Event monitoring devices for medication support (EMM’s) are tools that integrate a digital process and a physical medication package or storage device (box). Specifically, Event monitoring device for medication support (EMM) are tools that integrate a digital process and a physical medication package or storage device. EMM sleeves are a DAT that combines a paper or card stock sleeve that fits over a medication pill pack and includes printed instructions for the patient on how to take the daily medication dose and log this into the system. Dose reporting can be done by phone call or text message, depending on the country implementation. As the use of DATs continue to expand, daily medication dose may also be reported via USSD (Unstructured Supplementary Service Data), the method commonly used for topping up credit in prepaid phones.
Currently, there is one key example of the EMM sleeve DAT - 99DOTS. In this approach, existing Fixed-Dose Combination (FDC) antibiotic medication blister packs are repackaged in a custom card stock sleeve with a series of unpredictable hidden toll-free phone numbers or SMS codes that are revealed each time a patient takes their pills for the day. Patients engage with 99DOTS by making a (*free) call or sending a (*free) SMS daily to the revealed number, at which point the system will automatically log their medication intake on the adherence platform. 99DOTS is best suited for drug sensitive (DS) patients receiving their TB medication in standardized fixed-dose combination (FDC) blister packs.
*Although the calls and SMS are toll free to the patient, this cost is covered by either the use of national toll free lines, or privately procured lines for the intervention
After reading this section, you should be able to:
Describe the features of the EMM sleeves and how it functions
Describe the EMM sleeve products in the market and the companies that provide them
Understand the research evidence on DATs and how to reference them
Understand the learning from country implementations of EMM sleeves
Figure 1: Sample of a pill blister encased in an EMM Sleeve
Example of EMM -Sleeve
The EMM sleeve and phone call method were originally conceived as part of the development of 99DOTS by Everwell Health Solutions(the same developer as the Everwell Hub adherence platform). Everwell is a healthcare technology company based in Bangalore, India.
Everwell uses digital technology to empower patients to self-administer their drug treatments while enabling healthcare professionals to identify in real-time which patients require additional outreach to support high adherence and treatment completion. Everwell’s co-founders developed 99DOTS during their time at the software development lab Microsoft Research India. Since 2015, through support by the Bill & Melinda Gates Foundation, USAID, and DFID funding, 99DOTS has been implemented in India and has been integrated with India’s national health information system, Nikshay.
99DOTS is specifically referenced in the WHO Handbook as a digital technology to support TB medication adherence. ASCENT consortium members KNCV and PATH are working with Everwell in the TB REACH Wave 6 projects in the Philippines and Tanzania, funded by the Stop TB Partnership. Early learnings from these projects have informed (and will continue to inform), the Adherence Support Coalition to End TB project (ASCENT), a 5-country coalition, funded by Untaid.
Challenges experienced in countries during Implementation:
Variation in design of anti-TB drugs pill blister packaging supplied by Global Drug Facilities causing difficulties in using pre-designed and procured sleeves;
Stock out of TB medication;
A small selection of languages available on the web application;
Patients are sometimes unable to call and confirm daily medication or receive confirmation SMS messages due to network issues;
Patients who share mobile phones with family and friends (do not own the phones) are unable to call daily to confirm their medication, where the phone is unavailable;
It is not always feasible to set up multiple toll free lines due to country regulations.
Lessons learned by countries during Implementation:
Stakeholder consultation for buy-in;
User design workshop held with patients and HCWs improved the acceptability of the technology;
Translation of the app to the local language improves acceptance and usability;
Start implementation when all software adaptions and customization are completed;
Include counseling on DATs during enrollment of patients on TB treatment;
Involvement of Community Health Workers (CHW) for non-adherent patient follow-up contributed to improvements in patients’ adherence;
Institutionalization of DATs in the facility standard of care increases acceptability;
Integration with the existing country information system will improve data quality and reduce the workload of HCWs when enrolling patients (patient demographic data can be imported from country information system);
Setting up real time technical support and updates through group chats such as Watsapp with all facilities.
Pictures from Country Implementation(s)
Figure 3: HCW in Bangladesh showing a patient their adherence calendar on the 99DOTS platform
Figure 4: Sleeve adaptations in Uganda
Figure 5: HCW teaching an elderly patient how to use the 99DOTS DAT in Tanzania
Figure 6: HCW teaching a patient how to use the 99DOTS DAT in Tanzania
Figure 7: HCW counselling a patient before enrollment on the DAT in Philippines
Figure 8: Sample messages received by HCWs in Philippines, informing them of patients who missed their doses and require follow up
99DOTS hosted phone lines Versus 99DOTS portable
99DOTS can be hosted either on national toll free phone lines or on a portable solution (where the latter is unavailable or may be expensive). There are implications to the technical set up of the 99DOTS platform and this can impact the use of the DATs depending on the setting where they are deployed.
99DOTS hosted phone lines
99DOTS Portable phone lines
99DOTS hosted phone lines
99DOTS Portable phone lines
Phone lines are acquired directly from telecom providers, however there may be limitations in the number of phone lines that can be procured due to country regulations
Phone lines are acquired directly from the telecom providers and there is usually no limitations to the number of phone lines that can be procured as this is typically a private transaction not affected by government regulations
Technical set up
Phone lines are set up directly from the mobile network providers (MNO) to the 99DOTS server. This can be remotely done with support from Everwell working closely with the MNO.
Phone lines must be put into phones or tablets which must have a 4G or wireless internet connection
Cost to user
The phone lines are toll free to the user and they can call or send SMS the platform with zero air time. However the cost of the calls and SMS made by the users to the platform are covered by the DAT project. These costs can be negotiated with the MNOs.
Phone lines may be toll free to the user, however the user must have a minimum balance (differs across MNOs) to call os send SMS to the platform. The users are not charged for calls made or SMS sent
System stability and robustness
The system is stable as there are no physical connection to the adherence platform server
The system can be unstable as the 4G or WIFI connection can easily triggered off/on