Understanding How Prescription Medication Compliance Is Affected By Out Of The Home Activities

Abstract

The World Health Organization cites that compliance to a prescription medicine regimen is one of the most critical issues to the continued health and wellness of elderly people. [1] Extensive data also show that particular elements in the activities of daily living affect compliance. The areas frequently identified for solutions are primarily a result of studying at-home environments and experiences. As people live longer and healthier lives, elders are able to spend more time being active outside of the home. Creating a system to remind and motivate towards medication adherence can be a key factor in keeping an elder safely in his/her home and community. The following paper will describe the collaborative efforts between Intel's Digital Health Group and the Industrial Design program at Georgia Institute of Technology. Qualitative research methods were employed for this project. To better understand the current and future needs of active and mobile elders. The research was conducted in a 12-week time frame by seven industrial design graduate students. A multi-method research approach consisting of questionnaires, photo journals, and collaging exercises were used to understand the problem spaces and offer subsequent solution concepts. Initial findings have shown that participants performing short-term, outside the home activities (<3 hours from home) do not change a person's regimen or require specific products to aid compliance. Understanding these current behaviors also helped uncover latent needs for possible technology and systematic solutions. Prior to the start of this project, a team of researchers at Intel focused on ways to improve the quality of life in elders. [2] In conducting extensive ethnographic research on elders, it was noted that medication compliance is more than just a medical problem. Although it has long been recognized by the medical profession that taking medications is a key marker of the ability to live independently [3], hearing this from many informal interviews emphasized the subjective importance of this activity to elders and family. In addition, noncompliance costs the US healthcare system $100 billion per year. [4] Reports have shown that noncompliance to medication regimens range from 13% to 93%, with an average rate of 50% for long-term therapies. [5] Noncompliance is a particular problem for the older population. It is recognized that compliance itself is not necessarily the problem, but the consequences of noncompliance with the older population typically results in greater health complications and higher risk of adverse health effects. [6] Almost 30% of hospital admissions, and 40% of nursing home admissions for patients older than 65 years are due to noncompliance. [7]

Full text

Understanding How Prescription Medication Compliance Is
Affected By Out Of The Home Activities
Wayne Chung, Carnegie Mellon University
Janna C. Kimel, Intel Corporation
Brad Needham, Intel Corporation
ABSTRACT
The World Health Organization cites that compliance to a prescription medicine regimen is one
of the most critical issues to the continued health and wellness of elderly people.[1] Extensive data also
show that particular elements in the activities of daily living affect compliance. The areas frequently
identified for solutions are primarily a result of studying at-home environments and experiences. As people
live longer and healthier lives, elders are able to spend more time being active outside of the home. Creating
a system to remind and motivate towards medication adherence can be a key factor in keeping an elder safely
in his/her home and community.
The following paper will describe the collaborative efforts between Intel’s Digital Health Group and
the Industrial Design program at Georgia Institute of Technology. Qualitative research methods were
employed for this project. To better understand the current and future needs of active and mobile elders.
The research was conducted in a 12-week time frame by seven industrial design graduate students.
A multi-method research approach consisting of questionnaires, photo journals, and collaging exercises were
used to understand the problem spaces and offer subsequent solution concepts. Initial findings have shown
that participants performing short-term, outside the home activities (< 3 hours from home) do not change a
person’s regimen or require specific products to aid compliance. Understanding these current behaviors also
helped uncover latent needs for possible technology and systematic solutions.
Prior to the start of this project, a team of researchers at Intel focused on ways to improve the quality
of life in elders. [2] In conducting extensive ethnographic research on elders, it was noted that medication
compliance is more than just a medical problem. Although it has long been recognized by the medical
profession that taking medications is a key marker of the ability to live independently[3], hearing this from
many informal interviews emphasized the subjective importance of this activity to elders and family.
In addition, noncompliance costs the US healthcare system $100 billion per year.[4] Reports have
shown that noncompliance to medication regimens range from 13% to 93%, with an average rate of 50% for
long-term therapies. [5] Noncompliance is a particular problem for the older population. It is recognized that
compliance itself is not necessarily the problem, but the consequences of noncompliance with the older
population typically results in greater health complications and higher risk of adverse health effects.[6]
Almost 30% of hospital admissions, and 40% of nursing home admissions for patients older than 65 years are
due to noncompliance. [7]

PROJECT INTENT
The objective of this joint industry and academic project was to gain a better
understanding of the reasons and conditions behind compliance or noncompliance to
prescription medication regimens among the mobile elder population. The intention is
then to define opportunities that allow technology to enhance, aid, and assist regimen
compliance amongst the older population.
BACKGROUND RESEARCH
The student mobile medication reminder project conducted at Georgia Institute
of Technology was inspired by two previous research projects done by the Intel group.
One short project over a period of 4 weeks asked individuals to use a series of
reminders to best understand what types of alerts and reminders are preferred. In
addition to a no-reminder condition, common medication reminders from the market
including a watch, a visual reminder and an audio reminder were used. From this study,
it was discovered that a portable, audible or vibrating reminder was most preferred by
the 10 mobile, active elders who participated. Reminders with only a visual component
were much less preferred, as the individual needed to be near and focused on the
reminder to receive the benefits of it.
The prior study was done to inform a planned year long research project on
Context Aware Medication Prompting conducted by the Health Research and
Innovation team at Intel’s Digital Health Group in conjunction with Oregon Health
Sciences University. [8] For the better part of 1 year, 11 individuals aged 70+ who were
living in independent living facilities were asked to participate in a research study to
test a system utilizing information about past patterns of behavior and current context
to provide prompts at the appropriate time and place in the home. It was hypothesized
that most reminding systems, which work on a time-based rule to trigger an alarm, are
not overly effective because a reminder is generated whether or not the individual is
nearby and whether or not it is an opportune time or place to take medication. Some
reminders are actually irritating when they alert if the individual has already taken the
needed medications.
To implement the study, a system of sensors were set up in the homes of 11
individuals. Sensors captured data on location in the home, bed presence, open/close of
exterior doors and refrigerator doors, a watch to sense location inside the home and
whether an individual was on the phone. A pillbox designed for the research trials was
put into each home to capture when participants took a pill. (For reasons of safety, a
low dose Vitamin C was used in this study).
The study was presented in three phases. A baseline phase where individuals had
only the pillbox, a time-based phase where alerts sounded every day at the same time,
12 hours apart at a time chosen by the participant, and a context phase where the alert
sounded based on a set of rules, only if the individual seemed to have forgotten their
medication and only if the end of the deemed effective window, 90 minutes before or
after the medication time, was coming to a close.

This study was rich with information from artificial intelligence, to engineering
to human behavior and design. Most relevant from this work is the fact that although
context aware prompting, that is reminders that only alert if it seems a pill will be
missed, are the most effective. Unfortunately, this type of reminder is also most
confusing to the individuals as it has no set pattern and those participating in the study
were not told of the rules around context aware prompting. As an example, if an alert
goes off at 6 p.m. and the participant is in the dining room, there is no chance of being
reminded. However, if there is a window from 4.30-7.30 and the individual returns at
7.10 pm, the alert still has the capability to be effective upon the individual’s return
home. See Figure 1. Medication Adherence for Three Phases
Baseline
Time Based
Context Aware
Morning
54.10%
76.79%
97.22%
Evening
46.88%
77.19%
86.11%
Average
50.49%
76.99%
91.66%
Figure 1. Medication Adherence for Three Phases
It was also found that this group of elders was much more mobile than
anticipated. Vacations, leaving for home remodeling, visiting relatives and day trips
were more common than expected.
Given these findings, the next natural step in the design process seemed to be to
look at the out of home experience and determine a reminder that would assist this
engaged and active elder community in their day to day lives.
PROJECT METHODOLOGY
The process of inquiry included a multi-method research approach of
investigating the ‘Say, Do, Make’ behaviors of the intended user group. By addressing
these human behavioral areas with different research methods, the group could verify
and confirm responses and data. From this research and initial analysis of a literature
review, three primary factors were focused upon to better categorize and organize the
research process: user, medication intake, and environment. Within these primary
factors, more in-depth areas were identified. See Figure 2. Project Overview and
Strategy.

Figure 2. Project Overview
PROJECT FINDINGS
Our research revealed that many of the drug prescriptions for diseases included a
change of lifestyle, prescribed by the physician. This included more or less physical
activity, restriction or control of diet, therapy, and/or rest. The change in lifestyle may
ultimately affect the medicine regimen. For example, a Type I diabetic adheres to their
diet and exercise regimen, they may be able to adjust their medicine intake to avoid
insulin.
TYPE OF ACTIVITY
Through conducting a literature review and interviewing elders, the group learned
about the myriad of activities in which elders participate. These activities were
categorized into three primary groupings: Social activities, Productive activities, and
Fitness activities. These activities also can be either Planned or Incidental type of
behaviors. The final variable is the duration in which the person participates in the
activity. Duration was defined simply as short-term (less than 3 hours outside the
home) or long-term. The results showed that incidental activities created a lower level
of compliance.
THE USER
The use of literature reviews, interviews (19 participants), expert interviews (5),
image journals (7), and action research (6) provided a very good understanding of the

elders’ current experiences and most importantly their potential solutions for better
medication compliance outside the home.
From the interviews of participants ages 55+, students learned that the most
common medication reminders are placement (pills were placed in relation to exiting
the home), reminders from their spouse (or partner), and context based reminders
(associating medication intake with meals or food.) Participants reported forgetting to
take their medication when the routine changed or was interrupted.
The use of action research allowed the group to project future needs and an ideal
scenario or situation in comparison to their current regimen conditions. To inform the
design process, participants were asked what they commonly carry when leaving the
home. Not surprisingly, most participants carried mobile phones, keys, and wallet or
purse when engaging in outside the home activities. The collage exercise demonstrated
some interesting and reoccurring comments and ideas:
• Not comfortable with technology
• Quote: “The paper is 100%.” (reliable)
• Reminders were written on paper or post-it notes
• Reminders also included confirmation to themselves that they had taken their
medicine (to avoid double dosage)
• Most participants had either a family member or friend help monitor or remind
one another of regimen (but typically not a medical professional i.e. nurse,
doctor, etc.)
• Caretaker reminding them of medication compliance
• No mention of short-term activity problems
• Two participants carried emergency contact numbers and disease information
with them on paper
• Medications are considered private
• Quote: “I most definitely want privacy with my prescription”
As part of the action research, seven different participants were asked to keep a
photo journal. They were asked to keep track of their daily activities in relation to their
medication compliance both in the home and outside the home activities. Most
participants completed the journal on a typical day (weekday); two journals were
completed during an overseas, long-term trip for three days. See Figure 3.Photo Journal
Images.
Figure 3. Photo Journal Images
Some of the findings from the travel journals included:
• easy to use products like pill box containers
• storage of medication in original prescription bottles
• busy or fun activities made them forget medication

• medication compliance needed to be integrated into daily routine
• Quote: “If I have to do one more action, I would not use it (a special pill box).”
The analysis stage used the photo journals and subsequent follow-up interviews
to develop a mind-map of a participant’s daily activities. This highlighted areas of
opportunity – product, environmental, behavioral and/or cognitive.
USER DEFINED CONCEPTS
From the multi-method approach, several different concepts were developed to
satisfy different users, medication intake requirements, environments, and unmet needs.
It was also recognized that even though the project is dealing with outside the home
activities, the home is a critical hub for transitioning and memory strategies or aids.
The products were either stand-alone products with embedded technology to aid
the user or a networked device that was part of a communication, recording, and
reminder system. Several products could be categorized as a re-design where the new
idea was a combination or re-make of a familiar product. Finally some were completely
new, innovative products for development.
To follow are several sample concepts for products and systems to increase
medication compliance among mobile elders. The Rx pill container purse makes the
pill container visible with a unique exterior dock. The pill container and/or dock have
visual, audio, and tactile reminders. The externalization and visual/audio reminders of
the Rx pill dock allow the user and partner to see/hear the reminder alarm, increasing
compliance. The value of this design also lies in the consistency factor since most
women do not leave their homes without taking a purse. Taking the purse automatically
ensures taking the pill box in this instantiation. Figure 4. Rx Pill Purse.
Figure 4. Rx Pill Purse, Rini Ye
One concept, inspired by the notes seniors leave around the home for themselves, is the
‘NoteIt’ simple technology reminder pad. This design was inspired by the ‘Magna-
Doodle’ toy that simply allowed hand writing to be input by a stylus and erased by a
slider. The low-tech semantics would be embedded with wireless communication that
allows others to track and ensure medication compliance when leaving the home. There
are hi-touch and low-touch options for use. For low-touch, the user would receive a
message automatically uploaded when the individual is in proximity of the door. The

message would need to be erased as acknowledgement that pills were taken or being
carried as needed for the day. In a hi-touch situation, an individual would also be
prompted as s/he approaches the door, but prior to that would write his/her own
reminders on the slate, erasing it on the way out of the home as noted in the prior
scenario. If no interaction was input after the person leaves the home, a follow-up call
or alternate communication reminder could be employed. As an added benefit, the
device can be set up as an automated calendar to display reminders and other messages.
See Figure 5. NoteIt Concept design.
Figure 5. NoteIt Concept, Edo Eussen
In all, there were at least 18 distinct design concepts that addressed unmet user
needs to adhere to prescription medication regimens for outside the home activities.
All of the concepts referred directly back to specific user needs, scenarios, or
experiences. The designs and systems covered a range of technology applications such
as RFID, Bluetooth or short range communication/connectivity for tracking and
reminding, the ability to network and communicate to another person or system for
tracking and reminding, and smart medication foil printing to track medications taken.
Based on the findings from the interviews and research, the final designs
focused on concepts/systems that aid the varying needs of each user (both in or out of
the home). Each disease and each person had different needs and schedules. Therefore
many required different reminders and products, dependent on activity, environment,
regimen, and acceptance of technology. The concepts presented offered potential
solutions for various cross-sections of users. This research was unique because the
approach and intent was to bring design expertise to develop tangible concepts which
aid in compliance. The concept of developing products that were not just useful and
usable, but also desirable – may help compliance because of the aspiration to possess
and enjoy the product-user experience. This ‘non-push’ strategy may be important for
developing ideas that improve not just memory and reminders, but motivation to carry,
use, and inherit the device/system.
CONCLUSION
In 12 short weeks, the ground work was laid for future research into
understanding outside the home medication compliance. Continued research would
allow a greater number of participants and verification of the previous findings.
Control groups for type of disease, disease severity, medication regimen, similar
activities, and demographics should be applied to gain a fair assessment of that
particular population segment. A follow-up user survey of the design concepts should
be done to validate the group’s insights and assumptions.

However, within this short time span and based on initial findings, it is clear that
outside the home activities lasting longer than a few hours affect the medication
compliance regimen. This area has many unmet needs and dynamic requirements due
to the range and depth of variables present when addressing the elderly user, their
environment, and activities.
GRADUATE STUDENTS: GEORGIA TECH INDUSTRIAL DESIGN
Edo Eussen
Doria Kung
Ga Bin Park
Marisa Rolfson
Woo-Young Song
Camillo Vargos
Rini Ye
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