This presentation provides an overview of global health trends and medication adherence challenges. A review of some mobile medication adherence solutions is given. A discussion is provided on some early observations from usability studies. Future design considerations for medication adherence systems are discussed.

1. Global Trends in e-Health and
Medication Adherence
Yuri
Quintana,
Ph.D.
Division
of
Clinical
Informa8cs
BIDMC
and
Harvard
Medical
School
An Academic Division of the Dept of Medicine
at Harvard Medical Faculty Physicians at BIDMC, Inc.
TM
11/11/14

2. AGENDA
o Global health trends
o Global m-health trends
o Evaluation of medication adherence systems
o Design and evaluation considerations
o Road ahead
Global E-Health and Medication Adherence
11/11/14 2

3. Global Health Trend 1 – Aging Population
• The
global
popula8on
age
60
or
above
is
expected
to
more
than
triple
by
2050
Source: Deloitte 2014 Global health care outlook
https://www2.deloitte.com/content/dam/Deloitte/global/Documents/Life-Sciences-Health-Care/dttl-lshc-2014-global-health-care-sector-report.pdf
11/11/14 Global E-Health and Medication Adherence 3

4. Global Health Trend 2 – Cost and Quality
• 5.3%
annual
spending
increase
in
health
costs
expected
globally
over
next
five
years
Sector: Deloitte 2014 Global health care sector outlook
www.deloitte.com/2014healthcareoutlook
11/11/14 Global E-Health and Medication Adherence 4

5. Global Health Trend 3 – Access to Care
• There
will
be
a
shortage
of
230,000
physicians
across
Europe
in
the
near
future.
• The
number
of
caregivers
in
36
countries
in
Africa
is
inadequate
to
deliver
even
the
most
basic
immuniza8on
and
maternal
health
services.
Source: Deloitte 2014 Global health care outlook
https://www2.deloitte.com/content/dam/Deloitte/global/Documents/Life-Sciences-Health-Care/dttl-lshc-2014-global-health-care-sector-report.pdf
11/11/14 Global E-Health and Medication Adherence 5

6. Global Health Trend 4 – Technology
• New
technologies
(m-­‐health,
cloud,
wearable)
are
driving
change
in
the
way
physicians,
payers,
pa8ents
and
stakeholders
interact
Source: mHealth in an mWorld - Delloitte Center for Health Solutions
http://www.deloitte.com/view/en_US/us/Industries/life-sciences/2545b66b8dc4b310VgnVCM2000003356f70aRCRD.htm
11/11/14 Global E-Health and Medication Adherence 6

7. Global Medication Adherence Trends
Source: Economic aspect of medication adherence using mobile medication reminder in French Health System
http://www.medetel.lu/download/2014/parallel_sessions/presentation/day2/Economic_aspect_of_medication.pdf
11/11/14 7

8. Global m-Health Trends
• 247
million
Americans
have
downloaded
a
health
app
• In
2013,
95
million
Americans
are
using
mobile
phones
as
health
tools
• 77%
of
U.S.
seniors
own
a
cell
phone
and
their
smartphone
ownership
has
increased
55%
in
the
past
year
• 42%
of
U.S.
hospitals
are
using
digital
health
technology
to
treat
pa8ents
• Mobile
remote
pa8ent
monitoring
expected
to
save
the
U.S.
$36
billion
in
health
care
costs
by
2018
• Wireless
pill
bo^les
helped
increase
medica8on
compliance
• Mobile
health
is
a
$1.3
billion
industry
and
by
2018
is
expected
to
reach
$20
billion
Source: Mobile Health Tools Make Big Impact by Jonathan Spalter
http://mobilefuture.org/mobile-health-tools-make-big-impact/
11/11/14 Global E-Health and Medication Adherence 8

9. Drug information ✓ ✓
Drug interactions ✓
Multiple user profiles ✓ ✓ ✓ ✓
Profile sharing via ✓ ✓ ✓ ✓ ✓
email
Sharing across multiple ✓
devices
Evaluation of Mobile Medication Systems
Figure 1. Screenshots of the mobile medication management applications included in the assessment.
Source:
Phansalkar
S,
Zachariah
M,
Seidling
HM,
Mendes
C,
Volk
L,
Bates
DW.
Evalua8on
of
medica8on
alerts
in
electronic
health
records
for
compliance
with
human
factors
http://principles.
mhealth.jmir.J
Am
org/2014/Med
1/e11/ Inform
Assoc.
2014
Oct;21(e2):e332-­‐40.
doi:
10.1136/amiajnl-­‐2013-­‐JMIR 002279.
Mhealth Epub
Uhealth 2014
2014 | Apr
vol. 2 29.
| iss. 1 | e11 | p.3
PubMed
PMID:
24780721;
PubMed
Central
PMCID:
PMC4173170.
http://www.ncbi.nlm.nih.gov/pubmed/?term=(page number 24780721
not for citation purposes)
XSL•FO
RenderX
11/11/14 Global E-Health and Medication Adherence 9

10. wheelchair and okay, she wasn’t computer literate.
But had she been, you know, if she’d had it with her,
in her chair, she could’ve looked at it and said ‘yeah
hey I need to take this pill’ or there’s a reminder, or
‘no I can’t’, somebody’s making lunch for her, ‘no I
can’t have grapefruit because I’ve taken Lipitor’ or
something like that. I’m sure that kind of information
more useful, if you’re concerned, if you’re lot of medications. Because I know some people are taking seven or eight a day. [Female, Most also felt it was only appropriate for professionals to recommend an mHealth application used it themselves and if the patient was willing, was technologically literate.
User Perceptions of Mobile Medication Systems
Table 5. Participants summarize the experience of trying mobile medication management applications in one word.
Negative Words (Count) Neutral Words (Count) Positive Words (Count)
Frustrating (5) Different (1) Fascinating (2)
Challenging (3) Perplexing (1) Fun (2)
Overwhelming (2) Enlightening (1)
Stressful/nerve-wracking (2) Doable (1)
Confusing (1) Interesting (1)
Exhausting (1) Useful (1)
Complicated (1) Informative (1)
Functionality
Mobile medication management applications can be
conceptually separated into two categories: adherence
(MyMedRec, Pillboxie) and information (DrugHub,
PocketPharmacist). An “ideal" application was described as
including both features:
Source:
Phansalkar
S,
Zachariah
M,
Seidling
HM,
Mendes
C,
Volk
L,
Bates
DW.
Evalua8on
of
medica8on
alerts
in
electronic
health
records
for
compliance
with
human
factors
principles.
J
Am
Med
Inform
Assoc.
2014
Oct;21(e2):e332-­‐40.
doi:
10.1136/amiajnl-­‐2013-­‐002279.
Epub
2014
Apr
29.
PubMed
PMID:
24780721;
PubMed
Central
PMCID:
PMC4173170.
http://www.ncbi.nlm.nih.gov/pubmed/?term=24780721
When asked to estimate the cost of applications, participants valued drug information applications I found MyMedRec covers everything, it’s ordered
properly. But it did miss the other little features, the
Something like drug interactions? I don’t bothered by anything like that. I mean I know but I want my pharmacist to say to me when don’t take this or do take that. You know what I didn’t go to school, I don’t want to responsibility of worrying about that... Group 1]
11/11/14 Global E-Health and Medication Adherence 10

11. of a task in Pillboxie, users had to tap outside the task window.
felt this should be standardized,
So ultimately, you’d want a universal language, and
a universal kind of, you know, this is where the back
button is, this is where the forward button is. But if
that doesn’t happen, then every app has its own
unique way. [Female, Group 2]
Evaluation of Mobile Medication Systems
I’m impatient as hell. So when it comes to an app, it’s
got to be simple. See…it wasn’t easy for me to find
the prompts, you know, partly from [my] glasses, but
also I’m impatient and I quit looking. And I said ‘Oh
I’ve spent all this time entering the stuff but if I put
Table 6. Application actions and features identified by participants as being nonintuitive or difficult to interpret.
Action/feature Description of challenge
Though typically used to add a new item, the symbol had little meaning for first time users. Also, because it is often found
in the top corners it is easily missed.
A “+” to add a new item
The back arrow is used to return the user to the previous screen but instead of testing the button, the research team was
often asked, “How do I go back without losing my information?”
Go back
The word “cancel” typically means “undo” but many participants felt it implied finality and described how they “cancel”
social or service contracts such as memberships, subscriptions, and appointments.
Cancel
Scrolling Without a scrollbar, participants rarely looked for additional information.
Audio reminders The audio alarms were inaudible to many participants, especially males.
When typing, many participants focused on the keyboard and missed the autocorrect feature that would change drug names
or dosage units (eg, “mcg” to “mg”).
Autocorrect
Inconsistent terminology led participants miss features. For example, reminder features were called “schedule,” “dose re-minder,”
or “first dose” in each application.
Inconsistent terminology
Greyed text was used to provide examples of data that could be entered into a field, but participants typically misinterpreted
the grey text to be the information of another user.
Sample text
Participants associated a black frame as being outside of the application and noninteractive, thus overlooking peripheral
buttons completely.
Peripheral buttons
Accessibility
One of the challenges faced by participants was that the
adherence features we examined (dose reminders, refill
reminders) made assumptions about the end user. For example,
the reminder strategies (alarms, notification boxes) assumed
users were “attached” to mobile devices. Participants said, for
This is an important distinction because though the tablets are
less portable, they are more accessible to individuals with
age-related vision loss. In one case, a participant with severe
low vision noted that touchscreen devices were surprisingly
accessible,
Source:
Phansalkar
S,
Zachariah
M,
Seidling
HM,
Mendes
C,
Volk
L,
Bates
DW.
Evalua8on
of
medica8on
alerts
in
electronic
health
records
for
compliance
with
human
factors
principles.
J
Am
Med
Inform
Assoc.
2014
Oct;21(e2):e332-­‐40.
doi:
10.1136/amiajnl-­‐2013-­‐002279.
Epub
2014
Apr
29.
PubMed
PMID:
24780721;
PubMed
Central
PMCID:
PMC4173170.
http://www.ncbi.nlm.nih.gov/pubmed/?term=24780721
11/11/14 Global E-Health and Medication Adherence 11
I was always afraid to even look at them or try them,

12. User Interface Design Problems
• Simple
Screen
Design
-­‐
Linear
Naviga8on
• Most
used
features
must
be
simple
to
use
• Avoiding
feature
creep
and
clu^ered
design
• Design
for
Seniors
–
font
size,
color,
naviga8on
• Need
to
follow
User
Center
Design
Process
• Need
more
coordina8on
and
itera8on
between
user
requirements,
wire
framing
and
usability
tes8ng
11/11/14 Global E-Health and Medication Adherence 12

13. m-health Evaluations
• Global
case
studies
demonstrate
that
mHealth
solu8ons
for
NCD
management
are
feasible
..but..
there
is
li^le
evidence
about
the
costs
and
savings
of
these
technologies
Source:
dx.doi.org/10.1145/2093698.2093868
• A
review
found
18
of
29
mobile
systems
using
text
messaging
improved
medica8on
adherence.
Nega8ve
studies
tended
to
have
more
basic
and
repe88ous
content
with
a
simple
medica8on
reminder,
while
posi8ve
studies
delivered
a
variety
of
educa8onal
and
mo8va8onal
content
with
‘tailored’
or
‘personalized’
SMS
Source:
dx.doi.org/10.1111/jan.12400
• Diversity
and
mul8modal
reminder
methods
should
be
considered
to
increase
usability
for
seniors
Source:
www.ncbi.nlm.nih.gov/pubmed/?term=25099993
11/11/14 Global E-Health Conference 13

14. Global Design Considerations
• Care
coordina8on
needs
to
be
considered
in
design
of
systems
–
engagement
with
family
and
care
providers
• Cultural
and
language
customiza8ons
needed
• Health
literacy
needs
to
be
considered
in
each
popula8on
• Deep
integra8on
with
local
healthcare
IT
systems
is
key
• Training
of
staff
and
pa8ents
needs
to
be
planned
• Evalua8on
and
ROI
needs
to
define
the
metrics
for
adherence,
u8liza8on,
and
costs
that
relate
to
local
business
models
11/11/14 Global E-Health and Medication Adherence 14

15. Road Ahead
• Need
to
define
evalua8on
metrics
and
ROI
models
for
compara8ve
analysis
• Need
to
have
more
outcome
evalua8ons
of
implemented
systems
• Need
to
understand
the
modifica8ons
need
to
adapt
systems
to
other
healthcare
networks
and
countries
for
global
deployments
• Need
to
have
best
prac8ces
on
design
for
user
interfaces,
implementa8on,
cultural
and
language
localiza8ons
11/11/14 Global E-Health and Medication Adherence 15

16. References
Health literacy
http://www.nlm.nih.gov/medlineplus/healthliteracy.html
mHealth in an mWorld - Delloitte Center for Health Solutions
http://www.deloitte.com/view/en_US/us/Industries/life-sciences/2545b66b8dc4b310VgnVCM2000003356f70aRCRD.htm
mhealth Competence Center - Barcelona
http://www.mobilehealthglobal.com/catalogue/
Mobile Health Tools Make Big Impact by Jonathan Spalter
http://mobilefuture.org/mobile-health-tools-make-big-impact/
Deloitte 2014 Global health care outlook
https://www2.deloitte.com/content/dam/Deloitte/global/Documents/Life-Sciences-Health-Care/dttl-lshc-2014-global-health-care-sector-report.pdf
Emerging mHealth: Paths for growth
http://www.pwc.co.nz/healthcare-industry-sector/publications/emerging-mhealth-mobile-health-from-patients-payers-and-providers/
The effectiveness of interventions using electronic reminders to improve adherence to chronic medication: a systematic review of the literature
http://www.ncbi.nlm.nih.gov/pubmed/22534082
Economic aspect of medication adherence using mobile medication reminder in French Health System
http://www.medetel.lu/download/2014/parallel_sessions/presentation/day2/Economic_aspect_of_medication.pdf
Adherence to medication among chronic patients in Middle Eastern countries: review of studies
http://apps.who.int/iris/bitstream/10665/118131/1/17_4_2011_0356_0363.pdf?ua=1
Experiences in mHealth for Chronic Disease Management in 4 Countries
http://www.ghdonline.org/uploads/Piette2011-ExperienceMHealth4Countries_1.pdf
A quantitative systematic review of the efficacy of mobile phone interventions to improve medication adherence.
http://www.ncbi.nlm.nih.gov/pubmed/24689978
Evaluating User Perceptions of Mobile Medication Management Applications With Older Adults: A Usability Study
http://mhealth.jmir.org/article/viewFile/mhealth_v2i1e11/2

17. Thank you!
Yuri
Quintana,
Ph.D.
Director,
Global
Health
Informa8cs
Division
of
Clinical
Informa8cs
BIDMC
and
Harvard
Medical
School
yquintan@bidmc.harvard.edu
An Academic Division of the Dept of Medicine
at Harvard Medical Faculty Physicians at BIDMC, Inc.
TM
http://www.hmfpinformatics.org
Global E-Health and Medication Adherence
11/11/14 17