by Sachin Jain, MD

As physicians and hospitals continue to take on greater numbers of risk-based contracts for providing services to patients, there will be more attention paid to solutions to one of clinical medicine’s trickiest problems: medication adherence. Medication adherence refers to the reliability with which a patient follows a treatment course prescribed to him or her. Even conservative estimates suggest that failures in medication adherence cost our healthcare system billions of dollars in preventable morbidity and mortality. With a shift towards accountable care organizations and new penalties for hospital readmissions, clinicians will be increasingly responsible for finding ways to make sure that their patients are taking their medications as prescribed.

Medication adherence itself is a nuanced problem of overlapping types. Many patients choose never to fill their prescriptions (“non-fullfillment”). Other patients will fill their mediation prescriptions, take it briefly, and then stop (“non-persistence”). Others still will fail to take their medications reliably as prescribed, either because they lack the desire (“intentional non-adherence”) or because they lack a proper understanding of the medication and proper usage (“non-intentional non-adherence”). A World Health Organization consensus statement suggests that the factors contributing to each of these types of adherence problems can be described as: social and economic, healthcare system–related, condition-related, therapy-related, or patient-related.

I met recently with Doug Gordon, Director of Sales at SentiCare, a Massachusetts-based company that believes it has an answer to at least part of the medication adherence crisis. SentiCare has developed the PillStation, a novel pillbox that incorporates visualization of a patient’s medication use with a telephonic advisory service that provides feedback and assistance to patients who are confused about their medications. The PillStation has had early successes for patients with CHF for whom medication adherence had previously been quite challenging.

Can you describe the PillStation and how it works?

PillStation, an FDA-approved Class 1 device, is an in-home telehealth system, which looks and feels like a familiar weekly medication organizer. The device offers patients an intuitive format for organizing and storing their weekly medication regimen with seven removable daily medication bins for morning, mid-day, and evening medications.

What sets PillStation apart is its ability to personalize and bond with the patient and achieve 90% and higher adherence rates, not only in taking medications, but also in following hospital discharge instructions and wellness plans.

PillStation has a unique built-in camera, which captures images of a patient’s medications after the tray is loaded and after each use. PillStation transmits these digital up-to-date images to SentiCare Advisors for medication management and monitoring 24 hours a day, seven days a week. The photos are then compared to a patient’s active drug list. If the patient (or caregiver or even visiting nurse) loads the tray incorrectly, the Advisors identify the problem and contact the patient to correct the error immediately.

Additionally, when patients are late or forget to take their medications, the Advisors can see that their pills are still in the PillStation, and they contact the patient to advise him or her of the missed dose.

PillStation also offers customized reminders through voice and graphics text to provide additional support and encouragement. Each time a patient opens the lid, PillStation provides reminders such as, “Please remember to exercise today,” or “That light blue pill you are taking will lower your cholesterol,” or “Be sure to check your weight and blood pressure today.”

Another unique feature that sets PillStation apart is its CALL button. By pressing this, a user can talk to an Advisor and ask any questions about his or her medication regimen, hospital discharge instructions, and overall wellness.

What was the inspiration for the PillStation?

Our team’s initial focus was on creating a product that curtailed the problem of medication abuse. Soon we realized that there was a much larger problem with people not taking their medications as prescribed. Understanding that poor medication adherence can lead to debilitating consequences like disease state progression, increased doctor visits, unnecessary hospitalizations, emergency room visits, and even death, our team wanted to develop a product that would combat this dangerous problem.

After recognizing that most elderly people suffering from chronic disease generally need to manage 20-30 bottles of medications, it became clear that there was a great deal of confusion as to what medication to take and when to take each dose. The medication non-adherence and errors resulted in frequent visits to hospitals, where the medication regimen was different. When patients were discharged, new medications were prescribed, and at times patients would take a detour to a skilled nursing facility where, again, the medications were different. When patients arrived at home, the medications changed again due to mandatory generic substitutions. Finally, when they settled at home, patients would try to reconcile 10 or more old medications with new medications—meds that were prescribed in the hospital and short-term nursing facility. With all of these changes, it seems inevitable that elderly patients on 10-15 medications would get so confused—not to mention their caregivers.

Can you describe its clinical applications to date? How have you tested its effectiveness?

After receiving our FDA approval last year, PillStation has been deployed for patients with CHF, diabetes, mental health, cancer/transplant, and HIV/AIDS. With more than 2 years of operational and trial data, PillStation has consistently shown 90% or higher adherence rates. In terms of effectiveness, SentiCare has done several trials to measure this. In one of the trials, with more than 1,000 patient days, an average age of 69 years, and nine medications, PillStation achieved 97.9% adherence, compared to a 40% national baseline.

In fact, from the first day, patients become fully adherent and begin to “bond” with the PillStation. A gentle chime reminds the patient to take their medications. A blue glow gives them the comfort that all is well. In case they miss their medication window, an Advisor calls them and gently reminds them to take the missed dose. Very quickly, patients know that someone cares about them and their health, and is supporting them (and watching their meds to make sure there are no errors). The patients (and their families) become emotionally invested in the PillStation, its voice, and the Advisor, and try to be adherent—so as to not disappoint their support team.

How has it been applied in cardiology settings?

One of our big focus points is to combat high readmissions as well as ER/acute care visits within the HF population. Over the past 6 months, Northwestern Medical has been successful in using PillStation on a case-by-case basis at their Heart Failure Clinic. We know that some of the hospital/ER “frequent flyers” have been at-home compliant with their medication and wellness adherence. In fact, we know that we have reduced multiple hospital admissions. In the “frequent-flyer” patient population, PillStation can easily reduce one to two readmissions and ER visits per year for a net savings of more than $20,000 per patient, per year.

How is the PillStation different from the countless other solutions being proposed for problems with medication adherence?

PillStation has eyes, ears, and a voice. It is able to see the medications—for which we received a patent. The camera under the PillTray takes a clear image, allowing the Advisors to confirm that the right medication is in the correct bin and taken at the right time. Until now, consumers only had the option of using simple organizers or reminding-and-dispensing devices. None of these devices provides a complete solution to the management of complex and often changing medication regimens.

How does the PillStation specifically address the problems of clients with the greatest difficulty adhering to medications—the disabled, the elderly, etc?

When designing the PillStation, we partnered with one of the leading industrial design firms in New England. Our objective was to make it as simple as possible for elderly and disabled patients to install, fill, and take medications, and at the same time enjoy and look forward to using the device.

We also made the PillStation very personalized. In one case, we were able to get one of our 91-year-old patients to adhere to her medications; however, she was being moved to an assisted living facility because she could not remember to feed her cat, Chester. In a few minutes we personalized her PillStation message and now every time she opens the cover to take her medications, the PillStation says, “Please remember to feed Chester.”

Many users are unsure about calling their physician or nurse to ask questions about their medications. PillStation’s CALL button gives elderly patients an alternative and another level of comfort, providing them with a resource for questions regarding their medication, hospital discharge, and general wellness. Ultimately, PillStation can reduce the cumbersome effort of trying to get hold of a nurse or a doctor, or a family caregiver.

Have you done any return-on-investment (ROI) calculations on the PillStation?

Forty-seven percent of HF patients with Medicaid were non-adherent with their medication over the course of a year. Among these non-adherent patients, 47% were re-hospitalized and 45% had an emergency department visit. About half of those visits are probably due to non-adherence to medication or discharge/wellness instructions plans. With its 90% and higher adherence success, PillStation provides hospitals, accountable care organizations, and patient-centered medical home organizations an opportunity to save money, while also significantly increasing the quality of their care.

SentiCare has done several ROI calculations for different sectors (home health, pharmaceutical, hospitals) based on historical data. In an elderly comorbid population, PillStation can easily prevent one readmission for a savings of more than $15,000. The Shelah Leader study on PillStation demonstrated that for hospitals discharging 100 CHF patients per month, PillStation saves approximately $5.5 million in avoidable readmissions. For home health nurses, PillStation can save at least two to three visits per month.

What is your strategy for promoting adoption of the device? What do you see as the greatest challenges to the adoption of PillStation?

Given that we have FDA approval and trials which show 98% adherence success, the challenge now is to rapidly introduce this to payors, hospitals, and physicians.

Our greatest challenge would be the adoption of telemedicine by insurance companies, healthcare systems, and government agencies. We have found that change and adoption of new technology that alters patterns of healthcare delivery and the organization and structure of care can be very slow. However, based on trends to provide better healthcare at a lower cost within our aging and chronically ill population, we see this adoption as inevitable. It is simply a matter of exposure and providing clinical data that support our claims.

With the new incentives and penalties in place, SentiCare will continue to focus on avoidable readmissions. We are engaging with major healthcare provider systems on adoption.

How do you see the product evolving over time?

PillStation is currently on Version 1.5. Over time we see several key additions, including integration with our partner’s peripherals and EMR/PHR, as well as lower-cost hardware. Also, we’re introducing new services such as PillTray only with reminders on your cell phone, disposable medication trays, mail-order pharmacy filling, and filling by local pharmacies.

Sachin H. Jain, MD, MBA, is a physician at Brigham
and Women’s Hospital and Harvard Medical School and
Senior Institute Associate at Harvard Business School’s
Institute for Strategy and Competitiveness. He was previously
a key official in the Obama Administration, where
he helped launch the Center for Medicare and Medicaid
Innovation and the HITECH Act’s Meaningful Use provisions.
He is a leading national authority on healthcare
delivery reform.

Keywords: Nurses, Community Health, Chronic Disease, Device Approval, Blood Pressure, Patient Discharge, Hearing Loss, Conductive, Patient-Centered Care, Reproducibility of Results, Cholesterol, Ichthyosis, Patient Readmission, Telemedicine, Skilled Nursing Facilities, Accountable Care Organizations, Medicare, United States, Mental Health, Assisted Living Facilities, Neoplasms, Health Care Reform, Heart Defects, Congenital, Medicaid, Intellectual Disability, Caregivers, Medication Adherence, Heart Failure, Drug Substitution, Hospitalization, Diabetes Mellitus

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