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Mobile health (mHealth) apps have recently demonstrated the potential to engage and empower people to improve their own health. Although the availability of health-related apps is increasing, their adoption rate in Taiwan is exceptionally low mainly due to the preponderance of Western culture-based app designs that are challenging for non-English-speaking individuals. To our knowledge, no mHealth app is available in Taiwan that is culturally tailored for Chinese-speaking users and that applies a patient-centered approach to self-manage medication and health.
The purpose of this study was to design and deploy a culturally tailored mHealth system that could be easily integrated into current clinical practice and to evaluate how this mHealth system could support the continuity of patient care in Taiwan.
An mHealth information system and a mobile app were designed. To promote the best patient experience, a Quick Response (QR) code system was developed to enable efficient registration of personal medication information through the mobile app. The app also supported notifications for drug utilization, refills, and symptom checks. Patients were encouraged to record medication use, symptoms, and self-assessments in the app during their treatment period. Evaluation of the novel mHealth system was conducted from August 1, 2016 to December 31, 2016 at MacKay Memorial Hospital, Taipei, Taiwan. Population data and app usage statistics were analyzed.
During the 5-month implementation period, a total of 25,909 users downloaded the app with an overall 7-day retention rate of 15.4% (SD 3.9). Young male adults (range 25-44 years) were the predominant user population. Patients’ feedback on app usability and design, QR code system as drug input method, medication reminders, and linking family or friends into care networks was generally positive. Physicians showed great interest in utilizing patient-generated data in their care process, and the positive medication adherence rate was the most highly valued component of this system.
This pilot study demonstrated the value of a novel mHealth approach for individualized medication and health management in Taiwan. The mHealth system shows the potential to optimize personalized care into existing clinical services and may help hospitals and health authorities perform continuous quality improvement and policy development.
In 2003, the World Health Organization (WHO) reported that medication nonadherence was a global concern, especially for long-term therapies and resulted in increased morbidity [
Medication nonadherence may be caused by patients’ intentional or unintentional behaviors. Intentional nonadherence refers to deciding not to take a medication based on the patient’s own perceptions [
Recently, the popularization of internet technology and mobile health (mHealth) tools for public health or medical care purposes have transformed human life significantly [
The purpose of this study was to deploy a novel mHealth system that could help Chinese-speaking patients to self-manage their medication and health and to understand how this mHealth system could support the continuity of patient care in Taiwan. The new system leverages cloud technologies to integrate with existing hospital information systems and applies a patient-centered design principle for culturally tailoring to Chinese people, with easy-to-use medication registration, symptom tracking, drug information review, and quick health self-assessment. This system also aims to facilitate the coordination of care by seamless information sharing among patients and families.
The mobile app was developed cooperatively by MacKay Memorial Hospital (MMH), Taiwan, and HTC Corporation, Taiwan, for use on iOS and Android platforms. The information structure and design of the mHealth system is illustrated in
Systemic architecture for the mHealth system. HIS: hospital information system, QR: Quick Response, SQL: structured query language.
The app features 3 main functions tailored for Chinese culture that cover several determinants of medication adherence: (a) medication self-management, (b) care circle, and (c) symptom records and global self-assessment. The app operation procedure is illustrated in detail in
The deployment process of the system consisted of different channels and activities in the hospital from August 1, 2016 to December 31, 2016. First, for general users, the app was initially launched through iOS and Google Play stores. However, we realized that patients were the major target audience in this pilot study, and several promotional materials, including posters, flyers, and videos, were widely distributed within MMH. Help desks were also set up at several specific locations in the hospital, such as the pharmacy and reception counter, where in-house staff and project-recruited volunteers were able to interact with patients and help them download and use the app. Second, we promoted the system in some consultation rooms and partnered with medical care providers to help deploy the app at outpatient clinics. In this pilot study period, we selected cardiology, cardiovascular surgery, and rheumatology clinics as our target groups. The patients were encouraged to use the app by their primary care physicians so that the physicians could understand the patients’ medication usage reports on their return visits. Third, for hospitalized patients from internal medicine wards, instruction manuals and consultations were provided before discharge so that they could then self-manage their medications and to better bridge their care from in-hospital to outpatient status.
Data of all participants from the pilot study were recorded by computational backend. In our cloud, the SQL database used a python framework (3.0) to automatically retrieve predefined information from the cloud database. We collected the behavior, number, age, and gender of users, as well as the numbers of drugs by scanning prescription note (batch) or drug packaging (single) and count by browsing the information for each drug. The 7-day active users were defined as those users who used the app any time during the previous 7 days. Data were automatically collected every week. The 7-day retention rate was defined as the percentage of unique users who were still using the app for 7 consecutive days after the first installation.
Screenshots of the (a) operation procedures for medication entry by the Quick Response (QR) code system, (b) care circle feature, (c) user medication completion reports, and (d) symptom checker of the app.
IBM SPSS Statistics version 19 (IBM Corp, Armonk, NY, USA) was used to analyze the data. The proportion of each scanned drug was defined as the scanning counts of each drug divided by the total scanning counts of all drugs. The completion rate was defined as the doses of each medication that were taken by the user divided by those of each medication prescribed by the physician. The number of 7-day active users, number of daily clicks per user, and 7-day retention rate are presented as mean (SD). The data for age, gender, and drugs were only accessible from the Android platform. Feedback from the users of the system, including Google star rating and comments, were also assessed. Feedback taken by convenience sampling at outpatient clinics from the physicians was also collected for suggestions and future collaboration.
This study was approved by the Institutional Review Board of Taipei Mackay Memorial Hospital, Taiwan (No.18MMHIS016e).
The pilot test for evaluating the new mHealth system was initially conducted at MMH from August 1, 2016 to December 31, 2016. A total of 25,909 users downloaded the app, and the mean of 7-day active users over a 7-day interval during the implementation period ranged from a minimum of 253 (8; week 1, Aug 1-7) to a maximum of 638 (7; week 13, Oct 24-30) people, with increasing numbers of users every week since implementation (
The ways of registering medications were also investigated. In the app system design, users could register their drugs by scanning the QR code on the prescription note or drug packaging. As shown in
Statistical analysis of browsing the drug screen, which included drug pictures and detailed information, was used to initially assess whether the system could help users to enhance their knowledge of medications. Medication information surfing behavior via the app gradually increased over time, reaching 3445 times at the fifth month of the study (
(a) The cumulative user number and average of 7-day active users, (b) age and gender demographics, and (c) the cumulative count of browsing drug information and the number of medication registration by scanning prescription notes or drug packaging during the 5-month pilot period illustrated by 7-day interval (week).
The Google star rating of the app was 4.493 points out of 5, over a total of 64 reviews, and some of the comments from the users are as follows:
It was very convenient that I could manage all the drugs by scanning the QR codes on the prescription note or drug packaging and was notified for each scheduled drug without forgetting to take each medication.
The App was a useful tool for me because I could inquire about the function of my drugs and record my symptoms when I was uncomfortable.
Feedback taken by convenience sampling from physicians at hospital outpatient clinics was mostly positive. Physicians generally showed great interest in seeing the patients’ medication usage reports for the first time, including medication completion rate, symptoms, and global self-assessment of the patient at every return visit (formats of reports are shown in step 9 of
It does make me feel comfortable when my patient tells me that he uses this software to remind him to take medicine. And I know that the patient is engaged and motivated by the intervention.
Seeing the patient in my clinic showing me the software with the number of his personal medication completion and symptom status really make me understand my patients better.
The counts of total medication accessed by scanning the prescription notes or drug packaging were extracted from computational backend. A total of 25,267 scanning counts were analyzed using first-tier and second-tier drug categories based on the American Hospital Formulary Service classification, 2017 edition, and the top 30 registered drugs are listed in
The medication usage status could be also tracked and analyzed by computational backend, and the top 10 drugs ranked by completion rate are shown in
(a) Categories of top 30 registered medications and (b) the top 10 drugs ranked by completion rate from the mHealth system in 5-month pilot period.
As the population ages and cost pressures increases, the health care industry continues to face challenges and must find ways to enhance the role of patients in the management of their diseases. One of the ways by which patients can better manage their disease is to adhere to their medication regimens. This pilot study aimed to examine how to make patients familiar with using a new mHealth app for their medical treatments and to investigate the efficacy of integrating an mHealth system into clinical practice at a Taiwan hospital. Our experience suggests that the novel mHealth approach for personal medication and health management in Taiwan is feasible and that the mobile solution incorporating a QR code system and an innovative 2-step system design can provide an integrative solution for other medical institutions in Taiwan as a digital tool for engaging patients to encourage self-management.
Although many users were recruited during the implementation period, we found that the 7-day retention rate of the new mHealth app was low, 15.4% (SD 3.9), compared with previous randomized controlled trials for medication adherence [
In addition, the differences between daily counts of browsing the drug screen per person, 0.13 (SD 0.15) times, and daily clicks in the app per person, 30.6 (SD 5.8) times, demonstrated that the users preferred to use notifications, symptom records, global self-assessments, and statistical reports of completion rates rather than the medication information. This suggests that it is imperative we strengthen patients’ knowledge of medication in Taiwan.
In this study, younger adult males (range 25-44 years) were the predominant population who volunteered to engage with the app. This finding is consistent with previous studies [
Historically, several methods for measuring medication adherence, such as pill counts, refill rates, patient self-reports, biological and electronic monitoring, have been proposed [
During the 5-month implementation period, the pilot project showed certain limitations worth discussing and resolving. First, demographic results, including age and gender as well as the drug categories ranked by completion rate, were only extracted from the Android platform because our computational backend had no access to extract the data from the iOS platform. We tried to analyze the statistical numbers collected from the two platforms separately and found that there was no significant difference between the platforms, suggesting that the two populations showed similar usage behaviors. However, additional technical support is still needed to solve this problem in continuing updates of the new mHealth app.
Second, the patients tended to use the system in a repetitive way (ie, drug packaging, single input) to register each drug instead of registering all drugs just once (ie, prescription notes, batch input). However, the QR codes were unclear because of blurry prints, and creases caused medication registration in the app to fail at a relatively high rate during the implementation period. Therefore, QR codes must be printed on the prescription notes not only for chronic diseases but also for other diseases, and more promotion activities must be implemented to assist patients. By encouraging patients to register their medications through the prescription notes, we hope to avoid wasting time and reduce registration failures.
Third, in the predefined data retrieval, we only defined clicks either from browsing the drug screen or from other information check, including drug notification, symptom records, global self-assessment, and statistical reports of completion. Under this circumstance, we are unable to provide specific data for each function usage. We also could evaluate different periods of retention rate, other than 7 days, in our current system. For example, it would be interesting to know whether the 30-day retention rate is even lower to determine if patients would not use the app over a long term for medication compliance. Furthermore, since we did not retrieve users’ information from the cloud database, we were unable to know the sources of users. As a result, we cannot analyze if the behaviors are different among users from the public, clinics, or hospitalization.
Finally, although the physicians could search patients’ medication usage reports and symptoms from the smartphone at every return visit, this additional action still increases physician consultation time. Therefore, the collaborative patient-physician interaction needs to be optimized by building an encrypted Web-based information system so that physicians can directly access the patients’ medication reports and symptoms by using HIS, thereby reducing physician consultation time.
We believe that the promising achievements of this project will lead to further improvements for the innovative mHealth system. First, we will investigate the unmet needs of patients and physicians in their collaborative interaction and continually expand functions of the app to further optimize the newly developed patient-centered mHealth system. Second, we plan to execute a clinical trial to validate whether the mHealth app can significantly improve patients’ medication adherence after we receive informed consent from patients, following approval of the institutional review board at MMH.
Understanding the benefits of the system, physicians from different specialties, such as cardiovascular surgeons and pediatric rheumatologists, were especially interested in this system as their patients were among those with the most chronic conditions, involving multiple and complicated medications, with typically difficult self-management. The statistical numbers from the active users within the 5-month period indicated that the mHealth app would be a potential health care tool for Taiwanese patients. Moreover, we plan to provide tailored mHealth solutions for other physicians with different specialties and to help patients with different diseases have better therapeutic outcomes. Finally, we believe that the quality and design of our digital health solution for personal medication and health management can be easily integrated into other hospitals and will be the foundation that allows health care institutions to provide a more versatile and personalized approach toward advanced health care.
This pilot study investigated the role of a culturally tailored mHealth system for personal medication and health management in Taiwan. Study results show that the app’s medication registration and notification system helped users self-manage their complicated polypharmacy regimens. The most important feature of the new patient-centered mHealth system was that it reflected patients’ actual medication utilization status, symptoms, and self-assessment. The information is readily available to their physicians through optimization of the patient-physician digital experience so that health care providers and patients can function in a collaborative manner and facilitate patients’ medication adherence. The innovative mHealth solution has the potential to understand Chinese-speaking patients’ medication adherence and therapeutic outcomes as well as to engage patients and family as partners in long-term medical care.
The top 30 registered drugs by the mHealth system.
Top 10 drugs ranked by completion rate.
hospital information system
mobile health
MacKay Memorial Hospital
Quick Response
structured query language
World Health Organization
This research was supported by HTC Corporation, Taiwan (grant #1040004658). We thank our colleagues from Mackay Memorial Hospital who provided expertise that greatly assisted the research.
W-TH, Y-CS, H-LH, and M-YH conceived and designed the study; W-TH and H-LH implemented the study; W-TH analyzed the data; W-TH, Y-CS, H-LH, and M-YH contributed to the interpretation of the results; W-TH and M-YH wrote the original draft; Y-CS and M-YH reviewed and edited the draft; M-YH administrated the project.
None declared.