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MyMedMinder: Personal Health Records To Maintain Medication Lists
Patti Abbott pabbott2@son.jhmi.edu
Chris Bassler cbassler@wam.umd.edu
Okpetoritse Pessu opessu@gmail.com
Project Website:
http://129.2.168.8/medminder/
2 December 2006
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Abstract
MyMedMinder is a web based service designed to assist users in organizing and
keeping a history their medications. It is known from the literature that patients are
challenged to keep an accurate record of their medications, which can result in error.
This service will be beneficial in that it allows users to organize their medication history
automatically and store it digitally. Implementing MyMedMinder as a website allows for
instant access of these records from any location with an internet connection. For those
who feel more confident in possessing a hard copy of their medication record, the option
to print to paper is available. The system allows patients, via a password, to review and
update their medication histories as needed. We hope that this service will help to reduce
confusion among patients, assist doctors in treatment and help prevent deadly mistake
resulting from known drug interactions.
Credits
This project was the result of a team effort. Pat Kessler assisted with the
development of the mockup/prototype as did other members of the team. Okpe
completed the initial database development. Patti and Chris produced the written reports
and worked intensely on the development and refinement of the prototypes. Final
usability testing and analysis was completed by Patti, Okpe, and Chris. The final report
write-up was completed by the combined effort of Okpe, Chris and Patti.
Introduction
Polypharmacy is a common problem in older adults, and is defined as the
concurrent use of several medications at the same time. While the use of several drugs at
the same time is not necessarily a bad thing, it is a difficult task for the average older
adult to manage. Polypharmacy often results in missed medications, confusion, and
error.
The causes of polypharmacy are multidimensional. Most patients see more than
one provider, referral to specialists is common, and a “provider” is often times not a
physician. Therefore, it is common for patients to be treated by a myriad of providers,
each prescribing medications for different symptoms. From a providers perspective, the
complexity of trying to prescribe medications for health conditions without an accurate
understanding of the current medication regimen results in an increased chance for
adverse reactions, drug interactions, and medication errors. From the patient’s
perspective, barriers to compliance with treatment arise. Patients are confused about
which drugs to take when, and why they are taking the medications in the first place.
It is known from the literature that patients who participate in their care to a
greater degree have better healthcare outcomes. Being knowledgeable about what they
are taking, why they are taking it, and the most effective ways to take medication results
in patients who are better able to help manage their own disease. The challenge here is
twofold. First, how can we encourage patients to play a more active role in maintenance
of their own health conditions and second, how can we assist patients in organizing their
medications to reduce confusion and the chance for error so that they can play that more
active role?
There are many methods by which the first question is attempting to be
answered. For the purposes of this proposal, we will focus on the use of an “Electronic
Personal Health Record” or e-PHR for patient use. The e-PHR movement is gaining in
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popularity in the US, and there is a need to use user-centered design to build the e-PHR.
Since the e-PHR is designed for primary use by the patient, the user group therefore is the
patient, not the medical establishment. Our goal will be to design our prototype based on
the needs of the patient as the primary user.
Discussion of Previous Work/Studies with References
Barnsteiner, Jane H. (2005). Medication Reconciliation. AJN.
http://www.nursingcenter.com
This article discusses the errors of health records as they are currently
implemented, and also looks at solutions and their pros and cons. The amount of errors
involved with medical records is huge, according to the article. A number of paper
solutions and EMR (electronic medical record) are discussed. The main problem of
EMR, which our PHR will have to deal with, is user omissions. Apparently, both
patients and clinicians have a fair number of them.
Endsley, S., C. Kibbe, D., Linares, A., Colorafi, K. (2006). An Introduction to
Personal Health Records. Family Practice Management. www.aafp.org/fpm, 57-62
The article describes how the use of electronic PHR help patients on their
medicine usage and also doctors so they don’t prescribe medicine that may be in conflict
with a patient’s current medications or that the patient may be allergic to. The article
emphasizes that the PHR should be stored electronically. This is because the aftereffects
of Katrina when a lot of patient’s records were lost and patients seeking healthcare had no
records which made it difficult for doctors to prescribe medications. This article relates to our
project in the sense that patients prescription usage is recorded in our “MyMedMinder”
implementation of the PHR. This supports the goal of our project. It will also assist doctors in
prescribing appropriate medications.
Gleason, Kristine M., Groszek, Jennifer M., Sullivan, Carol, Rooney, Denise, Barnard
Cynthia, and Noskin, Gary A.(2004). Reconciliation of discrepancies in medication
histories and admission orders of newly hospitalized patients Am J Health-Syst Pharm.
2004; 61:1689-95
The article talks about how having different medical records for each patient
could be harmful. The study in the article focused on patients providing their medical
history to doctors and then matching the information they give with records on file. The
results were that there were discrepancies with the information given by patients and that
recorded on file. The article proposes a universal medication form to encourage patients
to keep track of their medication and allergy information. This relates to our project
because we are trying to create an interface that encourages patients to keep records of
their medicine usage and making the process of storing their medication histories easier.
Kim, Matthew I., Johnson, Kevin B. (2002). Personal Health Records: Evalutation of
Functionality and Utiliy. Journal of the American Medical Informatics Assocation.
Volume 9, Number 2, 171-180
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The article evaluated the usefulness of 11 web-based PHRs. Some of the
information is relevant to our project, but some of it is not. The major problem with
almost all of the web-based PHRs, according to the article, is data entry and validation.
There was no functionality with the purpose of making data entry easy for the user. This
seems like a major issue we will need to deal with, because the user must take an active
interest in keeping the record up to date, if it is difficult to update, then the user will be
discouraged.
Porter, S., Kohane, Z., & Goldman, D. (2005). Parents as Partners in Obtaining the
Medication History. Journal of the American Medical Informatics Association.
12(3), 299-305.
This article described the development and use of a touch-screen kiosk in an
Emergency Room for use by parents in recording their child’s medication history. The
goal of the study was to examine the accuracy of medication history entered by
laypersons. The results of the study showed that the parents’ reports of the child’s
medication history were more accurate than the nursing documentation of the same.
Parents had most errors on the medication name aspect of the recording process. This
article informs our project by emphasizing that a laypersons recall of a complex drug
name may be better with some sort of computer aided support (like a list of medications
that the layperson can pick from). It also shows us that the accuracy rate of layperson
entry of medications can exceed that of a provider.
Santell, John P., (2004) Reconciliation Failures Lead to Medication Errors. Joint
Comission Journal on Quality and Patient Safety. 32(4), 225-229.
This article discusses the implication of poor communication of medical
information at transition points of care and the known medical errors it has caused. It
discusses the need to incorporate a set of protocols and processes at each intersection of a
patients care. Common types of error and their typical frequency and severity are
reviewed in this article. A suggested list of improvements is included. This article shows
us where common errors in relaying information occurs, and there are some errors noted
that we will need to be aware of.
Saufl, Nancy M. (2006). Reconciliation of Medications. Journal of PeriAnesthesia
Nursing. 21(2), 126-127.
This article discusses reconciling medication during a patient’s transition of care.
The specific types of information that need to be reconciled is covered, as well as specific
steps that should be taken at different points in a patients care. The need for
standardization, at least at the level of specific organizations, is discussed. This relates to
our project by pointing out common errors in the transcription of medication histories.
Tang, Paul C. & Lansky, David (2005). The Missing Link: Bridging the Patient–
Provider Health Information Gap. Health Affairs. Volume 24, 1290-1295
The article described the how the use of PHR could help patients play active role in
their healthcare by entering information about symptoms, medicine taken, personal
exercise program, and other information regarding their health. The article also talks
about how the PHR should be “lifelong and comprehensive” and also to be accessible for
any place at anytime and most important of all, be secure. This article relates to our
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project because it emphasizes the fact that if patients record their medicine usage in a
system, it helps them play active role in their health care because they are able to present
it to their doctors so the doctor knows what kinds of medicine they are taking so as not to
prescribe conflicting medications for the patient.
Tobacman, J., Kissinger, P., Wells, M., Prokuski, J. Hoyer, M., McPherson, P., Wheeler,
J., Kron-Chalupa, J., Parsons, C., Weller, P., & Zimmerman, B. (2004).
Implementation of personal health records by case managers in a VAMC general
medicine clinic. Patient Education and Counseling . 54 (1), 27-33.
This study was done at a VAMC (Veterans Affairs Medical Center) in an outpatient
clinic. Although they did not use a computer approach to the PHR (they used a
checkbook sized series of cards), the study illustrated several things which may impact
out project. What the study did show was that approximately 50% of the study
participants had no record or personal health data at all prior to the study (such as
doctors, test results, medications, etc.). After the study, 60% of the patients who
participated had continued to enter data, make changes, and it stimulated better dialog
between the patient and their providers. Other implications for our project are that “build
it and they will come” does not hold true for all. Forty percent of the study group was not
interested and did not participate in their PHR. The investigators were not sure why, but
it only adds to the need to make the interface very easy and appealing in order to
influence use, which is something that will influence our project.
Tran DT, Zhang X, Stolyar A, Lober WB. (2005) Patient-centered Design for a Personal
Health Record System. AMIA 2005 Symposium Proceeding. 1140.
This project focused on designed a user interface for a personal health record
system that would model how patients view their health information. User needs were
assessed to created two different user interfaces for the Patient-Centered Health Record
System. Their design focus was on discovering useful content to include and ensuring
that the user interface was helpful, intuitive and easy to use.
Wang, M., Lau, C., Matsen, F., & Kim, Y. (2004). Personal health information
management system and its application in referral management. IEEE Trans Inf
Technol Biomed. 8(3), 287-97.
This study created a web-based PHR for patients in a surgical clinic to ease the
referral process of having to gather all the information at the time of visit from the patient
either verbally or by a written medical history form. The results showed that patients
were willing to learn to use the PHR if they perceived security and benefit (like better
care) and were willing to fill out detailed forms as well over the web. Providers (those
getting the referral) liked the system; they were appreciative of not having to illicit the
information verbally from the patient and then write it all down. This relates to our
project by showing that patients and providers may be willing to use a web-based PHR
platform if their security can be guaranteed and if they find benefit to the work.
Wuerdeman, Lisa, Volk, Lynn, Pizziferri, Lisa, Tsurikova, Ruslana, Harris, Cathyann,
Feygin, Raisa, epstein, Marianna, Meyers, Kimberly, Wald, Jonathan S, Lansky, David,
and Bates, David W. (2006). How Accurate is Information that Patients Contribute to
their Electronic Health Record? AMIA 2005 Symposium Proceedings. 834-848
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The article compares the results of an EHR (Electronic Health Record) with
patient's responses about health records. Basically, patients have good knowledge of
their basic health record, but are more likely to know the answers to “yes or no”
questions as opposed to specific test results (for example, exact percentages). The
article states that the rise of PHRs could give patients the power to contribute to their
health record much more easily, relating to our project. Most importantly, the article
shows that patients have a reasonable knowledge of their own record, which a PHR
would enable them to keep precise track of.
Relevant Websites
http://www.ihealthrecord.org/
This is a “free” website that offers a free location to store personal health data.
The site makes a good case for why the idea is a good one. The interface (limited access
unless you sign up) seems to be relatively easy to use. The medication aspect is
inaccessible, therefore could not really be judged. The difference between this and our
project is that our goal is to put the data in the hand of the patient rather than having it
stored on a third party server. This could cause suspicion and fear of privacy or security
loss, and aspect that our project would not have to deal with.
http://www.ahrq.gov/ppip/50plus/
This is a government sponsored website called Putting Prevention Into Practice
(PPIP). This is an online resource – but it is designed to be printed out by the patient.
There is a tool on here called “Medication Minder” which is designed to allow patients to
record their medications. It is very flat, and the process of using paper does not meet the
needs of a flexible and transportable medication record. Our project can benefit from the
PPIP page by using the structure that has already been validated by funded federal
studies. We can improve on it by taking it from paper fro a file structure.
http://www.medicalert.org/E-Health/
The Medic Alert Corporation is trustworthy and offers a thumb drive storage
device for the patient. The data is also stored on the MedicAlert database. We are unable
to view the interface as this is not a free service. There is a demo, but the view is limited.
This relates to our project in that the use of the thumb drive puts the data in the hand of
the patient, which is one of our goals. It was unfortunate that we were unable to view the
interface or input mechanism. We believe that the use of the MedicAlert database and a
fee for use is a negative. The reputation of the company is a positive.
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Design
The MyMedMinder website was designed to attempt to provide the most possible
features while maintaining an easy to navigate design. The transition diagram and
screenshots below will depict our final prototype and the paths users can take while using
this application. See Diagram 1.
Begin Here
Home
About
New Users
Login
Create Acct.
***Can be reached by all screens
Help
Logout
View
Print
Add
Welcome
Prep. Info
Enter Form
Opens new window
By Name
By Reason
By Name
By Reason
By Doctor
By Doctor
By Date
By Date
Legend:
The use must be logged in to access these pages
The user does not have to be logged in to access these pages
General Information
Diagram 1
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Screen Shots
The final version of the site is represented in the following figures (examples)
including the HELP screens. The live version can be viewed at:
http://129.2.168.8/medminder Prototypes follow these screen shots.
Fig 0.0: The opening screen when accessing MyMedMinder
Fig 0.01: Example of the HELP file (consistent across all screens)
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Fig 0.1: Available to non-members, this screen gives an overview of MyMedMinder.
Fig 0.2: The New Users Page. Users access this and are able to perform two functions,
either “Learn More About MyMedMinder” or go directly into “Create a New Account”.
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Fig 0.3: Create Account Page with information about creating a new account.
Fig 0.4: Login Page. If people accidentally end up here without a password, they can
click to register.
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Fig 0.5: The welcome screen that a member will see after a successful login. The system
verifies their name to be sure they are logged in properly and it also relays the number of
medication the user currently has stored in the database. Users are able to review, add or
print medications from this screen.
Fig 0.6: The options for viewing medications that have already been entered. Users are
allowed to review by date, in alphabetical order, by prescriber or by reason for taking.
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Fig 0.7 Medication view which has been chosen to be viewed by name of drug.
Fig 0.08: Medication View Sorted By Name of Prescriber
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Fig 0.09: Medication View Sorted By Reason for the Medication
Fig 0.10: Add screen with instructions.
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Fig 0.11: The standard form for entering medication into the database. An image to help
with terminology is included for user reference.
Development process
The development process for the MyMedMinder site consisted of two main steps.
First we met as a group for brainstorming sessions where we discussed our own beliefs of
what we believed the system functionality should include. The brainstorming sessions
began as meetings after class periods. The group members spent this time to familiarize
ourselves with the project and its requirements.
Each member of our group decided to prepare a conceptual design of the system
which would then be brought back to the next meeting and compared. Our final design
was they derived from the combination from all the prototypes. Each had strengths and
weaknesses, and we believed that the diversity of thought strengthened the design.
The decision to create a web based application for this project was unanimous
because it would increase accessibility and also had the greatest chance of being familiar
to users. We knew from looking at and discussing the Pew Report on public use of the
internet that the number one reason that Americans (in general) use the internet is for
medical information. Therefore, although we understand that not everyone has access to
the Internet, that is is becoming more common and acceptable for the general public. We
also know that people who do not own their own computer are increasingly using internet
cafes and public libraries as areas to gain access to the internet. We consulted friends,
family, and clinicians to create a better idea of functionality. After working within our
group, we compiled a prioritized list of features that we wanted to implement..
In developing the prototype conceptual designs, we believe that allowing each
member to be creative resulted in several benefits. It allowed us to better understand the
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nuances of the interface, it made us think deeper into the branching logic, and helped us
to piece together newly gained information about usability and interface design
principles. Team members chose a variety of formats to use for the draft including
Microsoft Word and Powerpoint as well as HTML developed in Adobe Dreamweaver. In
the discussions that ensued as we compared each design, we debated the pros and cons of
each design and gradually merged all of the concepts into one final prototype that was
constructed in one of the team members FTP site. This enabled us to work on the
prototype together, regardless of geographic location or time of day. We tweaked the
prototype until we believed that it resembled most closely our conceptual design. The
screen shots ahead depict some of the features we chose to keep as well as some of the
design differences in similar situations.
Low fidelity prototype examples follow:
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Fig 1.1: A welcome screen designed in MS Word
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Fig 1.2: A login screen that doubles as the welcome screen in HTML.
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Fig 1.3: Menu prototype for user navigation
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Fig 1.4: Suggestion to put form in a table
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Fig 1.6: Suggested design for viewing and adding medication information
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Fig 1.8: A Completion View highlighting the idea of a standard tool bar across the
bottom.
Prototype Testing
Our team handed in the prototypes represented above and received critiques from
the instructor. We modified the prototype based on that critique. The consolidated
conceptual design that we began to model our physical prototype upon is represented in
the screen shots below. We did discover during the actual building of the prototype that
we were unable to exactly replicate several of the features in exactly the way that we had
envisioned on paper. The core functionality was modeled successfully in our initial
prototype however. The prototype testing process will be described after the presentation
of the revised screens (below):
Revised Prototype (Figures 1.9)
Figures 1.9
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Figures 1.9
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Figures 1.9
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Figures 1.9
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Figures 1.9
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Figures 1.9
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Figures 1.9
Prototype Testing
We conducted small scale prototype testing using several people representative of
the final end user group (primarily parents and older relatives). Each person was asked to
sit down at the interface represented above (we used the ftp site prototype) and use the
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system to record several of their own medications. We chose older relatives based on
knowledge that they were taking medications, we were able to readily access them, and
the team members were with the relative as they worked through the system. This
enabled us to directly observe problems that the users had with the interface.
During the observation period, we asked the family members to verbalize what
they thought they were supposed to do as they were walking through the process. If
something confused them, we asked them to tell us about it. We did not instantly help
them solve a problem or a question in the process. Instead we let them try to figure it out
on their own. If they were really hung, we gave them advice and took note of the
struggle areas, and why the user had difficulty.
The next step of the process was to compare notes across the team to see if
common areas of user issues arose – which they did. There were several fields that the
wording was confusing and several spots where the users were not sure how to progress
or what the next step was. For example, we noted that at the completion of the data entry
process, there was no function visible for the user to say “finish and save”. The common
toolbar across the bottom was ambiguous for that particular function. We also noted that
the wording of the question requesting the user to enter the medication concentration
caused real confusion in the user. There were several other small issues that required us
to clarify. We did note that while there were several areas that people had difficulty
across the board, some of the struggle spots were unique to a particular user/subject.
Because we only tested 3 users in the prototype stage, we decided that we should address
each concern, even if only one person had an issue with it.
One area of real concern was the difficulty in entering the medications into the
form fillin. We believe this was due to the terminology – even the development team
struggled. The result was a change in several aspects of the interface for our first
revision. While not perfect, we believed that a reasonable way to graphically represent
the concepts from a label was to include a graphic that the users could reference if
confused. It seems to have helped considerably, but it is still a difficult aspect that could
use more work.
Review of the group in the first revision discovered more issues, so a second
revision was undertaken before we ended up with our final version. The final version
that was used for usability testing can be found earlier in this report – on pages 8-13.
There were some areas that, had we had more time and more expertise, we would have
liked to alter for the final. We have represented these aspects in our conclusion section as
areas where more work is needed.
Usability Testing
SCENARIO – We conducted our usability study with 6 users to evaluate our final
version of the interface to MyMedMinder. The users were purposively selected from a
candidate group of users similar to those who may use MyMedMinder. While we
planned to focus on older adults, ages 65 and up, the group believed that younger people
might also find value in MyMedMinder, particularly since some may be caring for aging
parents. Subject had to be able to read and speak English, and be without significant
mental or physical handicaps. Familiarity with a computer was a pre-requisite for the
evaluation of MyMedMinder. Subjects will be invited to participate by members of the
project team, and included parents, grandparents, colleagues, neighbors and friends.
Subjects were instructed on the purpose of the study, any risks involved,
guaranteed anonymity via the use of a coded id number (not a personal name). As
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planned, they were instructed that the focus of the study is on the interface and not
themselves or their performance. They were instructed to enter their medications into a
web-based interface so that we may study their actions and gain their feedback on the
process and the system interface.
TASKS – Users were tested at a standard PC in a quiet location. We decided to provide
3 of the same medications to each subject, using a printed (simulated) pill bottle label.
They were asked to use the system to enter those medications. The subjects were
encouraged to work with the interface themselves without any involvement of the
researchers – unless the subject got to a point of being totally hung. At only one time with
one subject did this occur. The researchers took note of issues that arise with the user –
such as areas where they struggled, areas that they made errors or expressed confusion,
and any missteps that occured.
Steps:
1. Click into MyMedMinder
2. Browse, learn about system, then make a selection for “new user”
3. Login
4. Review information screen/choices and explore as desired
5. Enter medication data as requested
6. Review entry
7. Revise entry if necessary
8. Save entry
9. Repeat if necessary for additional meds or if editing necessary
10. Review final entry
11. Save session and/or print record.
12. Logout
PRE-TEST – Prior to participating, the users were given a short pencil and paper
demographic questionnaire. No names or identifying information were used. The
subjects were given a code number which was used on all testing (computerized and
paper notes) to protect identity. Data that was collected included:
 Age, gender, years of computer experience
 Number of medications taken
 Experience with Internet (range from novice to expert)
REVISED POST-TEST FOR EVAULATION OF PROTOTYPE/USABILITY
(Actual evaluation handed out to subjects)
POST-TEST – Evaluation Testing for MyMedMinder
We sincerely appreciate the time you have taken to participate in this study. All data
will be anonymous, and we will not make any effort to match these surveys to
participants. The focus of this study is not on how YOU perform – instead the focus is
on the interface and how we can improve it to make the use of MyMedMinder easier and
more user friendly.
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After completing the exercise of entering data into the system, we would like for you
to share your opinion with us. We would appreciate it if you would complete this very
short survey. Simply read each question and put a mark in the box that best corresponds
to your feeling or opinion about your experience with MyMedMinder.
Please only mark one box per question. If you change you mind, make sure to make
your correct answer obvious to us by marking it clearly.
The test is structured on a scale. For instance, in question one, if you thought the
system was wonderful, you would make a mark in the box below the text of “wonderful”.
If you thought the system was “terrible”, you would put your mark in box number 1, right
below the word “terrible”. Boxes 2, 3, or 4 allow you to pick somewhere in between.
What is your overall reaction to this system? (please answer all 5)
Terrible ………….………………………….Wonderful
1
2
3
4
5
Frustrating …………………..........................Satisfying
1
2
3
4
5
Dull …………………………………………Stimulating
1
2
3
4
5
Difficult ………………………………………..Easy
1
2
3
4
5
Rigid …………………………………………...Flexible
1
2
3
4
5
1. What do you think about the appearance of material on the
screen?(please answer all 3)
Too much on one screen …………………………………Too little on screen
1
2
3
4
5
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Items arranged logically…………………………………Items arranged illogically
1
2
3
4
5
Screen sequence clear……………………………………Screen sequence confusing
1
2
3
4
5
2. What do you think about the saving and editing process? (please
answer all 3)
Easy to correct mistakes…………………………………Difficult to correct mistakes
1
2
3
4
5
Saving data was easy…………………………………….Saving data was difficult
1
2
3
4
5
System was too slow…………………………………….System was too fast
1
2
3
4
5
3. How easy was the system to learn to use? (please answer 1)
System was easy to learn………………………………..System was hard to learn
1
2
3
4
5
4. Do you have any comments that would help us to improve the
system in any way?
Thank you very much for your participation!
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Results
Narrative Reports By Subject
Subject 1:
Subject 1 was a 58 year old male who had 8 years of computer experience. This
subject takes an average of 2 prescription medications daily. By self assessment, this
subject considers himself an expert with the Internet. Subject 1 has a great deal of
medical experience.
This subject was readily able to gain entry into the website for MyMedMinder.
Subject 1 remarked that he liked the colors and the layout of the opening screen and
specifically asked about the graphic/picture and said he found it “appealing”. He was
curious about why we found it necessary to include the statement about “best viewed
with IE 6.0 or higher”, but we attribute this to the experience level with the web.
The subject also expressed that he wished he did not have to scroll to read the
whole first page. Similarly, he commented about the icons being located out of site at the
bottom of the active page – although he managed well and relied heavily on the toolbar
icons.
Issues that were managed probably due to the experience level of this subject
included the data entry function and the help function. In regards to the help function, the
user expressed that he wished that there was item specific help. While he appreciated the
general help and found it useful and reasonably well done, there were issues that he
needed help with that there was no help information for; in example, how to “edit” and
existing record. This actually pointed to his bigger concern about the inability to remove,
totally, records in the system. For example, if a medication is given and stopped due to a
reaction or something, there was no way to note that or remove the medication. If we put
this in context of a patient-centered effort, they must have the ability to do this.
The next big issue was in the medication entry process. It is inherently complex,
and it took awhile for subject 1 to figure you it and perform the tasks successfully. He
pointed out that the image was too small and that it might be helpful to somehow relate
each fillin with the area on the graphic example where users could refer their attention.
Subject 1 suggested that the display of medications (for review or printing) could
use some formatting work as it was not pleasing to the eye and was a little confusing at
first to interpret. Finally, he was also quite concerned about the inability to remove
records from the database.
Subject 2:
Subject 2 was a 27 year old male with 7 years of computing experience. He rates
himself as an expert on the Internet. Subject 2 takes no medications, but is a parent and
has a child who receives allergy medicines twice a day. Subject 2 expressed an interest
in using such an application if the need arises. This subject has no medical experience.
Subject 2 had no expressed issues whatsoever in navigating through the system,
however, there was an observed change in the concentration level at the area of entering
the medications. The subject was observed to spend several minutes reading and rereading the questions and studying the graphic intently. Several slips were observed, but
were corrected before saving the entry. This subject did mention that it might be good to
have better and more specific help functions for this process. Also this subject suggested
that we use better error prevention techniques – for instance he noted that he could enter
text into the date field.
Opessu, Abbott, & Bassler
33
Subject 2 did also asked why we are requesting certain information in the “create
new account” section since it did not seem to be used for anything and that it might make
some people hesitant to participate. While subject 2 did not have any major issues, the
rating on the evaluation tool was tepid.
Subject 3:
Subject three was a 25 year old female with 4 years of computing experience and
a moderate level of expertise on the internet. She takes no meds, but also is asked by her
grandfather routinely for help in refilling prescriptions and helping with his medications.
She expressed verbally that this might be of a help to her for helping with her
grandfathers medications more so than her own.
Subject 3 expressed a like of the opening screen. She liked the light blue and the
picture. She said she found it “soothing” and interesting all at the same time. Subject 3
had no difficulty navigating through the first few screens. This subject choose to just
click around, exploring the site before getting down to work. This actually resulted in a
little bit of confusion – for example, she clicked on “Returning Users” first and what was
in there did not make sense to her. She stated that “this is what I get for poking around
and not going at this in a structured way.” Subject 3 was allowed to continue exploring,
then settled into the task at hand.
Subject 3 noted that she wished she did not have to scroll through a page to read it
all and also commented that finding the maneuver icons at the bottom seemed to be odd.
She suggested that we move them to the top bar so that all maneuvering possibilities
would be viewable from any screen. She, like everyone else, had to take some time to
figure out the data entry screen – and was frustrated when she accidentally hit “clear
form” by accident and found that there was no easy way to reverse that action. She also
asked “how do I remove my data from this system?”, which highlighted the same issue
brought up by others. This subject was pleased with the application and encouraged us to
continue working on it because she viewed it as “important”. Her primary struggle point
was in the “Add a Medication” process, but stated that she found the graphic of the pill
bottle helpful in interpreting what data was required.
Subject 4:
Subject 4 was a 46 year old female with 3 years computer experience. She
considers herself as a moderate in regard to internet expertise. Subject 4 takes 2 meds a
day, but mentioned that she has 2 children who have severe allergies and she does them
twice a day and elderly parents – all of whom take medications and this subject feels as
though she has some responsibility for all of them. She represented that she “takes” 4
meds a day.
Subject 4 seemed to be distracted and just kept asking “what do I do next?”
instead of concentrating on the tasks at hand or trying to figure it out on her own. Subject
4 was asked to continue to try and work with the system – although hints were given by
the observer/researcher. The impression was that this person just wanted to “get it over
with” instead of doing a thoughtful testing.
She moved quickly through the procedure, entering all three meds without major
incident, however. It was noted that once she got the hang of medication entry on drug
number 1 that the next two went in easily. She did comment that some of the terms were
Opessu, Abbott, & Bassler
34
confusing, specifically that the word “concentration” is used twice in the form fillin to
represent two different data elements. Subject 4 also commented that the help screens
were not specific enough to offer some of the granular help that she needed. She did like
the pill bottle graphic, saying that it helped her figure out what was needed.
Subject 5:
Subject 5 was a male who was 22 years old. He had 6 years of computer
experience and considered himself and expert on the Internet. He does not take any
prescription meds, but he does use OTC on occasion (such as Tylenol for headaches)
therefore he chose 1 as the number of meds that he took.
Subject 5 did not seem to have any difficult with the application. He liked the
concept and expressed that “it was about time” that someone put this in an automated
format since he had been reading about medication error in the press and thinks
“something must be done”. This subject also mentioned that he thought the medication
entry screen could be improved, but did not offer specific comments in that regard. He
did mention that there needed to be a way to remove records. Subject 6 did not have any
difficulty printing or saving and thought that the help file was sufficient.
Subject 6:
Subject 6 was a male who was 79 years old. He takes 12 medications a day – a
combination of prescription and OTC (although primarily prescriptions). He has 4
months of computer experience and considers himself a novice on the internet.
Subject 6 was our most challenged subject – yet he represented a prime user
group for an application of this type. He needed more support than the other subjects
however, the observer only had to actually intervene once. While the subject did not
verbalize this, we noticed that he seemed to be squinting and tipping his head back and
forth to use his bifocals. It was more difficult for him to scroll because of vision and
hand coordination issues. For example, it would take him a period of time to find the
text, then he would have to look for the mouse – which made him lose his place in the
text. It seemed to indicate that we should try to get as much as possible on one screen so
that users do not have to scroll. The tradeoff is that the text has to be large enough for
those with elderly eyes to see. Related, we noticed that it was more difficult for this
elderly person to click on the top toolbar as well. He really had to “aim” and it was hard
for him to hit the target. Also, he mentioned that the font was a little small and hard to
see.
Subject 6 struggled in the add medication process. This is where the observer had
to intervene to assist. The user commented that it was hard to understand, and asked why
certain text was “red”. He said that it would be helpful if the data entry “slot” could
automatically point to the example label. He also said that the graphic was too small.
Subject 6 was somewhat confused with the options to display, but with a little
practice he figured it out and ended up liking it. He said that it helped him to organize his
meds based on what his goal was, for example, if thought that if he wanted to look up his
medicines that he had taken for pain.. The display however was a point of his criticism –
he wanted to know why the columns did not line up.
Opessu, Abbott, & Bassler
35
Subject 6 also had some issues with the help button – especially since one option
took him to “About MyMedMinder” and he did not know how to get back to where he
started. He wanted to know where he was in the process – and he may have benefited
from a “progress” screen similar to what appears on an airline ticketing site.
Subject 6 also had difficulty with the print and save function, most likely related
to a lack of expertise in working with printing and saving dialog boxes. He ended up
abandoning the effort to save, but mastered the printing function. There was some
confusion expressed by Subject 6 understanding conceptually the difference between
returning home from within the secure area and returning home from the public area as
well. He asked “why when I hit the home button I get two different views? Why does
that happen?”
Finally, subject 6 did find value in the site and verbalized that he thought it was
worth the effort to put his medicines in because he has so much trouble keeping it
straight.
Key Questionnaire Results in Graphs
There were a total of 5 questions on the evaluation. The first four questions were
based on the QUIS and were based on a Likert Scale with 5 data points. The fifth
question was free text. Questions 1-4 are represented in chart 4 below, but are plotted
only on the basis of summary scores. Summary scores are derived by adding up the
totals from each sub scale contained within a single question. For example, question 1
actually has 5 sub-questions contained within it, therefore for question 1 all raw data was
averaged across all subjects and reported as an average for the overall question. The
actual survey is included earlier in this report as is the raw data (nonsummarized).Summary statistic regarding demographic data are graphically reported
below. All raw data is also provided in Appendix 1.
90
9
80
8
70
7
60
6
50
5
40
4
30
3
20
2
10
1
0
0
1
2
3
4
Subject #
5
6
Number Years Computer Exp.
Age in Years
Age By Experience
Age in Years
Experience
Opessu, Abbott, & Bassler
36
Chart 1: This chart represents the age relationship to experience, with experience being
represented with the line and the legend on the right. The oldest subject has the least
experience. N=6
Gender
4.5
4
3.5
Frequency
3
2.5
Series1
2
1.5
1
0.5
0
1
2
Male = 1; Female = 2
Chart 2: Gender Distribution; N=6
Number of Medications
14
# of Medications/Day
12
10
8
Series1
6
4
2
0
1
2
3
4
5
6
Subject #
Chart 3: Number of medications per subject – demonstrating skewing potential of
subject 6
Opessu, Abbott, & Bassler
37
Summary Scores/QUIS
3.6
Average/Summary Score
3.5
3.4
3.3
3.2
Series1
3.1
3.0
2.9
2.8
2.7
1
2
3
4
Question #
Chart 4: Summary Scores (Averages) for Question 1-4
Question #1 is “What is your overall reaction to this system?”
Question #2 is “What do you think about the appearance of material on the screen?”
Question #3 is “What do you think about the saving and editing process?”
Question #4 is “How easy was the system to learn to use?”
Question #5 is free text/comment area and that will be reported separately (as part of
“key comments” at the end of the results section.
Analysis of Usability Test Results
Six subjects participated in the usability test of the final version of
MyMedMinder. They subjects ranged in age from 24 years old to 79 years old. Four
were males and 2 were females. The average number of daily medications taken was
three, with a wide range/skew (0-12). The range of computer experience was wide, from
4 months to 8 years, with the older subject having the least number of years of
experience.
After consenting and completing the pre-study demographic questionnaire,
subjects were given the identical three prescriptions (on a simulated paper label like one
would find on a pill bottle) and asked to record the medications in the system while we
observed. Observers took notice of where users struggled and took notes. In only one
instance did we have to step in and help, and that was with an older gentleman who did
not have much computer experience and was growing frustrated.
Opessu, Abbott, & Bassler
38
We used a modified version of the QUIS that was revamped after the instructor
critique in early October. Unfortunately, our evaluation results came out rather nondescript. Most everything ranked in the middle (averages reported):
•
•
•
•
•
Overall Reaction (scale of 1-5)
Appearance of Material (1-5)
Saving & Editing Ease(1-5)
Easy to learn & use (1-5)
Comments (general, more detail to follow)
– Med entry little confusing (terms)
– Need a way to delete “all”
– Unsure about OTC
3.5
3
3
3.25
More of the important data came from the observation and notes. For instance,
the survey tool was unable to capture the degree of struggle that people experienced with
adding a medication. We also watched people trying to figure out the next logical step.
While eventually they figured it out, it seemed that it could be less ambiguous and more
direct. Several people asked how to remove a medication, an issue which (due to time
constraints) were unable to resolve, but we certainly understand that this is an important
issue. For those without a great deal of computer experience, saving and printing were
challenging. While the standard dialog boxes appeared for printing and saving, those
with less experience had difficulty figuring it out.
The users were pleased overall with the idea of the application, and there were not
any aspects that they ranked poorly overall. That may be an artifact of the tool, or that
this was a group of people that we chose (therefore afraid to be totally honest since we
knew them). We observed areas that would need to be addressed were this project to go
further.
Comments & Prioritization
We examined all of the comments that had been recorded and determine that there
were about 5-6 that seemed to be common across our sample. A representation of these
comments is as follows:
1. “Could you reduce the scrolling? Maybe if you put more on the screen it would
help. There seems to be lots of white space available.”
2. “The pill bottle graphic should be bigger” of “there should be a way that the data
you need can be highlighted when you get to the blank to fill in.”
3. “How do I remove a med that I recorded by mistake?”
4. “Maybe one of those things like I get when I buy stuff online that shows me how
close I am to being down would encourage me.”
5. “The terminology in the add med form is confusing” and “why is certain text
red?”
6. “The help text needs to be more specific”
We discussed these across the group and assigned almost 5’s (high priority) to all of
these. We think this indicates the complexity of created an interface that works for a
wide range of users (particularly as related to the elderly).
Opessu, Abbott, & Bassler
39
Those determined to be of highest priority are question #3 (removing records), #2
(making the med input screens better), and #1 (reduce scrolling). Of these three, we think
that number 2 would take the most time, so chances are we would make the easiest and
high priority fixes first (1 & 3). Comment #4 (progress icon) is what we consider a “nice
to have”, but it is not critical and we think it would take a good deal of time to
implement, therefore it has a low importance score and a high effort score. Comment 5
(terminology and font) is moderately important and moderately time-consuming,
therefore it was not seen as one with the highest interest – moreover, we believe that this
might be fixed with the revision of item #2. Comment 6 (more specific help) is viewed as
moderately important and moderately time consuming.
Issue #
1
2
3
4
5
6
Importance
5
5
5
2
4
3
Effort to Repair
1
5
4
5
3
3
Conclusion
In summary, polypharmacy is defined as the concurrent use of several
medications at the same time, and is common problem with older adults because they
have to take different medications for different illness they may have. Polypharmacy
often results in confusion, error and missed medications.
To help to prevent polypharmacy with older adults, we developed “My Med
Minder”. “MyMedMinder” is a web based service designed to assist the users in
organizing and keeping a history of their medication history and backup their data either
digitally or on paper. Our hope of creating “MyMedMinder” as a web interface allows for
instant access of these records from any computer with internet access helping to reduce
confusion among patients preventing deadly mistakes resulting from wrong drug use.
We implemented a web interface similar to our prototype described. The interface
had two sections, one was the open site, where browing and information gathering was
encouraged. The second part of the interface was the secure area that required a
password to access. We developed two access points to the secure area, one for new
users which explained the system to them, and the other section was for returning users
who had already registered. Once inside the secure area, most of the functionalities to
help users prevent polypharmacy could be found.
In the first section, we had both a login page and new user registration page. The
new user registration page contained a form which takes user personal info and puts it in
the database that stores user personal information. The login page contained a form that
takes the login name and password and validates it against the database. The information
stored in database was designed to store information about each user to allow secure
authentication. If successful in logging in, the user is taken to their personal page, where
they can find their PHR medication record.
On getting to the secure section from a successful login, user has several options
including viewing, adding to, and printing their medications records. They can view these
by the reason for the medication, the doctor who prescribed the medication, the date
medication was prescribed, or by the name of the medication. This allows some degree of
internal locus of control – where the user can specify the output in a way that works best
Opessu, Abbott, & Bassler
40
for them. Also in this section of the system, the user is able to add additional medications
as a way of updating the record that may already exist.
Some future work possibilities include the creation of a better database structure
which will allow for quicker and more customizable retrieval of information. As of now
user information and medications are contained in one table. Large flat files encourage
redundancy and are can get unwieldy if many users participate in MyMedMinder.
Unacceptably long processing and retrieval times could be frustrating for users and
difficult to manage.
In addition to database structure, in the page that deals with insertion of
medications, we would have liked to create an input mechanism that would allow users to
insert medications based on illness, who medication was prescribed by, date in which
medications was prescribed, and time of the day in which medicine is to be taken. We do
have the option for people to extract data in this fashion, but we believe that when people
have to enter meds for the first time – where there may be many – that they might want to
enter medications in categories. This will require a more advanced database structure
There are many changes that may be possible for the interface itself. For
example, designing a way that the form fillin for the medication entry could be complete
easier (maybe by highlighting the area of the pill bottle image that corresponds with a
field mouse over) would be helpful. In addition, some sort of “progress bar” that would
show users how they are progressing through the process might be beneficial. There is
much work to be done in making the interface more appealing, which given more time,
should occur. Finally, we believe that the idea here is a good one and would be of great
benefit to patients, providers and society to develop further.
Acknowledgements
We would like to thank the kind persons (subjects, fellow students, & Ben) who
gave us pointers and advice on how to build and then improve this interface.
References
Barnsteiner, Jane H. (2005). Medication Reconciliation. AJN.
http://www.nursingcenter.com
Endsley, S., C. Kibbe, D., Linares, A., Colorafi, K. (2006). An Introduction to
Personal Health Records. Family Practice Management. www.aafp.org/fpm, 5762
Gleason, Kristine M., Groszek, Jennifer M., Sullivan, Carol, Rooney, Denise, Barnard
Cynthia, and Noskin, Gary A.(2004). Reconciliation of discrepancies in
medication histories and admission orders of newly hospitalized patients Am J
Health-Syst Pharm. 2004; 61:1689-95
IHealthrecord.org. Accessed November 3, 2006 at: http://www.ihealthrecord.org/
Kim, Matthew I., Johnson, Kevin B. (2002). Personal Health Records: Evalutation of
Functionality and Utiliy. Journal of the American Medical Informatics
Assocation. Volume 9, Number 2, 171-180
Medicalert. Accessed September 30, 2006 at: http://www.medicalert.org/E-Health/
Opessu, Abbott, & Bassler
41
Porter, S., Kohane, Z., & Goldman, D. (2005). Parents as Partners in Obtaining the
Medication History. Journal of the American Medical Informatics Association.
12(3), 299-305.
Putting Prevention Into Practice. Accessed October 15, 2006 at:
http://www.ahrq.gov/ppip/50plus/
.
Santell, John P., (2004) Reconciliation Failures Lead to Medication Errors. Joint
Comission Journal on Quality and Patient Safety. 32(4), 225-229.
Saufl, Nancy M. (2006). Reconciliation of Medications. Journal of PeriAnesthesia
Nursing. 21(2), 126-127.
Tang, Paul C. & Lansky, David (2005). The Missing Link: Bridging the Patient–
Provider Health Information Gap. Health Affairs. Volume 24, 1290-1295
Tobacman, J., Kissinger, P., Wells, M., Prokuski, J. Hoyer, M., McPherson, P., Wheeler,
J., Kron-Chalupa, J., Parsons, C., Weller, P., & Zimmerman, B. (2004).
Implementation of personal health records by case managers in a VAMC general
medicine clinic. Patient Education and Counseling . 54 (1), 27-33.
Tran DT, Zhang X, Stolyar A, Lober WB. (2005) Patient-centered Design for a Personal
Health Record System. AMIA 2005 Symposium Proceeding. 1140.
Wang, M., Lau, C., Matsen, F., & Kim, Y. (2004). Personal health information
management system and its application in referral management. IEEE Trans Inf
Technol Biomed. 8(3), 287-97.
Wuerdeman, L., Volk, L., Pizziferri, L., Tsurikova, R., Harris, C., Feygin, R.,
Epstein, M., Meyers, K., Wald, J., Lansky, D., and Bates, D. (2006). How
Accurate is Information that Patients Contribute to their Electronic Health
Record? AMIA 2005 Symposium Proceedings. 834-848
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Appendix 1: Raw Data File; MyMedMinder
Opessu, Abbott, & Bassler
Age
Gender
Subject 1
Subject 2
Subject 3
Subject 4
Subject 5
Subject 6
58
27
25
46
22
79
Averages
42.8
1
1
2
2
1
1
42
Years
Experience
Q1 - AVG "Overall Reaction"
# of Meds
Q1a
8
7
4
3
6
0.25
2
2
0
4
1
12
4.7
3.5
Q1b
1
3
3
3
3
3
Q1c
3
3
3
5
1
3
Q1d
3
3
3
3
3
3
3
2
3
3
2
3
Q1e
4
3
3
3
3
4
Male = 1
Female = 2
Q2a
Q2b
4
3
3
2
3
3
Q2 - AVG
"Appearance"
Q2c
3
3
3
2
3
1
4
3
4
3
2
5
3
Q3a
easy
Q3b
saving
4
4
3
2
3
2
Q3 - AVG
"Save/Edit"
Q3c
speed
4
4
4
3
3
1
3
3
3
3
3
3
3.1
Q4a
4
4
3
3
3
3
Q4- AVG
"Easy to
Use"
3.3
Comments (separate file)