By 2050, the number of Americans over age 65 will more than double. Our current health care system is ill equipped to accommodate their growing needs. The challenge for health providers, payers, business, and government is to redesign services to address those needs.
In response, the tech community is creating an abundance of devices to monitor and motivate an older population to exercise, eat well, take their medications, and live more engaged lives. But to make a difference, these products must be integrated into the daily lives of the population and the daily workflow of health care providers. Design thinking — which one HBR author describes as “an essential tool for simplifying and humanizing” — can help do this. A case in point is using technology to assist the elderly in adhering to their medication regimens.
Adherence is one of the most intriguing and complex dynamics in health care. According to the Centers for Disease Control and Prevention, about 40% of people over 65 take five or more medications per day. There is ample opportunity for them to be confused and overwhelmed. Researchers have shown even e-prescriptions do not fix this issue: Meta-analysis has revealed that more than 20% of first-time prescriptions for chronic conditions such as hypertension, hyperlipidemia, and diabetes are never filled. Medication nonadherence undermines even the best cost-saving and clinical intentions of evidence-based care.
Various solutions have been tried over the years, ranging from labeling the humble pillbox with the days of the week to internet-connected pill dispensers to simple reminder systems. None of these solutions is ideal since they require patients or caregivers to organize, combine, and synchronize the dispensing of numerous prescription medications.
To overcome these limitations, developers came up with software solutions. App stores have a wealth of smartphone reminders that allow users to create a daily schedule for their meds. At preset times, the app sounds an alarm. Most apps also show an image of all the pills to take at that moment, matching them to a database such as Pillbox, from the National Institutes of Health’s National Library of Medicine.
But in spite of developers’ best efforts, no app can prevent medication errors if it is physically disconnected from the dispensing mechanism. Ignoring for a moment the fact that some older adults may encounter difficulties using smartphones, reminder apps are at least two behavioral steps disconnected from medication intake. Users have to look for their pill bottles, take the right pills, and then inform the app that they have done so. Even a minor cognitive impairment makes this routine unreliable.
Internet-connected pill dispensers, which try to increase adherence by coupling reminder and dispensing actions, also have limitations. The dispensers have either cellular-connected caps that fit on a regular pill bottle or systems that replace the traditional pillbox with a dispenser that tracks the opening of the pill compartment or the amount of medication inside the bottle. While these systems represent an advance in preventing medication errors (such as an accidental overdose) and getting patients to adhere to their medication regimens, they are not without flaws. For one thing, most of them require setting up a smartphone app for communication, which makes them challenging for the elderly. Also, users are still faced with needing multiple medication trackers or needing to periodically refill pill compartments on the devices.
In our research and practice of health care for the aging population, we iterate on its design, observing patients as they consume new products to promote their health. We have observed the following requirements for improving the health status of the elderly:
Synchronization. Having multiple medications with different refill dates creates too much complexity. Patients are often tempted to wait until more than one medication needs a refill before returning to the pharmacy. Synchronizing the dispensing process requires taking into account all the various medications that the patient is taking — something that often is not done.
Personalization. Generate labels that are easy to read and understand, with larger, legible type or icons to illustrate dosing and schedules, and explicit instructions that incorporate graphics.
Reminding. Provide reminder cues that have a built-in reinforcement mechanism designed to enhance adherence.
Integration. Create a system around medications, devices, and digital reminders to help keep patients on track and engaged with their care, a system that seamlessly works with their lifestyles.
One system that meets these requirements is PillPack, a service that simplifies medication dispensing. (One of us, José, works for IDEO, the company that helped PillPack design its products, services, and communication. IDEO has a financial stake in the company, but José does not.) Users contact the service to have their prescriptions as well as supplements transferred to PillPack. Then a box with pills packaged in daily packs is delivered to users on a regular schedule. PillPack uses robotic lines to consolidate multiple medications into individual packs labeled by time of the day. It also takes care of refills by contacting prescribers before the last refill.
While PillPack was conceived as a hands-free, convenient service for patients, we think it can also increase adherence and reduce medication errors. Synchronizing the schedule for taking medication and consolidating multiple pills into single discrete packs reduces the chances of intake or dosage errors. Individual packs can be detached and carried outside home by patients according to their needs and can also function as a tangible reminder. PillPack removes most of the friction from the experience of taking medications, including picking up medicines at the pharmacy, contacting prescribers for refills, sorting medications into pill boxes, and managing multiple drug schedules. In addition, PillPack provides a free smartphone app to give users reminders that are triggered by time and location.
PillPack’s ability to consolidate patients’ medications into discrete packs with patient name, room number, and instructions could also help prevent medical errors in the hospital setting.
How do we ensure our elderly population is taking proven medications to alleviate suffering, treat disease, and promote health? By understanding end users and their environments, which is what design thinking is all about. Studying how patients consume their medications is key to generating better health outcomes. Design matters, especially for our aging population.
Rebecca Weintraub, MD, is director of the Global Health Delivery Project at Harvard University and associate director of the Harvard Global Health Institute. She is an assistant professor at Harvard Medical School and an associate physician at Brigham and Women’s Hospital.
José Colucci Jr. is an associate partner and senior portfolio director at the design firm IDEO, where he researches the impact of aging on society and its implications for the design of products and services.