High-Tech, Simple Solutions For Improving Patient Care Management

Abstract

Nonadherence is an incredibly complex and difficult-to-address problem. Several products designed to appeal to tech-savvy patients offer the promise of one simple solution.

Patient nonadherence to therapeutic regiments places considerable strain on already limited healthcare resources. By appealing to technologically savvy consumers, several new products are looking to improve medical outcomes while saving money.

Prescription medications are the core of most medical treatments. Unfortunately, many patients do not take them as directed. The terms that define this phenomenon are noncompliance and nonadherence, both of which refer to the extent to which a person’s behavior (in terms of medications and lifestyle changes) coincides with medical or health advice. The difference between these terms is subtle. Adherence reflects a more collaborative partnership between patient and healthcare provider, whereas compliance is associated with a relationship in which the provider assumes a paternal role in healthcare decisions and the patient passively follows instructions.

Patients who are described as noncompliant or nonadherent typically are associated with a deficiency in their medical treatment and follow-up, which leads to a detrimental medical outcome. The reasons for this behavior include misunderstandings about treatment and medication side effects, and a lack of patient motivation and involvement in care plans. Approximately 20 to 50 percent of patients are non-adherent to therapy (Kripalani 2007). Interventions that reduce dosing demands or involve monitoring and feedback have been shown to have the greatest impact on overall adherence (Kripalani 2007).

Marshall Fleurant, MD

TAKING ACTION

How does noncompliance translate into healthcare dollars? When a drug is assessed in clinical trials, an adherence goal of approximately 80 percent is expected. This means that it is assumed that patients will take at least 80 percent of the medication in the correct dose at the appropriate time. Those patients who do not adhere to that goal will not receive the full benefit from their medication (Osterberg 2005).

Noncompliance with prescribed medication regimens costs $100 billion a year and is believed to be responsible for at least 10 percent and possibly as much as 28 percent of hospital medical admissions (O’Connor 2006). In total, healthcare expenditures account for approximately 16 percent of the U.S. gross domestic product. Increasingly, employers are carrying a larger share of healthcare costs; in 2007, employer health insurance premiums rose by 7.7 percent. Healthcare costs are outpacing other costs of doing business.

Studies have found that actionable messages improve people’s willingness to adhere to therapy. For example, a simple experiment conducted in 1965 found that tetanus vaccination rates among college students increased from 3 percent to 28 percent when the students were provided with maps to the university health center and a list of office hours (Turpin 2007).

The same technique is being used today, but with much more powerful tools. Disease management programs and medication reminder systems, for instance, have shown promise in stemming healthcare-related costs and improving medical outcomes by combining communication technology and human behavior.

This article introduces five companies that have developed communication products that are designed to solve patient adherence and compliance dilemmas. Emmi Solutions (www.emmisolutions.com), Intelecare Compliance Solutions (www.intelecare.com), and InforMedix (www.informedix.com), have each developed a patient-centered technology that each claims increases compliance with medications and other medical treatments via informational and monitoring programs. Their products offer educational opportunities and daily medication reminders to patients, whether at home or on the go, and are geared toward the patient as the consumer.

The offerings of VisionTree Healthcare Solutions (www.visiontree.com) and Phytel (www.phytel.com) target patient compliance issues through increased coordination between healthcare provider and patient. Their products are designed to identify patients who are noncompliant with medical visits by equipping healthcare providers with documentation and tracking capabilities. Patients benefit through e-mail or voice mail reminders concerning follow-up care, preventive services, and pharmacy needs.

INFORMATION OVERLOAD

Chicago-based Emmi Solutions has created a Web-based communication platform, Emmi-Prep, to improve a patient’s experience with the healthcare system and to increase adherence to therapeutic goals through education, cooperation, and reinforcement. Emmi-Prep offers a series of animated, personalized tutorials that walk patients through their pending treatment or hospital course.

When a patient receives a new diagnosis, that patient may enter an emotional state in which the ability to retain new information may be less than optimal. A diagnosis often can represent a dramatic life change, requiring new treatments or medications along with lifestyle changes. Poor understanding may lead to a lower-than-expected compliance rate, poor medical outcome, and increased use of medical resources. Emmi-Prep can help patients with “information overload.”

A common scenario might involve someone who is preparing to undergo a surgical procedure. Routinely, prior to surgery, the physician team informs the patient about the procedure, its risks and benefits, and the pre- and postoperative courses, all while obtaining paperwork for medical consent. Patients often are overwhelmed, possibly intimidated, and frequently do not remember all of the information they were given. Emmi-Prep graphically shows patients why they need the procedure and explains the possible risks and benefits. The program is interactive, allowing patients to ask and answer questions and to send secure e-mail messages directly to their healthcare provider. This can be done in a relaxed environment prior to a physician visit, thus enabling the patient to be better prepared to discuss more detailed specifics about their upcoming surgery and hospital course, and affording the physician more time for treatment-related activities.

Emmi-Prep is designed to improve business outcomes by increasing patient satisfaction, mitigating risk, extending the reach of caregivers, and improving patient compliance with the overall treatment plan. This ready-to-use program requires little training. Procedures and medical conditions are explained by way of visual demonstration, audio instruction, and graphical text, with each component reinforcing the other to maximize the patient’s retention of the material. Patient-provided information is recorded and stored in a secure, HIPAA-compliant database. The data are retrievable and unaltered, and offer a reliable method to document patient comprehension and consent.

Screen shot of a sample Emmi-Prep tutorial

Programs also exist for patients with chronic medical conditions such as asthma, hypertension, diabetes, chronic obstructive pulmonary disease, and depression. General information regarding these disorders is reviewed, and questions concerning the course of treatment and self-management are presented in an easy-to-follow manner. Follow-up messages are sent to patients with simple reminders such as, “Go to the doctor to check hemoglobin A_1c,” or “You haven’t gone to the podiatrist. Please click here to make a doctor’s appointment.” One study found that through Emmi Solutions’ Web-based programs, the adherence rate for patients who were scheduled for colonoscopy improved by 20 percent (Thomas 2007).

Intelecare Compliance Solutions, based in New Haven, Conn., also offers a medication reminder system. Their program aims to connect to patients via telecommunication tools that are familiar and adaptable to the patient and sends reminders via e-mail, text messaging, and voice mail. The only tools needed are a cell phone or a computer. There is no orientation, and consumers may sign up via e-mail, the Internet, telephone, or through their employer (Zimmerman 2007). Intelecare has developed two basic products: IntelecareBasic, a free service that consists of an e-mail medication reminder system, and IntelecarePlus, which adds text messaging and voice mail messaging to the basic service.

The program offers four basic reminders: a vitals reminder (“check blood pressure”); a daily reminder (“take morning blood pressure medication”); an appointment reminder, and a refill reminder.

Intelecare also monitors U.S. Food and Drug Administration warnings and important patient information, and will warn consumers of possible changes in medication efficacy or safety. Intelecare’s product is easily integrated into third-party Web sites, such as employer servers.

Employers may use this product to inform employees of “well-worker” initiatives, e.g., to encourage participation in smoking cessation programs or employee health walks, or to distribute health-related information. Information is collected in aggregate so that no patient information is ever shared with third-party sources. Employees must opt in to this service. This product augments healthy employee initiatives, aims to reduces absenteeism due to medication noncompliance, provides a safety net for patients with complicated conditions, and delivers important educational and promotional messages to target audiences. Customers can also create voice mail reminders for their family members who may have complex regimens and need daily prompting to manage their medical conditions.

Intelecare’s medication reminder system

Intelecare has approximately 3 million subscribers to whom it delivers 5.3 million active reminders daily, and these reminders work with all mobile service providers. An unlimited number of messages is possible; each is encrypted and can be reviewed only by the recipient.

Intelecare also has developed a way to expand its consumer base at a reduced cost through its InteleMD program. This program allows physicians to offer the service to patients to help them adhere to their medication regimen. Not only do patients receive this product at a reduced cost, but it also leverages the doctor’s recommendation with the goal of improving compliance and enhancing the physician-patient partnership. The company claims that its system helps to keep patients compliant longer than the national average.

SMART PILLBOX

InforMedix’s Med-eMonitor system offers a personal electronic storage and monitoring device that has been dubbed the “smart pillbox.” This device can store and track up to 25 different medications, and uses musical chimes to help patients remember to take their medications at the right time. It is easy to use, portable, and has a 2-week battery life. Patients receive personalized health information and reports on medication dosing, administration, and health status.

Patients are able to input such health information as blood pressure and blood sugar readings into the device, and the accumulated data reflect overall health status. If a value appears abnormal, the device may ask the patient “Are you sure?”; if the patient confirms the abnormal value, a health alert is activated. Med-eMonitor also provides information on medication interactions with alerts such as “Please do not take this medication with grapefruit juice.”

The device comes with a communication cradle used for charging and transmitting data via a phone line. Patient information is synchronized daily provided that the device is placed on the cradle. If a patient fails to place the device on the cradle overnight, an alert is sent to caregivers. Data can be sent to a secure Web site accessible only to authorized health providers (e.g., pharmacists, physicians, and family members) who have been provided with a username and password. The site is HIPAA compliant.

InforMedix, based in Rockville, Md., also has collaborated with ADT’s home health security division, an arrangement that gives customers the option of having their health information relayed to nurses and nurse practitioners. The system can arrange appointments at specific clinical sites. The three levels of service (family and friend monitoring, ADT monitoring, and nurse care manager monitoring) provide a comprehensive set of options. Thus far, no usability issues have been reported, and the company reports a consumer satisfaction rate between 94 and 100 percent.

Among other locations, the device is in place at the University of Pennsylvania Health System, in Philadelphia; Wayne State University, in Detroit; and the University of Texas Health Science Center, in San Antonio. Patients have been found to have adherence rates in excess of 90 percent. Research presented at the Third International Conference on HIV Treatment Adherence, in Jersey City, N.J., found that use of the Med-eMonitor was able to achieve 89.5 percent medication adherence rates in HIV patients (Bangsberg 2008). The device may be particularly useful for patients such as brittle diabetics or transplant recipients, who have complex regimens and must maintain strict adherence rates to avoid costly hospitalizations.

Med-eMonitor, Infor-Medix’s so-called smart pillbox

Some companies have approached the issue of noncompliance from a practice management standpoint. San Diego-based VisionTree Healthcare Solutions used its decision-support software to create a Web-based healthcare management product. With the Optimal Care system, patients may enter personal information onto registration forms, patient history forms, or outcome data assessments online from anywhere. This information is synchronized with EMRs and practice-management software, creating a virtual chart; images can be saved as secure online files. This information can be collected for individual patient management, clinical trials, or quality guidelines. The system keeps track of completed appointments, and patient information is accessible for authorized healthcare providers via Smartphone. Patients receive reminders and personalized health information in the form of custom documents and videos at their office or through their home computer. The focus is on containing costs by improved workflow, efficiency, and practice management guidelines.

Phytel, based in Dallas, has won awards for its Proactive Patient Outreach Web-based platform, which searches for noncompliant patients through EMRs and practice management systems. Phytel maintains a registry of active patients who are lost to follow-up or who are noncompliant, contacts them either by voice mail or e-mail, and then monitors their response by tracking billing data and appointment bookings. Preventive strategies for patients are tracked and updated according to evidenced-based recommendations, such as National Committee for Quality Assurance Healthcare Effectiveness Data and Information Set measures. Patients also are sent reminders for prescription medications or refills. All information is secure and HIPAA compliant. The software comes with a comprehensive tracking system that allows providers to monitor the notification process and billing to determine the return on investment. Phytel guarantees a 300 percent ROI.

CONCLUSION

Nonadherence to therapy is a significant contributor to healthcare costs. As the prevalence of chronic disease increases, more emphasis is placed on efficacy of treatment. It is recognized that the success of any therapy is dependent on the partnership between patients and healthcare providers. Through the power of effective communication and the judicious use of resources, this relationship can be secured in a manner that is convenient for both healthcare consumers and providers. The correct combination of tools is currently unknown, but the perceived benefit of the products described may offer a significant ROI in terms of healthcare dollars and improved quality of life.