Nikhil A. Sangave, PharmD

Advancements in technology have provided patients with many new pathways to manage their cardiovascular health. Telehealth has introduced new ways to enable remote health care delivery in an attempt to provide better access, improved quality, and lower costs to patients, especially during the coronavirus disease 2019 (COVID-19) pandemic.

 In recent years, digital health devices have offered pathways for patients to record and send data, which may ultimately encourage the patient to be more interactive in their disease management.

Alivecor, Apple, coala, eko, iRhythm, Omron, and Oculus

 are some of the companies that have a stake in cardiac digital health devices. Generally, cardiac devices are wearables that can track blood pressure, heart rate, electrocardiography (ECG), fitness, and sleep patterns.

 Most wearable devices are used alongside a companion app to record data, allowing physicians to monitor cardiac function and screen for heart abnormalities via email or in real time through a dashboard that can be shared directly with the patient.

Additionally, medication adherence plays a critical role in treating cardiovascular disease, making pharmacists key players in disease management after initial diagnosis. To keep secondary cardiovascular events at bay, pharmacists can perform counseling and medication therapy management to help the physician better understand a patient’s prognosis. The implementation of digital health devices may add new dimensions to the existing processes and could allow pharmacists to incorporate daily cardiovascular parameters into patient evaluations. 

Although studied as beneficial add-ons to current treatment, digital health devices have been used alongside telehealth as standard treatment during the COVID-19 pandemic.

 Prior to the recent public health emergency, trusted telehealth platforms and digital devices were limited to those that were compliant with the Health Insurance Portability and Accountability Act (HIPAA). With the Department of Health and Human Services temporarily waiving the penalties affiliated with not following HIPAA, there has been a disorganized adaptation of multiple digital and telehealth services during the pandemic.

This shift has given foresight into digital health-based models and a better perception into adjustments that need to be made as technology and health care continue to blend.

High smartphone ownership across all demographics may reduce health-related inequalities,

 but the use of smartphone compatible devices does not address patients facing other barriers. In a study comparing a smartphone coaching application to a smartphone tracking application, most participants in both control and intervention groups spoke English as a primary language and had 4 years or more of college education.

Additionally, in Treskes, et al, for patients who opted out of the intervention of a smartphone health monitoring device versus a regular follow up, one of the reasons classified was “fear of not being able to cope with technology.”

 Whether the issue is education, language, older age, low health literacy, or low socioeconomic status, according to the 

European Journal of Preventive Cardiology, 

these patients have a lower likelihood of going online to communicate with a physician or even using a mobile device to track their health.

There is also a lack of synchronization between the tech industry and health care, which will not change unless manufacturers address regulations around device development and data exchange protections, as well as credible studies showing improved health care outcomes.

 Additionally, the financial burden and time investment for training health care professionals to review data from these devices may be an opportunity cost.

 If manufacturers incorporated quality of life and health care outcomes studies for patients and providers, the integration of such devices into the provider workflow could be streamlined.

Finally, patient and physician-related barriers may be alleviated if the roles and responsibilities of pharmacists are shifted as digital health advancements continue to occur. Pharmacists are readily accessible health care professionals in the community who could play a significant role in digital health communication as “translators” to further assist patients and providers in understanding how to use data from various apps and devices.

, digital health could also introduce a new “digital pharmacist” role, a pharmacist who specializes in educating patients and training health care professionals on digital health devices.

As manufacturers continue to develop digital health devices at an unregulated pace, multiple devices have the potential to become important components in cardiovascular disease management. With or without the possibility of introducing a “digital pharmacist,” the COVID-19 pandemic has shown that more research needs to go into addressing the divide between technology and health care before digital health devices can be incorporated seamlessly into practice.

Narla, A., Paruchuri, K. and Natarajan, P., 2020. Digital health for primary prevention of cardiovascular disease: Promise to practice. 

Patel, P., 2020. Telehealth - Impacting Access, Cost and Quality - Perficient Blogs. [online] Perficient Blogs. Available at <https://blogs.perficient.com/2015/01/05/telehealth-impacting-access-cost-and-quality-2/>

Keesara S, Jonas A, Schulman K. Covid-19 and Health Care’s Digital Revolution. New England Journal of Medicine. 2020;382(23):e82. doi:10.1056/nejmp2005835

Cardiology — Digital.Health. Digital.Health. https://www.digital.health/cardiology. Published 2020. Accessed November 19, 2020.

Crilly P, Hassanali W, Khanna G et al. Community pharmacist perceptions of their role and the use of social media and mobile health applications as tools in public health. Research in Social and Administrative Pharmacy. 2019;15(1):23-30. doi:10.1016/j.sapharm.2018.02.005

Persell S, Peprah Y, Lipiszko D et al. Effect of Home Blood Pressure Monitoring via a Smartphone Hypertension Coaching Application or Tracking Application on Adults with Uncontrolled Hypertension. JAMA Network Open. 2020;3(3):e200255. doi:10.1001/jamanetworkopen.2020.0255

Treskes R, van Winden L, van Keulen N et al. Effect of Smartphone-Enabled Health Monitoring Devices vs Regular Follow-up on Blood Pressure Control Among Patients After Myocardial Infarction. JAMA Network Open. 2020;3(4):e202165. doi:10.1001/jamanetworkopen.2020.2165

Frederix I, Caiani E, Dendale P et al. ESC e-Cardiology Working Group Position Paper: Overcoming challenges in digital health implementation in cardiovascular medicine. European Journal of Preventive Cardiology. 2019;26(11):1166-1177. doi:10.1177/2047487319832394

Vatanka P, Lofton J. Re-envisioning the Pharmacist's Role in the Era of Digital Health—CPhA's Inaugural Digital Health Conference.

Aungst T. Creating a 'Digital Pharmacist' for the Future of Pharmacy Care — The Digital Apothecary. The Digital Apothecary. https://www.thedigitalapothecary.com/pharmacy-innovation-news/2019/3/23/creating-a-digital-pharmacist-for-the-future-of-health-care. Published 2019.

Articles

In recent years, digital health devices have offered pathways for patients to record and send data, which may ultimately encourage the patient to be more interactive in their disease management.
 

Implementation of Digital Health Technologies in Cardiovascular Disease Management during the COVID-19 Pandemic

Digital health strategically leverages digital technologies, empowering patients to manage their illnesses, reduce health risks, and promote health and wellness. This era of digital innovation within our health care system provides new alternatives for managing chronic conditions, diagnosing diseases earlier, and promoting prevention. The extensive scope of digital health encompasses technologies such as mobile health (mHealth) apps, artificial intelligence (AI)-enabled medical devices, and smart connected devices.

One emerging technology—smart inhalers&mdash;is becoming one of the greatest opportunities for clinical pharmacy engagement. Traditional inhalers have long been the mainstay of therapy for patients with chronic respiratory diseases. Their ability to deliver medication (ie bronchodilators and corticosteroids) directly to the lungs and significantly reduce systemic adverse effects has been well established, making them an effective and ideal treatment option.

However, health care professionals still face several challenges associated with managing respiratory diseases such as asthma and chronic obstructive pulmonary disease (COPD). The efficacy of inhalers can be negatively impacted by incorrect inhaler technique and poor adherence. A recent study showed worsening dyspnea, greater health condition impairment, and an increased frequency of exacerbations associated with incorrect inhaler technique and non-adherence.

Furthermore, incorrect inhaler technique and non-adherence places an immense burden on the cost of health care for patients with respiratory diseases. In patients with chronic diseases in the United States, the excess costs associated with non-adherence alone are estimated to be $300 billion annually.

 The management and prevention of respiratory diseases are suggested to be among the most cost-effective health interventions available; however, many patients do not optimize their medication therapies.

Inadequate inhaler technique or non-adherence to their medication, consequently, may result in the progression of their condition and unnecessary health care expenses for respiratory disease patients. The CDC states that if all COPD patients were completely compliant with their medication, exacerbations could be decreased by 25% to 30% annually, saving $4 billion per year.

Smart inhalers have the potential to address the challenges faced by patients and health care professionals in the management of respiratory diseases. With digital features designed to connect with mobile applications, smart inhalers and mobile applications work simultaneously to monitor medication schedules and subsequent dosing. Smart inhalers can monitor adherence; accurately record the time, date, and location of each dosage administered; send dosage reminders; and provide access to readily shareable data via Bluetooth. Several smart devices either have sensors built into the body of the inhaler or provide external sensors that can be attached to traditional inhalers.

As the smart inhaler market grows, pharmacists will need to develop a baseline proficiency in the use of digital technology to support patients and health care professionals with tools in the management of respiratory diseases. Nonetheless, approaches to managing respiratory diseases with smart inhalers should be supported by clinical outcomes, be designed as a cost-effective system, and mirror the needs of patients and health care professionals before they can be widely accepted in practice.

Here is a look at some of the smart inhalers currently on the market in the United States:

Smart inhalers available internationally:

Digital Health Center of Excellence. U.S. Food and Drug Administration. https://www.fda.gov/medical-devices/digital-health. Published 2020. Accessed November 7, 2020.

Greene, G. and Costello, R., 2019. Personalizing medicine - could the smart inhaler revolutionize treatment for COPD and asthma patients?. 

Ngo CQ, Phan DM, Vu GV, et al. Inhaler Technique and Adherence to Inhaled Medications among Patients with Acute Exacerbation of Chronic Obstructive Pulmonary Disease in Vietnam. 

. 2019;16(2):185. Published 2019 Jan 10. doi:10.3390/ijerph16020185

Lareau SC, Yawn BP. Improving adherence with inhaler therapy in COPD. 

. 2010;5:401-406. Published 2010 Nov 24. doi:10.2147/COPD.S14715

. 2nd ed. Sheffield: European Respiratory Society, p.6.

Pal S. Epidemiology of Chronic Lung Diseases. Uspharmacist.com. https://www.uspharmacist.com/article/epidemiology-of-chronic-lung-diseases. Published 2020. Accessed November 7, 2020.

An Analysis Of The Smart Inhalers Market. Medical Product Outsourcing. https://www.mpo-mag.com/contents/view_online-exclusives/2020-06-09/an-analysis-of-the-smart-inhalers-market/. Published 2020. Accessed November 7, 2020.

Blakey JD, Bender BG, Dima AL, Weinman J, Safioti G, Costello RW. Digital technologies and adherence in respiratory diseases: the road ahead. 

. 2018;52(5):1801147. Published 2018 Nov 22. doi:10.1183/13993003.01147-2018

Propeller Health Sensor to Be Co-Packaged With Recently Approved Enerzair® Breezhaler® Asthma Medication in Europe. Businesswire.com. https://www.businesswire.com/news/home/20200706005585/en/Propeller-Health-Sensor-Co-Packaged-Approved-Enerzair%C2%AE-Breezhaler%C2%AE. Published 2020. Accessed November 7, 2020.

Teva Announces Availability of ProAir® Digihaler® (albuterol sulfate 117 mcg) Inhalation Powder for Patients with Asthma and COPD. Businesswire.com. https://www.businesswire.com/news/home/20200713005034/en/Teva-Announces-Availability-of-ProAir%C2%AE-Digihaler%C2%AE-albuterol-sulfate-117-mcg-Inhalation-Powder-for-Patients-with-Asthma-and-COPD. Published 2020. Accessed November 7, 2020.

Teva Launches Two Digital Inhalers in the U.S., AirDuo® Digihaler® (fluticasone propionate and salmeterol) Inhalation Powder and ArmonAir® Digihaler® (fluticasone propionate) Inhalation Powder. Businesswire.com. https://www.businesswire.com/news/home/20200921005170/en/Teva-Launches-Two-Digital-Inhalers-in-the-U.S.-AirDuo%C2%AE-Digihaler%C2%AE-fluticasone-propionate-and-salmeterol-Inhalation-Powder-and-ArmonAir%C2%AE-Digihaler%C2%AE-fluticasone-propionate-Inhalation-Powder. Published 2020. Accessed November 7, 2020.

How It Works | Hailie™. hailie. https://www.hailie.com/pages/how-it-works. Published 2020. Accessed November 7, 2020.

FindAir — Smart Inhaler. Findair.eu. https://findair.eu/#Produkt. Published 2020. Accessed November 7, 2020.

Lupin launches "Adhero," first-of-its-kind connected Smart Device in India to support treatment of Respiratory Disease - Lupin. Lupin. https://www.lupin.com/portfolio/lupin-launches-adhero-first-of-its-kind-connected-smart-device-in-india-to-support-treatment-of-respiratory-disease/. Published 2020. Accessed November 7, 2020.

3M Designs an 'Intelligent Inhaler' System for COPD, Asthma and Other Respiratory Ills - Lung Disease News. Lung Disease News. https://lungdiseasenews.com/2016/04/22/3m-designs-intelligent-inhaler-system-copd-asthma-respiratory-ills/. Published 2020. Accessed November 7, 2020.

BreatheSmart® Mobile App Virtual Tour - HeroTracker® Sensors. Coherohealth.com. https://coherohealth.com/BreatheSmart/demo/sensors.php. Published 2020. Accessed November 7, 2020.

Pharma company Opko acquires smart inhaler startup for at least $10M. MobiHealthNews. https://www.mobihealthnews.com/32207/pharma-company-opko-acquires-smart-inhaler-startup-for-at-least-10m. Published 2020. Accessed November 7, 2020.

Inspair | Biocorp. Biocorpsys.com. https://biocorpsys.com/en/our-products/connected-devices/inspair/. Published 2020. Accessed November 7, 2020.

Pneuma Respiratory debuts smartphone-compatible inhaler. MobiHealthNews. https://www.mobihealthnews.com/content/pneuma-respiratory-debuts-smartphone-compatible-inhaler. Published 2020. Accessed November 7, 2020.

Amiko | Upgrading respiratory care. Amiko. https://amiko.io/. Published 2020. Accessed November 7, 2020.

Smart inhalers have the potential to address the challenges faced by patients and health care professionals in the management of respiratory diseases.