Bulletin of Environment, Pharmacology and Life Sciences

Bull. Env. Pharmacol. Life Sci., Spl Issue [4] November 2022 : 230-238
©2022 Academy for Environment and Life Sciences, India
Online ISSN 2277-1808
Journal’s URL:http://www.bepls.com
CODEN: BEPLAD
REVIEW ARTICLE OPEN ACCESS

Digital Technology for Improvement of Medication Adherence

Sonal Setya*1, Mamta F Singh2,Sushama Talegaonkar3
*1Department of Pharmacy Practice, SGT College of Pharmacy, SGT University, Gurugram, India
2School of Pharmaceutical Sciences and Technology, SardarBhagwan Singh University, Balawala,

Dehradun, Uttarakhand, India

3Department of Pharmaceutics, Delhi Pharmaceutical Sciences and Research University, (DPSRU), New

Delhi, Delhi, 110017, India

*Corresponding author e. mail: [email protected]

ABSTRACT
Medication non-adherence is a major global health care challenge, especially with chronic conditions. It is a multi-
factorial concept, that can be improved by a combination of several approaches including educational, behavioural,
cognitive, and the use of adherence increasing aids. Patients, health care providers, and the health care system, together
are involved in optimizing medication adherence. This chapter describes the various types of digital tools such as mobile
phone applications, web-based education, engagement and gaming systems, smart pills, dispensers, packages and bio-
ingestors , that are under various stages of development or available to address medication management with the goal
of improving medication adherence. Most of these technological innovations provide holistic solutions to the patients in
their complete health care journey, but a number of these digital adherence supporting tools still remain expensive and
need compliance with regulatory standards and universal acceptance. Increased awareness amongst stakeholders,
integration in health care system, and implementation of regulation policies for digital adherence tools can positively
impact the patient’s therapeutic outcomes.
KEY WORDS: Digital, m- health, adherence, mobile health apps, non- adherence
Received 08.11.2022 Revised 12.1.2022 Accepted 02.12.2022
INTRODUCTION
As per World Health Organization (2003), medication adherence is defined as "the degree to which the
person’s behaviour -taking medication, following a diet, and /or executing lifestyle changes corresponds
with the agreed recommendations from a health care provider [33, 34]."On the other hand, compliance, a
relatively older term, is defined as the extent to which a patient’s behaviour matches with the prescriber’s
advice [6]. Compliance indicates how well a patient obeys the instructions related to medication given by
the prescriber, whereas adherence signifies that the patient and prescriber integrate to improve the
patient’s health by considering the medical viewpoint of the prescriber and the lifestyle, values and
preferences of the patient. Medication persistence is another related term, which is defined as the
duration of time from initiation to discontinuation of therapy [10].Medication adherence behaviour can
be understood as a combination of two concepts: adherence; taking medications as prescribed and
persistence; continuing to take the prescribed medication for the entire duration of the treatment. To
study and understand the adherence of digital technology in the field of medical industry.

MATREIALS AND METHODS

Medication adherence can be measured by a number of methods [1].
1.Direct method: including biochemical determination of detecting the presence of drug or its metabolite
in the blood sample or the urine sample of the patient obtained by adding a nontoxic biological marker to
the medication. This is a robust method, nevertheless it is not a practical method for routine use.
2.Indirect methods: including objective measurement of medication adherence through questionnaires
filled by patients, self-reports, counting the number of pills, prescription refills records, electronic
medication monitors, patient diaries, or using electronic medication event monitoring systems. Yet
another indirect method includes subjective measurement of medication adherence obtained by
enquiring the patients, their caregivers, and clinicians about the usage of medication.
Generally, a combination of the above mentioned methods is used for the assessment of medication
adherence behaviour. Mathematically, adherence can be expressed as percentage of the actual medication

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taken over a set period of time and can vary from 0% to over 100% [22].Typically, medication adherence
of 80% or more is required for optimal therapeutic efficacy. There are various ways to calculate
medication adherence depending upon the method used. A simple formula to find it is given below:
% medication adherence = number of doses taken X 100
number of doses prescribed

NON-ADHERENCE TO MEDICATION
Patients may be adherent, partially or completely non adherent. Studies indicate that non-adherence
accounts for nearly 50% of treatment failures and around 125,000 deaths and up to 25% of
hospitalizations per year in the United States. It is estimated that adherence to chronic medications is
around 50% [12].Non-adherence poses a challenge at all levels of society for all types of diseases,
irrespective of chronic or acute drug therapy or the type of drugs. Non-adherence results in wastage of
medication and resources, poor health outcomes, decreased functional abilities, poor quality of life,
increased hospital visits and stays and increased health care expenditure. Non-adherence is a major
challenge for prescribers, healthcare systems, and other stakeholders because of its wide prevalence,
consequent adverse outcomes and increased health care costs. Patients tend to miss doses, take
medication intermittently or do not take them at all, without realizing that this can result in relapse,
rehospitalisation, excessive dosage, enhanced resistance to antimicrobial drugs and adverse effect on the
long-term outcomes. Non-adherence cam also be viewed as unintentional and intentional. Non-adherence
to medication is termed as intentional when the patient intentionally chooses to either stop or decrease
the doses or number of prescribed medications due to personal beliefs about medication and treatment,
lack of motivation and unusual expectations from the treatment. Unintentional non-adherence is
attributed to patients’ lack of cognition and capacity compromising their ability to adhere to the
treatment regimen, or lack of access to health care and support [15].
The causes of non-adherence are multidimensional in nature ranging from patient’s behaviour, type and
severity of disease, complexity, number of medications, duration of the treatment, possible ADRs, social
factors, economics involved in the treatment, relation and interaction between patient and provider,
follow ups and/or organizational factors linked with the health care system. Figure 1 shows the
multidimensional determinants of non-adherence.

Socio-
economic
variables Health
Therapy sytem
related related
Medication
non-adherence

Conditi
Patient on
related related

Figure 1: Multidimensional determinants of medication non-adherence

To develop a better understanding of the concept of the non- adherence, all potential factors must be
considered, screened and selected. The relationship between a health care provider and a patient relies
on trust, truth, and collaboration with the aim to achieve mutually agreed treatment goals and
therapeutic regimen. Miscommunication between patients and health care provider may lead to
compromise in care or disease associated complications. Provider-related factors include barriers in
communicating with the patients and/or their caregivers, prescribing complex treatment plans, dosing
regimens and lack of coordination, if multiple providers are involved. Health care system factors include
limitations in accessing an appropriate provider, inadequate patient provider consultation time, high cost
of the treatment, lack of clarity in medication labelling, poor instructions and deficiency in providing
appropriate patient education material.

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STRATEGIES TO IMPROVE MEDICATION ADHERENCE
Several approaches have been used for monitoring and increasing adherence, because it leads to both
health as well as economic benefits [17]. Medication monitoring or assessment or measurement or
evaluation means using a method to observe if the patient has taken the medication or not. On the other
hand, intervention here refers to the means for increasing adherence or correcting it, once the fault is
detected. Majority of elderly patients and those with chronic diseases such as hypertension, diabetes, and
asthma are not adherent. Patients, health care providers, and health care system, all have a role in
optimizing medication adherence. Improvement in medication adherence takes time and may be brought
about by a single intervention or a combination of various techniques. Figure 2 summarises the various
strategies to improve medication adherence.

Optimised
patient
provider
relationship
Simplified
Integration
treatment
with digital
regimen at
adherence
minimum
tools
cost
Strategies to
improve
medication
Usage of adherence Early follow up,
medication adherence
adherence assessment on
improving subsequent
aids Patient follow ups
therapeutic
education
and
behavioural
support

Figure 2: Strategies to improve medication adherence

First and foremost, the health care providers should involve the patient in decision making at the level of
prescribing, whenever possible, so that they have a sense of partnership in the treatment plan. Medication
regimen management should be based on individual patient’s characteristics and done in the most
simplified manner possible. Patient education with health educators is another key component of
assessing and improving medication adherence. Communication between patient-pharmacist, patient-
physician through personalised counselling sessions for addressing the fears and concerns of the patient
regarding side effects, adverse drug reactions, and improved cognition of medication and treatment
carries prime importance. Clear medication related information to patients should be given regarding the
treatment regimen. Patient medication counselling should be accompanied with detailed written
information about medicines and adherence improving aids such as medication charts, pill boxes etc.
Behavioural interventions are aimed at changing a patient’s behaviour toward treatment by the use of
cognitive–behavioural techniques, therapies focused on dysfunctional emotions, promotion of healthy
lifestyles, and positive changes toward symptoms and regimen [9]. Regular patient follow-up is vital to
improve the medication adherence. Telephone calls or alerts, in-person follow-up visits for disease
monitoring and refill reminders may be used. Adherence can be assessed by direct and indirect methods
during consequent follow ups. The effectiveness of medication adherence aids used if any, barriers
related to adherence should be assessed, problems addressed, and informed to patient by the health care
team.
With the advancement of technological innovations in health care, digital tools are now-a-days emerging
to monitor and increase patient’s medication adherence. Digital tools may range from simple reminders
to take the medication to smart devices with health apps, or integrated with activity tracking devices or a
smart pill or a stand-alone medical device to administer the treatment. Figure 3 depicts the various types
of technological innovations for assessing and improving medication adherence.

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 RFID and NFC linked devices
Smart packages, pills ,drawers, pill dispensers

Digital education and engagement

IoT-enabled solutions

Intelligent wearable devices

Mobile health apps

Health information technology based services

Digital gaming interventions

Figure3: Technological innovations for assessing and improving medication adherence

DIGITAL TECHNOLOGY TO IMPROVE MEDICATION ADHERENCE

With the upsurge in the access and usage of mobile phones and penetration of internet, digital adherence
technologies have shown a positive impact on medication adherence in patients with diabetes,
hypertension, TB and HIV [27-32]. These smart solutions are based on cellular communication or other
form of innovations which can be integrated with internet of things to perform a variety of functions,
including reminding patients to take medications, digitally recording of medicines taken, compiling and
managing dosing histories, for the use of healthcare providers in identification and intervention on non-
adherence. Majority of the digital tools provide comprehensive solutions to the patient in their complete
health care journey in addition to managing treatments and medication by extending full support in
providing education, motivation, monitoring and evaluation resulting in holistic and enhanced patient
care. In comparison to manual methods such as direct biochemical approach, where the patient is
required to report to a centre for blood or urine testing with associated interventions acting as a great
burden on them, digital technology provide non-invasive, useful and simple solutions to monitor and
promote the medication adherence, nevertheless they are usually expensive. The following section
describes the various ways in which digital technology is used to increase medication adherence.
Radio frequency identification
Radio frequency identification (RFID) technology is a wireless system that make use of radiofrequency
waves to transmit and receive data and is useful for uniquely identifying an object. RFID system
comprises of a tag and a reader and because of its small size, it can be combined with various physical
forms. RFID works by placing a physical tag on an object that uses radio waves to send data such as
location, time, etc. to a remote reader. In the health care ecosystem, RFID technology has found
application in billing, tracking inventory, ensuring drug safety, blocking supply chain of counterfeit
medicines, monitoring and improving medication adherence. RFID technology can be integrated with
medication labels and blister packaging containing pills for identification of patients and tagging
individual medication containers to ensure that the right medication treatment is received by the right
patient in the health care settings [1, 16, 26, 24, 31].
Near Field Communication
Near Field Communication (NFC)is an extension of RFID technology, that provides two-way
communication process between two compatible devices such as an NFC tag and a smart phone. NFC tags
consist of small chips for storing data and can be incorporated into stickers, labels, packs etc. The smart
phones can read this data from a short range. In health care, NFC can be integrated into pharmaceutical
labels, packages, delivery devices and implemented using smart devices, to trace the consumption of
medication by the patient together with keeping the record of each dose taken [22]. NFC enables the
monitoring of the medication intake schedule by the caregivers, prescribers and pharmacies. NFC tags can
be attached to a drug delivery device, like an auto injector or an inhaler for medication adherence.
Tapping a tagged device with a smart phone, can further create a link to medication guides, helpful
information and usage videos for the patient.

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MHealth and mobile health application (app)
MHealth is an expanding field, and as per WHO (2011), is defined as a public health care service delivery,
supported by wireless and digital technology using mobile devices. M- health interventions are used for
the improvement of health outcomes, health care services and research. A mobile health application (app)
is a software created for its usage on mobile devices like smart phones, tablets for delivering health
information and communication technologies in the support of health fields using images, video, music,
word processing and internet service. These may be connected to wearable’s.
The advantages of using mobile health applications includes the ease and simplicity of usage, cost
effectiveness, broad reach and diverse user friendly features for offering holistic health care. Just one
touch can give access to health and medication related knowledge, remote review of records, interaction
with other users and healthcare providers in addition to receiving notifications and reminder messages
about medication. Examples include Care4Today®, Health Assistant, Mymeds, Medhelperetc. Another
benefit is that it can be connected to various smart drug delivery devices or dispensers via Bluetooth or
NFC technology. Mobile applications are dynamic in nature with continuous addition of new features and
updates for improving the existing apps. Smart phones based health applications can be used in a number
of ways to improve medication adherence. They can alert the patients when to take their medications,
record the event to their history, or use gamification, or engage the patient, to monitor and promote
medication adherence especially for chronic diseases. The marketed is flooded with varied and numerous
mobile health apps, however, there is still a long way for MHealth to be universally adopted in routine
clinical practice. Table 1 summarises features of commonly used mobile adherence apps.
Table 1: Features of commonly used mobile medication adherence apps
Sharing
Tracking Free
Mobile Reminder information with Refill
Education dose Gamification of
adherence app of doses health care alerts
history Cost
providers
Dosecast
(Medication √ √ X √ √ X √
scheduler)
Medisafe
√ √ √ √ √ X √
(Virtual pillbox)
Mango Health
(Medication √ X √ √ √ √ √
manager)
Round Health
(Medication √ X X √ √ X √
Organiser)
MyTherapy
√ X √ √ √ X √
(Pill Reminder)
CareZone (
Simplified
√ √ √ X X X √
Medication
manager)
Pillboxie
√ X √ X X X √
( Pill reminder)
Meds360o
(Medication √ √ √ X √ X √
manager)
Smart Package systems
Smart Package systems such as smart blisters and high tech strip packaging are pharmaceutical packages
which are designed to track the patient’s action of taking out a pill from them. The design of smart blister
package system is such that with each dose removed, an individual event is recorded thereby eliminating
the chances of patient opening the pack out of curiosity [29]. Another feature in the smart package is to
collect the information regarding rupturing time of the package, medication category and name, location
etc. These smart blisters can be linked to patient’s mobile phones to serve as pill reminders (Morak J et al,
2012). They may be linked to mobile phones of prescribing physician too. Thus, medication adherence
monitoring can be done by both the patient as well as the prescriber. Smart package systems are
beneficial for patients who take multiple drugs. These smart packages may also be linked to a pharmacy.
However, they can be very expensive and cannot find out if the pill was actually consumed after being
taken out. Examples of smart packs are CpaX™ connected medication adherence packaging and Schreiner
MediPharm’s smart blister pack and wallet. CuePath innovation provides one such solution, which
transforms ordinary bubble packs into smart packs. The patient’s medication is pre-packed by a

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pharmacist and whenever he burst the bubble to take the medication, the event is recorded. In addition,
the caregivers can monitor the usage via mobile app to track the patient’s adherence.
Smart pill bottles
These devices can monitor the adherence with the help of sensors in the cap, which are able to detect
when the bottle is opened, or by means of sensors in the bottle itself, which is based on determination of
weight of the pills that are remaining. They are easy to use, but they are expensive, and does not indicate
absolute adherence. Literature indicates that smart pill bottle together with pharmacist intervention has
improved adherence in patients with multiple myeloma [21]. Similar results have been obtained using
smart pills with mobile application in breast cancer survivors [24].
Medication event monitoring system (MEMS)
MEMS is an intelligent medication device used to monitor the medication adherence. The MEMS can be
customised as a cap that fits on standard medicine bottle or can be embedded in metered dose inhalers to
record and store number of dosing events. MEMS coupled with other approaches such as counselling,
motivational messages, reminder alerts may be useful in promoting adherence [11, 14].
Smart pill dispensers
These devices include various features such as voice assistants, cameras, alarms or lights to indicate the
time of taking medication, along with automatically dispensing the medication. Smart pill dispensers can
be very expensive devices and may not be able to track absolute adherence, nevertheless they can meet a
variety of patient needs and can provide remote access to health care provider. RxPense® is a smart pill
dispenser for blister packaged medications, designed specifically for geriatric patients and patients with
chronic diseases. RxPense® can also be used to automate the dispensing of DisPill® and Eco-Pill™
packaged medications. Table 2enlists some of the digital adherence marketed products with their salient
features.

Table 2: Commercial digital adherence products

Digital Adherence
Features Reference
Marketed Product
Tracks and records dosing when the cap is opened or inhaled Available:https://
Airduodigihaler (Smart
Provides feedback on inhalation instantly www.airduodigihal
Inhaler)
Shares data with health care providers er.com
Connects pill box via Bluetooth to mobile app
Program smart alarms
Available:
Elliegrid (Mobile app and Receive notifications when number of pills are running low
https://elliegrid.co
pill organizer) Reminders available when it is time to take the medication
m
Alerts for pills that are outside of box
Access patient compliance report daily
Holds up to a month’s supply of TB medication and is in sync with
Wisepill cloud service
Available:
evriMED1000 (MERM) Equipped with mobile phone communication chip to send reminder
https://www.wise
(Smart Dispenser) text messages
pill.com/evrimed
Records medication history
Can be customised for individual patient
Uses Bluetooth technology to send dose information, and reminders
to a mobile app Available:
inPen (Smart insulin https://www.comp
Offers dose recommendations and tracking of doses
delivery pen) anionmedical.com/
Delivers insulin doses
inpen
Shares reports with the healthcare team
Smart adherence system using bottles and devices to track doses
Provides real time care support and connect with pharmacy Available:
Aidia Smart Bottle (
Remind with music and light indicating the time to take the https://adheretech
Smart pill bottle)
medication .com/
Alerts if doses are missed
Fits on standard prescription bottles
Provides visual, audible, text messages ,mobile phone alerts to Available:
Glowcap (Intelligent pill promote medication adherence https://mantadesig
cap) Every time, the pill bottle is opened ,it records adherence data and n.com/work-pill-
send periodic progress reports to patients, their caregivers and dispenser/
health care providers

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Smart Drawers
Smart drawers are designed to scan the inventory(medication) which is stored inside them, identify them,
recognize the opening and shutting of the drawer, monitor the patient’s drug taking activity as well as
record these activities with a timestamp. Integration of smart drawer with Internet of Things (IoT) can be
used to monitor the adherence, alert the patients and their caregivers when the protocols of the
prescribed therapeutic regimen are not being followed [3, 122].
Bio-ingestible sensors and drug-device combination
These devices are pill-sized electronic chips embedded in oral medication, which on swallowing by the
patients alerts their smart phone. This data can be then sent to the health care provider to find out if the
patient has taken medication or not. Abilify Mycite is an oral tablet containing Aripiprazole with a bio-
ingestible sensor for tracking the adherence. It was the first bio- ingestible product to be approved by
FDA in 2017 [16]. Bio-ingestible sensors can only track adherence, and not improve it. More than 80%
medication adherence have been reported in clinical trials performed using bio-ingestors for
uncontrolled hypertension with type II diabetes and mental illness [13, 18]. Examples of integration of
adherence monitoring with drug administration devices includes smart inhalers and electronic auto-
injector devices (Choi SH et al, 2018). Literature indicates that these “Drug-device combination” enhance
medication adherence, although there are other needs which yet remain unmet [3, 35].
Digital education, engagement and gaming
Guiding and engaging the patients throughout their healthcare journey with the aid of digital tools
enhance communication with healthcare providers and adherence to their medication thus simplifying
the process, decreasing cost of readmission and relapse and leading to positive therapeutic outcomes.
Patient Engagement solutions by Elsevier's educates patients by giving them access remotely to evidence-
based information, prescribers trust, in interactive and patient-friendly ways. This gives them a sense of
engagement and involves the patients actively in treatment and care. Presently tele-health or tele-
monitoring are playing a key role in affecting adherence. These health information technology services
are non-invasive services that combines digital information and communication technologies to remotely
access patients’ health and provide care and support to them, promote adherence, especially for the
management of chronic diseases [6]. Meds OnCue by VUCA Health is an innovative digital patient
education platform for providing information to patients through prescription specific short duration
videos that can be accessed from a QR code on the prescription label through their smart phones. These
video includes their medication, dosage, frequency and the most common side effects. It instructs the
patients to contact their physicians or pharmacists for managing side effects and encourage them to stick
to their complete treatment regimens by providing medication reminders and also reinforces safe
medication use. There is also provision for certain Pharmacy Incentive IOT based programs offered by
some companies, for example Cigna, through its CoachRx service: an interactive website, helps its
members to identify the barriers of non-adherence, provides educational resources about ways to
improve adherence and send daily reminders text messages, voicemails, or emails. Walgreens’ Balance
Rewards for Healthy Choices provide a set of web, app and text-based programs for improving
medication adherence, promoting engagement and encouraging immunizations.
Interactive gamification solution related to health activities is a promising approach to increase
adherence. Gamification refers to applying game with playing features such as points, competition, levels,
rewards etc. to promote patients’ engagement, education and motivation towards their therapy
[24].Health Prize Technologies uses gamification and engagement for motivating the patients to-support
health literacy, increase adherence and improve health outcomes with the help of videos, quizzes,
surveys, rewards etc.

CONCLUSION
Improving medication adherence requires a continuous multi-factorial approach that is personalised as
per the needs and disease state of the patient. Digital adherence tools such as m-health apps, smart pills,
smart packages and dispensers are changing the patient’s healthcare path with their use ranging from
appointments, consultation, integration in decision-making, tailored regimens, medication dispensing,
monitoring to learning about routine medicine management. They can affect the medication management
at all levels including physicians, pharmacists, healthcare systems, individual patients and their caregiver.
A thorough understanding of on the part of the healthcare providers, stricter regulations and affordability
is required for a wide recommendation and acceptance of digital adherence tools by the patients.
Pharmacists are an integral member of the healthcare team and considered as one of the most trusted
and accessible healthcare professionals. While dispensing medications and refilling prescriptions, the
interaction between patients and pharmacists can lead to understanding of the patients’ thoughts about
disease and expectations from the treatment. Pharmacists are in a unique position to positively influence

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them and manage factors such as dexterity, vision and cognition that may affect adherence. Digital
solutions coupled with human interventions holds immense potential to address the problem of
medication non-adherence.

CONFLICT OF INTEREST
The authors declare that there are no conflicts of interest. The research received no specific grant from
any funding agency in the public, community, or non-for profit sectors.

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CITATION OF THIS ARTICLE

S Setya, M F Singh, S Talegaonkar, Digital Technology For Improvement Of Medication Adherence. Bull. Env.
Pharmacol. Life Sci., Spl Issue [4]: 2022: 230-238

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