=Paper=
{{Paper
|id=Vol-1574/paper2
|storemode=property
|title=MediTake, A Medication App to Improve Adherence -
A Service Design Evaluation
|pdfUrl=https://ceur-ws.org/Vol-1574/paper2.pdf
|volume=Vol-1574
|authors=Anita Das,Anne Lise Sagen Major
|dblpUrl=https://dblp.org/rec/conf/pahi/DasM15
}}
==MediTake, A Medication App to Improve Adherence -
A Service Design Evaluation==
https://ceur-ws.org/Vol-1574/paper2.pdf
MediTake, a Medication App to Improve Adherence
– a Service Design Evaluation
Anita Das1, Anne Lise Sagen Major2,3
1 SINTEF Technology and Society, Trondheim, Norway
2 Norwegian University of Science and Technology, Medical Faculty, Trondheim, Norway
3 Sykehusapotekene i Midt-Norge HF
Abstract. Medication is one of the most important factors for preventing,
treating, or revealing the impact of illness and disease. Medication non-
adherence is a challenge because it reduces the effectiveness of treatment and
imposes significant resources on the healthcare system and society as a whole.
Studies show that up to 50% of people with chronic illnesses do not take their
medications as prescribed. MediTake application was developed to support
people in their medication management, as a means to increase self-
management and medication adherence. The aim of this study was to implement
and evaluate a suggested pharmaceutical service, where the MediTake app had a
central role, to support patients’ medication adherence and self-management.
We here report on the professionals’ perspectives from the service design
evaluation.
1 Introduction
Medication is one of the most important factors for preventing, treating and revealing
the impact of illness and disease. The management of medications depends on several
factors such as correct diagnosis, correct treatment, implementation of measures, and
on the patients’ adherence to medications prescribed. Many people do not take their
medications as prescribed; this is particularly prevalent among people suffering from
chronic diseases and among people that use multiple concomitant medications[1-3].
Studies show that up to 50% of all people suffering from chronic diseases do not take
their medications as prescribed [1, 2].
Adherence is by the International Society for Pharmacoeconomics and Outcome
Research defined as “the extent to which a patient acts in accordance with the
prescribed interval, and dose of a dosing regimen” [4]. The cause of medication non-
adherence is broadly categorized as intentional or unintentional [5, 6]. The latter
involves that the patient intents to take a medication as instructed but fail doing so
because of reasons such as forgetfulness, carelessness, misunderstandings etc. Patient
characteristics, treatment factors, and patient-provider issues influence such non-
adherence. Intended non-adherence involves that the patient stops taking a medication
as instructed due to perceptions, feelings, or beliefs. Such non-adherence reflects a
rational decision-making process where the treatment benefits are weighed against
any adverse treatment effects [5]. Successful management of chronic disease is highly
Copyright © 2016 by the paper's authors. Copying permitted for private and academic purposes.
In: G. Cumming, T. French, H. Gilstad, M.G. Jaatun, E.A A. Jaatun (eds.):
Proceedings of the 3rd European Workshop on Practical Aspects of Health Informatics
(PAHI 2015), Elgin, Scotland, UK, 27-OCT-2015, published at http://ceur-ws.org
12
dependent on the individual patients abilities to take responsibility for own care and
treatment. The integration of mobile phones into our lives creates new opportunities
to enhance self-management activities through features such as reminders,
informational and motivational messaging, and, provides possibilities for self-
monitoring of symptoms and behaviors (e.g. adherence to medications) [7].
It is estimated that 10% of all hospital admissions are because of reduced
adherence, in worst case leading to illness and death [3]. The impacts of poor
adherence to medication regimens are severe, both for the individual as in worsening
of disease and death, and for the society as a whole because of health care costs and
societal expenses. Physicians’ ability to recognize patients’ non-adherence has been
poor, and interventions to improve adherence have been substantially complex, costly,
and with mixed results [2]. In short-term drug treatments, studies show that
counseling, written information and personal phone calls help [8]. For long-term
treatments, no simple intervention lead to improvements in health outcomes, and only
some of the more complex interventions are shown to have impact [8]. Therefore, the
need to explore approaches for improved service delivery and creating support tools
for those with long-term treatments are therefore still important. The two main
objectives of the hospital pharmacy enterprise in Norway are: (1) to provide
pharmaceutical services to ensure the correct use of medicine, and, (2) to ensure the
reliable and cost efficient distribution of medicine [9].
As part of this research study, a proposed pharmaceutical service model “app @
the pharmacy” was implemented into the hospital pharmacies in Central Norway. The
service involved that pharmacist promoted correct use of medication by introducing a
medication app, as a means that the patients could use in their daily life to improve
self-management and medication adherence. The objective of the current study was to
evaluate the suggested pharmaceutical service. We here report on the pharmacists’
perspective. The patients’ experiences are reported elsewhere.
2 Methods
The study was conducted 2014 – 2015. Norwegian Social Service Data Services
(NSD) approved the project. All participants provided informed consent when
participating in the study.
2.1 MediTake Medication App
The MediTake app was developed by Pierre Major in cooperation with the hospital
pharmacy trust and NTNU Technology Transfer. The app was programmed in
Android Native Development Kit, and was available for Android phones through
Google play at the time of the study.
The features of the app included:
• The patient’s medication list (had to be registered manually)
• Reminders (about when to take the medication: pop-ups with sound)
• Self-monitoring (statistics adherence rate: medications taken)
13
• Information about medications (hyperlink to felleskatalogen which delivers
patient information about medications)
Fig. 1: Two Screen Captions from MediTake Medication App
2.2 The Pharmaceutical Service
The pharmaceutical service, “App @ the pharmacy”, was implemented at the 6
hospital pharmacies in the Mid-Region of Norway. The service was implemented into
the regular daily work at the pharmacies without extra incentives, and involved that
pharmacists requested and offered the service to patients. Patients’ inclusion criteria
to receive the service were: (1) age above 16 years, (2) have an Android smartphone,
(3) manage own medications, (4) use medications for more than three weeks (long-
term use), and (5) provide an informed consent.
The service involved that the pharmacists taught the customer about the app and
provided patient information about the customers’ medications. To get access the app,
it had to be downloaded from Google play to the patients’ phone. The pharmacists
were instructed to facilitate the customer and provide a short introduction about the
app, before registering some of the patients’ medication so that the patients’ could
complete the list by their own, and, thereafter use the app in their home environment.
The pharmacists were instructed to call the patients’ by phone after a couple of weeks,
to follow-up the patients and provide support if necessary.
2.3 Data collection
Throughout the project period, 18 pharmacists provided the service. Data collection
involved 4 semi-structured group interviews with 13 (9 women & 4 men) of the
pharmacists who had provided the service. Both authors conducted most of the group
interviews together, except from the last interview, which was conducted by the first
author alone due to practical reasons. In each interview, 3-4 professionals attended,
14
and the participants represented 4 of the 6 involved pharmacies where the service was
implemented.
During the group interviews, participatory design methods were applied, such as
brainstorming sessions, storyboarding activities, presentation rounds, and plenary
discussion. Each interview lasted 2-2,5 hours, was tape-recorded, transcribed
verbatim, and analyzed inductively.
Fig. 2: Participant in group-interview creating a storyboard
3 Results
The participants reported on barriers and benefits of conducting the pharmaceutical
service. Four major themes were identified: (1) user groups, (2) workflow integration,
(3) usability, and (4) usefulness.
3.1 User groups
During the study period, the pharmacists provided the service to 77 patients but
reported to have offered the service to significantly more people than included. The
main reasons for customer rejection to the service were because of lack of experience
or competence to enable the technology, that they did not have the required
smartphone, or the time required to acquire the service. The fact that some customers
had limited experience in using a smartphone became a challenge for the
professionals, who used considerable recourses in teaching some customers basic
features of using a smartphones, a task they considered to be beyond their
responsibility:
“Well, I don’t think the challenge is merely the app. We are to access Google-
play. Okay! It is all the other stuff. Not all patients are qualified, even though
they have an Android phone, they aren’t there. We partly used lots of
resources in teaching them how to use a smartphone. And that isn’t, I don’t
think that is our… then we could have let it be. I don’t think it will be
successful either” (male, pharmacist).
The pharmacists acted deliberate in whom they offered the service, and whom they
avoided to request. Several reported that customers non-verbal language influenced
whether they would introduce the service: “it’s something with their body language,
15
they are like “can’t I just get my pills and leave?” (male, pharmacists). Thus, some
reported that it was easier to offer the service to the elderly, who they found to have
time. In other instances, the pharmacists would purposely avoid to suggest the service
to certain user groups whom they considered the service would to be an extra burden:
“I don’t remember all the reasons, but for instance a couple with a chronic ill child,
and those kind of customers, don’t bear to consider asking them”(female,
pharmacist). The pharmacists reported that they had avoided customer groups whom
they perceived to be vulnerable, such as cancer patients and patients in palliative care:
“I think it is so… I have avoided cancer patients, because I have felt
that they have enough. Even though they use complex medications”
(male, pharmacist).
“Another group are those in palliative care. Come and get their last
dose with strong opioids, then you don’t start talking about this
service… No, so there were actually quite many, I experienced, who
were like that”(female, pharmacist).
Another said that she wanted to protect the customer from an information overload:
“for those patients that already are frequently in the hospital and get a lot of
information, it is something with not overloading them totally” (female, pharmacist).
On the other hand, the pharmacists reported that the inclusion criteria for receiving
the service were too restricted because they considered that other user groups, in
addition to those with long-term medication treatment, would benefit of getting the
pharmaceutical service:
“User groups that would benefit of using the app would for instance be
parents of small children, or customers that are to use antibiotics for a week,
or ten days or so… [] I feel that some user groups are excluded. And some
who I really would like to get hold of, like the orthopedic patients, would
probably have been very positive, some of those who go for rehabilitation,
right? […] They use anticoagulant drugs and they use painkillers. It would be
very practical to get a summary of how much painkillers they have been
using.”(male, pharmacist)
Among other potential user groups they mentioned: (1) relatives that managed the
medication for their children or parents, (2) users that needed to establish new dosing
schedules, (3) users that needed time critical dosages (e.g. Parkinson’s disease, people
using painkillers), (4) for complex dosing schedules, (5) for people using time limited
medication (antibiotics) – and particularly if several times a day, and, (6) for those
who needed cognitive support/reminders to take medications.
3.2 Workflow integration
Most of the pharmacists in this study worked at the front desk in the public
department of the pharmacy, while a few also worked in the hospital wards,
conducting medication reconciliation and reviews. The success of the workflow
integration depended on where the service had been carried out. Those who conducted
it during their work in the hospital ward reported that the service became an
integrated part of their already established work:
16
“And when I was in the ward, I didn’t ask everyone, but I asked those who I
during the interview identified had a problem, who didn’t remember to take
their medication […] So when you start talking to them, you find that they
don’t have a regular intake, or that they don’t take it, that they forget it in the
evening, or that they… so you reveal many of those kind of things during the
conversation, and then I have asked if they would like this […] When I have
been in the ward, I think it has been easier to introduce it in a way, when you
have a conversation about their medications anyway” (female, pharmacist).
Providing the service in the public department involved more challenges with limited
workflow integration. The service often fell behind due to other work tasks, resulting
in that the pharmacists forgot to offer the service to their customers, as a female
pharmacist explained: “yes, I have just forgotten it”. Another pharmacist reported:
“And it is to remember to offer the service, in general. I feel that I have to [prioritize]
to have it in my head somewhere: That day, yes, okay, that day I will really do it.”
Another expressed that he found it challenging to introduce the service to the
customers: “Sometimes I think it has been difficult to introduce MediTake in a good
and informative way. But then, I have become better for each time I have done it.”
This was a shared experience by several. Self-confidence about providing the service
was connected with experience:
“Yes, I have asked everyone. Had to force myself to ask, though.
Because, then I felt, it became a routine, yes, to get used to it. But in the
beginning it was like “oh, no, don’t want to get rejected”(female,
pharmacist).
The main difficulties of conducting the service were related to limited time, resources,
and infrastructures. Short of staff, heavy workload and limited time at the front desk
and influenced if the pharmacists could prioritize conducting the service. Some
reported that they preferred requesting the customer about the service, and making an
appointment for the customer to come back to receive the service. Among the
infrastructural challenges, Internet access was reported to be cumbersome and
inconvenient, which made it a barrier because installing the app required Internet
access to download it from Google play.
3.3 Usability
A structured usability evaluation was not within the scope of the current study, but
usability issues concerning the app were identified as part of the project. The main
usability issue that influenced the service delivery was the required time to register
medications in the app, a task the pharmacists assisted the customers with. The
participants reported that time to conduct this task depended on the customers’
experience with smartphone and the number of medications prescribed:
“It takes enormous amount of time before they can register the one
medication. And it is not intuitive, that you are supposed to go there, and
there, and then I have to help them. It is not as integrated as for us younger…
if it is a person with less technological experience and who has many
medications, then it takes very long time. So it is a challenge (male,
pharmacist).
17
This resulted in that the pharmacists tried to plan to have sufficient time to carry
out the service, which again influenced the (dis) integration with their workflow.
3.4 Usefulness
The pharmacists reported about the usefulness of the service and app. They
considered the app to be a good support tool that they could offer to their customers.
Some experienced that the service involved increased direct patient contact that
facilitated promotion of correct use of medication:
“They, I have taken them [patients] with me to the information room, right? And
then they share more about their medications and their experience. And I became
kind of surprised, because when we are at the front desk, then, I don’t think people
are that sharing. So, then I have like…there was this guy who said that he had
impotence problems, and questioned the medications. And then I asked about
when he had started to take his beta-blockers. And I said that he absolutely
needed to discuss this with his doctors, and he was a bit…I felt that I was useful
there. Those kind of things.”(male, pharmacist)
The participants talked about the convenience of providing the app to certain users,
particularly younger users who needed a support tool to manage their medications:
“[…] in the conversation you discover that there are too many [medications to
handle], and that they need help to remember to take their medication. And I
feel that they get good help when you can offer them a support tool. And in the
hospital ward… you have more time and you can offer something to those who
feel too young to use a pillbox. Because, many are. You like, when you ask
them: “do you use a pillbox?” many answer “no, no, no, no! I am not that
old”” (female, pharmacist)
The pharmacists reported that pillboxes could be perceived as stigmatizing. The app
was not connected with stigma in the same way and was therefore considered to be a
great benefit:
“First of all, I think it is very good, a good support tool, if you get hold of the
right customers to recommend it to. And then I think, I feel that some
customers become so offended if you offer them a pillbox. Because then I
indirectly say that they are developing dementia. But you don’t get the same
problem when you start talking about the app. Then no one feels old and
forgetful […] so here you can say the same, but a bit, in a more youthful way
to say it. You don’t get this, or, it is actually opposite.” (female, pharmacist)
4 Discussion
In this study we have identified benefits and barriers of conducting a pharmaceutical
service concerning patient counseling involving introduction to a smartphone
application to long-term medication users. The results show that such a service model
has potential for various patient groups. From a professional point of view the
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application offers an entry to a more profound conversation with the patients about
their medications, and an approach to promote correct use of medications and self-
management activities.
The pharmacists expressed that the application could be a support tool for patients
in need of reminder aid, as well as to those that needed to establish new dosing
schedules, and to patients that had complex dosing schedules. In this way the service
model supports patients in the acquisition of skills and techniques to learn to manage
a chronic disease. Such interventions might be effective as one of the foremost
challenges in chronic disease management is the engagement in self-management
activities of patients in their daily routines [7]. Depending on the type of non-
adherence and patient characteristics, using a combination of tailored interventions
such as patient education, patient self-monitoring and stimuli to take medications
have the greatest potential for improving adherence [8, 10-12]. However, a number of
barriers such as usability issues, lack of workflow integration and challenges with
including users according to the inclusion criteria, influenced on how the service was
carried out. Another hazard in the front-desk pharmacy setting was the fact that other
customers were waiting for turn, and thus the pharmacist would not always prioritize
the counseling service because it would lead to additional waiting time for the
customers.
As part of this study the pharmacists collected patient questionnaires for
quantitative data collection. This involved paperwork that had to be done together
with the customer, but that would not have been part of a real service. This required
additional time and might explain some of the challenges considering time to conduct
the whole service. The situation in the hospital ward was different, and the pharmacist
found it easier to carry out the service there, as demands about time-efficacy was not
as prevalent there as at the front-desk. Conducting such patient education and
counseling is in line with the hospitals’ intention to conduct patient education and
medication reconciliation at discharge.
4.1 Limitations and Implications
This study was limited to patients with long-term medication treatments. However,
others such as relatives managing the medication for their children or parents, or
people on short-time medication treatment (antibiotics), were mentioned as possible
user groups. Of various reasons, the pharmacist found it difficult to implement the
service as part of their normal workflow at the pharmacy. The introduction to the
MediTake application was sometimes complicated and time-consuming due to limited
technological knowledge among the users. This might certainly be a problem today,
but considering the increasing number of people using smartphones and the
technological development in this area, one can expect that such problems might
diminish with time. The results of this study are limited to its qualitative approach,
and the results can therefore not be generalized. The results might have been different
if other participants, another setting, or other technology was studied. However, the
findings show a number of implications relevant to similar service design projects.
The usability issues, infrastructural, and workflow challenges identified in this study
are aspects that need to be addressed for increased workflow integration in potential
future projects.
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5 Conclusion
The need to explore approaches to facilitate self-management and improved
adherence is an important issue that becomes increasingly prevalent with the number
of people suffering from chronic diseases and thus, who require medication treatment.
The findings of this study show that a pharmaceutical service model involving patient
counseling including introduction to a smartphone application has potential. However,
there are a number of considerations that need to be undertaken when implementing
such services in real life. The pharmacists reported a number of benefits of providing
the service tool to their customers, but factors such as workflow integration, usability
issues and user groups, influenced on how the service was carried out. Despite the
limitations, adherence apps such as MediTake, represent a low-cost strategy that can
be incorporated into a variety of healthcare services as means to promote self-care
management and medication adherence.
Acknowledgments This study was funded by the Central Norway Health Authority.
We acknowledge the work of Liv Tran who conducted her master’s project in
pharmacy in connection to this study. We thank the patients and professionals that
participated in this study.
References
[1] M. DiMatteo, "Variations in patients' adherence to medical recommendations: a
quantitative review of 50 years of research.," Med Care, vol. 42, pp. 200-209, 2004.
[2] L. Osterberg and T. Blaschke, "Adherence to Medication " N Engl J Med vol. 353,
pp. 487-497, 2005.
[3] E. A. Schlenk, J. Dunbar-Jacob, and S. Engberg, "Medication Non-Adherence
Among Older Adults. A Review of Strategies and Interventions for Improvement,"
Journal of Gerontological Nursing, 2004.
[4] J. A. Cramer, A. Roy, A. Burrell, C. J. Fairchild, M. J. Fuldeore, D. A. Ollendorf, et
al., "Medication compliance and persistence: terminology and definitions," Value
Health, vol. 11, pp. 44-7, Jan-Feb 2008.
[5] A. Wroe and M. Thomas, "Intentional and unintentional nonadherence in patients
prescribed HAART treatment regimens," Psychol Health Med, vol. 8, pp. 453-63,
Nov 2003.
[6] A. L. Wroe, "Intentional and unintentional nonadherence: a study of decision
making," J Behav Med, vol. 25, pp. 355-72, Aug 2002.
[7] D. Swendeman, N. Ramanathan, L. Baetscher, M. Medich, A. Scheffler, S.
Comulada, W., et al., "Smartphone Self-Monitoring to Support Self-Management
Among People Living With HIV: Perceived Benefits and Theory of Change From a
Mixed-Methods Randomized Pilot Study," J Acquir Immune Defic Dyndr, vol. 69,
2015.
[8] R. B. Haynes, E. Ackloo, N. Sahota, H. P. McDnald, and X. Yao, "Interventions for
enhancing medication adherence," Cochrane Database Syst Rev, vol. 16, 2008.
[9] (07.09.15). Sykehusapotekene i Midt-Norge. Available:
http://www.sykehusapoteket.no/en/Om-oss/On-your-side-for-your-health/86500/).
20
[10] V. Conn, A. Hafdahl, and P. Cooper, "Interventions to improve medication adherence
among older adults: meta-analysis of adherence outcomes among randomized
controlled trials," Gerontologist, vol. 49, pp. 447-62, 2009.
[11] M. Graves, M. Roberts, M. Rapoff, and A. Boyer, "The efficacy of adherence
interventions for chronically ill children: a meta-analytic review," J Pediatr Psychol,
vol. 35, pp. 368-82, 2010.
[12] A. Williams, W. Manias, and R. Walker, "Interventions to improve medication
adherence in people with multiple chronic conditions: a systematic review," J Adv
Nur, vol. 63, 2008.