121 ACCEPTANCE protocol 5 diode (LED) on the device indicates the battery level. Battery life of the device is approximately 1 year. The app consists of several features which are detailed further. Patients in the intervention group receive instructions on how to use the EMD and how to download, log-in and navigate within the app. No specific instructions on the interaction with the device and application are given (i.e., patients decide which features of the application they use and do not use, and the frequency of interacting with the app) because we aim to mimic a real world situation in which a wide range of user interactions is possible. Logging and visualisation of actuation events The app receives and stores inhaler actuation events recorded by the EMD and visualises inhaler use over time. Patients randomised to the intervention group are registered in the Turbu+ system. Registration includes medication regimen (e.g., two inhalations two times a day). Changes in medication regimen are updated in real time and are visible for the patient in the app. Actuation events are plotted against the prescribed medication regimen on a timeline. In addition, patients can view the actuation events over a certain period (e.g., last week or month). Automatic reminder and messaging The patient can opt in to receive medication reminder messages as push notifications that pop up on the screen. The application also provides preconfigured missed doseengaging voice messages (30 minutes after a ‘missed dose’). These short messages are based on known drivers and barriers of treatment engagement and treatment perceptions (34). The application also sends overuse messages and weekly targeted motivational messages (e.g., ‘Great week. You’ve been following your prescription this week! Keep it up!’). Symptom and triggers Patients can record their symptoms and triggers daily in the app by indicating the severity or presence of the symptom or trigger on a 5-point scale. The separate items are projected in the form of a flower (i.e., a full flower is analogous to a happy flower, meaning a minimal presence of symptoms and triggers). The data can be viewed over time. Web-based HCP portal Inhaler actuation data are uploaded to the smartphone application and electronically linked to an online web portal (Turbu+ webportal), which can be accessed by the patient’s HCP. Within the portal, HCPs can view real time actuation data, including a date-and-time stamp. HCPs from participating practices receive a log in code to be able to set and change the medication regimen and to view the adherence data of their patients participating in the study. Furthermore, they receive instructions on how to access the online healthcare portal and navigate within the portal, but they do not receive specific instructions on the interaction with the healthcare portal and on the use of EMD data during or before patient consultations. Patients who are not
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