VA San Diego: Kathleen Sarmiento, MD, Carl Stepnowsky, PhD, Sue Hacklander, Kathleen DiVerno, Todd Smith, Carolina Smales.
VA Central Office: Marta Render, MD.
Intellica Corp: Vince Fonseca, MD, Jeff Fischer, Jose Lago, Rafa Morales, Marisol Smith, David Santana, Craig Rebo.
CPAP Manufacturers:
Philips Respironics: Mark D’Angelo, Bill Hardy, Peter Ridgway
ResMed, Inc: Cary Shames, DO, Adam Benjafield, Amy Cook
VA Center for Innovations: Blake Henderson

19. Extra slides

20. Remote Veteran Apnea Management Portal
A personalized, interactive web-site for veterans with OSA that promotes self-management by providing feedback on test results, PAP treatment, and response to treatment
Intake and FU questionnaires to evaluate patients and track clinical outcomes
Graphical displays of PAP and questionnaire data
Videos and educational materials
FAQ for self-management
Secure messaging
Questionnaire responses autofill progress notes
Interface with VA electronic medical record

21. Remote Veteran Apnea Management Portal Clinical Pathway
Veteran at Home
Linking Interface
Sleep Center Provider
Electronic intake sleep questionnaire
REVAMP website
Reviews responses
Initial evaluation with sleep provider
Initial evaluation with patient
Phone call
Home Sleep Testing
Equipment mailed
Sleep study ordered
Sleep test scored/interpreted
Treatment with positive airway pressure device
DME company delivers device
APAP device ordered
REVAMP Website
Reviews wireless APAP data
Follow-up questionnaires and evaluations
REVAMP website/ Phone calls
1- and 3-month follow-up evaluations

22. REVAMP provides standardized, patient outcome based management of OSA
Standardized history and sleep study collection
Patient centered outcomes
Wireless PAP Data
CPRS

23. REVAMP Login Page

24. Tom John

25. J Jones

26. Robert Jones

27. Tom John

40. REVAMP Success Metrics
Use objective measures and validated questionnaires to evaluate the success of the remote ambulatory pathway:
Assess improvement in functional outcomes (i.e., quality of life).
Daytime function will significantly improve.
Monitor failure rate of home sleep testing.
Failure rate on home sleep testing will be less than 10%.
Objectively measure patient adherence to autoPAP treatment.
Adherence to treatment will be adequate.
Assess patient satisfaction with the care.
Veterans will be satisfied with their care.
Assess Veterans’ rating of their remote interaction with the sleep provider.
Veterans will express satisfaction with their interaction with the provider.

41. REVAMP Challenges & Risks
Not all Veterans will be able to participate in home sleep testing. A patient with two failed studies will be scheduled for in-lab testing.
Not all patients will be candidates for treatment with an autoPAP device. Strong patient safety measures are built into the pathway to identify these patients so they can be scheduled for in-lab testing.
Veterans may not return the portable monitors and modems. We have developed a successful process to retrieve the equipment.
Not all Veterans will have internet access. However, REVAMP is compatible with I-phones, Androids, and I-pads. These devices are bridging the digital divide allowing veterans over a wide range of socioeconomic strata access to REVAMP.

42. Support for REVAMP and Next Steps
VA Sleep Network Meeting (VASN):
REVAMP was presented at the national VASN meeting in Baltimore in June, 2013 and was very well-received:
Well over 25 sites inquired about its availability and time to roll-out
VACO Support:
Marta Render, MD
Next Steps:
Conduct VISN-wide implementation leading to regional implementation
Expand pilot testing to identify areas for refinement and issues associated with implementation

43. Number of PAP units distributed - FY09-FY12

44. VA OSA Diagnostic Demand

45. REVAMP Model of Care

46. Health Care Costs of Unmanaged OSA McKinsey Study with Harvard, 2010