Jennifer Hanje, PharmD, will never forget the day her 9-month-old daughter Samantha was diagnosed with type 1 diabetes. “This was a shock because she seemed like a normal, happy, healthy baby,” said Hanje. Since that day nearly 4 years ago, Hanje has had to monitor Samantha’s blood glucose level around the clock. In the beginning, Hanje and her husband, Jim, a physician, drew blood samples every few hours and gave Samantha insulin shots.
When Samantha was about 14 months old, they switched to an insulin pump. “From there we got better at recognizing the symptoms of dangerously high or low blood sugar, but we were still shooting in the dark, going from blood sugar check to blood sugar check,” said Hanje, a clinical pharmacist in hematology and oncology at the Ohio State University Medical Center in Columbus.
In 2013, Hanje acquired a continuous glucose monitoring system called Dexcom, comprising a sensor that measures Samantha’s interstitial glucose every 5 minutes and transmits that information wirelessly to a small, iPod-sized device. The Dexcom shows a graph of all glucose readings, along with arrows to show glucose trends, and can even sound an alarm for high or low levels. This provides invaluable clinical context to those sometimes-confusing glucose numbers. The only catch is that it must be in very close proximity to the individual to see the numbers.
In 2014, a group of parents with children with type 1 diabetes who have united under #WeAreNotWaiting created a homegrown app called Nightscout, which allows Dexcom information to be transmitted wirelessly to a website so glucose readings can be viewed remotely using a smartphone.
“As a mother, this advance in mobile technology has been life changing. I’m comfortable leaving Samantha with other caregivers now,” said Hanje. “As a pharmacist, I see this technology opening up a whole new era for diabetes management. It allows pharmacists to check patients’ glucose levels remotely and follow trends instead of having to be there at their side.”
The field of mobile health (mHealth) has grown rapidly from simple fitness tracking apps to include an entire range of detailed health information that can be collected on a smartphone and sent directly to a patient’s physician, pharmacist, or electronic health record (EHR). “mHealth offers much for the practice of hospital pharmacy, with new technology being integrated into the medical workflow in an evolving number of ways,” said Timothy Dy Aungst, PharmD, Assistant Professor of Pharmacy Practice at the MCPHS University School of Pharmacy in Worcester, MA. “Collecting medical information from devices like wireless blood pressure cuffs, wireless scales, and wireless heart rate monitors on one personal device and having that information sent directly to a health care provider could lead to real time benefits for patients.”
There are thousands of health apps available for smartphones that help people track everything from blood pressure to heart rate, number of steps, weight, and more. “With the popularity of health tracking apps, there are a lot of companies that are interested in developing ways to integrate this information into the EHR,” said Aungst.
Last spring Apple unveiled its new Health app designed to provide users with a simple dashboard of health and fit-ness data. As part of the Health app, Apple is working on HealthKit, a developer platform for developers to merge or integrate software into Apple’s Health app. It will integrate data from third-party health and ﬁtness apps and monitoring devices such as wireless scales, fitness trackers, or blood pressure monitors. The data collected from various sources will be stored in the cloud to create a health profile.
Healthkit was supposed to launch as part of Apple’s new iOS8 mobile operating system, but the company is still working out a few software bugs. According to several media reports, Apple has partnered with two major health entities, Mayo Clinic and Epic, to develop ways for HealthKit to incorporate health information directly into patients’ EHRs. “This shows how seriously tech companies are taking health care,” said Aungst. Epic currently has an app called MyChart, which gives patients access to lab results, appointment information, med-ication lists, and immunization history.
In addition to apps, there has also been a dramatic increase in the use of wireless or Bluetooth health monitors, such as scales or blood pressure cuffs that transmit data wirelessly. Aungst, who works with patients with chronic heart failure, suggested the following scenario of how hospital pharmacists could improve care quality. One of the biggest red flags for hospital readmission in patients with heart failure is a quick and dramatic increase in weight. “What if a patient steps on the scale one day and there is an increase of 2 pounds,” explained Aungst. “Perhaps the patient would wait 1 day or 2 days before calling their provider because in their mind they were fine.”
But if a pharmacist saw the patient’s weight trending higher in the EHR, noted Aungst, then the pharmacist could send a note to the patient’s provider to contact the patient right away. “If the hospital pharmacist could identify warning signs ahead of time, then they could potentially reduce readmissions in high-risk patients,” said Aungst.
Information gleaned from wireless monitors, such as blood pressure, movement, or those that record current status like shortness of breath, could be sent to a patient’s EHR. “Pharmacists who work in transitions of care could use this data to help monitor patient therapy or provide patient education,” said Aungst. “Technologies such as smart pill bottles could help prevent readmissions caused by noncompliance in patients with chronic heart failure or other chronic diseases.”
Medication adherence problems are one of the biggest contributors to hospital readmissions. AdhereTech has developed a battery-powered smart pill bottle that measures the amount of liquid or solid medication in a bottle. Sensors placed in the plastic walls of the bottle detect how much medication a patient has taken. If doses are missed, a patient or his or her caregiver receive a text message or phone reminder. The data may also be sent to a patient’s family, friends, or physician.
Vitality Inc., a start-up based in Cambridge, MA, has developed GlowCaps, a special prescription bottle cap containing a chip that monitors when the bottle is opened. If the bottle is not opened, the cap will glow, a musical alarm will sound, and eventually the patient will receive a reminder phone call. When pressed, a button at the base of the cap will send a refill request to the pharmacy with an automated call back to confirm the refill. The device comes with a separate reminder light that can be plugged in anywhere in the house. The light glows when it is time to take the medication. The technology also includes weekly and monthly reporting sent to a patient, and his or her family or physician. “These smart pill bottles will help shape pharmacists’ interactions with patients and are a tool pharmacists can use to help patients stay adherent to their medications,” said Aungst.
Numerous apps are available for smartphones to help patients keep track of their pills and stay adherent to their medications. RxmindMe is a reminder app for medications, vitamins, and supplements. It allows users to enter all of their dosage information, set up reminders, and keep track of when the medication is taken. Other medication reminders apps include Med Reminder, Pill Monitor, Med Helper, Dosecast, iPharmacy, and Pill Prompter.
“Pharmacy chains are looking for ways to integrate patient-centered mHealth tools to help improve health,” said Aungst. The Balance Rewards for Health Choices program from Walgreens allows members to earn points for healthy behavior and lifestyle choices. The points can be redeemed for dollars off a future purchase. After joining this innovative program, users can use a number of health and fitness devices and apps to earn points. For example, members earn 20 points for each mile, 20 points when a weigh-in is added, and 20 points for blood pressure or blood glucose readings. Compatible devices include several Fitbit devices, iHealth Wireless Activity and Sleep Tracker, iHealthWireless Blood Pressure Wrist Monitor, Jawbone Up24, and others. Users can also receive points for prescriptions and immunizations and by purchasing certain products. A $5 reward can be redeemed with 5,000 points, according to the Walgreens website.
Although most experts agree that wireless and smartphone technology has the potential to drastically revolutionize health care, the technology isn’t quite there yet, and more research needs to be done to determine who should use the various technologies. “With a digital society where we socialize daily through messaging apps and social media and are lost without our devices, it’s not a hard jump to integrate such devices into our lives, and that may be what pushes mHealth in the coming years as a new paradigm in health management,” said Aungst.