Digital Medication Dispensers -- Patient and Clinician perspectives that need to be considered
I’ve been spending a lot of my time reading and catching up on studies during the Covid-19 Pandemic, and one area I have been focused upon is medication adherence studies in the digital health space. Now, there have been several studies that I have enjoyed, but two recently caught my attention that is really worth writing about, as I think they offer perspectives I really haven’t seen talked about.
Now, in terms of evidence for digital health adherence interventions - there’s not much. If you’ve read my other articles you know that. Rather, I have personally been working on a framework on why that is, and it centers around several aspects. Namely, I think the tech is one aspect, but buy-in by providers and patients will be key. Often, I’ve noticed so much research emphasizes the patient’s perspectives or outcomes, but rarely mentioning workflow or rollout of tech. We lack that data at this time, and I think too many companies want to publish about their clinical outcomes (hey I get it, need someone to back it whether a payor or pharma), but I think this has increasingly led to the unfortunate negative to mildly ineffective outcomes seen thus far.
One system of digital advancements has been home medication dispensers. There’s a lot of them, whether Spencer, Pillo, Hero, etc. Often, we are seeing them use independent pharmacies or TruePill to also deliver these medications to the patient’s homes to use with the robots. The devices all differ in approach, and I think each has its pros and cons. To date, there aren’t any outcome data I’ve seen with them making any clinical difference and would guess based on how things are going they either have studies ongoing or internal data to use or just don’t care.
Nonetheless, my personal experience in the home healthcare setting has led me to explore and believe these devices have a great possibility to play in the US health environment, what with an increased push for remote patient monitoring and care in the home. So let’s talk about these articles and why I think they are really interesting.
Health Professional’s Viewpoints on Home Medication Dispensing Systems (MDS)
Now this study really has gotten my attention, and I highly advise that if you work in pharma, a company making a digital health adherence product, or rolling something out in your clinic to really give this a read. They approach it in such a manner that I think it really has a lot to think about. But to summarize, this was a qualitative study conducted in Norway that interviewed 26 health professionals from home health services. Some key items they addressed and put some serious thoughts into, and my own observations, were:
Pushing is key. The design process and how things work really matter, but to get things going, you really have a hump to cross to get your team on board and to utilize it. We’ve seen this with EHRs in the US, but even the thought of RPM is difficult I’d say. So how do you do that? Change up the terminology and how you view things. Or, as they call it ‘Domestication,’ whereby you rearrange “objects into and within existing socio-technical arrangements.” I think this is brilliant. One of my biggest advice to digital health incumbents is that market shaping is where you really need to focus your work on, especially marketing. But this concept of domestication I can really get behind, or as they point out “WHen implementing a digital medication dispenser, it would need to become a natural part of the work practices and care arrangements.” Now that’s all well and good, but how do you do it, or rather, how did the health professionals get on board with it?
Now the authors don’t bat around the bush in why they are doing this analysis. “Politically, the goal of utilizing welfare technology [their terminology for this type of development] has been to increase the time citizens can live a home, thereby decreasing expenses within the health care sector. However, the actual implementation of welfare technology in municipal home services has proven slower than first assumed.” See, the authors came into this thinking that there would have been a great advancement to using these devices in the past 5-years, but found it wasn’t so, and that really is intriguing, similar to our own problems in the US I would say.
Human error really holds back people from accepting change in healthcare, and health professionals are actually probably one of the biggest barriers. The authors find in their interviews that health professionals themselves really have a big difficulty with the idea of patients using a device to self-manage medication administration. Now, patients do this all the time, with oral therapy and via other devices (e.g. autoinjectors, inhalers, insulin injection pens/syringes). But, when you have a home health service that is dedicated towards this work, saying we are placing a matching to replace your work so you can concentrate on other functions rubs people a little odd. Who is responsible they ask? You see, if I give a patient medication and they take it, its a singular transaction, and ultimately I have that relationship with the patient and I trust myself to do a damn good job at it. But, if I put my faith or whatever you want to call it in a machine, I am still liable if the machine works, or if the patient uses it right, or its other factors. So trust is key. I think a lot of digital health companies miss this if they don’t have an active health care practitioner(s) on staff with the development. The concept that people will just accept a new function in their work is not really ingrained in the health space. We teach health professionals of all scopes to be individualistic (yes, work in teams and interprofessional is a must though) and take ownership of their care and touchpoints with a patient. I take the analogy of building a product on an assembly line, multiple people touch and make the final product, but I often think in healthcare we take a singular touchpoint more in the emphasis than the greater whole (for good or bad). So you have this innate cultural issues to cross. That comes back to human error, or device failure for that matter. If trust cannot be established this machine is going to do what it is supposed to, then it will ultimately fail and be sidelined. Bottom line. Health professionals are not forgiving of this, they can forgive human error, but mechanical is something different.
Becoming dependent on a device is a change in thought. Similar to the previous point, the technical issue of remote delivery and management of medications means that a health professional now is thinking of not only the patient but the device, the technical support, the backend data management, etc. They are now TIED DOWN to a new continuous loop that really hasn’t existed and demands some level of responsibility around the clock that hasn’t existed before. That’s a big dynamic to get across. Interestingly, The authors found that one way that got people to use these devices was to still accept human clinical inputs. You see, one of my greatest hurdles and difficulties talking with founders or companies making an adherence product is getting them to realize that there is no way in hell their product will become a standard of practice for all patients. And I think this is an issue with tech at large. I can see some areas where it makes sense in the approach, such as AI in automated cars, with the argument it will only ensure safety once all cars are automated. Why? Because it removes the human element, which is just chaotic thought processes and action. I mean, the whole concept of adherence to me is based on trying to get people to take something that is good for them, but they don’t due to multiple factors. Human chaotic actions are intuitive I feel (look at the issues of global warming or vaccinations or even wearing a mask), and the issue is choice. Patients have a choice to take their medications, and we want to change their behavior. The same goes for health professionals that want to put trust and use in a device. So to have success, the health professionals had a choice on who to allocate and use these devices on. Now I know there is no formal protocol for this, I’ve looked and it doesn’t exist, and it’s a framework I myself and trying to figure out. Nonetheless, I love the one line they had: “Standardization did not fit with how they [health professionals] perceived quality of care, nor with their professional values.” One aspect they did I can get behind is to identify superusers or champions for using these devices to get it running, which I think is another proposition for Pharma to really consider. I mean, we have MSLs, I think having ambassadors to identify digital health interested parties will be key for startups and others to get their products going with those that can use them in patients and encourage colleagues to adapt.
Demystify the product. I thought this was interesting, and even the language I am writing in with ‘digital health’ could be offputting for some when I often quip I see digital health just being plain health in the future. So the terminology is key. Using terms and definitions that current practitioners know and can relate to can help. Treat this stuff as a tool to adapt and use, with the understanding that the choice of using any tool is still given to the clinician. That might fly in the face of some companies that want to seem cutting edge in terms of marketing, but when trying to play up that you are fast tech and getting investors on board, it may not be a good idea to impress that same dichotomy on your end-users.
Transference of ownership of care. Probably one of the largest hurdles of digital health is the concept of democratizing healthcare for patients to take ownership of their own health. The paternalistic model is still there (I mean, I can understate how many people I interview that say ‘they want to help people’ but their definitions of that vary). I see the value of digital health as putting an increased level of freedom for a patient to dictate their health. Some examples highlighted for that patients didn’t need to be confined to their home waiting for someone to give them their med, or even have to change outside of their robe in the morning. They dictated the flow of their health. We just need to trust the technology enables that for the ‘right’ patient.
Lastly, two points that caught my attention the authors found. One was that health professionals saw different values and means of using the tools than intended by their decision-makers. Take that for what its worth, but in health care, my experience is that administration will make calls that those conducting them for patients will learn to shortcut or make work for the patient at the end of the day. Secondly, they quip “Our results suggest that it is not possible for providers of welfare technology to manufacture trust. In this study trust was gained through identifying the dispenser as a contributor to their professional value of proving good care, thereby being a trustworthy part of the care arrangements of home care services.” I think that means a lot in many ways that aren’t being discussed currently in the market.
In summary, this paper I think while focusing on home healthcare and oral treatments has a large ramification for exposition to other treatments and populations. I have been looking for research like this for some time, and I do think more of its type are needed for fine-tuning workflow and rollout considerations. Again, if anything, give this one a good read.
So what do patients make of Home Medication Dispensing Systems (MDS)?
Ironically, the next study I came across was based on this very question! So this is another qualitative study conducted in Canada interviewing 13 participants using an MDS. Now, the MDS is never identified in the study, but, given that the device has a telecommunication component, is based in Canada (I think), and uses strip packaging, I think you could make an educated guess. In any event, the device itself doesn’t matter too much here, but the premise, as most of the functions are similar across the whole space, with differences I would argue around pricing and select features. So some key areas the authors identified, and my own thoughts, were:
The patients interviewed were lower socioeconomic, with a mix of living alone or with a loved one. They were 50 years or older, and had 5 or more prescribed oral medications. They excluded patients of lower cognitive status. I think the economic issue is key here, as we find that they like the service, but cannot afford the $100/mo fee for leasing the product after the study.
The device was found to be annoyingly beneficial, with reminders going off which required a certain amount of flexibility in their schedule. The participants admitted to triggering the device to stop the alarms or a caregiver/family member, but not taking the medication at the time. They did like the strip packaging it came in, as they could take it with them when leaving the house. Though several participants acknowledged they had difficulty opening the sachets and had to use a scissor or their teeth to get it open — now my thoughts are this is likely due to whatever machine the pharmacy is using to fill it so not necessarily a broad issue but I’ve heard this from other patients personally. Nonetheless, despite the alarms, participants actually found the device to help them build a routine, and several admitted that the device probably helped their adherence (though this was not an objective to measure in the course of the study).
Interestingly, majority of participants would recommend the product but did not find it necessary. This differed though as even if they did not think they needed it now, because they felt they could use it later in life. It was patients who acknowledged difficulty remember and organizing their meds that found it most useful. Though, one concern raised was security and privacy, as some hid the machine in their bedrooms so others wouldn’t see it when visiting.
I won’t go crazy in detailing this study, but I loved the data and insight if offered for a small sample on using these devices. My takeaway was it reinforced my view of several things:
Cost is going to be a barrier and leasing a device will be difficult for lower socioeconomic populations, who would probably from a public health viewpoint benefit the most, but cannot afford it. As such, these MDS are really playing into the worried well and upper classes that already benefit from better health aspects. So the age-old conundrum of digital health still plays out. This is probably why I am a fan of sensor-based drugs as the sensors are getting either cheaper, or it’s built into a device that a payor will take on. These MDS and similar I just am waiting to see if payors will eventually widely adopt.
No mention of other medications and how patients reconcile other routes of administration (e.g., injection, topical, inhaler) which I would have liked to have seen evaluated. In addition, the one thing I still can’t wrap my head around is how ‘as needed’ or PRN is tackled and tracked with these devices. That seems like the area where you can make some interesting impact to address if a condition or issue is of high concern (e.g. benzo — anxiety, analgesics — pain, bowel agents — constipation). In the same manner, they mentioned the device can link for telecommunication with a pharmacist, but that was also never discussed and one item I was disappointed not to see discussed from the patients on if they saw that as a positive or meaningless value. So I am still stuck looking for a paper that explorers the interrelationship of digital health adherence tools and pharmacists’ oversight and intervention, alas.
Well, that sums up these two studies. You can probably guess the first one excited me the most, but the second one was valuable nonetheless to reinforce some viewpoints i had and to lead me to evaluate some other items. Would welcome your comments!