“Nonadherence” has been estimated to cost the US healthcare system between $100 billion and $289 billion annually. But the cost of “patient non-compliance” is measured in more than just dollars. It is also measured in a diminished quality of life, lost mobility, impaired productivity, and untimely death. Patient adherence is one of the most fundamental drivers of positive patient outcomes and cost management.
A thorough review published in The New England Journal of Medicine about a decade ago estimated that up to two-thirds of medication-related hospital admissions in the United States were because of noncompliance, at a cost of about $100 billion a year. These included treatments for H.I.V., high blood pressure, mental health and childhood illnesses (it can be difficult to get children to take their medicine, too). New York Times, Nov 26, 2017
It makes sense, then, that medical groups and providers are turning to smart technology to improve adherence. Technology alone though is not enough. An ever-expanding scientific understanding of human behavior, habits, and the brain, is an enabling and critical part of the success equation. Technology and behavioral science will truly be transformative in the quest for better patient adherence.
Understanding why patients stop taking medicine or abandon a therapy regimen is a complicated endeavor, and much research has gone into determining the causes for both noncompliance and nonadherence. Researchers find that, by and large, the reasons for noncompliance or nonadherence generally fall into 3 categories.
Forgetting to take a medicine or deciding that a lifestyle change is unattainable is the common factor for non-compliance. The complexity of new therapies and cures can rival the best Rube Goldberg machines. In addition to being the largest category, this the most challenging to solve.
Financial challenges are increasingly more common with the cost of drug development still unsustainable, and the FDA approval process for novel medical devices long and arduous. Many Healthcare actors are addressing the cost of care, and I will not address it in this post.
Perhaps the easiest to solve, misunderstandings of how to manage a chronic condition is the smallest category. Ceasing medication too soon or not continuing with a therapy can be addressed with the use of smarter, more effective technology that aids in the communication and education process.
Behavioral economics theory and constructs are easily tapped and leveraged through Technology. I will focus on two of my favorites: Collaboration and Habit formation.
The human brain yearns for approval and validation. Decision making is an energy intensive and risky endeavor, and we seek for ways quickly ensure good decisions. For the rational brain, we often look for “experts” to guide and instruct; for the emotional decision maker, we seek affirmation and positive reinforcement. Mobile and wearable technologies can influence both of those decisions making pathways by delivering the right message, from the right source at the most relevant time. A call from your Dad when your watch indicates you might be feeling down, a text from your doctor when you’ve missed your meds, or a car door that won’t unlock when you’re about to drive drunk are all examples of this kind of “collaboration” in the decision making process.
The technology becomes even more powerful when the communication is bi-modal. For example, when adverse symptoms show up with a new drug you’ve been prescribed, you could talk to a nurse who has your medical records with a touch to your iPhone’s Health app. Don’t feel like exercising? Your virtual trainer can “harass” you until you get on the stationary bike and participate in the group ride.
Wearables enable individuals and groups to compete against each other in Ad Hoc fitness competitions. This group dynamic can be a powerful motivator of healthy behavior, and technology is able to deliver it on demand and in the right doses.
At the most macro level, habit formation comes down the three things: The Trigger – An Action – A Reward. (Think Pavlov and his famous dogs).
This basic concept is increasingly being used to help patients create healthy (adherence) habits. Online and Mobile programs that prompt users to take an action (take their meds, put on sunscreen, stand up from their desks), are combined with both immediate (digital) rewards (a song, a thank you, credits, badges, etc.) and near term (sweepstakes entry, points towards gift cards, etc.) rewards. Virtual assistants like Alexa and Siri are beginning to understand and anticipate the behavior and needs of their human owners. Developing good habits such as eating right, exercising, and getting enough sleep is low hanging fruit for these ever-present digital attendants. The reward can be as simple as a charming compliment or as complex as adding bitcoins to your wallet when you do push-ups, physical therapy, or take your meds.
Habits that encourage and support patient compliance is wide open for technology innovation. The medical industry needs to look at the complex interaction between daily behaviors, decision, and habits to work out the details. To the company or group that solves for it there will be rich rewards.
We are in a brave new world where technology is ubiquitous with every aspect of our daily lives. Every day we are asked to remember less, and are reminded of more. Our phones tell us where to go and when to leave to get there. Oh, and how to get there to boot. We log our food to make sure we’re eating healthy. You get the idea; people are used to this level of support in every aspect of their lives and it’s time for therapy compliance to get into the game.