Poor medication adherence costs a bundle. The U.S. healthcare industry spends 8 percent of total U.S. healthcare costs, or more than $200 billion each year, on avoidable admissions, outpatient treatments and prescriptions caused by poor adherence, according to the IMS Institute for Healthcare Informatics. 

With the stakes so high, the industry is looking to mobile devices as the platform for effective adherence tools. The innovations out there are largely untested, but a few pilots hint some promise at tackling this expensive problem. 

The App Marketplace

Noting the lack of testing of medication adherence apps, Lindsey Dayer, PharmD, assistant professor, University of Arkansas for Medical Sciences College of Pharmacy in Little Rock, and her team ranked 160 medication adherence apps available on Apple, Android and Blackberry systems.

They examined attributes such as online data entry, a searchable medications database, capability to transmit medication regimens to providers, medication reminders with tracking of missed doses, ability to input and maintain medication regimens and others.

Not all of them did what they claimed they’d do, Dayer says. MyMedSchedule, MyMeds and RxmindMe rose to the top due to their basic medication reminder features coupled with enhanced functionality levels.

Among the most critical attributes was complex medication instructions. “Patients receiving the newer oral antineoplastic medications sometimes face difficult dosing schedules,” she says. “Apps need to be able to tailor to patients’ specific medications regimens.”

Cloud storage is a crucial feature to back up regimens and help providers track missed doses, she says. Apps should be able to deliver medication reminders regardless of connectivity—perhaps by incorporating reminders into the user’s phone calendar.

A limitation of the current market is that apps are targeted primarily to consumers rather than healthcare professionals, Dayer says. “Nearly all apps require patients to enter and manage their prescription data, and most require manual data entry by patients.”

Despite being untested, medication apps represent a possible strategy pharmacists can recommend to non-adherent patients, Dayer and her team concluded. They are building a searchable website for pharmacists so they can prescribe apps to their patient population.

Personalize It

Perhaps most key to any innovation’s efficacy is its ability to personalize it to the user, says Dayer. This bears out in some successful pilots that used text messaging and apps to improve adherence.

Rebecca Dillingham, MD, MPH, director of the Center for Global Health, University of Virginia, and colleagues have been testing adherence mobile health strategies since 2008. “Mobile devices have tremendous promise but we still have trouble marshalling data showing that,” she says.

In 2008, her team conducted a small-scale HIV/AIDS pilot study in semi-rural Virginia, which saw a striking increase in patients out of care for more than six months. “In the HIV world, it’s impossible to discount the roles of stigma and denial. I’ve had people tell me that literally taking pills is a re-traumatizing event. It’s an implicit acknowledgement of disease in their life,” says Dillingham.

The relevance of medication adherence, she explains, was that such patients could only get prescriptions by visiting a clinic. “One social worker got 85 percent back in care, but after a year, it went down to 50 percent. That was the nail we wanted to move.” 

The earliest study sought to improve medication adherence by requiring participants to self-author text message reminders.

While the idea of patient-written messages stemmed from privacy concerns, it was “fortuitous” as they were potent motivators. The messages often were affirmative and deeply personal (i.e., “Believe in the impossible”) and spurred the pilot’s success.

Those on the intervention side were 88 percent more likely to be in care a year later, versus 59 percent in the control group.

“There had been concern that text messages would become annoying. Rather, participants in the intervention experienced a tremendous loss when the phone was taken away. It was far more than simply taking meds,” she says.

In another pilot involving patient-authored texts, 72 participants reported on medication adherence, behaviors around addiction and moods when triggered for three months.

“We were delighted that people were willing to report substance abuse and medication adherence.” Participants responded two-thirds of the time, providing useful data for their providers.

Dillingham’s group now is working on a demonstration project that requires newly diagnosed participants to report on medication adherence, moods and stress levels, while offering them access to an anonymous dashboard via an app.

Patient Engagement

Participants in a pilot at Healthy Communities Foundation, University of California, Berkeley, were particularly motivated to improve their care. 

Kathleen Morrison, project director, and her team enrolled 30 participants in a nine-month pilot to help individuals with Crohn’s disease achieve medication adherence and improve their care.

She believes effective apps require an organic, collaborative process that involves both providers and patients.

The pilot tested two tablet-based disease management apps. Adults with moderate to severe Crohn’s disease received an iPad, biometric scale and Fitbit monitors and tracked nine different types of “observations of daily living” (ODL), or daily health cues.

“It was a perfect disease to develop an app for because patients were highly motivated and involved in the app design,” says Morrison. Patients with Crohn’s are uniquely challenged because they respond to treatments in a highly individualized manner.

They hosted focus groups with providers and patients to develop clinically relevant ODLs to track. Then they engaged in usability testing, which entailed a lengthy iterative design process.

Using the apps, participants received medication reminders—which were highly successful—and tracked ODL trends over time.

The app enabled patients to understand the relationships between medication dosage, stress, pain, anxiety and activity levels. Sometimes patients would see a reduction in negative symptoms if they slept better or exercised more; as such they could scale back opioid dosages.

Patients and providers alike reported more meaningful interactions and ability to tailor medications properly. “It allowed patients to have more say during their clinical appointments,” she says. 

With patients driving their care, not only will avoidable costs from poor adherence be reined in, but they will experience marked improvements in their health as well.