Technology offers tools for ensuring adherence to medical therapy

What is the available technology?
There is no standard way to measure non­adherence. The most common, and simplest, measure—asking the patient—is unreliable and severely overestimates adherence.

Direct measures of adherence include observing the patient taking his medications and testing for the concentration of those medications in blood or urine. Indirect adherence assessment methods, such as pill counts, a medication diary, self-report, clinician ratings, pharmacy chart review, and electronic devices that monitor the opening of a lid or tablet strip, have all been used; yet reviews of those methods have shown less than favorable results.⁶

Pre-packaged pill packs have helped some patients with a simple method for medication management.

Electronic monitoring, using a medication vial cap device (Figure 2) that electronically records the date and time of bottle opening, has become common in general medicine and among patients with schizophrenia.^6,13,24-26 Diaz et al²⁴ reported that electronic monitoring detected a greater nonadherence rate (57%) than what prescribers reported (7%) or patients self-reported (5%)—demonstrating that prescribers and patients grossly overestimate adherence. In another study that looked at electronic monitoring, researchers reported that adherence was much higher in depressed youth (87%)²⁷ than what had been seen in adults (67%) in a similar study.¹³

The downside to pill packs and electronic monitoring? There is no guarantee the patient has actually taken the medication despite the data reported by the system.

Event marker-signaling devices. Novel technologies have been developed to measure adherence:

Proteus Digital Health feedback system (www.proteus.com) requires that patients ingest a tablet containing a tiny, dietary mineral-based “ingestible event marker.” Upon contact with gastric fluid electrolytes, the event marker emits a unique signal that is transmitted through bodily tissue to a small receiver in a patch worn on the torso. The receiver then transmits a signal to a cellular phone, indicating the time and date when the medication was ingested (Figure 3).

A 4-week pilot study²⁸ found that the ingestible event marker is feasible and acceptable to patients: 27 of 28 participants (96%) completed the study, with a mean adherence rate of 74%. Although the system identifies ingestible sensors with high accuracy and is easily tolerated by patients, the pilot study was brief; a longer duration of adherence while wearing the patch needs to be studied.

Breath analysis, facial recognition. Even directly observing ingestion of a medication can be problematic: Some patients don’t swallow the medication and spit it out later. One way around that subterfuge is to consider using other advanced medication adherence solutions that are breath-based or use facial recognition technology and confirm ingestion.

Xhale SMART (www.xhale.com/smart) is a handheld device that generates a reminder to the patient to take his medication; afterward, he (she) must blow into the device so that ingestion of the medication is detected (Figure 4). The medication has breath-detectable adherence markers already incorporated. The adherence marker then is released into the stomach and small intestine, where the adherence marker metabolite is transported through the bloodstream into the lungs and exhaled. The patient must breathe into a breath analysis device, which measures medication ingestion compared with a baseline breath print.

Several articles in the literature have reported the accuracy of this device in detecting the ingested metabolite in every participant, without adverse effects.^29,30 Clinical data on the use of the breath-based detector is not available to the public at this time.

AiCure (www.aicure.com) is a facial recognition-based technology platform that can work through any smartphone. The device is powered by artificial intelligence software and motion-sensing technology that can detect, in real time, whether the patient is taking the medication as prescribed. Patients who take an incorrect dose, or who do not use the software, are automatically flagged for immediate follow-up. This technology enables real-time intervention by a provider with the nonadherent patient.

An important note: These innovative technological advances are tools that can help clinicians manage an important aspect of treatment, but they do not show the entire picture: The physician−patient relationship and the therapeutic alliance are key to optimal treatment adherence.

Engage and empower the patient
Novel adherence technologies are, as we’ve described, available, and more are being developed. Incorporating these technologies into clinical care requires continued input and support from clinicians and patients. Digital and mobile health applications are multi-beneficial: They can empower patients to self-manage medication regimens and appointments while they also receive social and psychological information and support as needed. Understanding one’s own illness can, ultimately, improve outcomes and significantly reduce health care costs.

Patient empowerment is key. The physician is an important influencer in this regard.