One Pill Makes You Larger and One Pill Makes You Small


And the ones that you forget to take, don’t do anything at all.

A patient’s non adherence to their medication regimen is a well documented detriment to the healthcare field. This oft cited study published in the Annals of Internal Medicine found that direct costs related to medication non-adherence accounts for anywhere between $100b and $289b annually in the United States alone. These costs come from ER visits, hospitalizations, extra tests, etc. Not to be forgotten, an estimated 125,000 deaths each year can be traced back to non-adherence. These consequences are arguably preventable if viable systems were developed and used to improve medication adherence among the patient population.

Medication adherence does not simply refer to remembering to take the pill. Instead it implies adherence to the exact regimen that was prescribed by the physician to the patient. It may include taking the medication at a certain pre-determined interval (certain dates and times), after pre-determined actions (after a meal, before exercise), when health measures reach certain levels (blood pressure threshold or glucose levels). With many patients taking more and more prescribed medications as they age, these details become increasingly complex.

Sticking to the overall focus of this blog – In the US we have a population that is not only growing older but is also more knowledgeable and comfortable (hopefully) then ever in the use of information and communication technologies. It doesn’t take a neurosurgeon to see that the US is dealing with a real medication adherence problem and it doesn’t take an MBA to see the potential of a very lucrative business opportunity.

Some have tried to tap into this space and many have failed. Nobody has found the right formula yet so for now lets take a brief look at the past, the present, and most importantly the future of managing a patient’s medication adherence.

For the purpose of full disclosure: I am currently an intern at the Johns Hopkins Medicine Technology Innovation Center and in two weeks will be starting a digital strategy position at the Express Scripts New Solutions group. My work with each of these entities have and in the future will touch on aspects of medication adherence but the opinions expressed in this post are entirely my own. Speaking of Express Scripts, the New Solutions Lab put this information out a few years ago which sums up non-adherence quite nicely:


Go Ask Alice…what she did to adhere to her medications

Granted, Alice’s medication regimen may have been more recreational than most, but as she aged chances are high she was prescribed some more formal medications.

In the past we relied almost entirely on the patient to adhere to their scheduled medications. Of note, medicines were not as efficacious as today and often included worse side effects than people were willing to deal with. As time went on the medications continued to get better and clinicians became increasingly aware of the problems associated with the failure to adhere to them. As a result providers became more involved in educating the patient on the regimen, involving the patient’s family as a means of social support, and developing self report systems for tracking medication adherence during follow up visits. 

However, a call to action in 2003 by the WHO and a report in the New England Journal of Medicine in 2005 that put non-adherence rates at >50% proved that the problem still existed and was a much larger issue than anyone would have liked to believe. Enter the ICT movement in medication adherence.

There are now a wealth of web and mobile applications available for both the patient and the provider to help increase adherence rates. Some of the services that have been around for awhile include MyMeds, MyMedSchedule, RxmindMe, and Dosecast. There are hundreds like these, all of which are very similar and outside of Dosecast do very little to differentiate themselves from their competitors. They are usually HIPAA compliant, provide reminders to take medications, and have some form of tracking your adherence over time. Dosecast does provide EMR integration which is a worthy competitive advantage. A new player in the market Mango Health provides an incentive based system for adherence which has been shown to increase adherence levels. There are two underlying issues with all of these offerings. First, the effectiveness of each application is gravely understudied by the medical community, second all of these applications are still completely reliant on self report measures which are notoriously unreliable in medical research.

Some entrepreneurs are looking for ways to remove the human element and to track adherence in other ways. Local Baltimore startup emocha mobile health developed a solution for TB patients to send mobile videos of themselves taking their prescribed medications to caregivers. This fulfills a direct observation requirement for their medication regimens, removing the need for the patient to be physically present at the doctor’s office to take the medication. This is a huge time and money saver for both the patient and the physician.

In the device space, Pharmadva provides a practical albeit cumbersome solution to managing your medications. It holds up to 16 medications and dispenses the correct dosages at the correct time. However it’s not exactly made for taking with you on the gbottleo. In contrast, startups SMRxT and AdhereTech are both hoping to be the one who reinvents the pill bottle that we know and love. The SMRxt bottle (left) will recognize when a pill is removed and via a partnership with Verizon can send that information adheretechto whoever the patient deems necessary. The AdhereTech bottle  (right) will glow when it is time to take a medication and registers when the cap is removed, similar to Vitality’s successful snbbtmykrk4dnopdoventure Glowcaps (left) which work in tandem with the established pill bottle we’ve all come to love (or hate). Of course, each of these provide analytics for patient, provider, and payer alike.

Years from now there will be Today there are computer chips about the size of a grain of sand that can be implanted into your medications and communicate with a patch worn on the skin that then transmits data about when the pill entered your body back to your applications or provider’s platforms. There are also solutions that constantly monitor certain measurements in our blood to know when a medication has been taken and started working, but these are still in their infancy.

What the Doormouse Says…Assuming I am the Doormouse I’d like to share my opinion on what needs to be done for this field to take off. First, we need actionable, clinical trial data that analyzes the use of these services and their effect on medication adherence on a per condition/medication basis. Companies will need to learn that there will not be one solution for every medication regimen out there. That doesn’t mean that their solution cannot be modified to meet the needs of different patients, but rather that their one solution cannot meet the needs of all patients. Next, the realization that an integrated approach will prove the most effective in this space. In P’s opinion companies will need to create joint ventures or develop more integrated solutions for their own products that hit all these points:

  • Platforms that connect communication devices including phones, tablets, watches, and personal computers
  • Include educational information on the what, where, why, when, and how’s of taking their medications.
  • Allow for connections between social support groups including friends, family, and in home care-givers
  • Allow for communication between patient, provider, and payer
  • Provide alert systems that adapt to the patient’s preferred methods of interaction
  • Tie alert and adherence data to a real-time device that accurately tracks adherence removing the self report elements of the past

In order for all of these factors to be considered the teams developing these solutions will require a combination of computer scientists, engineers, and clinicians. Without the expertise from each of these individuals the offerings will be lacking in one or more of the areas listed above and will join the hundreds of other offerings swimming in the overcrowded sea of failed adherence solutions. Someone(s) will win over the market and in doing so will provide themselves with a hefty paycheck while also basking in the comfort of knowing that their innovation is helping improve the lives of millions of people…talk about feeding your head.


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