Electronic tools help patients remember to take their medication, but is memory alone at fault?
By Neil Osterweil
Reviewed By Michael Smith
Joyce Cramer is a professional nudge.
Well, maybe that's laying it on a bit thick. Let's just say that when she does her job right, people are healthier for it.
As an associate research scientist in the Department of Psychiatry at Yale University School of Medicine, Cramer has made a career out of studying how and why people take -- or more likely don't take -- their medicine.
According to a World Health Organization (WHO) report, "Adherence to long-term therapy for chronic illnesses in developed countries averages 50%. In developing countries, the rates are even lower. It is undeniable that many patients experience difficulty in following treatment recommendations."
Failure to take medication as directed -- doctor's call it "noncompliance" -- can have devastating consequences for people with chronic diseases such as asthma, high blood pressure, and diabetes, as well as those with difficult-to-treat infectious diseases such as AIDS and tuberculosis. Forget to take your over-the-counter cold medicine and you may wind up with a bad case of the sniffles; forget to take your prescription asthma medication, and you could wind up in the hospital, or worse.
The reasons why people don't take drugs how and when they should are varied and complex.
Sometimes a harried doctor, rushing off to the next appointment, fails to tell a patient how to take a specific medication, or doesn't explain why it's important to take a full course as prescribed.
Sometimes patients are concerned that the side effects of the drug may be worse than the malady itself. Others don't take their medications because they feel fine and think that the drug can't be doing them any good, a common misperception among people with high blood pressure, which often does not cause any obvious symptoms until it has already done its damage. Still others stop their medication when they start to feel better but before they've finished a full course of the drug, a dangerous practice that can lead to the development of drug-resistant strains of diseases such as pneumonia, skin infections, and tuberculosis.
"You can't tell by looking at somebody if they're going to be a poor complier. You can't tell when you do a new prescription and start them on it, or when you're working with someone with a chronic disease. There's no disorder for which the consequences are so severe that everyone takes their medicine," Cramer tells WebMD.Caps Off to Electronic Monitoring
When it comes to compliance, though, Cramer doesn't just take patients at their word. She begins by talking one-on-one with patients to help them develop a drug-taking system that will become a part of their daily routine. Then, if problems arise later, she uses a special device called a MEMS cap (for "Medication Event Monitoring System") to find the source.
The MEMS cap technology is ancient by current standards: it dates back to the late 1980's, although it's gone through some modifications over the last two decades. The system uses simple pill bottles with microprocessors -- computer chips -- embedded in the cap. Depending on the unit and how it's programmed, the chip can record the date and time of day on each occasion that the bottle is opened, counting each opening as a dose.
Cramer explains how it works: "If a patient starts on a new med or has been taking a med chronically but is not doing well, I say, 'Would you kindly use this MEMS cap for a while so I can understand how you're using your medicine?' They come back in, I put the MEMS cap on a little reader and on my computer up pops a screen that looks like a calendar, and I sit with the patient and I say, 'This is how you've done taking your medicine,' and if they were supposed to be taking it two times a day and there are a lot of zeroes in there, it's a very objective, nonjudgmental way of showing that they missed those doses."
With the data at hand, the health care provider and patient can talk about why the reminder system didn't work and adjust plans accordingly. Patients buy into it, Cramer tells WebMD, because "it's self-management. They almost challenge themselves to do better, because it's a report card."Call Me Ibuprofen
MEMS cap technology is only one of several different ways in which people are using electronics to help them take their medicine properly. As previously reported on WebMD, people with visual disabilities can use hand-held scanners with voice simulation software to read the information on labels, or the bottles themselves can do the talking, announcing their contents (to anyone equipped with a special reader) using programmable voice chips similar to those in newer telephone answering machines.
For people who just need the occasional nudge in the ribs, many drug companies and online pharmacies now offer a free e-mail reminder service when it's time to renew a prescription.
But if, as the WHO study suggests, only about half of people with chronic illnesses regularly take their medication, what's going on with the other half? Are that many people worldwide that scatter-brained?
"What are we assuming is the reason patients don't take their medications? If we assume that they're just kind of forgetful and need a reminder, then reminders will work great, says Bruce Bender, PhD, head of the division of Pediatric Behavioral Health at National Jewish Medical and Research Center and professor of Psychiatry at the University of Colorado School of Medicine in Denver. "Unfortunately, there are a lot of reasons patients don't use medication, and some of them don't have anything to do with remembering. They have to do with patients' distrust of medications, worry about side effects, worry about costs, perception that the drug isn't really helping them ... In the face of those factors, reminders aren't going to change anything."Bells and Whistles
Bender, who contributed to the WHO report, tells WebMD that "in my view electronic monitoring that comes back into the hands of the health-care provider is what really helps, because then the health-care provider and the patient can have a discussion: 'Oh, I see that you haven't been back to refill your medication. Tell me what you think about it.' It's caregivers that are really in the best place to change patient behavior and have the biggest impact."
He notes that in some closed health-care settings -- such as HMOs in which the drug prescription and dispensing are done in one system -- physicians can get electronic data about their patients prescriptions, and then talk about it when they next see the patient to determine the reasons for a failure to get a refill, for example. "I believe in that kind of monitoring; I just don't think that little things that buzz and whistle and remind people make much difference, unless we're talking about some elderly patients with memory problems, in which case it can make a big difference."
Cramer agrees that one-on-one counseling and education of patients, and not technology, are the keys to improving drug compliance.
"I go around and lecture to doctors all the time," she tells WebMD. "You've got to, when you give a prescription, spend less time on the molecular pharmacology of the drug and more time on what you want the patient to do, and how the patient can do it."
Published Dec. 10, 2003.
SOURCES: Joyce Cramer, Yale University School of Medicine, New Haven CT; Bruce Bender, PhD, National Jewish Medical and Research Center and University, Colorado School of Medicine, Denver. Report, WHO/MNC/03.01, World Health Organization. WebMD Medical News, "Pardon Me, but Your Medicine Cabinet Is Speaking."
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