EMM - Box
Overview
Event monitoring devices for medication support (EMMs) boxes make use of a simple low-cost medication box and a battery powered sensor. EMM boxes can be used in combination with a SIM card and mobile data connection for real-time transfer of adherence data to a platform or by connecting the box via a cable to an internet-enabled computer to upload adherence data. Patients store and organize their TB medications in the box, and when they open the box for daily medication intake, the sensor is activated and stores data on the device memory and/or sends dosing event information in real-time to the adherence platform using the mobile data connection. EMM boxes can usually be customized to divide compartments to sort by medications or daily dosing and can include treatment-specific instructions. EMM boxes can contain a small LED display and speaker to enable audio-visual reminders. EMM boxes are appropriate for all patients that take non-injectable medications, and are particularly well-suited for drug resistant (DR)-TB patients, as the box format is medication-agnostic and appropriate for storing the variety of diverse regimens possible.
After reading this section, you should be able to:
Describe the features of the EMM box and how it functions
Describe the EMM sleeve products in the market and the companies that provide and support them
Understand the research evidence on DATs and how to reference them
Understand the learning from country implementations of EMM box
Figure 1: Sample of a customized cadboard evriMED box partitioned for medication
EMM-Box Example
There are several electronic pill boxes with various features currently on the market which are used extensively in different countries. The evriMED EMMdevice has been used in several projects specifically in low and medium income countries and is referred to in the WHO Handbook for the use of digital technologies to support TB medication adherence.
This device is developed by South Africa-based Wisepill Technologies cc. Wisepill Technologies is a for-profit business[1],[2] founded in 2007 to tackle the problem of medication non-adherence in countries both in the global North and global South.[3] Wisepill is a manufacturer of a range of adherence monitoring technologies for use by patients in resource-limited settings. These medication dispensers have been used in more than 20 countries and 40 research trials[4], mainly for management of TB and HIV adherence, but also for patients with epilepsy, osteoporosis, chronic heart conditions, diabetes, leukemia, asthma, ADHD and hepatitis C. Wisepill developed the evriMED device specifically for TB care in resource-limited countries with funding from the Bill & Melinda Gates Foundation and the device have since been used in both clinical trials and clinical practice in public and private sectors in high-burden regions.
Figure 2: How to use the EMM box
Examples of Country Implementation(s)
| 1 | India | DS-TB, DR-TB | PATH | Bill & Melinda Gates Foundation |
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| 2 | South Africa | DS-TB adults aged ≥ 18 years and children (2-17 years) | The Aurum Institute | Bill & Melinda Gates Foundation, TB REACH (Stop TB Partnership), South Africa MRC | A pragmatic study to implement and evaluate an adherence monitoring system (using the Wisepill evriMED 1000 devices) with a differentiated response to patient care, among drug-sensitive TB patients in three provinces (Gauteng, Western Cape and Kwa-Zulu Natal). | Noriah Maraba |
| 3 | Tanzania | Smear positive and all presumptive TB cases | The Good Samaritan Foundation | TB REACH (Stop TB Partnership) | Effect of implementing evriMED with reminders and tailored feedback on adherence among TB patients in Northern Tanzania, Kilimanjaro region. | Marion Sumari de-Boer |
| 4 | Ukraine | DR-TB | PATH, KNCV, LHSI | TB REACH (Stop TB Partnership) | Demonstration of automatic dose monitors (medication “smartboxes”) to assist patients in treatment adherence in Odeska and Mykolaivska oblasts, expanded to 13 more districts in July | Aleksey Bogdanov abogdan@path.org |
Challenges experienced in countries during Implementation:
Poor internet connectivity in some areas;
Delays in shipment from manufacturer;
Distribution and set up of boxes takes a lot of time;
Adaptation of default system reports to fit country requirements;
Limited dashboard customization and adaptation to meet country specific requirements;
No access to in-country customization;
Limited translation to other languages.
Lessons Learned by Countries during Implementation:
Early stakeholder engagements for buy-in;
Customized training packages for users;
Allocate sufficient time for procurement there may be unexpected delays;
Continuous technical support and troubleshoot is required;
Engage patients during adaptation so technology meets their needs;
Examples from country implementations
Figure 3: EvriMED box and corresponding (Wisepill) adherence platform used in the TBMate project in South Africa led by The Aurum Institute south Africa
Figure 4: Distribution model in Ukraine - PATH
Resources
[1] https://www.wisepill.com/evrimed/
[2] http://www.stoptb.org/partners/partner_profile2.asp?PID=71298
[3] https://www.wisepill.com/about-us
[4] http://thearcadygroup.com/polaris/wp-content/uploads/2017/08/Global-Access-Strategy_FINAL.pdf
Liu X, Blaschke T, Thomas B, et al. Usability of a Medication Event Reminder Monitor System (MERM) by Providers and Patients to Improve Adherence in the Management of Tuberculosis. Int J Environ Res Public Health. 2017;14(10):1115. Published 2017 Sep 25. doi:10.3390/ijerph14101115
Ridgeway K, Dulli LS, Murray KR, Silverstein H, Dal Santo L, Olsen P, et al. (2018) Interventions to improve antiretroviral therapy adherence among adolescents in low- and middle-income countries: A systematic review of the literature. PLoS ONE 13(1): e0189770. https://doi.org/10.1371/journal.pone.0189770
