Did you take your medication today?

Text message reminders are a powerful new tool that can have a positive influence on medication adherence

One of the largest and most costly problems facing the healthcare industry is that patients don’t consistently take the medicine they’ve been prescribed. More accurately, between one-third and one-half of patients in the US do not take their medications as instructed, according to an August 2009 report released by the New England Healthcare Institute (http://bit.ly/xlZaW).

There are many reasons why people don’t take their medication as prescribed, “but the number one reason is they simply forget,” says Pam Swingley, founder of RememberItNow, a patient-centric eHealth service (www.rememberitnow.com). “As people get older and get very ill, it becomes confusing as to what pills to take and when to take them.”

That confusion is costly. According to the NEHI report, poor medication adherence results in poorer health, more frequent hospitalization, a higher risk of death, and approximately $290 billion in added medical spending yearly. Using technology to “jog” patients’ memories is one method for remedying the problem.

Studies support texting

E-mail alerts, cell phone calls, and more recently, text message reminders have been successful in improving adherence and outcomes where prescription medication and its consumption is concerned. For example, study results published in Pediatrics (http://bit.ly/1jqg4L) revealed significant improvement in medication adherence “and a reduction in rejection episodes with text message reminders for pediatric recipients of liver transplants.” Similarly, results published in Diabetic Medicine from a randomized controlled trial of Sweet Talk, a text messaging system to support adolescents with diabetes, improved both selfefficacy and adherence (http://bit.ly/cYAdPh).

Positive results? Yes, but Vincent DeBari, PhD, who oversees the division of medical residencies and fellowships at Seton Hall University’s School of Health and Medical Sciences, calls attention to a few caveats. “One of the things that concerns me is that the duration of most of these studies is fairly short. The longest was about a year,” DeBari explains. “I’m wondering if there might not be something like message fatigue that would happen over the long run.” He also wonders how generalizeable the data is in terms of patient age, considering the previously mentioned studies focused on pediatric and adolescent populations—groups that tend to have a greater affinity for cell phone and text message use. “On the other hand, if we were alerted to the fact that we have a chronic condition that requires medication reminders, I think [older populations] could learn to keep their cell phones handy,” he says.

Despite the relative success, text message reminders as a means of increasing patient adherence to medication regimens has been slow in gaining widespread adoption. The main reason why, says Ed Fotsch, MD, CEO of PDR Network (www. pdrnetwork.net), is that when it comes to sending text message reminders, someone has to receive the message and someone has to send it—and both parties have to want to play. Thus far, physicians have remained on the sidelines. “There are all sorts of good ideas out there, but when it comes to paying for them or their practical realities, they fall short,” Fotsch says.

In other words, text messaging patients simply isn’t reimbursed. And according to Erica Drazen, a partner in CSC Healthcare Group’s emerging practices unit (www.csc-groupinfo.com), physicians are already incredibly overburdened, so they’re unlikely to take the lead in the effort to improve patient medication adherence. And, she asks rhetorically, do they even need to? “Any time someone is on a complex medication regimen, it helps to be reminded,” Drazen agrees. “But for people for whom this is a life-anddeath matter, they’ve already figured it out. They have their own alarm clock. You can program your cell phone to do whatever you want it to do. Some people are already doing that. So, the reminder doesn’t need to come from the doctor’s office.”

Getting disruptive

Jason Hwang, MD, is the co-founder and executive director, Health Care, of Innosight Institute (www.innosightinstitute. org), a non-profit think tank devoted to applying the theories of disruptive innovation to problems in the social sector. He suggests there are better solutions to the medication adherence problem than trying to increase reimbursement levels or requiring physician involvement. “I’ve seen business proposals for services that would [provide reminders], especially for patients who have to take a lot of medications, such as HIV patients,” Hwang says. “But better yet is to not use a human at all, but to use technology.”

That’s the road some enterprising entrepreneurs are going down. RememberItNow’s medication reminder, which launched in January 2010, is an online software program requiring no download. Patients, or their physician or family members, input medication name, timing and special instructions, and schedule either a text or e-mail reminder to be sent to their cell phone or other device. The message can be customized for special instructions, such as not to take the medication at bedtime, or to use the pill bottle with the red dot. “Patients can set these up, or in the case of an elderly patient, a family member can set it up for them,” Swingley says. “The patient could give their password to their doctor before they left the office and the doctor could log in any new medications or special instructions.”

The program also enables patients to track their health and share progress reports with their doctor as well as family members—a factor that Hwang says is important but is often overlooked. “Today, even patients don’t necessarily get [updated reports], so families are even further excluded,” he says. “There are real missed opportunities here for [third-party entrepreneurs]. [Families] can play a very important role in ensuring that their loved ones are getting the care that they need.”

RememberItNow’s calendar function also provides reminders for doctor appointments or other events such, as taking blood pressure. An iPhone application is expected in April 2010; a Droid application is due before the end of the year.

Creating a caring community

Last September, Oakland, CA-based Ramsell Technologies (www.ramsellcorp.com) introduced its Tele-Adherence product, which utilizes proprietary mobile technology and the Software as a Service (SaaS) delivery model to remind patients to take their medication, answer treatment questions, and track results. Patients can be enrolled in the Tele-Adherence program either by an employer in the form of a prevention and wellness program, or as mandated by an insurer. The program utilizes a variety of methods for contacting patients, but Ramsell president Moses Cesario says the company is “banking on text messaging pretty heavily right now.” He calls the medium “the most efficient way that we can run a large scale program with many lives.”

Cesario explains that once enrolled, patients are contacted and taken through a setup process in which their preferences for contact are noted. “People have their cell phones with them and they’re interacting with them all the time,” he says. “We’re coming into that realm, so our take is we have to be sensitive in terms of how we utilize that presence for the patient. Our measure for success in Tele-Adherence is whether the patient feels this is a beneficial tool to help them care for themselves.”

The Tele-Adherence tool is also interactive. Patients receive text message reminders and are asked to send back information. The collected information is then shared with the patient’s physician to enhance treatment decisions. “We want the physician’s access to information to be as rich as possible,” Cesario says. “We want to take that information that the system collects and put it at the doctor’s fingertips. Then we’re really providing a connected community of care.”

Creating a community of care is also one of the goals at Vitality, a startup company that manufactures GlowCap (www. rxvitality.com/glowcaps.html), a bottlecap that reminds

patients to take their medications and keeps track of whether they’re taking them when they should. The caps are built into lids that fit on prescription bottles. They contain chips that communicate wirelessly with a home server that’s the size of a nightlight and plugs into an electrical socket in clear view in a patient’s kitchen and bathroom. If the bottle isn’t opened when a patient is scheduled to take his or her medication, the cap and nightlight blink as a reminder. If the blinking isn’t noticed, musical reminders are played. And if the bottle remains unopened for two hours, an automated phone call or text message is sent to the patient with a reminder. The system can also alert a family member that the patient has not taken their medication. “If you look at the history of reminder

systems for taking medications, they look like someone bolted a bad watch onto a pill box,” says David Rose, CEO of Vitality. “Our approach has been very different.”

It has also been successful. In a beta test of approximately 100 people with hypertension, one group was given the GlowCap system that did nothing but collect data, while the intervention group’s system provided all the appropriate medication reminders. The result was a greater than 20% absolute change between the hypertensive patients in the control group who took their medications about 70% of the time and those in the intervention group, which exceeded 95%.

The information captured by the GlowCaps can help a physician understand why a particular medication isn’t working—is it the wrong medication, or is the patient simply not complying—and then take appropriate action. Rose says the company plans to market the device to both insurance and pharmaceutical companies. He explains that it costs $4,000 to $5,000 more per year to care for a diabetic who isn’t taking his or her medication, compared with the cost of a diabetic who’s highly adherent. In comparison, the cost of GlowCaps starts at less than $20 per month. “There’s a lot of motivation for payors, self-insureds and employers to run a program that can affect this type of change.”

Pitfalls and promises

Beyond the physician reimbursement factor, there are few pitfalls or obstacles to using text message reminders to improve medication adherence among patients. As CSC’s Drazen points out, “I don’t think there are any medical/legal issues. And it isn’t the doctor’s responsibility to ensure the patient is taking their medication, or [doctors] would be more involved.” Still, there are some hurdles to overcome. “There’s a general fear of converting to electronic communications,” Hwang says. “The disadvantages are that it’s difficult to document that [medication reminders] are sent. On the other hand, I think the benefits of quick communication, patient access, and empowering patients to do more on their own so they don’t have to engage the provider or the health system every time they have a question, far outweigh any minimal costs or negatives associated with the technology. And as electronic medical records get better, it will be easier to capture the information.”

One fundamental issue, says Fotsch, is human behavior. The reaction of a patient who’s supposed to be taking asthma medication will vary not only based on the message, but the messenger as well. A text message from a doctor, he says, comes across entirely different than one sent by a patient’s health plan. “If your health plan sends you a message, the first reaction is, ‘Why is my health plan digging around in my medicines? And what else are they doing that I don’t know about?’” Fotsch says. “If you get something from Walgreens saying it’s time to refill your prescription, that’s different than a reminder from your doctor, because the pharmacy has an economic incentive. So, the biggest obstacle out there is not the technology. It’s the motivation, and it’s the relationship between those who have an economic dog in the fight and the patient.”

But if patient satisfaction is any indicator, text message reminders are making positive inroads. According to the diabetic patients who participated in the Sweet Talk trial, 82% felt that the text messaging support system had improved their diabetes self-management, and 90% wanted to continue receiving messages. Published in Archives of Dermatology,

a separate trial of text message reminders used to improve sunscreen use found that 89% of the participants said they would recommend the text-message reminder system to others (http://bit.ly/UNqbJ).

“It’s obviously a growing field, and people are being more responsible about taking their health in their own hands,” Drazen says. “We did a search about four or five months ago, and there’s something like 1,500 iPhone applications for health and wellness. These applications show that the interest is there, and it’s moving in the right direction. It’s just pretty fragmented at this point.”

Ed Rabinowitz is a veteran healthcare journalist based in Bangor, PA.