Timothy Dy Aungst, PharmD

Treatment modalities are expanding beyond medications to include digital therapeutics, which are software-based therapies that help manage, prevent, and treat disease.

The first prescription digital therapeutic (DTx) was cleared by the FDA in 2017 to treat substance use disorder (SUD),

and the first virtual reality (VR) therapeutic received FDA breakthrough device designation in 2020 to help treat chronic pain.

 Sensor-enabled medications that record and transmit data on medication use have entered the market, supporting patients in taking care of their health and providing pharmacists with actionable insights to guide medication optimization.

The coronavirus disease 2019 (COVID-19) pandemic has accelerated digital health advances. Direct-to-consumer prescription delivery services, patient monitoring, and telehealth have been instrumental in maintaining essential services during a time when virtual care has been critical to continuity of care.

Even beyond the pandemic, these technologies will continue to expand and integrate, creating a hybrid of in-person and virtual care. These hybrid models will augment, not replace, the human touch, enhancing the patient-provider experience and improving access, quality, and outcomes of care.

Pharmacists and student pharmacists should prepare for evolving roles that leverage advanced technologies to support patients' health, well-being, and treatment optimization.

Technological advancements in health care have yielded a range of products and solutions under the umbrella term 

. Examples include health apps, medication reminders sent via email or text, remote patient monitoring (eg, continuous glucose monitoring), wearables such as fitness trackers, and telehealth/telemedicine services.

 A framework categorizing these products and solutions has been developed by leading digital health organizations.

As described by the FDA, "these technologies can empower consumers to make better-informed decisions about their own health and provide new options for facilitating prevention, early diagnosis of life-threatening diseases, and management of chronic conditions outside of traditional health care settings. Providers and other stakeholders are using digital health technologies in their efforts to reduce inefficiencies, improve access, reduce costs, increase quality, and make medicine more personalized for patients."

Telehealth (clinical and nonclinical remote services) experienced an exponential rise in use during the pandemic, offering continued, safe access to care. Before the pandemic, the use of telemedicine (clinical remote services) was less than 0.01% of all medical appointments.

 Between mid-March and early May 2020, the use of telemedicine increased 300-fold.

 It is anticipated that there will not be a return to prepandemic rates, as health care providers and patients both value the virtual experience. There were unexpected benefits, as described by a pharmacist who, noticing her patient was always in his vehicle during telehealth appointments, learned that he had been living in his van. It helped explain some of his challenges, and she was able to initiate social worker services, something she would not have observed during a traditional in-person clinic visit.

It is estimated that telehealth may calibrate to 15% to 20% of care post pandemic.

 A key element for sustainability will be overcoming integration challenges, such as the gap between those who have ready access to computers and internet and those who do not, known as the digital divide.

Digital health companies have focused on ways to increase medication adherence. Technologcial advancements in the past decade have seen a push to go beyond notifications by a smartphone app in favor of sensor-enabled medications or the Internet of Things (IoT) integrated drug delivery systems. Studies have investigated the effectiveness of these devices and software on large-scale patient adherence with mixed results.

Trends include objective or subjective tracking of patients' self-administration of medications. For instance, an app may remind a patient to take their medication, and the patient then indicates if they followed through. Others include smart-pill bottles or packaging that lights up, alerting patients to take their medications. Once engaged (eg, the pill bottle is opened), the software indicates that the patient removed the medication. Fully integrated medications with built-in sensors, such as bioingestible drugs, smart inhalers, and smart injectable devices, also are available.

The advantage of these technologies is that pharmacists can remotely monitor how patients take their medication, allowing a targeted approach to support medication use, patient engagement, and treatment optimization. For instance, if a patient is using a rescue inhaler more frequently, it could be a sign that they are not using the maintenance inhaler as directed or there may be a need to escalate treatment.

REMOTE PATIENT MONITORING AND AT-HOME DIAGNOSTICS

IoT has enabled connecting commonly used products to a larger data set to observe use and provide insights into consumer habits. Integrating IoT with health devices was a natural evolution that led to blood glucose monitoring devices and smart blood pressure cuffs, enabling remote monitoring between patient visits. These devices will expand telehealth/telemedicine services by lessening the need for in-clinic objective measurements, as the data will be captured remotely, strengthening the trend away from episodic care toward continuous, proactive care and supporting hospital-to-home management strategies.

Another area that has seen growth is at-home diagnostics. Patients increasingly have access to a range of tests that provide results within minutes or that can be shared in an app for assessment via a combination of artificial intelligence and provider assessment. The accessibility of these products creates the opportunity for early detection of illness and connecting individuals to the health care system via telehealth and/or in-person patient care services.

DTx is "evidence-based therapeutic interventions that are driven by high-quality software programs to prevent, manage, or treat a medical disorder or disease."

 This category is focused on a central software platform that may integrate with external hardware, such as a sensor-enabled measurement tool or VR headset, or be paired with a medication for disease management.

Market examples include DTx focused on pain management with home physiotherapy delivered by an app, pulmonary condition management using smart inhalers to guide treatment, SUD with cognitive behavior therapy interventions, and sleep management. Ultimately, medications may come paired with DTx, and pharmacists will need to include them in the medication reconciliation process to ensure treatment continues.

PHARMACISTS' ROLE IN INTEGRATING DIGITAL HEALTH

Digital health products and solutions will increasingly be integrated into the care that pharmacists provide. Eventually, the term 

 may fade away as these treatment modalities become the norm. Pharmacists may find themselves serving as coaches, curators, and digital translators for patients, accessing data on remote patient monitoring platforms, assisting with setting up software or devices, engaging with patients via hybrid care models, and matching individuals with medication and a digital companion, all to contribute to health and wellness and support treatment optimization.

Articles

Digital health products and solutions expand ways to guide prevention and treatment.

New Technologies Boost Pharmacist's Role

The Rise of the Mobile App and Internet Use

Within the past decade, technological growth in the mobile sphere has been astounding. We remain firmly entrenched in the age of the smartphone. These ubiquitous devices do it all: texting, looking up the nearest restaurant, taking a picture of a meal and sharing it online, even crowd-sourcing a ride. It is undeniable that the smartphone has found a way into our personal lives. Due to increased processing power and developments in electronic components and widespread wireless connections, smartphones have ushered in a time in which it is possible to be in contact with anyone, anywhere, and to share all of our experiences through digital means. In an age where just about everyone is carrying a smartphone, it should come as no surprise that there is a growing movement to leverage their capabilities for health care.

Although the smartphone has undeniably fundamentally changed the way many individuals work and live, it is useless without its apps. Currently, both the Apple and Android mobile stores have more than 1 billion apps available for purchase, which encompass everything from productivity to social media to medical categories. Health care professionals have used their smartphones as a new means to access medical tools and literature, and even as clinical tools adjunct to their work.

 Pharmacists have been quick to replace their hard-copy drug-information textbooks for apps that are easier to access and use.

Beyond the use of smartphones as a tool for health care professionals, we cannot overlook the use of these devices and the widespread adoption of the Internet by patients.

 Indeed, patients now have access to a multitude of options (perhaps leading to overload for many) to help them manage their health. They can access their medical records, schedule online appointments with providers, and much more. Multiple pharmacies have also created mobile apps to help facilitate the process of helping patients get their medications. These apps provide assistance with medication refills, pill identification, drug interactions, and medication transfers, and offer direct communication with a pharmacist. These features are just the beginning of what mobile apps and the Internet can offer.

The most astounding aspect of all the recent technological advances is the level of communication now possible. There are numerous social media outlets (eg, Facebook), microblogging spheres (eg, Tumblr, Twitter), and online forums (eg, Reddit) that provide the means for individuals to communicate across the world. Currently, Facebook is the most popular platform, with upward of 70% of adults using the social network; other social media spaces are growing as well.

 Patients are turning to these social media realms to connect and communicate with other patients who have similar disease states. This, in turn, has led to the coining of the term “e-patient.” Perhaps the poster child for the e-patient movement would be David deBronkart, also known as “e-Patient Dave,” who has been heavily involved in sharing his success in beating kidney cancer through his participation in online communities and has given TED talks on the subject.

 According to the late Tom Ferguson, MD, an advocate for informed self-care, the e-patient can be summed up as “engaged, empowered, equipped, and enabled.”

The e-patient movement is not a new concept, but it has been growing in the past few years due in part to the large increase in Internet users and steadily growing patient communities, including the formation of a cooperative health organization called the Society of Participatory Medicine.

 These online patient communities allow users to discuss their diseases in depth, get social support, and discover new treatments, therapies, and health care providers. Although predominately used by patients, health care practitioners have gradually become aware of the benefits of engaging with these online communities as a way to advertise and share services.

One striking example is PatientsLikeMe, a Boston-based, patient-focused health care research company that has gained a large group of users.

 Their claim to fame includes a sizeable patient base that has relatively uncommon diseases, and their site creates the opportunity to gather a large enough community online for meaningful discussion. Researchers have been apt to gravitate to these online communities as a form of research gathering. One example has been the use of PatientsLikeMe to identify adverse drug events that patients share, and the FDA has shown interest in leveraging this as a new form of post-marketing medication monitoring.

 Along the same lines, research into the presence of adverse events (AEs) has been monitored on other social media websites, including Twitter. Online communities, by their very nature, may serve a new means for tracking unknown or new AEs that was not previously available.

Similarly, PatientsLikeMe allows users to discuss not only the AEs of their therapies but also the benefits. This has been tracked to the point that it is now possible to evaluate diseases and drug treatments through PatientsLikeMe and determine how most patients are tolerating and benefiting from treatment. Walgreens has partnered with PatientsLikeMe to include these data in its online platform, allowing patients to use these data for their own health management.

The e-patient movement is not only limited to online communities and their digital interactions; many e-patients have embraced the rise of digital health and mobile devices to collect and measure data on themselves to share. This includes using wearable devices currently on the market, along with medical and health care apps that allow data tracking. Whereas many wearable devices are dedicated toward physical fitness (eg, Fitbit), there are a substantial number coming to the market that are tethered to smartphones as a means of collecting vital health data. These include devices that can measure a patient’s heart rate or rhythm, and track weight, temperature, blood pressure, respiratory rates, and more. A massive project called the Tricorder X Prize is dedicated to creating an “all-in-one” health device capable of collecting all of these data.

While e-patients are slowly quantifying their health, they are also able to share their data with their health care providers to help manage their own care and take charge of their health. Health care providers have been apt to use this data as a means of helping to equip their patients with tools to manage their health and hopefully avoid hospitalization. In essence, this is telemedicine 2.0, replacing a phone call with data that can be shared via an electronic health record (EHR) and providing patients with face-to-face communication digitally through their smart devices. Indeed, there are multiple start-ups and companies that have created apps and online services meant to help patients reach a doctor at any time, in any place.

Technology companies are quickly learning that the health care field is ripe as a potential profit area and are slowly starting to develop products for patients and health care practitioners. One example includes Apple, which has been working to get in on this possibly lucrative market with 2 new projects: ResearchKit and HealthKit.

HealthKit allows users’ data to be shared with potential EHRs, such as Apple’s partnership with Epic, one of the largest EHRs in the country. This is currently being tested at several medical institutions across the country, including the Mayo Clinic.

 ResearchKit aims to make any person with a smartphone capable of tracking and sharing data with medical researchers. One example is a health trial focused on cardiac issues that tracks patients’ overall activities using the accelerometer and built-in GPS in their iPhones.

It can be difficult, however, to keep patients engaged in their health. This challenge has spurred a movement to find a mechanism of keeping patients’ attention by using apps to help manage their health and stay active.

In its simplest form, gamification incorporates gaming mechanics or gamelike elements such as scoring to an application to help attract user attention. This tactic has been used to engage consumers for some time in the forms of loyalty rewards programs or health programs to get workers more physically fit. Gamification should ideally include some form of meaningful feedback for patients to encourage continued interaction that will ultimately lead to a desired outcome. This could include rewarding patients for certain actions or making an activity enjoyable to increase loyalty and utilization of a service, and to ensure the patient will come back.

One example that is relevant to pharmacy is the creation of apps that help patients with medication adherence. Although many of these medication apps rely on reminding patients to take their medication through alerts and notices, some patients may eventually ignore the app. Gamification techniques include rewarding patients for their diligence in using the app. MangoHealth, for example, rewards patients for continual self-reported adherence by giving the user gift cards they can use toward purchases. A project by Sick Kids Hospital in Toronto, Canada, used an app to help children report their pain scores. Each time a child used the app to track their pain scores through the day, they would level up. When they moved up to the rank of police detective, they were rewarded with videos from a popular Canadian crime drama. The researchers noted that adherence to data reporting shot up more than 75%, demonstrating that such a service could help increase patient engagement. Another example is an app that allows children with type 1 diabetes to learn about the use of insulin and managing their health by taking care of a virtual pet with a pet who also has diabetes and requires insulin. The thought is that by taking care of a pet with a similar disease state, a child can learn to understand their own health and not fear treatment.

Opportunities and Challenges for Pharmacy to Leverage Social Media and Gamification 

Pharmacy must look to be involved with new technological developments if it wishes to remain relevant in the minds of patients and consumers. Although some may fear that this means substantial investments of capital and time to keep up with the times, this may not always be the case. Take, for instance, the use of mobile devices: since the iPhone’s release in 2006, it has seen multiple iterations and advancements in software and hardware development, but its basic premise, a handheld computer that can do a lot, has remained the same.

Companies that wish to create apps for their consumers and patients must understand that such a product must be user-friendly and provide a good user experience while performing functions pertinent to the pharmacy organization. The only concern here is with upgrading app software when major changes happen to the operating systems of the devices (such as the impending change from iOS 9 to iOS 10 on iPhones). That being the case, any pharmacy organization seeking to create an app must be cognizant that there is significant upfront cost in creating an app and some cost for maintenance. The payoffs for a company include increasing their profile by supplying a feature that many consumers have come to expect.

The e-patient movement and the prevalence of patients “googling” health conditions make digital technology ripe for pharmacy involvement. Pharmacies have the opportunity to be suppliers of not only medications, but of a new wave of digital health tools and to use their resident pharmacists as stalwart figures of community health information who educate patients. This shift may not be an overnight phenomenon, but it goes in part with the recent push by many retail pharmacies to embrace technology to help bridge the patient care conundrum of the home and the clinic. Reaching out to these patients through technology can leverage the inner e-patient in the wide populace and, by doing so, help them become more engaged.

The development of front-facing digital cameras in devices that connect the pharmacist and patient may prove to be a large benefit in terms of giving more face time to a profession that is often not visible to the general public. The payoff of putting pharmacists and the pharmacy in the public sphere through social media engagement may be that it helps to encourage consumer retention and growth in consumer use. However, this does not necessarily mean Tweeting or posting on the social media sphere advertisements and discounts for the pharmacy.

Social media can serve as an important tool, as it not only opens up a discourse between pharmacy organizations and patients, but can also be a link to what patients want. This is not simply a customer service response, but a push to help patients. Take, for instance, the success that Google has seen with its Flu Trends web service, which tracks flu outbreaks by leveraging the search histories of patients who are trying to determine if they have the disease. Organizations were quick to latch onto these data, link it to announcements of which pharmacies carry flu vaccinations, and serve as a public outreach to help patients get their vaccinations by putting the risk for infection into perspective.

Pharmacy organizations that can learn to leverage multiple forms of technology and create a sustainable product can operate on the cutting edge of digital health. Using social media to help maintain a presence with patients, involving them in their health and helping to navigate them through the health care system, is one benefit. Using gamification to help maintain that engagement and foster continued consumer and patient interaction is another. Involving pharmacists as health information experts with knowledge and training on techniques for disease care and medication adherence will most likely help increase patient goodwill and lead to improved medical outcomes.

Timothy Dy Aungst, PharmD is an assistant professor of pharmacy practice at MCPHS University, Worcester, Massachusetts. He has a vested interest in the power of mobile and digital health in the field of pharmacy and health care at large. He has published previously on the role of mobile and digital health for pharmacists, conducted reviews of mobile apps and devices, and coauthored the e-book 

 with the American Society of Health-System Pharmacists. He has given numerous talks locally and nationally on mobile devices, digital health, and e-patients. 

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In an age where just about everyone is carrying a smartphone, it should come as no surprise that there is a growing movement to leverage their capabilities for health care.