Smart Care for Heart Care: eSolutions for Improving Patient Compliance

Tools that help patients adhere to doctor’s recommendations improve patient outcomes—it’s simple math with a host of benefits. For patients with heart disease, tracking daily routines and ensuring compliance with recommended medications and behaviors can be a difficult, but necessary part post hospitalization. eTools are emerging to help physicians and patients deal with monitoring changes in condition and keeping abreast of medications and recommendations.

These tools can provide reminders and serve as a means to check patients in a place where physicians these days never, or rarely, go—at home.

But, what’s out there? And what are the costs and benefits associated with some of the more popular technologies? Several research groups have been exploring the options. Smartphone apps, web-connected devices, and web portals are all areas being tried out by physicians worldwide to help patients in addition to more traditional telephone reminders and patient engagement training. Some approaches combine old and new technologies, texts, phone messages and internet connectivity to create an approach that works best for patient and provider.

Here’s a look at some of the eTools currently being applied to better manage doctor’s orders when heart patients go home.

Talking tablets

ETools can provide physicians a way to improve effectiveness across the board with their patients, including those who have been harder to engage in the past. Gautam Shah, MD, and his team from the Cleveland Clinic recently looked at the effectiveness of tablet-based telemonitoring intervention among high-risk, low-income patients with heart disease in reducing hospital readmissions (Circulation: Cardiovascular Quality and Outcomes. 2015; 8: A117).

Through the Cleveland Clinic network, his team works largely with low-income African American patients. “Just given the kind of the population we work with, we have a lot of problems with patient adherence to medications and we’re always trying to come up with different ways to improve it,” he says. 

The tablet-based system assists in monitoring a patient’s heart rate, blood pressure, weight and other vital statistics while also providing the patient with reminders about taking medications and making health information available—all without the need for frequent office visits. It also provided patients the opportunity to interact with their physician without having to try to catch the doctor over the phone when they had questions. “Rather than having to call and leave a message, they can communicate with their healthcare provider, either the nurse or the primary care physician through the monitors.”

While the sample size was small, Shah says the findings are promising. Patients had little trouble adopting the technology once they had it. While there were some instances of needing to contact patients when data weren’t acquired on a given day, it was easier to weed out those who needed help from those who didn’t.

The biggest barrier to replicating the findings on a large scale, he notes, is in obtaining the tablets. “That would be expensive and we don’t know if that would be cost effective. We just did a feasibility study with this trial,” Shah says. “We would need more nurses and more healthcare providers in our team because we had to constantly remind patients to measure their weight or their blood pressure. There were very few who actually just did it.” They are looking into the question of cost, but Shah says “we’re not there just yet.”

Smart thinking with smartphones

Smartphones are everywhere. And for most people, these go-anywhere devices are a standard part of living. When the patient already has the device, it increases the simplicity of getting a monitor up and running when the patient leaves the hospital, especially when all a discharging physician needs to do upload an app.

During the initial phase of the trial, Aimee Layton, PhD, from Columbia University and NY Presbyterian in New York City utilized an app developed initially for the Apple iOS, which has since been broadened to include Android and a range of languages.

“One of the great things about a smartphone intervention is that it allows us to integrate the data directly into our computer as opposed to telephone surveys or paper surveys that are not real time,” says Layton. She notes that older methods of tracking patients outside the care setting also are more labor intensive, schedules may be hard to synchronize and that with the chance of vital data not making it to physicians, things have a chance of getting missed. “The beauty is that the patient can fill out the information at a time that’s convenient for him or her, hopefully in as close proximity to when we want to know the information as possible,” she says, achieving as close to real-time as possible without a wearable monitor. “Those data don’t get lost because they go directly to our computers and to the dashboard.”

The app also helps patients confirm discharge or verbal instructions by allowing them to get back into contact with the professional who gave them, whether it be a floor nurse, the attending physician at the hospital, or their own primary care physician. She notes that sometimes there are extra instructions given verbally that may not make it on to written discharge papers. Instead of having difficulty contacting these providers to confirm, “they can just message the dashboard with their question: ‘What’s the dosing? What should I be taking? What shouldn’t I be eating?’”

The app also allows caregivers to send messages and ping patients with things they should be doing at various points throughout the day. “Things like ‘Have you done your walking today?’ or ‘Have you checked your blood pressure today?’ Things that patients are supposed to be doing that they may forget or put off that clinicians can give them friendly reminders about,” Layton says. And, a benefit to the healthcare provider is that these reminders don’t need to be sent in real time. They can be scheduled and set to go off whenever they feel a prompt might be needed, instead of requiring someone to call directly. “It’s much less labor intensive.”

Even with the positives, Layton was surprised that overall patients didn’t use the app as often as she’d anticipated they would; while for some this appeared to be an issue with the learning curve, others it may have been more about their health status. “One of the things we noticed was that the sicker patients used the app significantly less than patients who were feeling well,” she says adding that they found that those who were readmitted “were the ones who after they left the hospital never used the application.” These patients, she says also were readmitted shortly after initial discharge. Of the adoption of the app by these patients, she says “They were really sick and when you’re really not well, having to do more, whether a little or a lot more, might be energy they don’t have.”

Being outside of the trusted doctor-patient relationship may have had a negative impact on adoption too, Layton notes. Uptake may have been slow for some because “we weren’t actually their doctor. They were trying out this app as part of a study, so they may have perceived us a barrier or someone outside the loop. If it was actually their doctor or their nurse or their physical therapist, they might have used the messaging part of the app more frequently.”

Even under these conditions, the study was successful at showing smartphone apps can indeed be effective at improving patient adherence to medications and to physician instructions; however it worked best for patients who used it most. They also found that in the cardiac patients studied, those whose condition was less severe were more likely to access and use the app (Int J Telemed Appl. 2014;2014:415868).

Because, in the real-world setting, most patients already have smartphones, projected costs of this type of intervention would be minimal. They could simply download the app and get rolling.

Web-connected… anywhere

Some groups are using the web to connect with patients anywhere. Stephen Agboola, MD, MPH, is associate director for Connected Health’s Data Science and Analytics in Boston. He and a Harvard-based team combined web- and telephone-based monitoring to cover a variety of bases. While this is one of the newer tools in their arsenal, Agboola and his team have extensive experience bringing telemedicine to patients to better improve their adherence and their lives.

This program was intended to be less intensive and less expensive than prior endeavors, Agboola says. In other telemonitoring programs used by his team, patients were expected to provide daily data points on weight, blood pressure and other vital statistics through a monitor that required patients to have a land line and modem. These devices and components were expensive and labor intensive and stationary; they also required a specialist to install them. “We’re trying to move away from the idea of being able to take readings only in one place,” he says, because patients themselves are more mobile. “All the components are mobile and patients can travel with their devices.” This means that clinicians can monitor patients in real time—whether at home, work or on vacation—for a fraction of the cost.

Much like with the smartphone intervention, the internet-based intervention provides patients and providers more interaction and better care. “Our programs connect with the medical records so that clinicians can see how patients are doing at home. If a patient knows you’re watching, he or she does better. They tend to engage more,” Agboola says.

Patients receive reminders which also help—as long as they are dynamic and not automated. They also comply better when messages require a response. “Required response motivates them to do better. Those who respond do better than those who do not,” he notes.

The real-world trial showed significant and consistent improvement through four months using the Connected Cardiac Care Program; Hospitalizations and mortality rates decreased for patients on the program compared to those who weren’t by nearly half (J Med Internet Res. 2015;17[4]:e101). This was in spite of issues older patients can have with learning new technology or encountering small typeface on the provided iPads, Agboola says, adding that the learning curve was fairly minimal. “Almost everyone has access to these platforms now, which helps.”

Cost studies are pending, but look promising as the technology has become cheaper and has been shown to reduce secondary admission rates, he says.

“These tools and their dashboards are helping to better identify patients who are doing poorly and when you’ve identified who’s at risk, reach them,” Agboola says.

Partners in Improving Patient Adherence: A Pharmacist-Driven Intervention

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Janice Pringle, PhD, is the director of the Program Evaluation and Research Unit at University of Pittsburgh School of Pharmacy. She is part of a team that explored the viability of including pharmacists in assuring patients are taking their medication.

“The outcomes were much better than expected.” She says, “I expected it would improve adherence, but I didn’t expect it to improve adherence as well as it did, for as many medications as it did and also to affect downstream healthcare costs as it did.” Since the intervention they used was one they had previously applied to reducing alcohol consumption and appeared to be more effective, she noted, “I think we got off easier than when this application is for alcohol, so therefore I was surprised by the magnitude of the change.”

The intervention uses an assessment tool to determine patients most at risk for having an adherence problem, says Pringle. This allows the pharmacist to direct efforts to those who would be best affected based on the screening results. “The process uses a mnemonic device we developed to help pharmacists remember strategies, motivations and principles,” she says, adding that the process helps patients better understand the impact behavior has on health and provides a platform for discussion about medications, empowering both patients and pharmacists to improve care.

Over the course of this large-scale pilot, the number of patients who achieved medication adherence of 80 days or better improved by 3.1 percent among those taking beta blockers and 4.1 percent among statin users (Health Aff [Millwood]. 2014;33[8]:1444-1452). Even with the cost of healthcare increasing over the course of the study, adherence saved both inpatient and emergency costs per patient annually: Beta-blocker prescriptions on the lower end of the range, at about $19 per year. Patients taking statins saved approximately $241 annually.

Pringle notes that while this initial study was pencil and paper, she foresees a link to electronic health records “as more pharmacies move in that direction going forward.” It would fit nicely, she says, “because you would have an ability to put in screening results and to document the results of the intervention so that next time the patient comes in, whether or not he or she sees the same pharmacist, there is a record of what the visit entailed and go from there.”

More pharmacies have expressed an interest in using this intervention, she says, and noting that more on the Pennsylvania Project, its intervention and how pharmacies can join is available at pharmacist.com.