The CareWave Technology System

CareWave is a new approach to delivering customized "anytime anywhere" support to patients on medical or behavioral treatment programs. It uses the internet and wireless communication to communicate with patients in real time via:

· Personalized web page

· Email

· Two-way pagers

· Personal Digital assistants

· Cellular or land line phone

CareWave provides communications with patients that provide:

· Behavioral support that reduces the loneliness of illness by creating a caring connection.

· Frequent assessments of mood, medication side effects, knowledge of medication

· Reminders to reorder medications, to make or check clinic appointments

· Diagnoses of and delivery of timely solutions to simple problems that affect adherence

· Reminders to take medications, eat meals, or exercise

CareWave keeps a permanent record of all communications that are summarized for delivery to treating physicians and others. The system will interface with any clinical database, electronic medical record or scheduling system that uses HL7 or other commonly accepted standards. The system operates on a regular web browser and the patients or clients use an information appliance-- there is no proprietary hardware. To evaluate the acceptability of CareWave we did pilot studies for one year at a University Hospital based HIV clinic

Case Study

The goal of the study was to determine if CareWave like devices could improve adherence to complex antiretroviral regimens in the treatment of HIV. Some authors believe improved patient compliance with medication therapy could produce greater improvements in patients' health than any medical treatment itself[1].

Problems with patient adherence to medication regimens are well documented. Barriers to adherence include: 1) complexity of medication regimens; 2) forgetfulness; 3) lack of belief in the benefits of the medication; 4) failure to understand instructions; 5) lack of motivation to comply with the regimen; 6) inability to pay for medication; and 7) unpleasant side effects. Reducing one or more of these barriers is a needed component for successful medication treatment.

Overcoming adherence barriers requires using comprehensive interventions that combine behavioral, cognitive, and affective components. Roter's (1998) meta-analysis reported higher patient compliance using comprehensive interventions than single-focus interventions and recommended a multi-faceted approach to improve medication adherence.[2] Counting and measuring techniques provide retrospective medication adherence information but do not address reminding the patient. Reminders and timers only tell patients to take their medication and do not address cognitive, educational, social, and/or affective barriers to adherence. Fully comprehensive care needs to deliver reminders in conjunction with affective (such as monitoring mood, quality of life, and social support) and cognitive (such as health care education and medication side effects) interventions.

The CareWave system we studied used two-way pagers that we instructed patients to carry with them at all times and a web interface for clinicians. The interface enables clinician to both review messages already received by the patient and to add, remove or edit the outgoing message schedule at any time. The system enables clinicians to monitor the patient on an almost continuous basis.

The subjects received between 3 and 8 messages daily via the two-way pager. In an attempt to maintain the subjects' interest in the system, communication via the pager was kept varied and interactive. All messages invited acknowledgment and approximately one half of the messages asked that the subject select a reply from a multiple-choice list sent with the message. Message content included reminders to take medication or food and information or questions about medication adherence, food intake, quality of life, and medication side effects. We asked questions directly about medication adherence but also asked questions about issues indirectly related to adherence including: medication use, side effects, educational or knowledge messages, attitudes to pager system, sleeping habits, hard drug, alcohol or marijuana use, life changes, mood and attitudes to medications.

We enrolled 25 patients, for a median of 208 days (range 11-398 ) using a 2-way pager as the information appliance. CareWave sent approximately17,000 messages to patients, who responded about 15,000 times by choosing either a pre-configured reply or typing out a custom response. In almost all cases subjects have reported positive feelings about the pagers, responded to queries within minutes, and report that they feel the pagers help them with adherence to their complicated HIV medication schedules[3].

Conclusion

The study demonstrated that potential benefits for patients include:

1. Removing the burden of remembering routine medication

2. Delivering just-in-time information about their disease and medications

3. Providing immediate answers to questions, solutions to problems

4. Delivering personalized emotional support and care

5. Provides an easy to use and always available help line

The potential benefits to providers include:

1. Reliable and timely data on adherence, side effects, and sentinel events

2. Real time summarized reports of patient responses

3. Early warning of side effects and other clinical deterioration that reduces cost of care

4. Increases the efficiency of office visits as the CareWave Report gives a starting point to discuss progress since last visit.

CareWave offers a low cost highly pervasive support for complex out-patient medical care. We are unable to show that CareWave improves adherence because the number of subjects limited the power of the trial but the system caused the attitudes and situations to be created that are reported to improve adherence. The twice-weekly questions about adherence show patients report late doses at the same rate as other authors. The patient self-report that their adherence is easier is also evidence of better adherence. The investigators are pursuing NIH funding to undertake a definitive trial of the system.

CareWave can be deployed either by our central office or we can license a system a customer such as a hospital or clinic can use at their own facility. More details are available at our website http://www.carewave.com

1. Haynes RB, McKibbon KA & Kanani R. (1996). Systematic review of randomised trials of interventions to assist patients to follow prescriptions for medications. The Lancet, 348(9024): 383-6. (back)

2. Roter DL, Hall JA, Merisca R, Nordstron B, Cretin D & Svarstad B. (1998). Effectiveness of interventions to improve patient compliance: a meta-analysis. Medical Care, 35(8): 1138-61.

3. Dunbar PJ, Madigan D, Woodward J, Groshof L, Minstrel J & Hooton TM. (2000). Feasibility of a two-way messaging system in HIV-infected patients on HAART. (in press).

© 2000 Dean F. Sittig

The Informatics Review > Thoughts - The CareWave Technology System

dfs 4/15/00