Fixing Noncompliance

It is considered as a black mark on a patient’s chart.  Being labeled as a noncompliant patient basically sends the message that no matter what medical instructions a physician gives you, you will not abide.  A recent post by Dr. Danielle Ofri, associate professor of medicine at New York University School of Medicine and editor in chief of the Bellevue Literary Review, discusses what it truly means to be noncompliant and how the issue of noncompliance could be better handled. 

Dr. Ofri quotes the example that a hypothetical medical chart was constructed for a 67-year-old patient with diabetes, hypertension and high cholesterol.  In order to remain truly compliant, the patient would have more than 3,000 behaviors to tend throughout the course of a year!  These include anything from taking medication as prescribed to exercising three or four days a week to attending recommended checkups.  Day in and day out (for some reason medical issues do not like to take time off), the patient must turn instructions into habit so that they may remain compliant.

The question needs to be asked, what can we do as Healthcare and Pharma professionals to improve medical adherence?  This could potentially be a multi-billion dollar question as improved medical adherence would directly impact prescription drug sales and provide new avenues for healthcare companies to facilitate and monetize physician-patient dialogue.  Now that smartphones and apps seem to be within arms length of almost everyone, we believe one key strategy will be to develop apps that allow patients and physicians to monitor key stats such as daily caloric intake and provide the ability to set reminders to adhere to a prescribed plan (see Prescription Smartphone Apps for Medication Adherence). 

However, this is just the beginning.  Improving adherence will require input and effort by everyone involved.  It is important for the Healthcare and Pharma industries to understand that adherence can be a “complicated balancing act” for patients.  Particular issues in a patient’s therapy may trump others and professionals in Healthcare and Pharma need to recognize this so that a prioritized plan can be developed.  Together we can develop strategies that improve medication adherence, and with this improvement, everyone will be better off.

Monitoring Consumer Sentiment in Pharma

Sifting through social media sources is one of the best ways to find information regarding new technology.  While perusing Twitter, we came across this article written by Jennifer Zaino of semanticweb.com.  With today’s world of constant data streams, managing it all and applying it in a meaningful way is a priority of successful companies.  Effectively utilizing this data requires semantic technology and sentiment analytics, and in turn, a user or business can continuously adapt their social customer relationship management (CRM).  Gartner, a leading information technology research and advisory company, recently released its Magic Quadrant for social CRM. 

Several players exist in the semantic technology arena that work with companies to develop business strategies and social experiences that generate improvements for sales, marketing, and customer service, while also benefiting online communities.  Gartner has divided these players into the following four quadrants based on completeness of vision and the ability to execute that vision: niche players, visionaries, challengers, and leaders.  On this spectrum of social CRM players, it is evident that the leaders, such as salesforce.com, are the ones that effectively utilize social and sentiment analysis strategies that are evolving with today’s world of social media and ever developing  “emotional state” of the Internet.  Learning from the leaders of this area of information technology will allow for better overall consumer experiences across industries.  Going beyond keywords for developing a sense of consumer sentiment will be the new normal, and those who effectively utilize this information technology, will be the leaders of their respective industries going forward.   

With regard to pharma, noticeable improvements will be necessary in the future regarding the consumer experience.  Developing efficient methods of monitoring consumer sentiment of various biopharma products will allow companies and healthcare providers to adjust quickly (assuming they are willing to) and provide necessary support for patients in times of non-compliance.  

Prescription Smartphone Apps for Medication Adherence

When it comes to embracing new technology, we like to think that we are ahead of the curve.  However, our approval is only bestowed upon technology that provides a substantial benefit, especially given costs or numerous unavoidable advertisements. As illustrated in a recent article by Pamela Lewis Dolan at American Medical News, a new wave of technology will become the norm in healthcare by way of smartphone and tablet apps that will allow physicians to closely monitor many aspects of patient compliance. 

There are a few questions however for the future implementation of these “prescribed apps”:

1. Does the app serve a utility that is worth the cost/adherence?
2. How much data will the app produce for the patients?  
3. Will the physician have the time/man power to properly utilize the data?
4. How will physicians monetize the use of the apps?
5. With data being retrieved without office visits, will this mean decreased revenue?
6. As with any prescribed therapy, how does a physician ensure patient compliance?
7. Will health-related apps be regulated by the FDA?

Physician-patient communication desperately needs creative improvements to ensure therapy compliance and persistence.  With the growing use of smartphones, using healthcare apps and the field of mobile health is only expanding in the coming years. The FDA has already approved a select number of apps to deal with clinical care and bills are currently in place to create an FDA Office of Mobile Health.  For a fraction of the cost for an office visit, patients can purchase an app that allows them and their physician to monitor health progression, collect critical health outcome data between office visits that may reduce visits to the office.  

We know medication adherence and health outcomes can be improved by allowing healthcare professionals to track metrics that normally are not monitored, such as heart rate, glucose levels, and calorie count.  This is not driving the conversation out of the exam room, but extending the reach of the physicians diagnostic and treatment capabilities.  With 10% of smartphone users having downloaded health-related apps, the practice of “Prescribing an app” will continue to catch on.  Generating a large market from the almost 1 billion smartphone user base will be as easy as posting that picture of dinner to Instagram. 

ACOs and Fierce Communication

So here’s a question to ponder while you’re reading our carefully honed prose: How do you attract patients to sign up for an accountable care organization?

Last week, Cigna announced that its two ACO pilots were doing, at least preliminarily, what they should be doing: improving patients’ health and saving money. The giant insurer is so happy with the results that it is planning a national expansion of its ACO program this year.

Here’s why they’re happy: At its multi-specialty medical group practice division in Phoenix, the average annual savings per patient was $336; ambulatory surgery was down 11%; preventive care visits, overall, were up 3%, and up 12% for adults. And, its partner in New Hampshire is “closing gaps in care 10% better than the market.”

A few years ago, Cigna jumped on the ACO bandwagon. The goal: “Achieve the ‘triple aim’ of improved quality, lower medical costs and improved patient satisfaction by creating a care model anchored in the principles of the patient-centered medical home that also builds in accountability by rewarding physicians for results.”

In its press release Cigna says its collaborative ACO model is big on communication. Its doctors and nurses speak frequently with its customers’ doctors and nurses, “to help with coordination of patient care.” Cigna’s program also includes disease management programs and lifestyle management programs, including stress management.

Cigna doesn’t say how its customers reacted to the idea of participating in an ACO. That notion is even more interesting for Medicare patients. How will Medicare—by law, mandated to start pilot programs by next January—attract its seniors, normally an independent, privacy-loving lot? According to the new healthcare law, the pilot ACOs will take care of all the healthcare needs of at least 5,000 Medicare patients for three years, minimum.

FierceHealthcare says the success of these ACOS will require “fierce communication strategies,” like physicians doing things they don’t normally get paid for—contacting patients by e-mail, instant messaging and so on.

But as usual, it comes down to communication. We somehow doubt that it will matter what the medium is: word of mouth, Twitter, radio, smoke signal. If the ACO healthcare providers are communicating among themselves, sharing information about a patient’s well-being, and that patient’s health is improving, along with his quality of life, then that patient will spread the word.

And that can be pretty fierce, don’t you think?

The VA Shouldn't Hold Its BREATH

What a mess. In 2009, the Department of Veterans Affairs abruptly halted a study called the BREATH study, designed to help 413 veterans manage their advanced COPD, because of unspecified safety concerns.

Apparently the deadly type of safety concerns.

The VA, keeping mum about what happened until it publishes in a peer-reviewed journal, had all the right intentions. It wanted to help the sick vets cope with this chronic lung illness by teaching them how to manage it–-with the hope of then keeping them out of the hospital.

But apparently the trial backfired. While the study’s researchers wouldn’t give details, one told the Pittsburgh Tribune-Review, “If someone were to start a disease management program, I would suggest they probably not do it just yet, until the information is available," said Dennis Niewoehner, a pulmonary doctor in Minneapolis, a co-chair for the trial.

Forgive us, Dr. Niewoehner, but we disagree. One, the VA should tell healthcare providers now what happened. There may be a clinical trial going on that could benefit from your knowledge. And two, stalling the start of a disease management program until a paper is published is not right. For those with chronic diseases, every minute has got to be torture.

What is ironic is that maybe the VA should have waited to start its study. Just recently, a review was published in Current Opinion in Pulmonary Medicine on COPD and older adults. The researchers looked at various areas, including comorbidities and disease management.


Older adults with this disease have an average of nine other comorbidities, including depression, cardiovascular diseases and chronic renal failure. What they found was that research suggests that “aging is a determinant of the progression of disease and that management of this population requires different metrics and strategies.” According to the summary information of the VA study, the study group received an education program, an “action manager," plus care. They also received telephone calls. The control group received standardized care.

Since we have no clue as to what went wrong with the study, we can only speculate, but the take-away message is that patient monitoring and management could have potentially signaled these problems sooner. While we think publishing what goes wrong is as important as publishing what goes right, we also believe the use of monitoring technologies like MedAdherence can help providers manage patients with many comorbitities remotely, and possibly better.

Let us know what you think.

Pharma: Know Thine Enemy

Mindless habitual behavior is the enemy of innovation. 
Harvard Business Professor Rosabeth Moss Kanter 

Might we suggest that pharma begin thinking about investing serious money into healthcare that does not only involve drugs? We keep tripping over stories and studies of how non-traditionalists are stepping into the healthcare space using social media.

We found this interesting.

One group of researchers has published two papers on smoking cessation; both papers involved the same number of subjects, 27. Another group took a look at the 47 apps, designed to help smokers quit smoking, all of which are currently sold for iPhones only.

The two groups of researchers found different results.

In the first paper  the researchers first used fMRIs on the subjects, all heavy smokers, to learn which parts of the brain were fighting, or giving in, to the urges to smoke. Their description of this battle: “A war that consists of a series of momentary self-control skirmishes.”

The researchers theorized that by mapping the brain areas where these skirmishes are fought, they could predict which of the subjects would have more success at quitting–-because these brain areas were more active. The motivation they used on these subjects was text messages, eight messages a day for three weeks.

“We are really excited about this result because it means that the brain activation we see in the scanner is predictive of real-world outcomes across a much longer time span than we thought,” said one researcher. “The tasks that we use in the laboratory are simplified models of these real-world processes–-but they seem to be valid models.”

In the apps paper, the researchers checked out the 47 smoking cessation apps, just to see how effective they might be. They looked at how each app approached smoking cessation and its adherence to the U.S. Public Health Service's 2008 Clinical Practice Guidelines for Treating Tobacco Use and Dependence.

The conclusions? The apps had “low levels of adherence to key guidelines in the index. Few, if any, apps recommended or linked the user to proven treatments such as pharmacotherapy, counseling, and/or a quitline.”

What an opportunity for pharma; it’s tailor-made.

Telehealth: Simple Is Beautiful

One challenge with healthcare is figuring out when people alone can produce the best healthcare outcome for the patient, or when technology can do the job better.

Or a combination of the two.

We present, as an example, a three-year Department of Defense study involving pediatric care in the Pacific Rim. The DoD wanted to see if physicians who consulted with pediatric subspecialists online regarding consultations, treatments and so on, could improve health outcomes for young patients while saving the DoD money. The conclusion: Yes on both counts.

The study, conducted between 2006 and 2009, looked at more than 1,000 tele-consultations in community hospitals from the area, including Guam and South Korea, often in areas where pediatric subspecialists are not available. Most of the tele-consultations, 75 percent, came from these areas.

Because the doctors spoke, the diagnosis and/or treatment plan was changed for 74 percent of the children – preventing patient transfers to other facilities between 12 percent and 43 percent, saving American taxpayers between $208,283 and $746,348 each year – not to mention saving the children and their families unnecessary expense and concern. The study authors said the number of “tele-consultations has grown significantly since 2006.”

It didn’t take long for the Twitter world to react to this study. One tweet [Feb. 8, 8 p.m.] asked if healthcare pros who don’t use telemedicine are negligent; another [same time] said Alaska and Hawaii are teaming up to extend telehealth to remote locations in those states.

The straightforwardness of this study, and its convincing outcomes, dispels the healthcare challenge this particular problem presented. That is why we wanted to bring it to your attention.  If only all things were this simple.