Assessment of medication adherence app features, functionality, and ...

SCIENCE AND PRACTICE Journal of the American Pharmacists Association 56 (2016) 293e302

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Assessment of medication adherence app features, functionality, and health literacy level and the creation of a searchable Web-based adherence app resource for health care professionals and patients Seth Heldenbrand*, Bradley C. Martin, Paul O. Gubbins, Kristie Hadden, Catherine Renna, Rebecca Shilling, Lindsey Dayer a r t i c l e i n f o

a b s t r a c t

Article history: Accepted 24 December 2015

Objectives: To assess the features and level of health literacy (HL) of available medication adherence apps and to create a searchable website to assist health care providers (HCP) and patients identify quality adherence apps. Practice description: Medication nonadherence continues to be a significant problem and leads to poor health outcomes and avoidable health care expense. The average adherence rate for chronic medications, regardless of disease state, is approximately 50% leaving significant room for improvement. Practice innovation: Smartphone adherence apps are a novel resource to address medication nonadherence. With widespread smartphone use and the growing number of adherence apps, both HCP and patients should be able to identify quality adherence apps to maximize potential benefits. Interventions: Assess the features, functionality and level of HL of available adherence apps and create a searchable website to help both HCP and patients identify quality adherence apps. Evaluation: Online marketplaces (iTunes, Google Play, Blackberry) were searched in June of 2014 to identify available adherence apps. Online descriptions were recorded and scored based on 28 author-identified features across 4 domains. The 100 highest-scoring apps were usertested with a standardized regimen to evaluate their functionality and level of HL. Results: 461 adherence apps were identified. 367 unique apps were evaluated after removing “Lite/Trial” versions. The median initial score based on descriptions was 15 (max of 68; range: 3 to 47). Only 77 apps of the top 100 highest-scoring apps completed user-testing and HL evaluations. The median overall user-testing score was 30 (max of 73; range: 16 to 55). Conclusion: App design, functionality, and level of HL varies widely among adherence apps. While no app is perfect, several apps scored highly across all domains. The website www.medappfinder.com is a searchable tool that helps HCP and patients identify quality apps in a crowded marketplace. © 2016 American Pharmacists Association. Published by Elsevier Inc. All rights reserved.

Disclosure: The authors have no actual or potential conflicts of interest to declare for themselves or their immediate family members including any financial interests in any product or service discussed in the manuscript (i.e. employment, gifts, stock holdings or options, honoraria, consultancies, expert testimony, patents and royalties). All authors were involved in the development of the website www.medappfinder.com and no author is currently receiving or anticipates receiving any financial gains from this Web-based searchable database (more details of donated Web development expertise and bandwidth in acknowledgments). * Correspondence: Seth Heldenbrand, University of Arkansas for Medical Sciences, Department of Pharmacy Practice, College of Pharmacy, 4301 W. Markham #522, Little Rock, AR 72205. E-mail address: [email protected] (S. Heldenbrand).

Medication nonadherence and health literacy Impact and types of nonadherence Medication nonadherence produces serious health and economic consequences for patients and hinders the ability of providers to effectively manage many chronic diseases. The average adherence rate for chronic medication therapy is approximately 50%, regardless of disease.1 Despite many strategies to improve medication adherence, it remains a common health care problem.2 The estimated avoidable

http://dx.doi.org/10.1016/j.japh.2015.12.014 1544-3191/© 2016 American Pharmacists Association. Published by Elsevier Inc. All rights reserved.

SCIENCE AND PRACTICE S. Heldenbrand et al. / Journal of the American Pharmacists Association 56 (2016) 293e302

Key Points Background Medication non-adherence continues to be a costly and significant problem for patients on chronic medications. Smartphone adherence apps offer a new mode for addressing medication non-adherence and storing health information. The adherence app marketplace has grown exponentially and offers apps with varying quality and level of health literacy compliance. Findings As of June 2014, there were over 400 medication adherence apps available and they vary widely in functionality and quality. 100 of the highest-scoring apps were user-tested for both functionality and level of health literacy. Results were catalogued in a searchable website database (www.medappfinder.com) to enable both patients and providers in identifying quality medication adherence apps. health care cost associated with medication nonadherence is between $100 billion and nearly $300 billion annually.3,4 Moreover, data suggest that nearly 70% of medication-related hospitalizations are due to nonadherence.5 Medication nonadherence is broadly categorized as unintentional or intentional nonadherence. Unintentional nonadherence involves the failure to take a medication when one had every intention to do so (e.g., forgetfulness, thoughtlessness).2 In contrast, intentional nonadherence involves a patient consciously deciding not take their medication based on influences (e.g., medication cost, perceptions, feelings, or beliefs).2

health care professionals continue to use behavioral interventions, patients are turning to more novel methods. Traditional pill reminder systems (e.g., weekly pill boxes, packaged calendars) passively remind patients to take their medications and are difficult to use with complex medication regimens, so they are more useful for cases of unintentional nonadherence.21-23 Other types of electronic systems are available (e.g., telephone reminders, pagers), but may be impractical for widespread use.2 Early mobile devices provided text messaging (short message service [SMS] or multimedia messaging service) functionality for telephone messaging adherence interventions. Limited studies show that SMS reminders improve adherence outcomes (e.g., adherence rates, appointments made, decreased missed dosages, improved attitudes towards medication, less treatment interruption).24 However, security concerns, lack of HIPAA compliance, and the need for connection to a service provider limit the usefulness of mobile telephone messaging interventions with the use of only SMS messaging. Behavioral interventions, including patient counseling and education, are also still commonly used in an attempt to improve adherence.24 Smartphones primarily use cellular data to access the Internet and do not require an additional subscription Internet service provider to download applications (apps) or access information. Smartphone use is prevalent in the US and continues to increase, with nearly two-thirds of Americans owning a smartphone.25 Estimates suggest that 62% of smartphone users in the US have accessed health information via their phone.25 Although the consumer use of smartphone medication adherence apps (adherence apps) is difficult to measure, the rapidly growing number of such apps available in the marketplace suggests that they are becoming a popular tool to address nonadherence and patient behavior. Adherence apps are readily accessible, can engage and educate the patient about their medications, and serve as a source of patient- and medication-specific health care information. These adherence apps can potentially consolidate all of the user’s medicationspecific information and thereby provide a more streamlined method to educate the individual about his/her disease or care.2

Impact of health literacy Like medication nonadherence, low patient health literacy has many negative health consequences. Patients with lower health literacy are more likely to inappropriately use health services and have less knowledge about medical conditions and treatment than patients with higher levels of health literacy. Additionally, these patients are susceptible to higher hospitalization rates, poorer health status, higher health care costs, and worse psychologic effects.6-14 Compared with those with adequate health literacy, patients with lower health literacy also experience increased serious medication errors, they overuse emergency departments, underuse preventive care, and have increased mortality.15-19 Methods to improve adherence Historically, behavioral interventions, including patient counseling and education, have been common methods used in an attempt to improve medication adherence.20 Although 294

Health literacy in app design The widespread use of smartphones and their continued growing popularity present an ideal opportunity to design adherence appebased interventions to improve medication adherence. However, if such interventions are not properly designed, they may be counterproductive.26 Individuals with low health literacy have difficulty accessing health information online.27 In particular, such individuals may struggle with mobile apps designed with smaller text size and higher user demands than typical Web-based interfaces.26,28 The Institute of Medicine has endorsed an approach calling on developers to consider usability and literacy demands in app design to mitigate barriers that mobile health applications such as adherence apps may pose to those with low health literacy.26 Decreasing user demands of adherence apps through design could enhance their potential to address medication nonadherence by maximizing their utility for all users, including those with low health literacy.

SCIENCE AND PRACTICE Helping health care providers and patients find quality medication adherence apps

Effectiveness of smartphone adherence apps By the fourth quarter of 2012 there were approximately 160 unique general adherence apps available.2 At that time, literature on the clinical application and effectiveness of smartphone adherence apps to improve medication adherence was lacking. To date, quality data are still sparse on the role or effectiveness of such apps in improving medication adherence.24 Despite the lack of high-quality evidence regarding their efficacy, adherence apps are being used by patients. Therefore, as medication use experts, pharmacists should be well positioned to help patients in locating adherence apps that best meet their needs. Previously, researchers developed a resource to compare adherence apps and identified 3 apps that offered the widest range of features and would be the most appropriate to recommend to patients.2 Since then, the popularity of smartphones and medication apps has continued to grow in number and sophistication as health care becomes ever more patient centered. A need exists to reevaluate the adherence app marketplace and to develop a readily accessible searchable resource for patients and providers to help them in identifying and comparing apps based on usability, literacy demands, and features that meet their needs. The objective of the present project was to assess the features, functionality, and level of health literacy of available medication adherence apps in the marketplace and to create a Web-based searchable adherence app resource for health care professionals and patients. Methods Marketplace search In June 2014, three online marketplaces (iTunes, Google Play [Android], and Blackberry App World) were searched to identify all available medication adherence apps with the use of the following search terms: adherence, compliance, dosage, dose, drug, med(s), medication(s), pharm, pharmacy, pill(s), prescription, remind, reminder, Rx, script, take, therapy, treat, and treatment. In each online app store, the “Health and Fitness” and “Medical” categories were also comprehensively searched to identify any medication adherence apps undiscovered by the search terms. App name and manufacturer were recorded to allow the investigators to easily find the app at a later time. English-language apps with the stated capability to generate medication reminders were included in the analysis. For apps with “lite” or “trial” versions, only the fully featured version was included in our analysis. However, apps available on multiple platforms (Apple, Android, Blackberry) were treated as separate entities. Apps were excluded if they were specific to a single medication (e.g., oral contraceptives) and disease state (e.g., diabetes). Initial evaluation and scoring The authors identified 28 features to assess the adherence app quality, as described in Table 1. The features were divided into 4 domains: Adherence attributes, Medication management, Connectivity, and General features. Each feature was evaluated on a nominal scale and assigned a weighted score based on the importance within the respective domain

(1, modest; 2, moderate; and 3, high), as presented in Table 1. Because the rating system was developed based on author consensus before evaluating individual adherence apps, it reflects the perspectives of the authors (academicians, clinical practitioners, health literacy specialists, and student pharmacists) and does not directly assess the desirability of these features by patients. The maximum point totals that could be achieved in each domain were: Adherence attributes, 21; Medication management, 15; Connectivity, 13; and General features, 19. Two investigators independently analyzed the developers’ descriptions and available screenshots in the online marketplaces to determine if an app possessed any of the 28 author-identified features. Investigators cross-verified initial app scores available on multiple platforms. Discrepancies were settled by revisiting the developer’s description in the online marketplaces. The sum of the weighted scores was used to calculate an initial score (maximum of 68 points). Apps were ranked by means of these initial scores based on the developers’ descriptions.

User testing The top 100 highest-ranking adherence apps were then subjected to user testing to compare their quality against the developers’ descriptions by installing the apps on smartphones. Adherence apps that could not be installed by at least one investigator or failed to generate reminders were excluded from further user testing. Two investigators tested each app independently over a 7-day period. The following standardized 6-drug regimen was used to ensure full functionality: vitamin E 400 IU once daily, diltiazem 120 mg twice daily, simvastatin 40 mg once daily at bedtime, prednisone 20 mg taper (3 times daily for the first day, 2 times daily for the second day, and once daily for the third day), azithromycin 500 mg once daily for 3 days and then stop, and alendronate 35 mg once weekly. During user testing, the original 28 features were reassessed and scored with the use of the scoring system described above with a minor modification when scoring the feature “Capable of complex medication instructions.” Owing to variation among the apps for this feature, it was decided that the scoring for this feature should reflect more precisely which medications tested could generate reminders. For example, an app capable of sending reminders for the prednisone taper and capable of reminding about the other 5 medications received the maximum score of 3. An app capable of completing the azithromycin stop date or the once-weekly alendronate reminder along with the onceand twice-daily medications received a score of 1. Apps that were unable to remind about the once- and twice-daily medications received a score of 0 for the “Capable of complex medication instructions” feature. In addition to the initial 28 author-identified features, several desirable features for adherence apps were identified based on the approach to app design endorsed by the Institute of Medicine.26 The 100 highest-ranking adherence apps, per initial scoring, were user tested and compared for the inclusion and functionality of these health literacy level attributes (Table 1). A separate Health Literacy domain was created containing an additional 12 features. The Health Literacy domain was scored with the use of a Likert scale (1e5) to give a total of 60 points possible for this domain. To avoid 295

Domain Adherence attributes

Connectivity

General features

Pointsa

Description

Tracks missed and taken doses Specific medication reminders

3

Apps with ability to remind patients to take their medication as well as to record taken and missed doses that could potentially be used to calculate adherence rates Apps that provide a reminder including specific name of medications that are due to be taken

Medical social networking

3

Apps that can reach out to caregivers or health care providers by means of text messages or over the Internet when a patient has failed to acknowledge medication reminders

Reminder postponing

3

Apps with the ability to “snooze” a medication reminder temporarily if a patient is unable to take the medication at that time

Customizable reminders

2

Apps that let the patient choose or customize the tone, sound, or volume of medication reminders

Escalating reminders

3

Apps with reminders that escalate in intensity (loudness, vibration, text message, or automated call) when the patient does not acknowledge the initial reminder

3

Refill alerts

2

Apps that alert a patient when it is time to refill a prescription at the pharmacy

Incentives

2

Apps that reward a patient for achieving medication adherence goal through encouraging messages

Complex medication instructions

1e3

Apps with the ability to schedule nondaily, monthly, every x days, medication tapers, or medications with stop dates

Database of medications

3

A medication database was available that allowed the user to enter, search, and select medications using features such as autopopulation

Identifies potential interactions

3

Apps that have the capability to check new medications for potential drug or food interactions with current medication

Transmit refill requests

2

The ability of an app to transmit a refill request to a specific pharmacy when a patient is running low on medication

Multiple profile capability Extensive medical history Provider can input data Generates reminders with no connectivity Cloud data storage Export/share data Online data entry Latest revision

2

Apps capable of generating medication reminders for multiple individuals (i.e., for family use)

2

Apps that can store medication, diagnosis, provider, and other miscellaneous health information

3

Apps that allow providers to input and maintain the patient’s medication regimen on a computer and “push” the regimen to the patient’s device

3

Apps capable of generating medication reminders without the use of cellular or wireless connectivity

3 2 2 1e3

Apps that have the capability to back up and retrieve a medication regimen from a cloud storage system The ability to transmit, print, or export medication regimens and/or medication taking behaviors for use by the patient or health care providers Apps with companion websites that allow data and medication regimen entry from a computer Scored on the basis of the frequency of continued app updates/support by developers: 3, updated in past 6 months; 2, updated in past year but not updated in past 6 months; 1, most recent update more than 12 months ago Apps with a statement from their manufacturer claiming HIPAA compliance Apps available on more than one platform.

HIPAA compliance Multiple-platform app Free-only apps Multilingual Patient-taken medication image Password protected Advertisement free

3 3 3 2 2 1 1

Completely free apps (no fees for “pro” upgrades or charges to unlock additional features) Any app available in English plus any other language (English þ1) Apps with the ability for a patient to take a photo of their medications and have that photo displayed in the reminder when it is time to take the medication Apps that require a password to access medication profile or health information. Apps free of advertisements or pop-ups of any kind (continued on next page)

S. Heldenbrand et al. / Journal of the American Pharmacists Association 56 (2016) 293e302

Medication management

Attribute

SCIENCE AND PRACTICE

296

Table 1 Attributes of adherence apps and descriptions


Instructions are not in paragraph format, or appropriate use of lists and bullets of key information are used throughout the app

App font is large and easily readable, or the user has the ability to zoom in to enlarge font as desired Important information is displayed primarily on the center of the screen to minimize scrolling

App uses meaningful headings to help users quickly focus on desired areas or information

Home screen for the app is simple and engaging to the user App’s graphics are simple and meaningful to the user and are not overly complex or distracting App’s screen-based controls are simple to use and enlarged to accommodate users that are visually impaired or have limited coordination App maintains adequate “white space” and is free of cluttered words or graphics

1e5

1e5

1e5 1e5

1e5

1e5 1e5 1e5 1e5

Easy to understand and set up Use of bullets and short lists Readable font Centered information Meaningful heading Home screen Simple graphics Enlarged controls Clutter free

overweighting this domain relative to the other 4 domains combined, the Health Literacy scores were transformed as follows: An adherence app receiving a score of 1e12 in this domain had 1 point added to the user-tested score, and a score of 13e24 had 2 points added. This scoring system continued in increments of 12 up to a possible maximum of 5 points that could be added to the user-tested score. In addition to the maximum point total of the desired feature domains listed above, with the Health Literacy domain, the overall maximum user-tested score was 73. The user-tested scores were cross-verified resulting in a final consensus score for each app. Any discrepancies were resolved by reinstalling the app and confirming that the app possessed that feature. Multiplatform apps with scoring discrepancies across platforms were cross-verified by the authors through consensus. Apps were reranked based on the usertested score. Abbreviations used: HIPAA, Health Insurance Portability and Accountability Act. a All ratings based on author consensus weighting of attributes by point scale except Health Literacy level, which was based on a 5-point Likert scale.

App is written in plain language that is easy to understand; apps lost points if they contained more than 3 words on screen that were 3 syllables or more (3 words ¼ 5 points; 7 words ¼ 1 point) Initial setup of the app is easy to understand; loading medications and setting up reminders is intuitive 1e5 Plain language Health literacy

1 App provides stock photo

Apps that provide a generic stock photo of medications from an internal database

Pointsa Attribute Domain

Table 1 (continued )

Description

Helping health care providers and patients find quality medication adherence apps

Establishing a visual rating scale (star rating) Using the final user-tested scores, apps were given a “star rating” in each of the 5 domains, ranging from 1 to 5 stars. Adherence Attributes, Medication Management, Connectivity, and General Features received a star rating based on where the domain’s total value fell on the distribution of user-testing scores. A rating of 5 stars indicated that the app had a score in the top 5% of all apps tested in that domain. Four, 3, 2, and 1 stars were assigned to apps that had a score in the 80th to 95th percentile, 21st to 79th percentile, 6th to 20th percentile, and the bottom 5%, respectively. The health literacy domain star rating was based on the Health Literacy user-testing score described previously. For example, an app that received a Health Literacy score of 3 also received a star rating of 3. The overall star rating for each app was generated by averaging the star values from the 5 individual domains, and overall star ratings were rounded to the nearest whole number. The star rating system was intended to help the lay user identify quality adherence apps without understanding the methods behind the individual domain and overall scoring system. Results The initial search revealed 461 adherence apps across all 3 platforms. Of these, 52 adherence apps were excluded because they were the “lite” or “trial” versions; 3 apps were identical, but under different names, and 39 apps addressed only specific medications and/or disease states. Therefore, in total, there were 367 unique evaluable adherence apps. Of the evaluable adherence apps, 325 (88.5%) were available on a single platform (iTunes, 180; Android, 165; Blackberry, 22), and there were 42 apps available on multiple platforms. The median initial score calculated from the developers’ descriptions was 15 out of 68 (range, 3-47). Table 2 summarizes the frequency of app features by domain and their corresponding operating system. Based on the rating of developer claims, the top 100 highest-ranking adherence apps were distributed across the 3 platforms as follows: 46 iOS, 50 Android, and 4 Blackberry. Nineteen of these adherence apps failed user-testing because they did not produce medication reminders or were unable to be successfully installed by at least one author and were not 297


Table 2 Frequency and scoring of medication app characteristics by app operating system and domain, n (%) App features, n (%)

Domain Adherence attributes


Connectivity

General features

iPhone

Android

Blackberry

Attribute

(n ¼ 180)

(n ¼ 165)

(n ¼ 22)

(n ¼ 367)

Tracks missed and taken doses Specific medication reminders Escalating reminders Medical social networking Reminder postponing Customizable reminders Refill alerts Incentives Complex medication instructions Database of medications Identifies potential interactions Transmits refill requests Multiple profile capability Extensive medical history Provider can input data Generates reminders with no connectivity Cloud data storage Export/share data Online data entry HIPAA compliance Multiplatform Multilingual Patient-taken medication image Password protected Advertisement free App provides stock photo Free-only apps

70 49 6 10 46 19 64 12 28 27 7 28 43 13 2 164 20 52 7 3 30 67 27 22 175 11 81

57 85 5 6 57 51 47 12 32 18 3 27 30 10 6 159 5 37 7 2 42 36 17 18 157 5 115

7 8 0 2 4 6 7 2 6 1 0 5 3 1 1 18 0 8 1 1 8 3 0 5 21 0 12

134 142 11 18 107 76 118 26 66 46 10 60 76 24 9 341 25 97 15 6 80 106 44 45 353 16 208

Health Literacy scores, mean (SD) Health literacy

Plain language Easy to understand and set up Use of bullets and short lists Readable font Centered information Meaningful headings Engaging home screen Simple graphics Labels reflect words users know Enlarged controls Audio and visual components Clutter free

(38.9) (27.2) (3.3) (5.6) (25.6) (10.6) (35.6) (6.7) (15.5) (15.0) (3.8) (15.5) (23.8) (7.2) (1.1) (91.1) (11.1) (28.9) (3.9) (1.7) (16.7) (37.2) (15.0) (12.2) (97.2) (6.1) (45.0)

(34.5) (51.5) (3.0) (3.6) (34.5) (30.9) (28.4) (7.2) (19.3) (10.9) (1.8) (16.3) (18.1) (6.0) (3.6) (96.3) (3.0) (22.4) (4.2) (1.2) (25.4) (21.8) (10.3) (10.9) (95.1) (3.0) (69.6)

(31.8) (36.3) (0.0) (9.0) (18.1) (27.2) (31.8) (9.0) (27.2) (4.5) (0.0) (22.7) (13.6) (4.5) (4.5) (81.8) (0.0) (36.3) (4.5) (4.5) (36.3) (13.6) (0.0) (22.7) (95.4) (0.0) (54.5)

Total

(36.5) (38.6) (2.9) (4.9) (29.1) (20.7) (32.1) (7.0) (17.9) (12.5) (2.7) (16.3) (20.7) (6.5) (2.4) (92.9) (6.8) (26.4) (4.0) (1.6) (21.8) (28.8) (11.9) (12.2) (96.1) (4.3) (56.6)

iPhone

Android

Blackberry

Total

(n ¼ 44)

(n ¼ 33)

(n ¼ 0)

(n ¼ 77)

1.6 3.0 4.1 3.1 3.4 3.2 3.2 3.2 3.2 3.3 4.0 4.1

(0.61) (1.02) (0.95) (0.87) (0.92) (1.13) (0.96) (1.08) (0.98) (0.82) (1.05) (0.95)

1.7 2.8 4.2 3.4 3.4 3.2 3.4 3.0 3.1 3.1 3.8 4.2

(0.84) (1.20) (0.83) (0.96) (0.93) (1.20) (1.03) (1.02) (0.89) (1.01) (1.10) (0.94)

d d d d d d d d d d d d

1.7 2.9 4.1 3.2 3.4 3.2 3.3 3.1 3.2 3.2 4.0 4.1

(0.72) (1.10) (0.90) (0.92) (0.92) (1.10) (0.98) (1.10) (0.94) (0.90) (1.10) (0.94)

Abbreviations used: HIPAA, Health Insurance Portability and Accountability Act.

tested further. Additionally, the 4 Blackberry apps were not subjected to user testing because they were not supported by the device, required a specific insurance plan, or needed a pharmacy-specific prescription number. Seventy-seven apps (44 iOS and 33 Android) underwent user testing to assess features and health literacy compliance and were scored. The median overall user-tested score was 30 out of 73 (range, 16-55). Table 3 shows the frequency of app features for the 12 highest-scoring apps based on user testing. User-testing results of all evaluated apps can be found at: www.medappfinder.com. Adherence Attributes domain The median score for user-tested adherence apps in this domain was 8 out of 21 (range, 0-19). The ability to issue reminders about specific medications (70%) and track missed 298

and taken doses (69%) were the most commonly found features of this domain. The ability to customize reminders (47%) and to postpone a reminder to a later time (45%) were other prevalent features in this domain present in the user-tested adherence apps. Medication Management domain The median user-tested score in this domain was 5 out of 15 (range, 0-10). Adherence apps varied greatly in their ability to handle complex medication regimens. For example, all apps were able to send either once-daily or twice-daily reminders, but only 44% were able to remind about the once-daily, twicedaily, once-weekly, and stop-date medications. No app was able to send an accurate reminder for the entire prednisone taper regimen. For complicated regimens, a few apps allowed providers to use a companion website to input the patient’s

Table 3 Attributes and cost of highest-scoring apps after user testing Domain

Adherence attributes

Connectivity

General features

Price ($) Health literacy score (range 1e5)

Medisafe Medication Manager

Care4today Mymeds Dosecast Mango Premium Health

Medcoach Pill Reminder by drugs .com

Healthassist Med Helper Pro

Carezone Meds

Pills Mymedrec (hourly)

Apple iOS Android User-tested score þ Health Literacy Tracks missed/taken doses Specific medication reminders Escalating reminders Medical social networking Reminder postponing Customizable reminders Refill alerts Incentives Complex medication instructions Database of medications Identifies drug/food interactions Orders refills from pharmacy Multiple profiles Extensive patient history Provider can input regimen Generates reminders with no connectivity Cloud storage Export/shares data Online data entry HIPAA statement Multiplatform Multilingual Patient photo of medications Password protected Advertisement free App provides photo of meds Free-only app

X X 55 X X X X X X X

X X 51 X X

X X 50 X X

X X 40 X

X X 39

X X 38

X

X

X

X

X X

X

X

X X

X X

X X X

X

X X 0.00 2 5 5 3 5 3 5 5 4 4

X X X X X 0.00 2 4 5 2 3 3 5 5 4 4

X X X X X X X X X

41 X X

X X

X X X X X X X

X X

9.99/y 1 4 5 3 4 4 3 3 2 5

39 X

X

X

X X X

X X

X X

X X 38 X X

X

38 X X

X X 38 X X

X X

X

X X X X

X

X

X

X X

X

X

X X

X

X X 3.99 1 4 4 3 3 2 3 3 3 3

X X X X 0.00 2 4 3 3 4 5 5 4 4 5

X X

X X X

X X

X

X X

X X

X

X X X

X X

X

X X

X

X

X

X

X

X X X

X X

X

X

X

X

X

X X X X

X

X X X X

X X X

X

X X

X X

X X X X X

X X X

X X

X 0.00 2 4 5 2 4 4 4 4 4 4

X 0.00 2 4 3 2 4 5 2 5 4 4

X 0.00 1 2 2 3 4 1 4 4 1 3

X X X

3.99 1 2 4 5 3 2 4 3 3 4

X X 0.00 1 4 4 3 3 4 4 3 3 3

X

1.99 1 3 5 4 1 4 4 4 3 4

X X X X X X 0.00 1 2 4 4 2 2 2 2 2 3

(continued on next page)

299


Plain language Easy to understand and set up Use of bullets and short lists Readable font Centered information Meaningful heading Engaging home screen Simple graphics Labels reflect words users know Enlarged controls

X X

X X X X X

X X 45 X X

Helping health care providers and patients find quality medication adherence apps


Attribute


300

4 31 3 3.2

3

regimen and send it directly to their mobile device. Only 2 adherence apps possessed the capability to identify a potential food and drug interaction.

4 42 4 3.8

3

4 38 4 3.8

General Features domain The median user tested score in this domain was 9 out of 19 (range, 1-16). Of the 77 adherence apps that underwent user testing, 69 (90%) did not have a HIPAA compliance statement. Although all apps were tested with the use of the English language, almost 50% had an option to use different languages, including Spanish, Chinese, French, and others. To allow for easy recognition when the reminders occurred, 55% of apps either provided a stock photo of the medications or allowed patients to upload their own photo. Adherence app prices ranged from free to $15.99, with the average cost being $0.96. Additionally, some apps were initially free to download, but required in-app purchases to unlock extra features.

5

4 48 4 3.6 4 38 4 4.2

5 47 4 3.8

5 45 4 3.4

4 32 3 3.2

5 42 4 3.8

The median user-tested score in this domain was 5 out of 13 (range, 2-13). Almost all adherence apps (96%) were capable of generating reminders without connectivity (e.g., calendar or alarm-type reminders); however, many apps (60%) required either cellular communications to provide medication reminders (e.g., SMS text messaging), or an internet connection for other functionalities (e.g., export and share information, medical social networking, or ordering prescription refills).

Health Literacy domain

5 47 4 4.4

5 42 4 4.4

5

5 51 5 4.6 Clutter free Total score Total transformed score Star rating

Audio and visual components

5

3

5

5

5

3

5

5

Connectivity domain

Abbreviations used: HIPAA, Health Insurance Portability and Accountability Act.

Domain

Table 3 (continued )

Attribute

Medisafe Medication Manager

Care4today Mymeds Dosecast Mango Premium Health

Medcoach Pill Reminder by drugs .com

Healthassist Med Helper Pro

Carezone Meds

Pills Mymedrec (hourly)

S. Heldenbrand et al. / Journal of the American Pharmacists Association 56 (2016) 293e302

The median user-tested score in this domain was 40 out of 60 (range, 24-51) and the mean transformed score was 3.47 out of 5 (range, 2-5). Of the 25 highest-ranking user-tested adherence apps, nearly 50% of apps averaged a Health Literacy score of 4 or above. The 2 most commonly found attributes were the ability to add both audio and visual components to the reminders (78%) as well as being organized in appearance and lacking any unnecessary clutter on the screen (82%). The lowest-scoring component of this domain was the use of common words (33.5%). Discussion Implications for pharmacy practice and future directions Since September 2012, the medication adherence app market has more than doubled.2 We evaluated more than 400 adherence apps and subjected the 100 highest-ranking apps to user testing and found the majority of adherence apps are designed to be patient oriented rather than health care provider oriented. Therefore, it is concerning that nearly 25% of the top-scoring adherence apps could not perform a basic function (i.e., issue reminders) to mitigate nonadherence, could not be installed by a student health care professional, or possessed other barriers to using them. Of the 77 unique apps that underwent cross-verified user testing, there was considerable variability in the quality and functionality between the adherence apps. None of the adherence apps tested possessed

SCIENCE AND PRACTICE Helping health care providers and patients find quality medication adherence apps

all quality features; however, several were highly rated across all 5 domains of quality. Nonadherence is a longstanding problem across many chronic diseases.24 Although current methods of improving adherence for chronic health problems are mostly complex and to date have not been very effective, there continues to be a gap between adherence research and the rapid developments in technology.24 Despite the continued growth in the adherence app marketplace, our data show that many of the available apps lack many basic adherence app attributes. This finding may merely reflect the inability for research in this area to keep pace with the technologic advances that hold potential to improve medication adherence. In assisting patients with selecting an adherence app to meet their needs, pharmacists should be aware of this gap and consider additional strategies that can be maintained throughout the course of therapy. Of concern, we found that while a majority of adherence apps are capable of handling straightforward medication instructions, fewer than half were capable of adequately handling complex medication regimens, where reminders may be of most importance. Many medication management factors have previously been associated with medication adherence, including number of medicines, adverse effects, and regimen complexity.29 Although the data are somewhat mixed, all of these factors generally negatively affect adherence, particularly among older patients. Persons that are more likely to use and sustain use of apps for medication adherence are those that are older and are on more medications, which highlights the importance of handling complex medication regimens.30 To meet their needs, pharmacists should be aware of the adherence apps that can navigate complex medication instructions or regimens. Future aims that could address this gap could include adherence apps having a database capable of interfacing with a variety of community and institutional large health care databases such as electronic medical records or pharmacy dispensing data to download the patient’s current medication regimen. This would simplify medication changes ranging from primary care medication changes to complicated hospital discharge medication instructions. An estimated 64% of American adults own a smartphone, of which approximately 20% access online services and information regularly with these devices.25 Indeed, people report that next to using the traditional mobile telephone functions, they use their smartphone to access health information more frequently than they use it to perform online banking.25 Currently, smartphones are the only means of access to highspeed internet for approximately 10% of the population and many individuals are choosing to own a smartphone in place of a personal computer for internet access.25 As smartphones become more pervasive, adherence apps have the potential to improve patient health. However, this potential may not be reached by many of the apps available today. We found many adherence apps to be poorly designed and implemented which made them difficult to use or yielded subpar functionality. The present study used health care professionals and students, rather than patients, to evaluate adherence apps. Based on our results, a majority of adherence apps were not intuitive to use and were difficult to set up, which may prove more difficult to use for patients who are unfamiliar with these types of devices and technology. These

deficiencies and difficulties will also be magnified in patients with low health literacy.26 The importance of choosing adherence apps that take into account use by individuals with low health literacy cannot be minimized. More than one-half of American adults have low health literacy. Furthermore, low health literacy affects many of the same populations who rely on smartphones for online access at elevated levels (e.g., non-whites and those with low household incomes and levels of educational attainment).25,31,32 A challenge for patients and providers looking for an adherence app that meets their needs is sifting through the sheer number of available apps. Search results may be compromised depending on the initial search term(s) one uses (e.g., “med,” “pill,” or “adherence”), which can inadvertently preclude the highest-quality adherence apps from being displayed for download. A secondary objective of the present project was to create a Web-based searchable adherence app resource for health care professionals and patients to identify adherence apps that meet their needs and were subjected to a rigorous and systematic method-based review. The results of our analysis were used to create and maintain such a resource (www .medappfinder.com). This resource has patient (basic) and provider (advanced) portals where the user can select specific features or entire domains of attributes they desire their app to possess. Once features are selected, the website queries a database and displays the highest-ranking apps from our evaluation. Potentially, this site may alleviate the frustration and possible expense of the trial-and-error method users currently have to go through when searching for an adherence app. The adherence app marketplace changes rapidly as new products are made available, new features get added to existing adherence apps, and adherence apps are removed from the marketplace. For this reason, we intend to evaluate the medication adherence app marketplace and update www .medappfinder.com annually. Study limitations The following limitations should be considered when interpreting the findings presented here. First, the features assessed and weighting of those features reflect the desirable attributes from a health care provider viewpoint and do not directly incorporate patient viewpoints. A small qualitative study of patients assessed attributes of a hypothetic adherence app for hyperlipidemia and found many attributes similar to what we tested, including cost, privacy, appearance, connectivity, and sharing information with health providers, so it is likely that many of the features we assessed would also be important to patients. Second, the user testing was performed on a small number of smartphone devices and tablets available to the authors and we recognize that the functionality of apps may vary by smartphone device and version of the operating system. Assessing many of the attributes, particularly the health literacy attributes, is inherently subjective, and ratings of these attributes may be influenced by the testers’ viewpoints. To mitigate potential measurement error, we used an adapted standardized framework to assess health literacy and user tested each app by 2 independent raters who reached consensus ratings. Although smartphone use has increased dramatically over the past 5 years, smartphones are not ubiquitous, and recommending an adherence app would be a

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potential strategy to improve adherence only of those who own and use a smartphone. Conclusion The adherence app marketplace doubled over a year, with more than 400 general medication adherence apps available to patients and their health care providers. The vast majority (>90%) are consumer-oriented apps that do not allow health providers to input or otherwise manage or “push” prescription reminders. There is considerable variability in the features available on these adherence apps and our website (www .medappfinder.com) can assist patients and their health providers to identify apps based on the individualized features patients want. Although data on the effectiveness of apps to improve adherence is largely untested, medication apps represent a possible low-cost scalable strategy that pharmacists and other health care professionals can recommend to nonadherent patients and incorporate into their practice. Acknowledgments The authors acknowledge the University of Arkansas for Medical Sciences Center for Health Literacy for developing and hosting the website www.medappfinder.com. This site would not have been possible without the donated bandwidth and Web development expertise of Philip Walter and Benjamin Lamb. References 1. Iihara N, Tsukamoto T, Morita S, et al. Beliefs of chronically ill Japanese patients that lead to intentional non-adherence to medication. J Clin Pharm Ther. 2004;29(5):417e424. 2. Dayer L, Heldenbrand S, Anderson P, et al. Smartphone medication adherence apps: potential benefits to patients and providers. JAPhA. 2013;53(2):172e181. 3. IMS Institute for Healthcare Informatics. Avoidable costs in U.S. healthcare: the $200 billion opportunity from using medicines more responsibly. Available at: www.imshealth.com/en/thought-leadership/webinar-library/ avoidable-costs-in-us-healthcare-200-billion-opportunity. Accessed July 8, 2015. 4. Benjamin RM. Medication adherence: helping patients take their medicines as directed. Public Health Rep. 2012;127(1):2e3. 5. Osterberg L, Blaschke T. Adherence to medication. N Engl J Med. 2005;353(5):487e497. 6. Bennett IM, Chen J, Soroui JS, White S. The contribution of health literacy to disparities in self-rated health status and preventive health behaviors in older adults. Ann Fam Med. 2009;7(3):204e211. 7. Griffey RT, Kennedy SK, d’Agostino McGownan L, et al. Is low health literacy associated with increased emergency department utilization and recidivism? Acad Emerg Med. 2014;21(10):1109e1115. 8. National Library of Medicine. Health literacy. Available at: http://nnlm. gov/outreach/consumer/hlthlit.html; 2013. Accessed July 16, 2015. 9. Agency for Healthcare Research and Quality. Low health literacy linked to higher risk of death and more emergency room visits and hospitalizations. Available at: http://archive.ahrq.gov/news/newsroom/pressreleases/2011/lowhlit.html; March 2011. Accessed July 16, 2015. 10. Berkman ND, Sheridan SL, Donahue KE, et al. Low health literacy and health outcomes: an updated systematic review. Ann Intern Med. 2011;155(2):97e107. 11. Omachi T, Sarkar U, Yelin E, et al. Lower health literacy is associated with poorer health status and outcomes in chronic obstructive pulmonary disease. J Gen Intern Med. 2013;28(1):74e81. 12. Office of Disease Prevention and Promotion, US Department of Health and Human Services. National action plan to improve health literacy. Available at: www.health.gov/communication/hlactionplan/; 2010. Accessed July 16, 2015. 13. Howard DH, Gazmararian J, Parker RM. The impact of low health literacy on the medical costs of Medicare managed care enrollees. Am J Med. 2005;118(4):371e377.

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14. Wolf MS, Williams MV, Parker RM, et al. Patients’ shame and attitudes toward discussing the results of literacy screening. J Health Commun. 2007 Dec;12(8):721e732. 15. Kripalani S, Gatti M, Jacobson T. Association of age, health literacy, and medication management strategies with cardiovascular medication adherence. Patient Educ Couns. 2010;81(2):177e181. 16. Davis TC, Wolf MS, Bass III PF, et al. Literacy and misunderstanding prescription drug labels. Ann Intern Med. 2006;145:887e894. 17. Baker DW, Gazmararian JA, Williams MV, et al. Functional health literacy and the risk of hospital admission among Medicare managed care enrollees. Am J Public Health. 2002;92(8):1278e1283. 18. Bostock S, Steptoe A. Association between low functional health literacy and mortality in older adults: longitudinal cohort study. BMJ. 2012;15:344. 19. Sudore RL, Landefeld CS, Perez-Stable EJ, Bibbins-Domingo K, Williams BA, Schillinger D. Unraveling the relationship between literacy, language proficiency, and patient-physician communication. Patient Educ Couns. 2009;75(3):398e402. 20. Nieuwlaat R, Wilczynski N, Navarro T, et al. Interventions for enhancing medication adherence. Cochrane Database Syst Rev. 2014;(11):CD000011. 21. Mahtani KR, Heneghan CJ, Glasziou PP, Perera R. Reminder packaging for improving adherence to self-administered long-term medications. Cochrane Database Syst Rev. 2011;(9):CD005025. 22. Zedler BK, Kakad P, Colilla S, et al. Does packaging with a calendar feature improve adherence to self-administered medication for long-term use? A systematic review. Clin Ther. 2011;33(1):62e73. 23. Harbig P, Barat I, Damsgaard EM. Suitability of an electronic reminder device for measuring drug adherence in elderly patients with complex medication. J Telemed Telecare. 2012;18(6):352e356. 24. Kannisto KA, Koivunen MH, V€ alim€ aki MA. Use of mobile phone text message reminders in health care services: a narrative literature review. J Med Internet Res. 2014;16(10):e222. 25. Pew Research Center. The smartphone difference. Available at: http:// www.pewinternet.org/2015/04/01/us-smartphone-use-in-2015/; April, 2015. Accessed July 10, 2015. 26. Broderick J, Devine T, Langhans E, et al. Designing health literate mobile apps. Discussion paper. Washington, DC: Institute of Medicine of the National Academies. Available at: http://www.iom.edu/Global/ Perspectives/2014/HealthLiterateApps.aspx. Accessed July 6, 2015. 27. Levy H, Janke A, Langa K. Health literacy and the digital divide among older Americans. J Gen Intern Med. 2015;30(3):284e289. 28. Harrison R, Flood D, Duce D. Usability of mobile applications: literature review and rationale for a new usability model. J Interact Sci. 2013;1: 1e16. 29. Gelland WF, Grenard JL, Marcum ZA. A systematic review of barriers to medication adherence in the elderly: looking beyond cost and regimen complexity. Am J Geriatr Pharmacother. 2011;9(11): 11e23. 30. Becker S, Brandl C, Meister S, et al. Demographic and health related data of users of a mobile application to support drug adherence is associated with usage duration and intensity. PLoS One. 2015;10.1:e0116980. 31. Paasche-Orlow MK, Parker RM, Gazmararian JA, et al. The prevalence of limited health literacy. J Gen Intern Med. 2005;20(2):175e184. 32. Institute of Medicine. Health literacy: a prescription to end confusion. Washington, DC: National Academies Press; 2004. Available at: http:// www.nap.edu/openbook.php?isbn¼0309091179. Accessed July 17, 2015.

Seth Heldenbrand, PharmD, Associate Professor of Pharmacy Practice, Department of Pharmacy Practice, College of Pharmacy, University of Arkansas for Medical Sciences, Little Rock, AR Bradley C. Martin, PharmD, PhD, Professor of Pharmaceutical Evaluation and Policy, College of Pharmacy, University of Arkansas for Medical Sciences, Little Rock, AR Paul O. Gubbins, PharmD, Associate Dean, and Professor of Pharmacy Practice, Division of Pharmacy Practice and Administration, University of Missouri Kansas City School of Pharmacy at Missouri State University, Springfield, MO Kristie Hadden, PhD, Assistant Professor, Director, Center for Health Literacy, UAMS Regional Programs, University of Arkansas for Medical Sciences, Little Rock, AR Catherine Renna, PharmD Candidate (2016), College of Pharmacy, University of Arkansas for Medical Sciences, Little Rock, AR Rebecca Shilling, PharmD Candidate (2017), College of Pharmacy, University of Arkansas for Medical Sciences, Little Rock, AR Lindsey Dayer, PharmD, BCACP, Assistant Professor of Pharmacy Practice, Department of Pharmacy Practice, College of Pharmacy, University of Arkansas for Medical Sciencess, Little Rock, AR