Klynn Alibocus

What success have you seen in Cell/mobile driven patient adherence schemes?
Comprehensive Behavioral Health Management to Introduce Life:WIRE’s Innovative Mobile
Health Management Solution to Support Community Care Coordination Study
http://insurancenewsnet.com/article.asp?a=featured_pr&id=103867

Steven Dean
I'm one step removed from the patient/end customer in this space, but as the Director of
Medical Marketing at TI, I believe any and all success will be born out of an automated system
wheras the patient is removed from the process. Any body worn device that behaves
independently, monitoring and communicating via GSM/GPRS, or other means to a 'hub' or
directly would be a hit.

Sean Wheeler
I'd like to see this kind of adherence scheme pushed further to use not only data
communications, but exploit the full potential for integrated ubiquitous communications. I
believe to be a successful offering, monitoring (automated or not) is not enough. Ultimately,
the benefits of adherence must be communicated to the patient, otherwise even the best
monitoring technology is wasted. I think real person-to-person interaction is more valuable in
achieving this goal than delivering predefined adherence tips, for example.

In my opinion, given the cost of patient monitoring, the remote partner in adherence schemes
may not even be a caregiver (especially in a cost-sensitive deployment), but a peer (such as a
partner in a patient social network site).

Susan Dorfman
I would hardly call patient adherence programs "schemes." If done properly, the use of mobile
devices can be quite beneficial and convenient for some patients. Cegedim Dendrite has good
and comprehensive adherence methodology, which includes the use of mobile devices as a
component of proactive care.

Lyle Bullock
As the Director of Confidant Hawaii, we are currently conducting a study with a local hospital
and university on the use of cell phone technology to improve compliance and improve patient
communication concerning Gestational Diabetes. There are drawbacks due to the carriers and
networks involved, but the results have shown the patient is more likely to take glucose
readings at the correct times as directed and since it is automated, there is little error in the
readings obtained. In addition, the system provides automatic feedback based on the readings
and the clinical staff has an easy way to message the patient with information and instructions.

Mikko K. Leino
Using cell phones, text or mobile applications, for reporting readings is one thing. For
medication compliance, Helsinki, Finland-based Addoz has a product with embedded GSM
connectivity. Daily medication is prepared to compartments by caregiver, and the automatic
dispenser device reminds the patient to take them on time. If the medication is not taken
despite the reminders within one hour's grace time, the device sends out an alert by SMS.
There's a case study where reminders combined with back-up calls from the care centre to
patients has provided 97% medication compliance rate. With GSM connectivity, there's no
need for other infrastructure like care phones. However, medication dispenser may also have a
proprietary social alarm transmitter, in which case alerts are first received by a carephone and
then forwarded to the care centre.

Chris Johnson
Ouch, Steven. Compliancy is a complicated psychological issue for most clients. While some
may simply forget, others are concerned about side-effects, trust their own feelings and
embark on self-dosing, while others believe more in herbal remedies than in pharmaceuticals,
or simply don't want big brother looking over their shoulder. In my opinion, the main enabler
for compliancy discussions is an accurate (electronic) registration of probable dosage events to
enable self-monitoring, involvement of carers and family, and fact-based discussion with
professionals. I do not see any effective route forward in which the free-will of the patient is
removed from the process.

The mobile phone is a useful tool. Patients can easily check their own compliancy on a personal
device. Providers benefit from an existing infrastructure with the widest coverage. Feedback
and coaching is done on the same device. "Hubs" can also be developed using mobile
technology for simple use by the elderly - see our site www.cypak.com for one example.

Marc Stober
Let's not overthink this, and start with what's simple. It could be pretty cheap to build an
iPhone or Blackberry app that lets patients track their measurements or dosages and optionally
share that information with a provider between visits. If getting 100% compliance from
Medicare patients is too complex then pilot it with a population like gestational diabetes or IVF
patients who are looking for more ownership of their health and are already seeking out ways
to do this with technology.

Susan Dorfman
If you want to start with the basics, take a look at Chris Johnson's comments on barriers to
patient adherence in relation medical regiments. What you will find is that mobile technology
can be a great source to address many of such barriers through electronic interventions - all of
which should be complimented by other personal and non-personal touchpoints for ultimate
success.

David Youngs
We have not used this approach before. It will be interesting to see its efficacy in improving
adherence to regimens addressing chronic problems such as diabetes and weight control,
exercise. Also, across age groups. Will older people, aging boomers, etc. find it effective? To
me it seems that a combination with an automated CRM system might work.

Khinlei Myint-U
We recently completed a trial to assess the effectiveness of simple text message reminders on
adherence to topical medication. We found that adherence rates for the reminder group were
almost double that of the control group. There's more information
here: http://www.connected-health.org/programs/medication-adherence/center-for-
connected-health-models-of-care/sunscreen-adherence.aspx

Jennifer Priester
To follow-up on Khinlei's comment, Joseph Kvedar, MD is presenting data about this study this
week at the the 67th Annual Meeting of the American Academy of Dermatology. More info is
here: http://news.prnewswire.com/ViewContent.aspx?ACCT=109&STORY=/www/story/03-05-
2009/0004983952&EDATE=

David Doherty
I share Steven's opinion.

@Chris Johnson: Steven isn't saying that the patient' free-will needs to be removed from the
process but that the process itself needs to be automated.

I'll give an example of this. Using technology to measure body temperature every time the
phone is placed next to the ear can be very useful in long term monitoring and requires
nothing more than the patient using a specially designed phone in exactly the same way they
would normally use a cellphone ie. NO BEHAVIOUR CHANGE.

I have had access to enough data on mobile applications to know that they have a shelf life
that isn't compatible with long term medication/monitoring.

I'm afraid i think it is only when completely automated (as in this example) OR some type of
community game is being played that these technologies will be a hit with patients.

David Youngs
This approach could be used for elder/disabled market, particularly in the PACE setting.
Program of All Inclusive Care for the elderly are hospital based, so maybe an approach like the
one used in Lyle Bullock in Hawaii could be expanded to that population.

Chris Johnson
David Dohertry, I do agree that solutions have to be very easy - even automatic - for clients.

We have done a lot of work on using NFC cell phones to read data from a standard medication
pack. The pack contains an active RFID tag to record dosage events and other client feedback.
They can be read simply by putting the phone and the pack in close proximity. The battery life
for the tag is not a limiting factor.

NFC phones are becoming more common after the success in Japan, where over 100 million
have been sold for applications like payments and transport. They are also cool for the youth
market because it is much easier to swap photos and ring tones than setting up sessions with
Bluetooth.

David Doherty
@Chris Johnson: I'm a big fan of mobile device (and SIM card based) NFC but it seems there is
a lot of confusion as shown by your own comments...

* The tag in the meds doesn't need to be active as this adds cost, the phone is carried all the
time anyway, and it is a less capable and not as well designed as a mobile to store healthcare
data. A good place to find out more about these issues would be the Nokia/Visa/Telefonica
research into NFC that was conducted last year at Imperial College London.

* How does client (patient?) give feedback to an active tag?

* In Japan/Korea etc NFC technology is NOT being used to transfer multimedia content as
Bluetooth is still a lot better for this purpose. They are being used to HANDSHAKE the mobiles
so that a bluetooth push and download is initiated. The data transfer is still taking place using
a Bluetooth session and all the NFC is being used to do is avoid the need for the send/accept
to be initiated.

Hope this helps with a bit of clarity?

A good source for more general information about NFC can be found at
http://www.technovelgy.com/ct/Technology-Article.asp?ArtNum=50

Chris Johnson
The active tag is embedded in the medication pack (carded blister, bottle, etc) to record
dosage events. So for example, when a blister is popped a printed trace is broken and the
event time stamped and recorded in the pack. The same when a bottle is opened or an inhaler
used.

The advantage of this approach is that it is "automatic" for the client. And the data is stored
and can be read by any NFC reader - by client themselves, visiting nurse, carer, pharmacist,
etc. Some of these readers may be embedded in Blackberry, PDA, Cell phone - others not.
The cost of an active tag is low enough to make the pack disposable in many therapies

David Doherty
Interesting... we've designed and tested a solution that takes into account the patient
experience in so much as how they are reminded and would then physically use a medication
dispenser. As a result of this we can avoid the need for an active reader completely. This gives
some clear advantages because RFID is already in medication packaging for other reasons
(pharmacy/supplychain/recall etc) so no need for ANOTHER tag to be fitted.

Whilst i admit the cost is "low enough" for MANY therapies it could never be the case for MOST
therapies. With MOST people having a mobile (and it being possible to integrate NFC in the
Subscriber Identity Module) and MOST patients having compliance problems we should be
aiming higher with mHealth. With no change or additional cost the chance of adoption is much
higher where there is no need for another tag (especially a more expensive active one). Time
to market is also a lot quicker if there is no requirement for a change in behavior from the
manufacturers. Manufacturer participation is also primed by the anticounterfeiting, supplychain
and recall benefits of passive tags in packaging - none of these would be enhanced by the use
of more expensive active tags.

The solution you have also means that it is difficult for me as a Doctor/Carer to give a patient
another medication or a one off medication, and medications cannot be quite so easily pooled
or shared. I suspect that most home care providers would probably find a huge increase in
time and the medication packaging costs if these active sensors where used instead of patient
controlled sensing. I think we should try as best we can with mHealth medication compliance
to emulate the successful nurse stations you can see in use in leading hospitals (produced by
companies such as Cardinal Health etc) - with these you will see substantial reduction in
packaging costs/med shrinkage AND much better compliance and error reductions.

Chris Johnson
It seems that you describe something like a patient diary in which clients enter data on a 3G
phone and can have direct contact with a Doctor using the phone?

The solution I was describing is more generic. The advantage of using active tags is that the
registration of dosage events is automatic and does not rely on the patient to input data. It is
also not dependent on having the phone with you, or remembering to read a passive tag. By
the way, if you use active tags then you have the other applications such as supply chain, anti-
counterfeit, etc free of charge. You can also monitor for tampering and changes eg in storage
temperature.

Medication adherence is complex and not a case of "one size fits all", so I suppose many
solutions have their place. A plus for the approach I was describing is that I expect that it will
work with many phones, without the need for a 3G model and accompanying 3G subscription.

Care homes are a special case. Patient controlled sensing is often a non-starter. The trend is to
individual packaging of multiple drugs by pharmacists so they can be administered reliably by
"nurses". In this case, active tagging makes perfect sense. Not only do you reduce staff time,
but you can reliably see when drugs were dispensed to clients, and even who did it.

Karen Sorel
Just a comment from the front lines. I would strongly encourage vendors to think about the
target patients when designing technology. Demographics at present include a lot of baby
boomer and older clients. So far, in our over 65 population, it has taken a lot of teaching and
encouragement to get them to adopt any kind of technology. These are the people who
currently have the bulk of chronic diseases and thus generate a bulk of the costs. Please
consider what they can afford, and what they can manage physically and mentally. That will
direct you to what health care entities will find useful and worth buying.
David Youngs
Karen Sorel is on target that we need to develop systems that work for elderly, they are using
75% of health care expenditures. Any system that facilitates their "wellness" will be of
significant benefit. I think often programs are focused at the younger population, without
planning for elderly, baby boomers. They are going to be with us for the next 20/30 years.

David Doherty
@Chris Johnson: Whilst the company i work with does indeed offer 3G Video Mobile healthcare
services the solution i am describing does not require 3G, Video or our service. In fact it works
on some of the most basic and familiar cellphones in the market as it works with the worlds
most popular patient diary application - having been developed and distributed by Nokia.

Don't be too concerned about patients not having the phone with them. The vast majority of
the 4 billion people on the planet with a phone carry it with them at all times. The reason for
this is that most people carry their phones to be reachable not to make calls. Patients in
particular benefit from being even closer to their mobile for reasons such as personal safety,
social support and assistance summoning.

Don't be too concerned about the need to swap out a mobile for a new one. These are mass
produced consumer technologies that when compared with medical grade products are very
cheap, have much better user experiences, are upgradable/programmable and may also offer
other lifestyle/entertainment/communication benefits for patients. Even for NFC to work >99%
of people in the world will need a new phone or at least a new SIM card.

As for "the need for a 3G model and accompanying 3G subscription"

> there is no such thing as a "3G subscription" you can have exactly the same payment plan
as with any other mobile offering ie pay as you go, contract etc. However your solution will
obviously be using mobile data so it might be best to make plans to switch to 3G as data is
cheaper on these more capable mobile networks.
> whether customers like it or not their mobile operators are making the upgrade to 3G and
will eventually switch off their 2G networks in the same way that TV stations all over the world
have upgraded from analogue to digital. This has already happened in Japan where you can't
buy a new 2G mobile.

I cannot see why you need more expensive active tags to offer supply chain/anti-
counterfeit/etc applications when simple cheap passive ones will do the job perfectly well.
Whilst these passive tags are already in products the need to fit smart tags to every
medication to monitor it's precise storage temperatures is to my mind technologically
wonderful but will probably just be a big waste of limited healthcare resources.

Ultimately i think the problem with your way of thinking is that instead of converging to the
mobile device (something we have seen to be successful with lots of very complex things such
as pager/text messaging, internet, video, PDA functionality, TV, bank ATM/money transfer, etc
etc) you are moving intelligence out from the mobile device and to another very limited,
unreliable and relatively dumb device (an active tag). To my mind this may be ideal for a very
short term gain but it brings unneccesaary cost, complexity and more barriers to market
success which are probably going to critically affect its chance as a mass market offering.

David Doherty
@Karen Sorel: As someone who has taught a 80 year old to text i've some experience of the
very many different factors at work here and you can rest assured that some very smart
people are working on precisely this problem for example Arlene Harris at GoJitterBug.com .

One of the biggest problems is creating the proof that mHealth can deliver health benefits and
cost savings as a large part of usability relies on motivation. Key to motivation will be the
ability for patients to appreciate the benefits of using new technology to improve the care
experience.
@David Youngs: Whilst it is obvious that the elderly consume most of our current healthcare
costs there are several issues that suggest mHealth should make ground by proving clinical
merit and this may be easy to achieve if we target the easiest battles to win. Young people
currently represent these and mobile is a perfect medium to reach them with because 1) they
all use mobiles 2) they like mobiles 3) preventative and behavior changing interventions are
best started early.

Whilst we may have baby boomers with us for the next 20/30 years the young people today
will hopefully be around a lot longer and with predictions that the obesity epidemic alone may
lead to their parents outliving them their need for behavioral/lifestyle changes right now is
pressing.

Chris Johnson
Let me try and help.

I suspect that teaching older people to use mobile phones, even to make calls, is harder than
you believe. However, think of a group which is an avid user - young women who are taking
the contraceptive pill.

Compliancy with "medication" is high - around 97%. Yet the consequences of being part of the
3% are great. They want to check whether they are 100% compliant and the vast majority
willing and able to use a phone to do so.

Active tagging of the medication pack is the only way I know to provide a totally reliable record
of dosage events

David Doherty
@Chris Johnson: You mustn't of read me right when i wrote that i am "someone who has
taught a 80 year old to text". I understand very well the difficulties. Be careful not to dismiss
the potential patients have to do new things if we can support them properly and make it clear
how they can benefit by learning new behavior.

I am reliably informed by Doctors working with us here in the UK and Ireland that MOST of the
young women who are taking the contraceptive pill today are ALREADY using their normal
mobile calendar/alarm function to remind them to take their medication.

Nothing in Active tags makes them 100% reliable and they cannot give a "totally reliable
record of dosage events" because they only record when the blister is opened. To my mind it's
just as easy to think of reasons for forgetting to take a pill once it's blister has been opened as
it would be with a passive RFID tag picked up by your NFC mobile.

When young people would sooner leave home without their purse/wallet than their mobile
what is the USP of an active tag here?

Chris Johnson
Totally endorse your remark Karen.

My father, 86, has a mobile phone which is carried - switched off - only on the golf course. He
likes to think that he can make a call if his partner (Sonny is over ninety) has a heart attack. I
have given up trying to explain that he needs to charge the battery regularly in case this
unlikely situation occurs.

@David. Back to the technical. Passive tags only work if you remember to ping them at the
right time. Pencil and paper would work equally well and could be used by many more people
in the target audience.
Chris Johnson
Not sure if my last remark got posted so I'll say it again - sorry if repetitive.

@David. To monitor compliance you want to know if the evening dose is taken in the evening,
and sometimes if doses are taken in the right sequence. A passive tag, even when pinged
consistently, will only tell if a dosage event has occurred. You could in theory give every blister
or compartment a tag, but then the client will have to read the right tag and the cost will
exceed the active tag approach.

David Youngs
It sounds to me as if people assume elderly to be a hard market. Even thought about 37%
have cell phones with an annual growth rate of 10%. And this is an old figure from AARP study
(2003). I have many older friends who text me successfully. The learning curve may be
different but not impossible. If you can play golf, you can use a cell phone I would imagine.
Elderly people, living independently in the community can use a modular phone, as well as a
cable box or telephone.

David Doherty
@David Young: Great comparison. I think many elderly people take up and learn to play golf
very well but it starts with the individual "wanting to play golf". In my successful and
unsuccessful attempts to teach seniors to use mobiles and text messaging i found the most
important influence came from the fact that using a mobile is very rarely something seniors
want to do.

Finding this want was key to the learning experience and a very good example i found was
from the mother of a school teacher who wanted to communicate with her daughter during the
school day. As her daughter could only take SMS messages and not calls during class times
learning to text was something the grandmother wanted to do.

Chris Johnson
David D. is right. Big difference between can and will. Many seniors grew up in the era of the
horse and cart, walking to school, pre-tv and even pre-phone. Even most baby boomers did
not have TV in the formative years.

Learning curves are very steep and the need has to be great. Contact with family is usually
most important the older you get, so I buy the sms-grand daughter analogy, but I doubt
whether the majority accept the need to get to grips with 3G phones to manage their health.

Brian Dolan
Klynn, thanks for starting this discussion.

Many very helpful points. Not sure if this is well-known yet, but Kaiser Permanente recently
mentioned its plans for a national rollout of SMS (text message) based appointment
reminders. Their pilot went well and the CIO greenlit it, according to one KP speaker at a
recent event. I wrote it up last month here:

http://mobihealthnews.com/2009/02/kaiser-to-rollout-text-message-appointment-reminders/

In the year preceding June 2008, more than 600B text messages were exchanged in the U.S.
Whether or not everyone (elderly or technophobic) is on that trolley is besides the point--
enough people SMS to make it at least one mobile technology that caregivers should start
leveraging in their practices... today.

Wunmi Omoniwa
first,I am exited that finally attention is being given to closing the gap between technology and
access to health however in these era of technological complexities i also want to make a call
for re simplifying things. for example cannot even get my father who is just over 60 to learn
how to use a mobile phone to send text messages and to store my number in his contacts and
not on a piece of paper he has to look for any time he wants to call.

Brian Dolan
Apple seems to be right on top of this trend... the new iPhone 3.0 announcement had a
number of mHealth angles and featured a speaker from Lifescan/J&J onstage:

http://mobihealthnews.com/2009/03/iphone-30-all-about-mhealth/

Looks like more and more medical devices will be connecting to the iPhone and other phones
soon...