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.

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.  

Should T-Mobile jump into the medication adherence space?

One thing that’s so fascinating about watching various businesses and groups try and solve the problem of medication adherence is that they are so diverse – if you need convincing, pick up Monday’s New York Times.

One business that is exploring whether it wants to enter the market is T-Mobile. It already has a name for its product; the product itself is developed; T-Mobile even showed an advertisement of its product at a mobile health fair last month at Stanford University.

So why isn’t the cell phone company ready to launch its product? As the mobihealthnews article points out, T-Mobile has its marketing channel in place, so what is it waiting for? According to the article, T-Mobile execs are concerned about “liability issues” and whether they “know the space.”

Know the space? Why should T-Mobile be different than anybody else? Jump on in, boys, the water is just fine!