Needfinding: Medication Management

Introduction

You shift through several pill bottles whose nomenclature you vaguely remember but can’t spell off the top of your head. One of your bottles is looking a little empty. It might be time to call your doctor for a refill at your upcoming appointment.

In the United States, nearly 66% of U.S. adults take prescription drugs (Health Policy Institute, 2021). About 46% of U.S. adults have taken a prescription drug in the past 30 days with about 11% taking more than five prescription drugs in the past 30 days (CDC, 2019).

https://hpi.georgetown.edu/rxdrugs/

On the surface, it seems like everything is doing well. Many people successfully manage their medications everyday. For most, this is a relatively painless process: go to your primary doctor, get your prescription, pick up at your local pharmacy, and repeat in 6 months. It’s been the patient’s responsibility to track their own health and medications.

However, digging deeper and looking at those who suffer from more unusual circumstances and extreme cases, the current healthcare system is full of holes. Patients might have multiple doctors, take multiple medications, and/or pickup at multiple pharmacies. Prescriptions might get jumbled up from various medical professionals, and the patient might not get proper care in time. Moreover, due to HIPAA privacy laws and unstandardized data practices, pharmacies, doctor offices, and hospitals don’t have readily available access to a patient’s medical data which can lead to dire consequences (Treatspace, 2016).

The current method for patients to remember their prescriptions is inefficient. They aren’t medical professionals, and when they have to come to a new doctor, their medical records aren’t guaranteed to be transferred. Whether due to their inordinate amount of medications, forgetfulness, confusing medical advice, or just plain laziness, there is a certain subset of patients who just don’t remember their medications. The current method of pen and paper or physically bringing all their prescription bottles to appointments is a hassle. My goal is finding a way to make patients better recordkeepers.

Methodology

I interviewed five people who currently take prescribed medications. For anonymity purposes, I will label them Person P1, P2, P3, P4, and D5. All interviews lasted 20–30 minutes long and were conducted online using the meeting program Zoom. Interviewees were sourced via local connections and online social networks such as Discord.

My pet gecko instead of my face

Participants were chosen with a certain criteria in mind. P1 and P4 were both college-aged, a group that often doesn’t have many ailments, but undergo long-term treatment that requires multiple prescriptions and more frequent doctor visits. P2 and P3 were from the 65 years+ demographic (Medicare) and identified as taking multiple prescriptions with regular doctor visits. P2 was on the healthier end of the spectrum, while P3 on the other end. D5 was chosen as a domain expert and is an internal medicine doctor practicing in Florida.

Person P1

I asked them questions regarding ten questions with some follow-up questions based on their responses.

1. How many and what kind prescribed medications do you currently take?
2. Can you list your past prescribed medications?
3. How many doctors do you get prescriptions from? Tell me about your last visit, if any, to the hospital/ER or out-of-town doctors?
4. Tell me about your process to get a refill on meds.
5. What do you currently use to track when to refill your meds (or running low)? and why?
6. How often do you need to get refills?
7. Do your medications run out at the same time? Have you unexpectedly run out of medications?
8. When was the last time you forgot or lost your medications?
9. Where do you get your refills? Do you pick up all your meds from the same place? If not, why?
10. How do you track the prices of your medications? How do you pay for them?

For Person D5, I asked additional questions with follow-ups as needed regarding being a doctor:

1. How often do you get patients that don’t know their meds? Describe some example(s).
2. Why does this situation occur?
3. What has your office done to deal with this problem?
4. Why is a patient’s information not readily available? How does this impact your work?
5. How do you deal with new patients?
6. How do you sync a patient’s medications?
7. What’s the process to fulfill a patient’s refill request?
8. Can you tell me about any frustrations with the current system?

Results and Analysis

After conducting these interviews, here is the brief overview:

• Person P1: an international college student who has nephrotic syndrome. As a result, he has to visit a specialist every 1–2 months for a checkup and get refills every 1–3 months. However, since his doctor is in another country, he is provided a 5-month supply of medications until he can come back home at the end of the semester for his doctor visit. Since starting college, he has attempted to visit a specialist referred by the college but has unable to get an appointment until February. He keeps track of their overall supply of medications with pen and paper, and a pill box for weekly consumption. If he runs out too soon, he has to schedule an appointment with his doctor. His parents and insurance cover any medical costs.
• Person P2: an elderly lady currently on Medicare. For her age, she is considered healthier than average and only has a single prescription to deal with high cholesterol. She visits her doctor every 6-months. The prescription is delivered to her house once a month and is taken twice a month lasting until the next checkup (6-months). Medicare covers all the cost. If she forgets to take it, it’s often not a big deal.
• Person P3: an elderly lady currently on Medicare. Unlike P2, has currently five different prescriptions for diabetes, high blood pressure, and thyroid. Moreover, she has to manage 10 medications for her husband who has dementia and is bed-ridden. She uses two pill boxes to track her own medications and two for her husband’s. She often goes between two pharmacies since certain medications are cheaper at one over the other. Since her husband’s medications tend to run out at different times, she finds herself going twice or more every month to pick up medications.
• Person P4: a college student who is currently undergoing hormonal replacement therapy. She has to visit her doctor in the college’s student health service every 3 months for tests and her prescriptions often vary depending on results. She often gets one- or two-month supplies of prescriptions that she tracks with a pill box. Usually her medications run out at different times, and she has to go to the pharmacy once or twice a month. She relies on the CVS app, text message notifications, and doctor’s message notifications on their phone to stay informed about refills and pay for their medications. She has to pay 20% out of pocket while the rest is covered by insurance.
• Person D5: a internal medicine doctor from Florida. She herself takes two prescriptions, and she has 3 doctors all together. Her prescriptions often run out at different times. Sometimes they are auto-refilled, but other times she has to call the pharmacy herself. She currently tracks her meds by when she can roughly see the bottom of the pill bottle. Patient-wise, roughly 25% of her patients tend to have trouble remembering their medications especially older patients, which hinders her ability to help them until they can confirm their records.

An empathy map was made of the most insightful interview: Person P3

Below is a more elaborate breakdown from the five interviews and details that relate to the empathy map above.

The problem is my medicines don’t finish all at the same time. I got to pickup one [medication], one month, then another [medication] another month. They (pharmacy) won’t refill unless there’s only 5 days left. ‘You have to wait’ they said. I don’t know what to do— Person P3

I can use all the same one [pharmacy] but it’s more expensive. So I always look for the place that is cheaper. My insurance makes me pay by month or 3-month, so I can’t do a 1.5 months, might as well get the most supply — Person P3

[My medications run out] weirdly enough at different times. I don’t know how that is, honestly… I only get one or two months [prescriptions]. For some reason, I’ve never received a 3-month supply on its own, which is kind of weird— Person P4

In 4 out 5 my interviewees, I found the odd problem of medications not being synchronized. Normally, a doctor prescribes a supply of medicine lasting long enough until the next appointment. The patient has a set number of refills that can be sent to the pharmacy, and they can call the doctor if they need more refills. Usually, the next doctor appointment is every 6 months, so the supplies should last 6 months. However, oftentimes, you might get prescribed new medication(s) from other doctors in between other prescriptions, or your insurance might change only allowing a certain supplies to be allowed. The doctor can attempt to get your all your medications synced together but in some cases it isn’t possible. For Person P1, they are an international student and since their doctor is from out-of-country, they would pick up a 5-month supply of their prescription at home, which had to last until the end of the semester. There was a case in which they ran out early and so had to reschedule their appointment to be earlier. According to Person D5, this is a common problem (even for her own medications) that unfortunately isn’t that easy to fix. There are problems with how much an insurance is willing to pay for and what size increments are allowed for a patient. Moreover, the current system requires the doctor to manually calculate the expected time they would run out, but doesn’t take into account method to sync up the medication. If patient still has any remaining supplies, they can’t be prescribed more until they run out. Overall, there’s little incentive for the doctor to do the math, the patient isn’t closely tracking it, and the insurance isn’t paying for it, so they end up taking the extra pharmacy trips.

I just look in my pill bottle. I don’t really bother to count. It’s fairly obvious how many there are left…I can just tell there’s roughly 10 left or 20 left. And I can get a general sense how long it’s going to last. Usually [the pharmacy or doctor] notify me before I even realize. — Person P4

Laziness is another factor I noticed. With the exception of Person P1, who diligently takes notes of their overall supply and Person P2 who has only a single medication, the rest of the interviewees don’t pay close attention to the remaining amount of medicines. Like the quote of Person P4, they rely purely on the visual indication of the pill bottle to get a rough estimate. This generally works well for most people, under the assumption that they are going to have the same doctor(s), same pharmacies, same insurance, and aren’t going to suddenly go the ER or move to a new place. But according to Person D5, this often is harder for older patients who may suffer from memory loss, have multiple prescriptions, or are not paying close attention. How can we expect elderly, at-risk patients who have no medical knowledge to be good record keepers, when even medical practices have trouble with records themselves…

If a patient brought a list of their meds, it would be easy, but the hospital also doesn’t know what patients take either. One bad record leads to another bad record…and now we’re trying to decipher all these old records. — Person D5

In the United State, specifically, privacy laws and differing record keeping systems prevent the easy transfer of patient data from one office/pharmacy/hospital to another. Even with the patient’s permission, electronic health records are not standardized. In fact, according to Person D5, records have to be faxed over and then manually inputted into the system which could take 1–3 business days. Moreover, these records themselves may not be complete and various offices or pharmacies need to called for past records, wasting more time.

Person D5, whom was my domain expert, described some common situations. For example, a patient’s cardiologist doubled their dosage, but the patient forgets to tell their primary care doctor who just refilled the old dosage. A patient found their medications are cheaper at another pharmacy, but their doctor called it in at the old one. A new patient arrives at a doctors office of which none of their medications are in the record keeping system, and their records are scattered across multiple offices/pharmacies. Or they got a new insurance and now their usually prescribed medications now have different names which they fail to remember. This lack of knowledge prevents doctors from being able treat their patients (unsafe to do so) and leads to unnecessary complications in the process. To counter this problem Person D5, requires patients to bring in their prescription bottles or take pictures of them to present at appointments, so records can be up-to-date. Patients seem to believe that doctors magically have access to all their medical records from their pharmacies and other doctors, which isn’t always true.

From what I observed, there’s no getting around the patient’s responsibility. Between insurance and privacy laws, in the U.S., the patient needs to know their medical information. In an ideal world, the patient would know about their ailments and medications from the top of their head and not have to rely on their doctor. However, people get sick, people forget, and people are lazy. From Person P3’s empathy map, I mapped out some needs and insights.

First, I noticed they all relied heavily on visual cues from their pill boxes and bottles to signal when they are approximately running low on medications. While P1 used paper and P4 used messaging notifications, they were both college students who are more likely to use technology and have higher mental acuity. Thus, I mainly need to focus on the older demographic whose mental awareness and memory have degraded and whose estimation skills might not be so great. The simplest solution would then to use physical prescription bottles that have the information already present on them. However, patients might misplace them or not want to carry them with all the time, so the ability to take a picture of them would serve the same purpose.

Second, there needs to be better synchronization of medications. After a 5 medications, it becomes a hassle managing so many medications for themselves (and sometimes others for Person P3) and constantly having to go pick them up when they are all the same amount. There are mathematically possible ways to sync the medications up based on start date, refill date and amount, but doctors don’t have the time to figure that out, and patients aren’t aware of the math (as seen above, most just wait until the bottle looks empty). Therefore, it would be game changing if there was an easy way for them to calculate for themselves an ideal schedule that doesn’t lend them having to pick up medications at different times.

Lastly, patients are forgetful. No amount of design can fix that, but hopefully, by presenting information in such a way that can easily preserve records with little effort. Patients might be able to easier receive the care they need without all the hassles.