• Treatment adherence
  • eHealth for medication compliance made no difference

    Complying with drug prescriptions can be a challenge. Using eHealth has considerable potential to help. The reality might be different. A study reported in the Journal of the American Medical Association (JAMA) Internal Medicine of wireless technology and behavioural economic approaches to vascular re-hospitalization and medication adherence for Acute Myocardial Infarction (AMI) survivors found no statistically significant differences for three variables. They were times to first re-hospitalisation for a vascular event or death, medication adherence and cost.

    The 1,509 AMI patients in the study were prescribed at least two of four medications, statins, aspirins, ?-blockers and antiplatelet agents. They’d spent between one to 180 days as inpatients and discharged home with a principal AMI diagnosis. The control group didn’t have smart pill bottles. The other group did, but the eHealth group had no significant benefits. 

    The findings are a salutary reminder that eHealth’s potential benefits don’t always translate into actual benefits. Rigorous attention to other variables are needed to maximise eHealth’s probable benefits, and the study has considerable value in emphasising that eHealth’s much more than the just the technology.

    Studies that show eHealth’s limitations can offer more insights than successful projects. Africa’s health systems have to address this to maximise their own eHealth benefits.

  • Some EHRs may have medication benefit barriers

    EHRs can have a wide range of benefits. In Africa, medication adherence is often seen as a high eHealth and mHealth priority. A research team led by Duke University in the USA has found some persistent barriers in EHRs helping to improve patient’s medication adherence. 

    In the Journal for Medical Informatics Research, the team set out its study. There are four persistent eHealth barriers to medication adherence. They are:

    1. Underdeveloped of data reciprocity across clinical, community, and home settings, limiting the data capture needed for clinical care
    2. Inconsistent data definitions and lack of harmonised patient-focused data standards, making existing data difficult to use for patient-centred outcomes research
    3. Inability to use the national drug code information effectively from EHRs and claims datasets for adherence purposes
    4. Lack of data capture for medication management interventions in EHRs, such as medication management therapy.

    Limited semantic interoperability’s seen as an underlying constraint in removing or minimising these barriers. It’s been a longstanding issue.

    Poor medication adherence data reciprocity across systems has two characteristics:

    • Data complexity, coding syntax, and the transmission infrastructure on which data resides
    • Output, such as medication history, refill rates or patients’ experiences of side effects.

    Common to both features, data’s not accessible, timely, nor easily understood by healthcare systems. Consequently, providers, patients, family members, and community support often lack adequate communication about using medication. 

    The study highlights the role of mHealth in medication adherence, which is important for Africa’s health systems. Barriers identified for EHRs can apply to mHealth too, so all need assessing rigorously as part of mHealth medication adherence projects. Just having an app doesn’t seem to be enough.

  • Good SMS results have some limitations

    Reminding patients to take their drugs is a good idea. It’s especially important for patients with chronic conditions. SMSs are ideally suited to the task. An international team from the Cardiology Department at Westmead Hospital, Sydney, Sydney University, Johns Hopkins Bloomberg School of Public Health and the George Institutes for Global Health at Oxford and Sydney Universities has reviewed evaluation literature and found improved compliance, but two limitations that are helpful to Africa’s health systems.

    Its report from 16 Randomised Clinical Trials (RCT) of 2,742 patients, in the Journal of the American Medical Association, JAMA Internal Medicine, had services from five using personalised services, eight using two-way communication, and eight using daily SMSs. The findings showed that SMS significantly improved medication adherence, almost 18%. It wasn’t sensitive to the different types of patients’ chronic diseases and approximately doubles the odds of compliance.

    There are two big buts. One’s the short duration of RCT’s. The other’s reliance on self-reported medication adherence. These combine to create an important caution in using the findings. They need including in future studies of SMS effectiveness to identify the SMSs that improve success, patient populations that can benefit most, the sustained effects, and influences on clinical outcomes.

    An extra theme can be added to these. SMSs studies are needed to show their cost-effectiveness or costs and benefits over time. There may be better ways to improve compliance, or SMSs are the best way. It’d be good for African health systems to know.

  • Patient portals are effective

    Should patients have access to their medical records? It’s an important decision for Africa’s eHealth if it increases the benefits of EHRs. There may be trend emerging.

    In 2012, a study in the Journal of Internet Medical Research (JMIR) of patient portals’ effectiveness by and Austrian team found:

    • Five papers presenting found studies
    • No statistically significant changes between intervention and control group in the two randomised controlled trials investigating the effect of patient portals on health outcomes
    • Significant changes in the patient portal group, compared to a control group for:
      • Quicker decrease in office visit rates
      • Slower increase in telephone contacts
      • Increase in the number of messages sent
      • Changes of the medication regimen
      • Better adherence to treatment.

    A USA study in 2015, also reported in the JMIR, found the availability of notes following visits to GPs was associated with improved adherence by patients to prescribed antihypertensive medications, used to treat high blood pressure. It didn’t find an improvement for antihyperlipidemic medications, used as cholesterol busters.

    Surveys, interviews, and focus groups have shown that patients taking medications and offered portal access to their GPs notes reported better adherence to their regimens. There’s a big but. The study says that objective confirmation hasn’t been reported, so the team completed a retrospective comparative analysis at a site of the OpenNotes quasi-experimental trial. Quasi-experimental research has similarities with the randomised controlled trials, but they don’t have a random assignment to treatment or control.

    Patients in Danville, Pennsylvania, older than 17, in the Geisinger Health Plan insurance, and taking at least one antihypertensive or antihyperlipidemic agent from March 2009 to June 2011, provided data for the study. From 2010, patients were invited and reminded to use the portal to read their GPs notes. Control patients had portal access too, but their GPs notes weren’t available. There were 2,147 patients, 756, 35%, in the intervention group, and 1,391, 65%, in the control group.

    The 756 patients with access to their GPs notes were more compliant to antihypertensive medications regimens. The rates were nearly 80% compared to 75% for the control group. For antihyperlipidemic medication, the rates were about 77% for both groups.

    The study says as the “Use of fully transparent records spreads, patients invited to read their clinicians’ notes may modify their behaviours in clinically valuable ways.” How can Africa’s eHealth take advantage of it?

  • Diálisis 24H's app helps kidney treatment adherence

    Two nurses and an IT engineer joined forces to create the Diálisis 24H app, to improve adherence to kidney treatments. The team worked closely with renal patients to ensure the app design is user friendly and provides benefits.

    An article in Healthcocreation says Diálisis 24H is innovative in the way it supports kidney patients. It aims to motivate patients to manage their health and take control of their care. The app’s free and can be downloaded for iOS and Android.

    It has a number of self-monitoring features. First, it has a calculator for hydric balance, a crucial value for renal self-care. Most people aren’t aware of the influence of specific foods and liquids and the importance of maintaining a healthy balance to achieve an appropriate water flow. The app helps to address this. It includes a food catalogue that informs patients about the amounts of potassium, sodium and water, certain foods contain. In an interview with Healthcocreation, the team says “We want our dialysis patients to be able to eat all kinds of food but in a healthy manner. It is not about prohibiting, it is about giving the tools to allow patients to eat what they like taking into account the quantity and the portions.”

    Diálisis 24H has a gaming component to encourage learning. Users can play the quiz alone or with other users to solve challenges. There’s a digital pillbox too, to remind users to take their medications.

    The healthcare advice section provides patients and relatives with information on nutrition, lifestyles, dialysis, care on vascular accesses, vaccines and many other issues. It’s updated regularly to keep up with latest findings and developments.

    Historical dialysis records also promote treatment success. With this information patients get a powerful tool for self-care, and can share the information with their healthcare professionals. 

    The app’s currently available in Spanish, but’s easily translated. Renal patients in Africa, who don’t have easy access to clinics or healthcare facilities, could benefit from it. Diálisis 24H would allow them to monitor and manage their care from home and could reduce the frequency of the need to see health workers.  

  • More eHealth to stop TB

    TB incidence in Africa is unacceptably high. So are its mortality and drug resistance rates. Both are fueled by poor treatment adherence.

    For the vast majority of cases, TB is treatable. Success needs a few simple things to work: early diagnosis, access to treatment, and adherence for at least six months. This is the nub. Most of us aren’t good at following a treatment regimen, even if it’s simply a daily dose. Compliance deteriorates if we have to do it for months. So, well-trained health workers help. They’re called Directly Observed Treatment Short-course (DOTS) supporters, part of WHO’s DOTS programme.

    DOTS has five components:

    • Political commitment with increased and sustained financing
    • Case detection through quality-assured bacteriology
    • Standardised treatment, with supervision and patient support
    • An effective drug supply and management system
    • Monitoring and evaluation and impact measurement.

    eHealth and other technologies have an important role too. They’re emerging as a sustainable solution.

    In India, uNotify supports text messages, fingerprint scanners and intelligent pill dispensers to support treatment adherence. uNotify devices send information to a centralised server that monitors programme activity and alerts administrators when a patient misses a dose. In South AfricaOn Cue Compliance does much the same. It uses specially designed pill bottles fastened with a SIM card and transmitter. When the pill bottle’s opened, the transmitter relays a text message to a designated healthcare worker. If patients don’t open pill bottles on time, they receive a text message reminding them to take their medication. According to the programme’s reported results in the CHMI database, 90% of patients complied with their medication regimen, compared to a compliance rate of 22 to 60% without the system. Similar results have been achieved by SIMpill and Wisepill reported in eHNA.

    Protecting the drug supply chain is also important, since gaps in supply don’t do treatment adhernce any good. TexTB, in the Philippines, and the Uganda Health Information Network help to monitor and manage the supply of TB meds. The Ugandan programme reports 24% improvements in efficiency when compared with paper-based data management, where officials in five districts monitor drug and supply levels at health centers via PDAs.

    The MOTECH Suit, using Dimagi CommCare mobile phone-based tools for community health workers, provides health workers with text messages, electronic forms, job aids, medical protocols, alerts, and other features to identify and respond to symptoms for high-burden health issues like TB. World Health Partners uses text messages included in the MOTECH Suite to enable rural medical providers and consumers alike in Bihar, India to better manage their TB. D-tree International is developing a TB module to help health workers in Tanzania identify TB among HIV-infected clients; the module suggests diagnostic tests even when clients miss a visit.

    Africa’s healthcare is moving its eHealth role in TB treatment forward. There’s still plenty to do.

  • mHealth to encourage treatment adherence in Tanzania

    The Vodacom Foundation has donated mobile phones to the Sickle Cell Foundation of Tanzania to support treatment adherence among patients. About 150 sickle cell patients are set to receive mobile phones that will simplify monitoring of their health condition says an article in BIZTECH Africa

    Sickle cell disease rate in Tanzania keeps rising, as 11,000 babies are born with the disease each year. The Sickle Cell Foundation is committed to supporting prevention, care and effective management of disease in Tanzania. It’s working with Muhimbili University on the Mighty Dots (MDOTS) project that uses graphic screen designs for mobile phones to improve adherence to medication.

    The pilot will see 150 patients on long-term medication receive mobile phones. These patients will be monitored daily by recording themselves ingesting the medication and sending the video to the clinic using the new phones.

    MDOTS Programme Coordinator, Dr. Robert Mongi said, “We prescribe medication for different strains of sickle cell. Patients with severe sickle cell disease are prescribed medication that must be taken daily however, not all patients observe these instructions. This project will help us determine whether monitoring intake of medication is effective in ensuring adherence to medication on a daily basis.” Many long term patients tend to skip taking their medication based on lack of symptoms. The accountability aspects of the initiative should help improve adherence.

    Tanzania ranks fourth in the world for the highest number of sickle cell disease births a year, after Nigeria, India and DRC. Sickle cell disease is manageable with comprehensive care, but needs diligent treatment adherence. This basic mHealth initiative could help patients manage their disease better.

  • Treatment adherence is never easy

    When was the last time that you completed a full course of medication prescribed by your GP, taking each pill as prescribed, on time, every time? The truth is very few of us comply, which creates all kinds of problems both small, when it takes longer for us to recover, and big, when we help drug-resistant super bugs to take hold even more.

    It seems that South Africans know a thing or two about treatment adherence. This is not surprising, given the long, hard battle being fought in South Africa to bring challenges such as Tuberculosis and HIV, and their nefarious combination, under control, without creating escalating problems associated with poor treatment adherence, particularly drug resistance.

    Over the last decade South Africans have made valuable contributions to real-time support for treatment adherence. Dr David Green, as inventor and innovator of Simpill, and Ricci and Lloyd Marshall, a husband and wife team, as entrepreneurs and owners at Wisepill Technologies are good examples. Both use a portable medication dispenser with a GSM communicator, connected to Internet software that drives adherence services customized to patients’ unique medication regimens.

    Simpill was a pioneering concept, invented in the early 2000’s by Dr David Green to help TB patients remain compliant. It’s now used in a number of countries to help patients manage their chronic conditions and avoid costly and unpleasant hospital admissions needed to deal with poor treatment adherence.

    Wisepill was founded in 2007, contributing a suite of solutions to the real time adherence support. Wisepill’s been selected by Family Health International (FHI360) for their trials of antiretroviral agent Truvada and used by Massachusetts General Hospital (MGH), Harvard and Columbia Universities in HIV research in Uganda and in South Africa.

    In 2011, Wisepill won South Africa’s Department of Trade and Industry (DTI) Technology Award in the category of small businesses. Director and owner Ricci Marshall said, “Our focus has been on providing innovative products and service excellence in the field of medication adherence. It is gratifying to see our solutions being used more and more for personal adherence management as well as in clinical trials internationally.”

    So why don’t we see more of these technology solutions helping people stay healthy and avoid running up unnecessary costs? There are probably a number of reasons, though cost, often regarded as the key deterrent to serious scale-up, should not be one of them.

    When I first came across these devices I was curious about the cost question, so produced a cost minimisation assessment of a SIMpill pilot, with Prof Maurice Mars of University of KwaZulu-Natal. Our assessment published in January 2012 found that the discounted net present value, the estimated value for money quantified by the accumulated economic benefits less costs over a project cycle, was nearly half a million US dollars. It also showed substantial improvements in health outcomes.

    So either “if it sounds too good to be true it is” or something else is the limiting factor to their increased use, not costs. The real difficulty is that pilots do not deal with a wide range of additional, complicated issues necessary for wider implementation. Important factors such as integrating the new solution into regular working arrangements and dealing with affordability and the extra cash needed to finance the project.

    Economic assessments usually don’t address these issues, though they do help to point in the right direction, so that more substantial cost benefit analyses, or eHealth impact assessments can be applied to tease out the hard work that’s needed to realise real benefits.

    Without a doubt, real-time treatment adherence support is here to stay, and sound economic assessment methods will be critical tools to help position them properly. On both of these topics, South Africans are likely to continue to contribute, helping eHealth improve health and healthcare in Africa and elsewhere.

  • Asthma apps are about breathing

    For most of us, breathing isn’t difficult. I certainly don’t spend much time thinking about it, except for the occasional scary sea-swimming moment, caught clutching the sand after diving beneath an unexpectedly large wave. For asthmatics though, breathing can become impossible and the signs of deterioration are often small and subtle and only noticed by patients and their families once the patient is already in trouble, ‘trapped below the surface’ of a tight chest, needing urgent rescue through medical care, and often hospitalization, to avoid death. Keeping these patients out of the dangerously deep water of a serious attack is about helping them to identify danger signs long before they are serious, to take action, or to identify and avoid triggers that accelerate a plunge into the abyss.

    Open mHealth says that mHealth is about making “health data as useful and actionable” for patients and clinicians. The growing industry around mHealth is equally interested in reducing costs and the burden of care faced by health workers by reducing hospital visits. For asthmatics, both will sound like good news and they are no doubt pleased that innovators are not sitting idle.

    A number of companies now offer Apps and sensors to monitor breathing and help manage Asthma. Three quite different examples, sharing the same aim, are AsthmaMD that offers a Peak Flow Meter to measure lung function, iSonea that gauges adherence by monitoring wheezing, and Propeller Health’sapp and sensor, which attaches to a standard inhaler. All focus on helping asthmatics manage their condition and reduce the number of visits to healthcare providers. Ephraim Schwartz provides more detail in his June piece in mHealth News.

    AsthmaMD uses a Peak Flow Meter, a device that measures the force with which the patient breathes out, a key aspect of breathing particularly reduced in asthmatics. The meter syncs with an App via Bluetooth. When patients blow into the meter, a value is transmitted to the App, which then explains to the patient what the value means. The App will also track lung function over time and produces easy-to-read, color-coded peak flow charts, which provide healthcare providers with information to use to tailor treatment plans. They’ve reported a 10% improvement in lung function for active users, compared to a control group, and reduction in hospitalization and readmissions. It’s available over the counter in the US for $20.

    AsthmaMD apparently has 100,000 users and its developers have begun thinking about how to use their growing data source to answer questions about how to improve asthma care.

    iSonea’s device is called iSoneaAir. It records wheezes, a characteristic sound associated with obstructed airways. By measuring the wheeze rate, health workers are able to monitor patients’ progress outside of the clinical environment and assess how effective medications are before and after inhaling. “Doctors as well as insurers are looking at our application because it gives them a disease management focus,” said Ross Wilson, senior clinical manager at iSonea.

    The solution consists of an iPhone or Android App and the wheeze monitor, which is placed against the throat. The device syncs with the App via Bluetooth and wheeze recordings can be sent to health workers or stored in the cloud.

    The Propeller Health App, along with its sensor, tracks exact location, time and frequency of medication taken.

    Africa’s health challenges need solutions of their own, and the mHealth community in Africa is expanding its capacity to deliver. There’ll be lessons to learn from projects that gain traction elsewhere. Though probably none that will help me avoid the next big wave, or hold my breath longer when I get it wrong.

  • Birth control pill-tracking app

    MediSafe, a company based in Israel, has added a birth control pill tracking feature to its medication adherence app. MediSafe offers a cloud-based app system for medication adherence. Patients using MediSafe get a reminder to take their medication on their phone and are then prompted to record doses when they take them. If they don’t indicate that they’ve taken their medication, friends and family members are notified and can then take action.

    While a number of women were using MediSafe as an adherence app, the app wasn’t specifically designed for tracking birth control pills. “Female users have been using MediSafe for birth control pills for some time now, but it was a bit awkward,” MediSafe CEO Omri “Bob” Shor told MobiHealthNews“You know a continuous medication is something that you take every day but it wasn’t really perfected for contraceptives.”

    Even before the new feature was launched MediSafe found that women who were entering birth control pill reminders increased their adherence by 23% and were adherent close to 94% of the time. Women can now make use of the new feature, which includes the option to assign friends or significant others the responsibility of reminding you, if you forget to take your birth control pills. 30% of the women who have singed up are already making use of this option.

    Similar platforms can be developed to address African specific healthcare challenges. There is no reason that HIV or TB medication can not be tracked through a similar application. eHNA’s reprted on South Africa’s SIMpill and Wisepill. There are certain to be more.