Page 21 - Delaware Medical Journal - July 2017

TELEHEALTH
TABLE 1: Methods to Measure Adherence
Subjective
Objective
– Question the patient*
– Evaluate patient diaries for completeness *
– Ask patient to complete questionnaire*
Comment: These are less accurate than objective measures since patients may overstate use.
Conduct pill counts
Use electronic monitors*
Determine prescriptions filled at pharmacy* Measure levels of medicine (blood/urine)
Comment: Pill counts and records from electronic monitors do not establish if the treatment was taken. Prescription refill data records date of refill, not when taken
Blood levels give one point in time and biased if patient is aware that they will be monitored. Also they are intrusive.
*Reflects use for Telemedicine
TABLE 2: Strategies to Improve Adherence
1) Simplifying regimen characteristics: number of daily doses,fixed combinations*
2) Education in self-management*
3) Modifying patient beliefs, counseling*
4) Behavioral interventions*
5) Enhancing clinician communication
by training in person and over internet: Motivational Interviewing*, Shared Decision Making*, Stages of Change*
6) Monitoring adherence*
7) Reminders*
8) Telephone follow-up*
*Strategies in Asthma Adherence PathwayTM
features in telemedicine in Delaware.5 Features include: 1) An operational data store which receives data feeds from electronic health records of participating health systems; 2) The care coordination team receives real-time admission real-time updates from all hospital and outpatient laboratory facilities in Delaware; 3) The use of a shared population health management electronic health record allows a geographically dispersed Care Link team to collaborate on the care of the patients; 4) Incorporation of a predictive engine that learning technology to enable the Care Link team to identify populations most
at risk; and 5) A care coordination team of registered nurses, pharmacists, social workers, respiratory therapists and medical directors provide education and counseling to patients, their families, and their circles of care.
ADHERENCE
Telemedicine provides the opportunity to bring all elements of asthma disease
management to patients and clinicians, including those related to adherence.6 Adherence to long-term therapy, for all chronic diseases in the US, averages
50 percent.7 The consequences of poor adherence to long-term therapies are poor health outcomes and increased health care cost.7 In the United States, the estimated direct and indirect costs of non-adherence totaled $337 billion in 2013, the most recent year for which 8

to which a person’s behavior — taking medication, following a
diet, and/or executing lifestyle changes — corresponds with agreed recommendations from a health care provider.7 Increasing the effectiveness of adherence interventions may have a far greater impact on the health of the population than any improvement in 9
The Asthma Adherence PathwayTM (AAP) adherence management model hypothesizes that four strategies used sequentially will achieve adherence: 1)

and 4) patient-centered communication skills.10 A recent controlled study validated the theory.11
MEASURING ADHERENCE
There are subjective and objective methods to diagnose adherence. (See Table 1.) Questionnaires such as those developed by Morisky et al. may be helpful to determine adherence when combined with objective data.12 Various types of containers and devices can objectively monitor dose dispensing with internet technology. These include:
1) Medication Event Monitoring System (MEMS). A device used to monitor medication adherence. A MEMS monitor consists of a conventional closure that records the time and date each time the container is opened and closed.13 2) Blister packs of medication with embedded microelectronic components (including printed electronics) to record the timestamp and amount of pills taken.14
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