Medication adherence: Whose problem is it?

By Jonah Comstock
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AdhereTech's smart pill bottle. AdhereTech's smart pill bottle.

The market for digital tools that improve medication adherence is heating up. Over the last year Mango Health launched, AdhereTech announced a new clinical trial, Janssen Healthcare Innovations completely revamped its Care4Today app, and Proteus demonstrated its tracking accuracy. And we're constantly learning about new devices and apps like those from CyberDoctor, Ai Cure, and Nightingale, among many others.

The widely-cited NEHI figure, that medication nonadherence is a $290 billion problem, makes it a very attractive market opportunity, but there's little to no agreement on how best to solve the problem or even how exactly to articulate it. In fact, there's a growing awareness among adherence-focused companies that medication is not just one problem, and there won't be just one winner in the space.

Hardware-centric vs. software-only

Developers in the adherence space tend to break down the market into hardware-centric offerings, like smart pill bottles and caps, and software-only offerings like smartphone apps.

"There are solutions that are really, really cheap and marginally effective, and then there are solutions that are more expensive, like ours, but will have a much larger effect on treatment adherence," Josh Stein, CEO of smart pill bottle-maker AdhereTech, told MobiHealthNews. "If you look at hardware solutions, and the trials that hardware solutions have performed, they increase adherence a lot better than a pure software play."

The argument from the other side is that software solutions are much easier to scale, allowing them to target larger patient populations and to be rolled out more cheaply and easily. Adam Hanina is the CEO of Ai Cure, a software company that uses a mobile device's webcam to interact with a patient and make sure they're taking their medication.

"I think when you create a piece of hardware, you lock yourself into a certain model because the cost of hardware may be expensive," he said. "When you go with a software-based model, because the incremental costs of software can be very low, the types of business model can be very flexible."

Many more software offerings are direct to consumer plays for that reason, while many smart pill bottles, like AdhereTech, are looking to have providers and pharmaceutical companies be the payers. But this is a good example of how breaking down the market shows room for all kinds of solutions. Stein says the scale problem pushes AdhereTech, at least at first, into specializing in a certain kind of drug.

Care4Today app from Janssen Healthcare Innovation Care4Today app from Janssen Healthcare Innovation

"I don't think it's going to be the sort of thing where every single patient will have an AdhereTech bottle," he said. "We are concentrating on particular uses that fall into categories like: Are the drugs expensive? Is it extremely critical that patients take their drugs? Are there major negative consequences when patients don't take their drugs? Are the windows for taking these drugs rather tight?"

For instance, AdhereTech's first pilot focuses on HIV medication, which is expensive, often complicated, and can be a matter of life or death for a patient. On the other hand, Care4Today's new app wants to allow the user to track even vitamins and bottled water. Pharmaceutical companies are unlikely to subsidize that kind of adherence, but consumers might pay 99 cents for it (although Care4Today is currently a free app, and they've told me they have no plans to begin charging). Ai Cure's highly accurate verification, on the other hand, has an advantage with drugs for mental illness, where a provider might need to be sure a patient is taking their meds.

Stein said the biggest problem with software solutions is that using an app isn't part of the normal process of taking a pill. It's an added behavior, which means to start using it requires a behavior change. If nonadherence is essentially a behavior change problem, that's something of a catch-22: patients have to first change their behavior to change their behavior. While that might work for some, he argued many will need a passive solution that doesn't require them to change their process.

Whose problem is it?

Ai Cure and AdhereTech are taking different approaches technically, but they both boil down to monitoring a patient's medication behavior in order to change it through outside motivation. That's been the pattern for a long time, and companies with those sorts of approaches do have some success.

David O'Reilly, chief product officer of Proteus Digital Health, has long been an advocate of a different approach. Proteus is working on an adherence tracking system that includes an ingestible sensor and a patch that relays data from the sensor. But O'Reilly says it's monitoring adherence for the patient, not for a care provider, to put adherence behavior in context with other vitals and deliver an increased understanding of medications.

"We're not trying to create a system that allows other people to check up on individuals taking their medicine," he said. "We're trying to put the personal choice in the context of other product features, connected to things people actually care about. Most consumers don't care about 'compliance' as a benefit. It's really a health system or a physician benefit and attribute. But if you're going to have something that lives in the life of an individual, design something that people want to take into their daily lives and have an emotional connection to."

proteus-digital-health.top_ The Proteus Digital Health feedback system.

A few other, app-based approaches that have arisen recently have also taken a more holistic, patient-driven approach. For instance, Nightingale, which released its patient-facing app in July and its physician app just recently, leverages Validic to take in data from all kinds of consumer devices like Fitbit and Jawbone and combines that data, and GPS data from the phone, with a medication tracking calendar.

"A lot of apps have tried to do medication reminders, but they haven't been super successful because you kind of create the equivalent of Google calendar, but there's no huge value add," said Nightingale cofounder Delian Asparouhov. "What we do is we monitor the accelerometer, WiFi and GPS, on the phone and essentially we try to learn the patient's schedule. We learn that [a patient] takes his medications when he gets to the gym every single day. We'll set up a GPS alarm so if he goes to the gym at six one morning or ten another morning, the alarms come in at the right time."

CyberDoctor recently released its PatientPartner app, which is a radical departure from the genre in that it doesn't track medication usage at all. Instead, the whole goal of the app is to get patients to think more about the effect taking their medication has on their overall health by playing through a role-playing game -- and a small clinical trial showed it increased adherence from 58 percent to 95 percent, even three months after patients used the app.

There's a place in the market for a wide variety of adherence approaches, be they apps, smart bottles, smart caps, or smart pills. After all, $290 billion is a huge hole to fill, and its early to tell what the best approaches will be. But adherence is ultimately a behavior change problem and it's in the hands of the patients. Companies that succeed will show a value to patients above and beyond making sure they take their pills.