One of the very first areas I started blogging about on Dose of Digital dealt with medication compliance. After working on compliance challenges for my final two years at AstraZeneca before moving to my current job at Bridge Worldwide, I’d seen pretty much every tactic you could think of to improve compliance. So, this seemed like a natural place to start blogging. You can read my first post on this subject (from back in December 2008): “Glorified Alarm Clocks.”
Since then, I’ve written a few posts about compliance/adherence (yes, I know the difference, but won’t get into it here) issues. One of my favorites, “The Only Way Pharma Can Improve Compliance: Fun,” was a big hit with a number of people. I still believe that adding elements of fun (yes, even to serious diseases) helps people cope with their disease and better learn how to manage it. I think there are also many tactics that have very little impact on compliance for the vast majority of people and yet, they remains a very popular. One of these is the reminder. In fact, I wrote about this too a long time ago, but wanted to add some additional perspective.
On the surface, medication reminders seem like the perfect solution to the huge issue of compliance (i.e., the lack of it), which affects a huge proportion of people taking all manner of treatments. From drugs for asthma to allergies to high blood pressure and even cancer and birth control, many people simply don’t take their medications as they are prescribed. Importantly, they typically don’t take their medications for as long as they should especially when these are chronic, lifelong treatments. This is the case even for the most serious conditions. Take people with chronic myelogenous leukemia (CML). Prior to the release of Gleevec (from Novartis), studies showed that patients diagnosed with CML the “median survival time was 69 months.” In other words, half the patients lived more than 69 months and half less. That’s not a great prognosis. Enter Gleevec. A study from the NEJM showed that “the estimated overall survival of patients who received imatinib [Gleevec] as initial therapy was 89% at 60 months.” That is, almost 90% lived at least 60 months when starting with Gleevec versus about 50% prior to Gleevec.
So, you’d think that this would be the drug with the highest compliance rates. Right?
Wrong. A full third (33%) of Gleevec patients were non-adherent in one large study. Why? The authors added this fact: “Poor compliance was not related to length of treatment or to side effects of Gleevec. Poor compliance occurred despite the fact that patients knew they would be monitored for compliance, as they had signed a consent form for this purpose.” So, do you think they didn’t take their medication because they forgot? You have a disease that can kill you in months AND you know someone is checking to see if you’re taking your medication and you still forget? Sounds unlikely to me. I don’t think you can easily forget that you have CML.
From all the research I’ve read and been a part of, for most people, the drivers of compliance are related to the patient truly understanding the risks and benefits of their treatment and their willingness or openness to persuasion (notably, from a physician or other HCP). Hats off to Andrea LaFountain, who I worked with at AstraZeneca, and who pioneered a lot of this work (be sure to check her company out) and can explain it far better than I can.
So, in other words, reminders aren’t enough. They can be a component, but aren’t enough on their own. Yet, that’s what I see today…reminders. Reminder programs put forth as the cornerstone of improving compliance. I’m not suggesting that you forget about offering reminder services to your patients, but I am suggesting that you shouldn’t expect too much from them.
For today, I want to show you some of the reminder programs that are out there and highlight the good and the bad. I’ll also show you that it doesn’t need to be as complex as we sometimes make it out to be.
First, to the title of this post, “Are you reminding me or annoying me?” Many “reminder” programs are simply annoying programs. They are annoying because they aren’t smart and don’t learn from your actions (or lack of actions). Case in point (and the inspiration for this post), eTrack. Their first program is for ADHD and it tops my list for annoying. I signed up for this program after someone mentioned it on Twitter so I could see what it was all about.
After signing up, you can turn on reminders…oh wait…you don’t turn them on…they turn them on for you automatically…a personal pet peeve.
Not only do they turn on reminders, but they sign me up to get them twice a day, five days a week (and also sign me up for their newsletter). And, the reminders start coming…
You’ll notice that I haven’t even opened one yet and still, they keep coming. If someone never opens your email (and you can tell if you have a proper email delivery platform), when is enough enough? When should you give up, so that you avoid annoying your customers and finding yourself the subject of a blog post? Sure, you can’t always tell when someone opens an email (e.g., if they use the “preview pane”) or perhaps opening these emails isn’t important, as they only are supposed to jog your memory. Okay. Well then, how about stopping these emails when I don’t go to your site after, say, a week to input whether or not I took my medication? Isn’t that an indication that I don’t care or I’m not interested in your service?
One other major problem with this whole concept is that you have to remember to track your medication, which involves visiting a site everyday (or twice a day) to report whether or not you took your medication. Think about that for a moment. You can’t remember to take your medication, so I’m sending you reminders so that you remember to take your medication AND remember to visit another website to track it. In other words, now I have to remember two things, one of which has no bearing on my health whatsoever. That seems extremely unlikely to me and not a viable long-term solution. A reminder to be reminded. Odd.
PS: if you do opt me into your program, make it easy for me to opt out. For example, I should be able to reply to these annoying emails and say stop, but that’s not an option.
And how come these emails don’t actually remind me to take my medication? They remind me to track it on their site. If you really care about my outcomes, shouldn’t you encourage me to take my medication before you encourage me to visit your site. Just saying…
Some other options for reminders involve the use of text messages or SMS. Depending on the target audience for your product, I like these much better than the email reminders. I’ve seen a lot of expensive, complex SMS reminder programs in my day and have always argued that they shouldn’t be this difficult. Enter Free Rx Reminder. Simple…enter your medication, when you want to be reminded, and your mobile number and get an SMS at that time.
They even created a handy widget that anyone can embed on their site: You can try it out by visiting their site.
How simple was that? Did you pay a fortune for an SMS reminder system for your brand? I did once. Here’s what you get from them when the time you designated comes around:
A couple of things I should point out. First, unlike eTrack, spelled out in the message is a simple way to opt-out. This is a must. You’ll also notice that I can reply with “MORE” and get additional information about discounts, so I checked it out and got this:
I have no idea what this discount is nor how much it’s worth, but as a “customer” (I don’t take Nexium) I certainly would appreciate this. It would be nice to see exactly what the discount is ahead of time though.
One final reminder system involves using “push” notifications that are common on most smartphones today. For example, many applications let you set up push notifications to alert you when some new piece of information or message is available. Because it’s push, you don’t have to open the application to see what’s new. Instead, the update is “pushed” to your phone no matter what you’re doing. This is what a push alert looks like:
Notice that I didn’t need to be in the AP News application to get this, it just shows up on my screen when the server pushes it to my phone. This is another way to set up a reminder.
What you notice is missing from each of the examples I’ve shown you is a simple way to track that you actually took your medication (if this is important to you or you’re part of some program that needs this data). However, this can easily be incorporated into each reminder type. For email, you can include the option to reply to the message with “yes” or “no” (as in: did you take your medication today?). SMS could work the same way and allow you to reply with “yes” or “no.” For push notifications as part of an application, you can include an action in the push message. Check out how Remember the Milk does this for its application:
You see here that you not only get the push notification, but also can open the application right from the notification. This could open a screen in the app where you click “yes” or “no.”
Of course, if all this is too complicated for you, then you could always just set up your own tracking application.
Bottom line: feel free to offer people the option of signing up for reminder services for your product, but don’t expect this service to solve your product’s compliance problems. Reminders can be one tactic in a series of options that could impact compliance, but reminders aren’t enough. If you do use reminders, please keep in mind these simple rules so that you ensure that you’re just reminding people and not annoying them.