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General Topics

Technological advancements and innovations to improve medication adherence

  • Medication non-adherence is an important challenge that leads to suboptimal treatment outcomes1.
  • Using innovative technologies in interventions can help in combating this issue.
  • Smart interventions specifically concerning packaging, monitoring, record keeping, and reminding medication are now available and can significantly improve patients’ medication adherence2.

Medication adherence defined as the extent to which a patient’s behavior coincides with medical or prescribed health advice1 is a major challenge in realizing the clinical trial-like efficacy of therapies in real-world clinical practice. Poor or inadequate adherence to prescribed regimens is also an economic burden on individuals and the healthcare system. As per one estimate, almost half of the 3.2 billion annually dispensed medications are not used as prescribed in the USA. Patients suffering from chronic diseases adhere to only 50-60% of the prescribed medications3.

Medication non-adherence:  Key factors and implications

Medication non-adherence is the result of an interplay of a range of factors including patient views and attributes, illness characteristics, social contexts, access, and service issues. Factors can be categorized as

a) Patient-related factors that include forgetfulness, disorganized attitude, and behavior, impairment in cognitive thinking or inadequate understanding of the reasons for taking a specific medication, age, and comorbidities.

b) Medication-related factors that include treatment side effects burden (e.g. fatigue, tiredness, increased appetite, weight gain, sexual dysfunctions, etc.), duration of therapy, frequency of intake, concomitant medications, and complex treatment regimens.

c) Socio-economic factors, which include education, employment, financial status/income, social support, co-payments, and medication costs4.

Medication non-adherence results in relapse and rehospitalization, enhanced drug wastage, and enhanced resistance to drugs5,6.  It also makes it more challenging for physicians to assess the effectiveness of the treatment. Unable to distinguish medication ineffectiveness, whether due to poor adherence or due to patient’s poor response to the specific medication, prescribers may increase the dose, switch the person to a different medication, or add concomitant medications unnecessarily, as a result of poor adherence5. These issues inadvertently can complicate clinical management of the patients and add to the overall healthcare cost.

Multidimensional solutions to tackle medication non-adherence

Although the issue of medication non-adherence has been widely accepted, it has been relatively neglected in the mainstream delivery of primary care health services. Nonetheless, a variety of methods have been evaluated to improve adherence. Some of the strategies that have been employed to improve medication adherence and do not involve much technological breakthrough include providing financial incentives to patients7, direct observation of medication uptake, and in-person support interventions like cognitive adaptive training, which is an application of environmental supports maintained by weekly home visits by a care-worker8. The strategies are labor-intensive, time-consuming, and not scalable to a bigger scale. Other methods like follow-up phone calls, frequent patient contact, and unlimited provider or case-worker access are also equally challenging and financially burdensome for the healthcare system7,9.

Smart Solutions to the complex problem

Burgeoning growth in technological advancements is being actively explored to ensure meaningful gains in addressing medication non-adherence. It has spearheaded an era of medication reminders, health-tracking apps, smart pill canisters, and nanosized biosensors containing medications. A recently published review on emerging smart technological innovations in the healthcare sector outlined various advanced technologies that are available for measuring medication adherence, including medication event monitoring systems (MEMS), smart blister packs, radio frequency identification (RFID) embedded smart wristbands/packaging and wireless connection based smart pill bottles2. Key examples of these SMART devices are listed below.

  • Electronic medication monitor (Med-eMonitor) is a smart pill container capable of prompting the use of medication, warning patients when they are taking the wrong medication, recording side effect complaints, and promptly alerting treatment staff of failures to take medication as prescribed8.
  • Electronic Medication Packaging (EMP): Employing Smart packaging technology, EMP devices have been reported to positively enhance medication adherence. EMP encompasses electronic devices integrated into the containers in which pills, inhalers, or other products are dispensed. EMP is applicable in resource-poor settings because it requires little healthcare infrastructure. Various forms of Smart packaging technology exist with integrated features such as condition monitoring, event recording, feedback mechanisms, reminder systems, and status display technology10. Smart packaging technology, however, possesses limitations like reduced ease of use, dosage flexibility, and higher cost2.
  • Medication Event Monitoring System (MEMS): MEMS is a customizable medication bottle cap with a microprocessor that records the occurrence and time of each bottle opening of the medication bottle. MEMS caps fit on standard medicine bottles and are integrated with microcircuits to record the date plus time at which the bottle is opened and closed. It is capable of recording and storing up to 4000 dosing events. The device also has a liquid crystal display screen that shows the time elapsed since the last dose and the total number of doses taken by the patient. These devices are available in a wide range of shapes and sizes2. The use of MEMS is reported in diseases like schizophrenia, ulcerative colitis, and asthma2. A few other smart pill bottle technology offers automated visual and audible alerts to the users during a window of scheduled medication dosage. The systems also have an integrated Mobile app to view and track their medication adherence in near-real time.
  • Smart blister packs: Smart blister packaging uses electronic circuitry that can track the action of taking out a pill. Besides this, it can collect information regarding the rupturing time, medication category, and location. Smart blister packaging can also act as pill reminders when integrated through a mobile application. More importantly, both physician and patient can monitor the medication uptake at the requisite time by accessing the records2.
  • Smart drawers: Remembering the procedure of the medication could be challenging for old-age patients, who often suffer from memory loss. To address this issue, Smart drawer project was created that can track the inventory stored inside the “drawer” and record plus monitor the patient’s drug-taking activity. Smart drawers can also alert the patient in the case of not following the protocols of prescribed treatment. Smart drawer act as a programmable system that can be utilized as an autonomous tool to assist elderly patients in adhering to their medications11.
  • Digital Medicine Systems (DMS): Digital Pill is a novel medication adherence-assessment device, designed to assist healthcare providers in objectively assessing patient adherence to prescribed medicines. It electronically confirms adherence to oral medication, acquires physiologic metrics remotely, and provides this information in a centralized manner18. DMS is tablet formulation of a drug embedded with a small edible sensor (1 mmx1 mm). After the ingestion of the digital medicine, acid fluids of the stomach activate a signal, which is detected by a wearable sensor. The sensor forwards data to an application on the patient’s smartphone, which sends data to a cloud-based server. Caregivers and physicians can eventually access, through a web-based portal, information on medicine use12. Despite the advantage of increasing medication adherence and providing real-time tracing of the drug, there have been concerns about the potential negative effects of giving ingestible drugs with sensors to patients with serious psychiatric illnesses. Moreover, concerns with the accuracy of medication tracking and issues of false negative rate have also been highlighted that can lead to increased risk of drug overuse and overdose13.
  • Mobile Health (mHealth) and Mobile Apps: Mobile health is regarded as practices concerning public and medical health that are aided by mobile devices such as mobile phones, patient monitoring devices, and other wireless devices2. The growing use of mobile phones or similar devices that can be carried in close proximity to their owners with integrated automated message-sending capability is useful in improving medication adherence. Additionally, mobile phones and devices can be employed for appointment reminders, setting up appointments, monitoring health parameters, and preventing misconceptions regarding health2. However, formal certification of such apps by authorized regulatory bodies (like CE marking), security, and patient data privacy concerns impedes them from being recommended by healthcare providers in their routine practice14.

Conclusion

In this new era of applied technology, partnerships between pharmacists and software developers are becoming more commonplace and would play a critical role to maximize medication outcomes and improve overall safety. It can be envisioned that a multidisciplinary approach requiring coordinated action from health professionals, researchers, health planners, policy-makers would enable better progress in tackling the issue of medication non-adherence.

“Healthcare is yet to be transformed by technology.” —Joshuha Kushner

References

1.    Brown MT, Bussell JK. Medication adherence: WHO cares? Mayo Clin Proc. Apr 2011;86(4):304-14. doi:10.4065/mcp.2010.0575

2.    Pankaj Pal SS, Vivek Dave, Shailendra Kumar Paliwal, Sarvesh Paliwal, Monika Sharma, Aadesh Kumar, Nidhi Dhama. A review on emerging smart technological innovations in healthcare sector for increasing patient’s medication adherence. Global Health Journal. 2021;5(4):183-189. doi:10.1016/j.glohj.2021.11.006.

3.    Bosworth HB. Enhancing Medication AdherenceThe Public Health Dilemma. Springer Healthcare Tarporley.

4.    Mathes T, Jaschinski T, Pieper D. Adherence influencing factors – a systematic review of systematic reviews. Arch Public Health. 2014;72(1):37. doi:10.1186/2049-3258-72-37

5.    Velligan DI, Kamil SH. Enhancing patient adherence: introducing smart pill devices. Ther Deliv. Jun 2014;5(6):611-3. doi:10.4155/tde.14.33

6.    Jimmy B, Jose J. Patient medication adherence: measures in daily practice. Oman Med J. May 2011;26(3):155-9. doi:10.5001/omj.2011.38

7.    Volpp KG, Loewenstein G, Troxel AB, et al. A test of financial incentives to improve warfarin adherence. BMC Health Serv Res. Dec 23 2008;8:272. doi:10.1186/1472-6963-8-272

8.    Velligan D, Mintz J, Maples N, et al. A randomized trial comparing in person and electronic interventions for improving adherence to oral medications in schizophrenia. Schizophr Bull. Sep 2013;39(5):999-1007. doi:10.1093/schbul/sbs116

9.    Granger BB, Bosworth HB. Medication adherence: emerging use of technology. Curr Opin Cardiol. Jul 2011;26(4):279-87. doi:10.1097/HCO.0b013e328347c150

10.  Checchi KD, Huybrechts KF, Avorn J, Kesselheim AS. Electronic medication packaging devices and medication adherence: a systematic review. JAMA. Sep 24 2014;312(12):1237-47. doi:10.1001/jama.2014.10059

11.  Eric Becker VM, Roman Arora, Jyothi Vinjumur, Yurong Xu, and Fillia Makedon. SmartDrawer: RFID-based smart medicine drawer for assistive environments. 2009:

12.  Papola D, Gastaldon C, Ostuzzi G. Can a digital medicine system improve adherence to antipsychotic treatment? Epidemiol Psychiatr Sci. Jun 2018;27(3):227-229. doi:10.1017/S2045796018000082

13.  Egilman AC, Ross JS. Digital medicine systems: an evergreening strategy or an advance in medication management? BMJ Evid Based Med. Dec 2019;24(6):203-204. doi:10.1136/bmjebm-2019-111265 14.       Backes C, Moyano C, Rimaud C, Bienvenu C, Schneider MP. Digital Medication Adherence Support: Could Healthcare Providers Recommend Mobile Health Apps? Front Med Technol. 2020;2:616242. doi:10.3389/fmedt.2020.616242