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. 

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.

Medication Adherence: A Glance At PubMed

Do you need proof that certain treatment adherence programs can work?

Just plug in “patient adherence” and “cell phones” into PubMed. You'll likely see two Lancet articles on mobile phone use and HIV treatment adherence.  In the Chi and Stringer article, these researchers found that weekly text messages sent to HIV patients in sub-Saharan Africa improved adherence -- 62% versus 50% for the control group – and allowed for better rates of virological suppression (57% vs 48%). Patients who didn’t respond to the text message within 48 hours received a follow-up phone call.

Chi and Stringer raise interesting points in their article. They recognized that the calls were too spread out to actually remind patients to take their antiretrovirals; they speculated that “[p]ossibly the SMS [short message service] intervention worked by improving communication and rapport between health providers and patients.”

Two other points of discussion:  One, the cost. Chi and Stringer write that SMS costs less than $8 per patient.  “This intervention might prove cost effective, particularly when one considers the cost and complexity of second-line therapy. However, this aspect still requires formal analyses.”

The second point the researchers raise: Can cell phones be used to help other patients with other types of chronic diseases?  Chi and Stringer might find the answer to that question in other PubMed articles. In India, at the L.K. Diabetes Centre in Lucknow, diabetes specialists use videos made with mobile phones for diabetes education. They call them “mobi-films.” These mobi-films are used in multiple ways: patient to patient communication, doctor to doctor communication, doctor to patient communication, and patient to doctor communication. As to whether these films have helped improve patient care, the authors write, “Over the years, we have seen a sea change in the knowledge and day-to-day diabetes care skills of people visiting our center and benefiting from our diabetes education films.”

Some physicians are experimenting with cell phones for patients with hypertension; other researchers have seen success with patients with malaria.

And, by the way, Chi and Stringer aren't the only researchers who found that HIV patients are adherent when prompted with cell phone messages; a literature review by other researchers found similar findings.

To us, the travesty of patient non-adherence is that solutions to the problem exist and that people in this country are not adhering to physician recommendations. What is reassuring: That studies are suggesting that innovation can occur anywhere.

Mobile Health Tech Study: Get Linked

A new PricewaterhouseCoopers' Health Research Institute survey says that physicians recognize that mobile health technologies can help with patience adherence issues, physician shortages and other long-standing healthcare problems.

The results of the Healthcare unwired survey, which involved 1,000 physicians and 2,000 consumers, suggest that physicians and the public alike are ready for mobile health technologies. But PWC says various stakeholders, including some in industry, are essentially ignoring this news. The primary reason: The way the U.S. health care system makes its money. Because only in-person consults are reimbursed, the system is dependent on volume to make its money, so it is not likely to embrace the idea of reducing that volume or transferring that model to lower-cost care -- Americans feel they are entitled to the best healthcare.

According to the survey results, most physicians said they would like to receive healthcare data from their patients’ smart phones or cell phones. (Three out of 10 consumers surveyed were good with tracking it that way.) While these might not seem like big numbers, this is the start of the innovators' curve and this country will reach the tipping point. Our goal is to make our readers aware this "IS" coming and like many other changes, try not to let these opportunities slip by.

We believe that receiving such data could help with patient adherence, 88% of the physicians polled said they would want their patients to monitor certain numbers at home, especially blood sugar levels, blood pressure, and weight. Moreover, 57% of the physicians said they’d like to receive similar data from discharged patients under their care -- this lack of data is one of the biggest issues in medicine today and causes millions of dollars in inefficient care.

A few years ago, physicians, as a group, were not technologically in tune. But that has changed. In this survey, 63% said they are using personal devices to help their patients – and these devices aren’t connected to hospitals or their practices. Of those using smart phones and cell phones, 56% said the technology quickens the decision-making process, and 40% said these tools shave time spent on administration.

And time is what it’s all about: 45% of the doctors said Internet visits would allow more patient access, and 43% said mobile health technologies like e-mail and texting could reduce actual office visits. The gains, PWC says, would be huge. They could:

• help with physician shortages;

• reduce costs of hospital readmissions; and

• increase access for those patients who put off care because they won’t wait for an appointment.

The actual study (you'll need to register to get it) points out two (pharma and retail pharma) members that are tapping into this market: Bayer and CVS Caremark. Bayer has integrated its digital glucose monitor, DIDGET, into the Nintendo game console. And CVS has an iPhone app that allows members to get information on refills and other pertinent information.

Our point is that the industry needs to embrace change, especially technological change like the ubiquitous use of mobile phone technology.  

The Evidence for Texting As "mHealth": Another Tool For Population-Based Care, Medical Homes and Disease Management

Thought as one of our first blog entries, I would direct you to another blog post that I find very interesting. The application of Mobile technology and Medication Management is a very interesting combination that I believe the Pharmaceutical and Biotech industries need to consider embracing.

The questions that may be interesting for debate are who are the stakeholders and what role should they play in this issue. Let me know your thoughts after reading this. We will be back with more of our thoughts.