Tools For Improving Adherence to Treatment in Diabetes

Tools for Improving Adherence
to Treatment in Diabetes
Iris Thiele Isip Tan MD, MSc, FPCP, FPSEM
@endocrine_witch #HealthXPH
Associate Professor, University of the Philippines College of Medicine
Chief, University of the Philippines Medical Informatics Unit
App Sketching by Johan Larsson,
https://ﬂic.kr/p/dHLKPt

Disclosure Statement of Financial Interest
I, Iris Thiele Isip Tan DO NOT have a financial interest/
arrangement or affiliation with any healthcare related
companies that could be perceived as a real or apparent conflict
of interest in the context of the subject of this presentation.

Adherence &
mHealth
Black and White Crime 2 by Egahen,
http://www.freeimages.com/photo/1115701
The App Store by PhotoAtelier,
https://ﬂic.kr/p/9rCQw8
Apps for
diabetes
Runkeeper and health on iPhone by Jason Howie,
https://ﬂic.kr/p/e5CBwN
Apps
(un)regulated

Eating salad for health by typexmick,
“Adherence
WHO definition (2003)
the extent to which a
person’s behavior - taking
medication, following a diet,
and/or executing lifestyle
changes, corresponds with
agreed recommendations
from a healthcare provider

In developed countries, adherence to
long-term therapies in the general
population is around 50% and is
much lower in developing countries.
WHO report (2003)
“
Take your medicine! by Morgan,
https://ﬂic.kr/p/6jfAxH

The Five Dimensions of Adherence
WHO (2003)
Adherence to Long-term Therapies: Evidence for Action

mobile phone-conference image by xristine_faulkner
https://ﬂic.kr/p/4Xn9Q7
medical and public health practice
supported by mobile devices, such as
mobile phones, patient monitoring
devices, personal digital assistants
(PDAs) and other wireless devices
“mHealth
WHO definition (2011)

mHealth
research
2002-2012
Mobile phone in hand 2 by DragonTash,
Health promotion (38%)
Self-management (33%)
Communication (22%)
Remote monitoring (21%)
Data gathering (21%)
Improvement of adherence (20%)
Training/education (17%)
mHealth Research Impact Areas
Fiordelli M et al. Mapping mHealth research: a decade of evolution
J Med Internet Res 2013;15(5):e95

Conditions addressed
by mHealth research
Fiordelli M et al. Mapping mHealth research: a decade of evolution
Diabetes
Obesity/Overweight
Mental health
Tobacco use
Other kind of chronic condition
HIV
Other acute conditions
Well-being
Cancer
Medication compliance/Appointment reminder
Sexual health
Cardiovascular condition
Tuberculosis
0 5 10 15 20 25

Measurement
On-person or
embedded sensor
sampling in real time
Ecological
Momentary
Assessment
Global positioning
system
Diagnostic
Point-of-care
diagnostics
Portable imaging
Biomarker sensing
Clinical decision
support
Sensor sampling for
diagnostics
Treatment/Prevention
Prevention & wellness interventions
Remote behavioral treatment
Medication adherence tracking
Chronic disease management
Dissemination of health information
Disaster support/care
Global
Access to healthcare services
Remote behavioral treatment
Dissemination of health information
Disease surveillance
Medication tracking and safety
Prevention & wellness interventions
Continuum of mHealth Tools
Kumar S. et al. Mobile Health Technology Evaluation:
The mHealth Evidence Workshop.
Am J Prev Med 2013;45(2):228–236
Arrow background by ralev_com,

conectandonos by El_Turista_Accidental,
https://ﬂic.kr/p/7EWqg3
There’s an
app for that!
Patient Apps for Improved Healthcare:
From Novelty to Mainstream (Oct 2013)
IMS Institute for Healthcare Informatics
40,000+ healthcare apps on
US Apple iTunes app store

Patient Apps for Improved Healthcare
IMS Institute for Healthcare Informatics Oct 2013
n= 43,689 apps
Healthcare &
Fitness or
Medical
n= 20,007 apps
Miscategorized
or only loosely
health related
n= 23,682 apps
Genuine
healthcare
related
n= 16,275 apps
Consumer
oriented
n= 7,407 apps
Healthcare
professional
oriented
1,980 therapy area specific apps
270 apps for endocrine, nutritional & metabolic diseases

Functionality score + User score = IMS Health App Score
No. of reviews
+ star rating[ ]
25 individual criteria
information provided
how user data tracked/captured
communication processes
quantity of device capabilities[ ]

Top diabetes apps
strong functionality
with ease of use
IMS Health App Score
IMS Institute for Healthcare
Informatics Oct 2013
Daily Carb
Maxwell Software
Glucose Buddy
Azumio, Inc.
GoMeals
Sanofi Diabetes
1
2
3

Currently, there are more than 15,000 health-related apps (free and paid) on
app stores, but we were not able to find any study assessing any of them.
So what is publicly available has not been evaluated, and what
has been evaluated is not publicly available.
Mapping mHealth Research: A Decade of Evolution
Fiordelli M, Diviani N, Schulz PJ. J Med Internet Res 2013;15(5):e95
“
Puzzle 1 by jakubson

Features of Mobile Diabetes Apps:
Review of the Literature & Analysis of Current Apps
Compared Against Evidence-based Guidelines
Chomutare T, Fernandez-Luque L, Arsand E, Hartvigsen G. J Med Internet Res 2011;13(3):e65
iPhone
Android
Blackberry
Nokia
online markets
+ journal databases
+ gray literature on mobile apps
INCLUSION criterion
self-monitoring
of blood glucose
EXCLUSION criteria
No English user interface
Intended exclusively for HCPs
n = 973
n = 137 (101 online + 26 literature search)
Smartphone icon by Loraw200,

SELF-
MONITORING
Blood glucose
Weight
Insulin & medication
BP
EDUCATION
Disease-
related
ALERTS &
REMINDERS
Integration
of SOCIAL
MEDIA
functions
Disease-
related DATA
EXPORT &
COMMUNICATION
Synchronization
with Personal
Health Record
(PHR) systems
or patient portals
Features from
brainstorming
of authors; focus group
discussions between
MDs and patients

A tree on the horizon by Ydiot,
GAP
ANALYSIS
[
Literature typically reﬂects emerging
applications and new trends ...
“
... the market gives a good indication of
mature applications and functionality.
Chomutare T, Fernandez-Luque L, Arsand E, Hartvigsen G.

A tree on the horizon by Ydiot,
GAP
ANALYSIS
[
Literature
Search
PHR or Web
server
synchronization
18 (69%)
Insulin &
medication
recording
17 (65%)
Diet
recording
17 (65%)
Data
export &
communication
16 (62%)
Insulin &
medication
recording
63 (62%)
Data
export &
communication
61 (60%)
Diet
recording
47 (47%)
Weight
management
43 (43%)
Online
Market

#1 Insulin/meds
#2 Communication
#3 Diet
#4 Physical Activity
#5 Weight
#6 BP
#7 PHR
#8 Education
#9 Social Media
#10 Alerts
A CB
Variables in diabetes self-
management NOT addressed
Personalized feedback
Patient monitoring by primary care
physician
Foot & eye care
Psychosocial care
Immunization
Complication management

Very little inﬂuence of social media
on current diabetes mobile applications
Provide link to groups on FB or Twitter
No functional links or integration
between information in app & social media
Instagram and other social media apps by Jason Howie,
https://ﬂic.kr/p/d41HES

Mobile Apps for Diabetics: A Systematic Review & Expert-
based Usability Evaluation Considering the Special
Requirements of Diabetes Patients Age 50 Years or Older
Amhold M, Quade M, Kirch W. J Med Internet Res 2014;16(4):e104
iOS n=276
Android
n=266
Both
n=114
Smartphone icon by Loraw200,
GENERAL
INFORMATION
Name/language
Date of release/
update
Desktop app
OPERATING
SYSTEM
iOS
Android
Both
DEVELOPER
INFORMATION
Name
POPULARITY/
USER RATINGS
No. of downloads/
installations
User rating
No. of user ratings
TARGET
USER
GROUPS
Patients
Physicians/qualified
health personnel
Both INTERFACES
Interface/
connectivity to
external sensor(s)/
device
ACQUISITION
COSTS
Freeware
Exact price
Availability
as”lite” version
Feb-Apr 2013

0
25
50
75
100
Free Paid Paid/Lite
iOS (n=276) Android (n=266)
Both (n=114) Total (n=656)
Price distribution of diabetes apps and “lite” versions
%

Worried senior woman talking by SalFalko,
https://ﬂic.kr/p/gFCeMN
Usability & Assessment Criteria for
Diabetes Apps for Elderly
COMPREHENSIBILITY
Use of understandable semantics, simple comprehensibility & interpretability of displayed
images and depictions, simple self-explanatory menu structures
USABILITY
Instant and easily understandable feedback, intuitive usability,
simple recognition of click-sensitive areas
PRESENTATION (Image & Text)
Sufficient color contrast, large size of operating elements, ability to adapt the size of
operating elements and displayed images
GENERAL CHARACTERISTICS
High fault tolerance/efficient fault management,
password-protected services
Randomly selected 66/656 apps (iOs n=29, Android n=28, Both n=9)

Comprehensibility
Presentation
Usability
General characteristics
0 1 2 3 4 5
Likert Scale
Usability Assessment of
Diabetes Apps for Elderly

Patients face a dizzying array of
healthcare apps to choose from,
with little guidance on quality
or support from their doctors.
Some efforts are underway to help
provide professional healthcare
guidance in both the US and the UK
but these are limited in scope
and impact to date.
“

Hyperwall by Florian Plag
https://ﬂic.kr/p/8aro3Y
It’s the Wild West out there.
It’s hard to sort through them
all and there’s little evidence
about which ones really work.
Murray Aitken
Executive Director
IMS Institute for Healthcare Informatics
“

Apple by VanessaGF,
An app a day keeps
the doctor away.
“ When a prescription drug goes
generic, it has at least seven
years of data about its
effectiveness and safety, which
gives physicians assurance that
patients can use it for self-care.
Medical apps have
no history of either
effectiveness or safety.
Mike Paskavitz
Editor-In-Chief, Quantia Inc
“

Mobile apps that are NOT medical devices ... will NOT be
regulated by FDA.
device but because they pose a lower risk to the publi
Mobile apps may meet the deﬁnition of a medical device but
because they pose a lower risk to the public, FDA intends to
exercise enforcement discretion.

Caledos runner by Nicola,
https://ﬂic.kr/p/fP18Jx
Although the FDA has focused
on safety, it has largely left
the review and certiﬁcation of
apps to the marketplace.
The currently available reviews of
mHealth apps have largely
focused on personal
impressions, rather than
evidence-based, unbiased
assessments of clinical
performance and data security.
Powell AC, Landman AB, Bates DW.
In Search of a Few Good Apps
JAMA. Published online March 24, 2014,
doi:10.001/jama.2014.2564
“

Mobile medical applications that
FDA has cleared or approved
http://www.fda.gov/MedicalDevices/
ProductsandMedicalProcedures/ConnectedHealth/
MobileMedicalApplications/ucm368784.htm

http://spectrum.ieee.org/biomedical/devices/bluestar-the-ﬁrst-prescriptiononly-app
This is a piece of software getting the same treatment as a
medical device. It’s pretty world-changing.
Sonny Vu
Cofounder, Misfit Wearables
“

Evaluation & Evolution of Diabetes
Mobile Apps: Key Factors for HCPs
Seeking to Guide Patients
Ristau R, Yang J, White J.
Diabetes Spectrum 2103; 26(4):211–215
PATIENT
DEMOGRAPHICS
Older generation
less likely to be
technologically savvy
FINANCIAL BURDEN
Can the patient afford
the device & the app?
Busy woman by JetMedia,

Evaluation & Evolution of Diabetes
Mobile Apps: Key Factors for HCPs
Seeking to Guide Patients
Ristau R, Yang J, White J.
Diabetes Spectrum 2103; 26(4):211–215
DEVICE
& APP
PLATFORM
Not all apps available
for all platforms
APP FEATURES
Logging & tracking, data
sharing & social support,
SMS & reminders
EASE OF USE
Easy to navigate,
modify, enter, retrieve
& share data
GUIDELINES &
REGULATIONS
Follow guidelines?
FDA approved?Busy woman by JetMedia,

Measurable behavior change is the desired outcome of diabetes
education. The diabetes professional community must step
into the market void and embrace mobile technology
as part of the solution.
“

Tools For Improving Adherence to Treatment in Diabetes

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Tools For Improving Adherence to Treatment in Diabetes