PRE2015 4 Groep3

Members of this group:

• Maurits Ambags - 0771400
• Wesly Chu - 088994
• Arthur Geel - 0907552
• Jasper Sparla - 0844019
• Twan Weernink - 0851703

Project Description

The aim of this project is to design and build a secure medication dispensing system that helps seniors manage their medication regimens. It can be used for seniors who:

• Take multiple medications or has complex medication regimens
• May have been hospitalized for misuse of medication
• May have cognitive impairment
• Require assistance with medication today

Introduction

In present day, people are using more medicine than ever. Patients are expected to take the right amount of their medicine at the right time, often multiple different ones per day. Each of these activities is a process that can easily go wrong, which has the potential to do some serious damage. As we get older, we generally use multiple medicines at the same time, yet our memory becomes worse. The budget cuts in health care result in doctors and pharmacists having less time for each patient, which means they might not understand exactly what they are taking. With the rush of internet and communication sciences, a lot of the patients files are being converted to digital files, yet not everyone is using a standardized format, which means communication can be an issue.

A report that the dutch government has released in 2013, entitled ‘polyfarmacie bij kwetsbare ouderen’ [citation needed], states that over one million people aged 65 and over take five different types of medication every single day. When we expand our view to those aged 75 and over, we see that 20 percent of those take nine different types of medication every day. When you combine that with the fact that up to 40 percent of the elderly receive insufficient information about their medication, an over- or underconsumption of medicine is the frightening result. Often, the medicine old people take are quite potent, leading to hazardous situations when taken incorrectly.

Finally, when we consider the prevalence of dementia amongst the elderly, of which over thirty percent of the people older than 80 years old suffer, it is clear that there is a need for a tool that helps people with their medication, both for when they need to take their medicine, but also as a safeguard to prevent dangerous combinations.

State of the art

Introduction

Fig X.: A simple medication storage box. It consists of different, individually closeable compartments that can be used to store various types of solid medications.

Medicine boxes are not a novel concept. Medicine has been around ever since the ancient ages, and medicine boxes are a logical extension of medication, required to keep things organised. Modern pharmacies often have the medication distributed in individually sealed boxes or bags with the date of when the medicine should be taken on them, and there are also a plethora of physical medicine cases with dates on them to remind the patients of when medicine needs to be taken. Some of the aforementioned medicine cases can be locked to prevent medicine abuse, yet there is no medicine box on the market that functions as a double-check and as an assistant to remind you to take your medication.

Medicine boxes

Medicine boxes or pill organizers are useful tools to both keep your medicine organised, and to help remind the patients of taking them at the right time. Most of the existing medicine boxes have the date and time on them, such as this one-month pill organizer. (http://i.ebayimg.com/00/s/ODM0WDEwMDA=/z/NMcAAOSwHjNWCEgu/$_57.JPG). While a product like this is both useful for organised storage and reminders of when medicine needs to be taken, there are some flaws to it. As the procedure of replenishing the medicine inside has to be done manually, there is a good chance of it going wrong. In most care homes, care givers or house pharmacists are in charge of the replenishing, yet the elderly that still live on their own have to do it themselves. There is no inspection that determines whether medications can be used in addition to eachother, and finally, the medicine can be taken at all times. There is nothing that stops the patients from under- or overconsuming medicine.

Medicine Reminder Applications

Medicine reminder applications are a step up from medicine boxes in terms of relative usefulness. These applications function as a digital notebook that helps you remind when medicine should be taken. In the user interface of these applications you can see a schedule of what medicine should be taken by what time, along with some visual information about how it looks, what it does and the instructions for use.

Source - (http://www.fastcodesign.com/3048368/the-best-pill-reminder-app-ever (accessed on 19-05-2016))

Pill Dispensers

Pill dispensers are more advanced editions of medicine boxes that have the ability to deliver medication at pre-determined times. They can be helpful in regulating medicine intake, for those who either intentionally or unintentionally take more or less medicine than they actually need. With most automatic pill dispensers there is a visual or an audial notification when a pill is dispensed. Pill dispensers can also function as a means of supervision: if a dispensed pill is not taken out of the space, the caregiver or supervisors can be notified, making improper use of medicine very much preventable.

Source - (http://www.prweb.com/releases/2011/11/prweb8973872.htm (accessed on 19-05-2016))

Philips Medicine Dispensing Service

Fig X.: The Philips Medication Dispenser Service, a device that helps patients regulate their medicine intake.

The Philips Medication Dispensing service is a simple way to manage even the most complex medication regimens. It is designed to help seniors who: - Take multiple medications or have complex medication regimens. - Have or are likely to be hospitalized for misuse of medication. - Have varying degrees of cognitive impairment. - Have limited mobility and are at risk for falls - Require assistance with medication today.

The Philips Medication Dispensing Service is a highly reliable system for dispensing medications accurately and on time. When a simple audio reminder is played, the patient has to push a button to get their medications at the pre-programmed times. This service makes it easy to know what medication to take at what time, if one is struggling to keep track of this by themselves. This system effectively eliminates missing doses, and it gets rid of the struggle some have with pill bottles. If the medication is not taken at the pre-programmed time, the allocated staff at Philips is notified, which enables them to alarm the caregivers.

This product is fairly simple to use for the care takers. All of the medicine is already inside of the machine, and they get a visual and audial notification when it’s time for them to take the medication. The care takers has to press the red button on the front of the display, which dispenses the cup with the medication. An in-depth explanation can be found below.

STEP 1: Load. Caregivers or those close to the care takers put the medications into individual cups and load them into the dispenser. They then provide the medication schedule to Philips who will program the dispenser.

STEP 2: Dispense. When the visual and audial reminder is played, the care taker has to press the red button. The dispenser will dispense the medication you have loaded for the care taker– at the programmed times. It is possible to dispense the medication early, this can be done by interacting with the display.

STEP 3: Alert. The dispenser can be connected to a telephone line. If a dose is missed, the dispenser has the ability to contact allocated people through said telephone line. This way, they can visit the patients to ensure the medication is properly used.

ADVANTAGES: The Philips Medication Dispensing System is a solid foundation for safe medicine use for those who are unable to keep track of it themselves. The interaction with the system is straight-forward, and should be understandable for the majority of the patients. The system has a great way of truly taking care of the patient. If the patient misses out on the medication, the allocated staff at Philips get a notification, which prompts them into contacting the care giver. This way, improper use of medicine is instantly noticed, and can be prevented.

DISADVANTAGES: This machine functions using pre-loaded single-use cups filled with medication. This means that the doses are static, it cannot be changed once the cups have been put in. This machine does not ensure that the patient actually takes the medication. It merely ensures that the patient is given the medication at the pre-programmed times, though the patient could (in)voluntarily skip the medication, even after it has been dispensed. Loading the dispenser is a troublesome task. It is advised that it’s done by the care givers, as senior citizens still living on their own can have a hard time managing it by themselves. Some seniors definitely require a more automated system, which negatively impacts this service as they would also need an additional care taker. The allocated staff at Philips are no pharmaceutical experts. This means that while they do review the medication regimens while pre-programming the service, mistakes that the doctors or pharmacists have made can slip through their supervision. It also means that they do not have the authority to make adjustments to the patients’ medication, if such is needed. Finally, his system is fairly expensive in use. In order to use this service, a monthly fee is to be paid. This monthly fee is priced at $59.95/month, which can be an issue for some senior citizens, as they have a limited pension entitlement, which sometimes is pretty small.

Source - (https://www.lifeline.philips.com/health-solutions/health-mdp.html (accessed on 19-05-2016))

Source - (https://www.youtube.com/watch?v=HOeamcwDFbg (accessed on 23-05-2016))

Philips Medido

Fig X.: The Philips Medido, a medication dispensing device.

The Philips Medido is an automatic medication dispenser that reminds patients to take their medication with an audial and visual notification. It can ensure correct medicinal usage by reminding and dispensing medicine at the appropriate times. It is designed for those that use a lot of medicine at specific times, a lot of different times, or for those that have difficulties keeping up with their medication. The interaction is designed to be extremely simple to ensure correct use amongst all people. It can also automatically notify care givers of circumstances when the patient does not take their medication, preventing further occurrences.

Functionality

Just like the Philips Medication Dispensing System, this product is specifically designed to be easy to use. Special ‘medication rolls’ have to be placed in the machine, after which the patient only has to press the ‘OK-button’ at pre-determined times when medication needs to be dispensed.

STEP 1: Get medication. Before it’s able to be used, the Medido has to be filled with the medicine. At pharmacies, it’s possible to have your medication to be packed in so called ‘medication rolls’, a plastic sequence of bags containing your medication for certain times.

STEP 2: Fill. Usually, the Medido is filled when the medication is received at the pharmacy. The bar code on the medication roll is checked to ensure the medication roll belongs to the right person, and the Medido is loaded with the correct medicine.

STEP 3: Dispense. When reading the corresponding bar codes on the medicine rolls, the Medido will prompt the reminder of the medication at the right times. By pressing the ‘OK-button’, the medicine will be dispensed.

STEP 4: Alarm. If the medication is not taken in x minutes, a report will be automatically filed to the care giver. They will be responsible to contact the patient to ensure their well-being. This way, a correct use of medication is ensured.

ADVANTAGES: The Philips Medido is a great device that has the ability to make medicine use for seniors less complicated. The very simple user interface makes it easy for the patients to get their medication at the right time. The dispenser also automatically cuts the medication rolls to allow simple medicine usage. This device has the ability to notify care givers if medication is not taken. Because of this, (un)intentional abuse of medicine can be avoided. Finally, this dispenser can be obtained through the Dutch home care system. If one is legally entitled to help with their medication intake, one can be acquired for free. This makes it a good alternative to the more expensive Philips Medication Dispenser System.

DISADVANTAGES: The Medido can be hard to use, the much-needed instruction manual1 is a testimony of this fact. The main difficulty people seem to have is re-filling the dispenser with the medicine rolls. The manual states that the rolls need to be folded in ±4cm increments, which can be very hard for seniors with decreased hand coordination. Dispensing medicine has the potential to go wrong. If the patient does not understand the interaction properly, they might start pulling the medication rolls when they are dispensed. This can lead to interruptions, which have to manually be fixed. Before the device is fixed, the patient will not be able to get their medication unless the dispenser is opened. If the patient does not have access to the key to open the device, this could mean they miss medication for longer periods of time, which should not be allowed to happen. This machine functions because of the medicine rolls. If these are unavailable, this machine is not able to operate. As said before, it’s hard to re-fill the dispenser with the rolls. It’s possible for the pharmacist to do this, though the dispenser would have to be taken to the pharmacist in this case. Because a lot of seniors are less mobile, this can be a challenge. The medicine rolls also do not allow any flexibility. The medication has to be pre-determined at the pharmacist, so adjusting the medication is not an option. The whole roll needs to be finished before it can be adjusted again.

Source - http://www.kcwz.nl/doc/zorg_en_technologie/Eindrapport_project_Medido_fase_1.pdf

Conclusion

The current state of the art has limited or no communication with the pharmacy or the doctor's office. These systems can only notify a caretaker that the medication wasn't taken. The dosage is also prepackaged in plastic bags and thus cannot be adjusted on the fly. This forms a problem for patients with a unstable medicine regime whose prescription may change weekly. The date and time for the medicine intake is also fixed which isn't very flexible. The patient may not be able to take its pills at that time or is simply somewhere else where the device isn't available. There must be an ability to change the timetable or delay the medicine intake. We hope to remedy this shortcomings in flexibility of the medicine intake.

Requirements

This medicine box should be able to dispense medicine into a compartment that the user can access whenever the time is right. To do this, the box should keep track of its schedule and dispense medicine when necessary. When medicine is due, the user should be notified by the box that medicine is ready to be taken. The medicine storage consists of several separate containers, not directly accessible by the user. The box should dispense medicine from these containers into the aforementioned compartment, according to its internal scheduler. It should also remind the patient in what kind of manner it has to use the medicine e.g. on a empty stomach, before sleep etc,etc. The patient also should be able to delay the medicine intake by pressing the snooze button if the patient isn't able to take the medicine at that time.

Secondly, the box should be remotely accessible by caretakers and doctors. They should be able to use an application to update the dosage of medicine in the box. This should alleviate some of the confusion for the patient when dosages change, and should prevent over-consumption of medicine, since dosage can be changed without an intermediate appointment with the doctor. It should also be possible for the doctors and caretakers to see the historical medicine intake of the patient and if it is following its prescription.

To refill the box, the user should be able to pick up (parts of) the box, so that it can be taken with them to the doctor and/or pharmacist. We rely on the caretakers' expertise to fill the box and update the data in the application accordingly, so that the user should not have to concern themselves with their medicine intake.

These requirement should lead to

• An increase in the autonmy of the patient
• An increase in compliance with the medicine regime
• A decrease in healthcare costs
• A decrease in incorrect medicine intake
• An increase in the efficiency of the care givers

Design

The design of our medication dispensing system is carefully considered and designed to fit our design requirements. By taking a look at already existing products and services, we were able to gain awareness on how we can make our product stand out in the highly-competitive medical market. In the pictures below is shown how the box will be built, the side-parts are missing here. These will complete box and will make it possible to get the box with medicines for ingestion. This box will slide through the rails which are visible in the pictures. The draw at the end gives us the sizes of the intern materials, the PI, engine and helix are shown here. This helix will work in a similar way to a vending machine.

Side view of an early mockup.

Mechanical drawing of an early mockup.

A rendering of an early, discontinued design.

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USE Aspects

User

The main benefit of this technology is that we can provide a better structure in the medicine intake of the patient. This should relieve the user of the burden of remembering when to take which medicine, and also notify them to take medicine when the user might otherwise forget. This should provide the user with several benefits:

More controlled medicine intake

Patients nowadays are generally solely responsible for taking their medicine and finishing treatments. This leads to cases where a patient might forget to take medicine, or even take too much medicine. In the first case, this has a direct negative effect on the effectiveness of the treatment. In the latter case this will probably have a negative effect on the well-being of the patient. Especially when medicine treatment is required over longer time period, or when patients should continue taking medicine even if they are no longer sick (think of for instance antibiotics), patients are more likely to slack on their medicine intake. By encouraging the patient to continue taking their required medicine, we hope to see treatments being more effective.

Preventing over-consumption after treatment ends

Since patients so often are required to take several kinds of medication simultaneously, it may be difficult for the patient to keep track of when to stop taking which medicine. This may result in patients continuing to take medicine even after the intended end of the treatment. Pharmacies nowadays already attempt to prevent over-consumption by only giving exactly as much medicine as is required, though this is not always the case. Also, considering the above, if a patient forgets to take their medicine several times, they assume that they have to finish all of their medicine anyway, resulting in them taking medicine after the end of intended treatment.

More importantly, especially in the case of elderly, some medicine may be given on a recurring schedule until further notice from a doctor and/or caretaker. In these cases, the patient should meet with the doctor once more, at which point the doctor may decide whether to continue using the medicine or not. However in reality, patients may continue taking medicine just because they are in the habit of doing so. This is especially a problem for the elderly, where long-lasting or even continuous treatments are not uncommon. This technology should serve as some kind of threshold for the doctor to consider repeating a prescription, and hopefully cancelling it when possible to prevent unnecessary medicine intake.

Minimising medicine resistance

Over-consumption of medicine also leads to future risks in the form of medicine resistance. In some cases, the patient's body may regard the incoming medicine as being hostile (especially for antibiotics) and the immune system may try to combat the medicine. On the long term, this results in the immune system effectively dispatching of the medicine, and therefore making the patient immune to the medicine's effect. Needless to say, over-consumption of medicine will only speed up this process, and preventing medicine resistance may be beneficial to the patient in the future.

Society

The medicine box should remind people to finish their prescription and not simply stop when their are feeling better. When they complete their prescription they prevent unnecessary bacteria resistance against the medicine. A caretaker has also less work since he/she doesn't have remind the patient to take his/her pills, This lowers medical expenses for society or frees more money for more critical care activities.

Enterprise

Standardising the way people take medicine should allow pharmacists and doctors to more effectively prescribe and dispatch medicine to patients. This in turn should allow both parties to be more time-efficient.

It is worth noting that over-consumption of medicine is beneficial to pharmacists and pharmaceutical companies, since it increases their sales. While this technology does not in any way hinder their intended sales, there may be a decrease in sales from these enterprises as a result of less redundant medicine intake.

Stakeholders

The primary stakeholders for the medicine box are elderly people who can still live on their own or with assistance. The patient must be able to take the pills on their own in the correct way since the box can only encourage medicine usage and cannot enforce it. The patient doesn't have to worry about their pill intake anymore and wonder whether they have taken their pills and if they have taken the right pills. Since pills are stored in a central place the risk of accidents will be smaller. Small children will be less at risk of finding medicine randomly scattered in a home and eating them.

The secondary stakeholders are the pharmacists who will fill the box and the doctors who will set the schedule for the machine. The pharmacist already is able to see which treatment the patient is on. He will need to have a way to accurately restock the machine with the correct medicine in the right compartment. The doctor must have the ability to see the historical medicine usage of the patient and whether the patient adheres to the treatment. If he sees an anomaly in the usage he can discuss this with the patient. The doctor also must be able to change the prescription and dose remotely.

Tertiary stakeholders will be the companies that will produce and install these machines in peoples homes.

Scenario/functionalities

User

It's 1 o' clock, its time to take your medication.The smart medicine dispenser turns on it's alarm and lights start to blink, the brightness and sound volume increase over a period of 5 minutes. The subject has to walk up to the dispenser and touch a button on the screen in order to turn off the alarm. At the time the button is pressed the required medication in the proper dosage is released and the compartment for that medication is unlocked. The subject can also choose to press the button saying he does not want to take the medicine, if this is done a couple of times the responsible physician is notified and can contact the subject. If the alarm is ignored for 5 minutes, the alarm will stop and repeat itself 30 minutes later. After 60 minutes a caretaker could be notified about the medicine intake if that is configured.

When the medication is released, a pop-up will appear on the display showing the types of medication that are released and suggestions on how to take them individually. There should also be an option where the subject can ask for more information regarding the medication if the subject is interested or worried. There should be a button on this screen where the subject can click agree after which the display is shut off or turned to it's home screen. A snooze button is also available to delay the medicine intake.

Pharmacist

Restocking of medication happens at the local pharmacy. The subject should get a warning on the display of the medicine box that for instance that the medication in slot 1 is running low and that this medication should be restocked at the pharmacist. The pharmacist can take out a cartridge kind of structure out of the medicine box and is able to scan a chip in the box that lets the pharmacist know what type of medication to put in which slot.

Doctor

When the patient makes an appointment with the doctor, the doctor will be able to see the current medicine intake of the patient and the compliance with the regime of the patient. If the compliance is low the doctor asks the patient what's wrong with the medicine regime and what should be changed. The doctor is able change the regime remotly from his office so that the patient doesn't have to drag the device with him/her to the doctor's office.

• • Scenerio from the perspective of the Pharmacists

• • Scenerio from the perspective of the Doctors

Business case

To see widespread adoption of this device the benefits must outweigh the costs. These costs include

• Installation of the device and instruction in its use
• Promotion of the device and selection of the patients. (the patient should be able operate the device independently)
• Cost of setting up the medicine regime and adjusting the regime.
• Monitoring of the patient in the initial period to see if the patient is able to operate the device independently.
• Possible response of a caretaker if the patient doesn't take its pills
• Restocking of the medicine box

Possible benefits are

• Less time used by the caretaker to help the patient with its medicine use.
• Fewer trips of the caretaker to the patient solely to remind and help the patient with the medicine intake. This often happens since the moment of medicine intake often doesn't overlap with other care activities like helping to dress the patient or making a meal for the patient.
• Less accidental waste of medicine since they are stored in a central place.

Useful links for our own group

Historic Log

Individual work log: https://drive.google.com/open?id=14Ykl9HAKBMtJr3HRHOROLrNeHBLKUgkcpnDh3Kak1tQ)

Software src + dist 29/5/16: https://drive.google.com/folderview?id=0B1oQUCKHpzBfbzY0VmZacGkybzQ&usp=sharing

Planning

Week 1
Brainstorm session on project ideas and directions
Field research

Week 2 ✓
Define project direction
Clarify our project goals
Define USE aspects
Literature research
Field research

Week 3 ✓
Design sketches
Start up qualitative questionnaires
Start up quantitative questionnaires

Week 4 ✓
Develop UI for app
Write code for UI
Start prototyping the final design
Questionnaire Data processing

Week 5
Market comparison:
Mobile reminder applications
Philips MDS
Philips Medido

Week 6
User-test medicine box

Week 7
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Week 8
Review wiki and update if necessary
Buffer week

Week 9
Prepare final presentation