My-Medi-Health
Vanderbilt University Design Team
Design Phase Report
The focus of the My-Medi-Health project is to invent a future where a totally interoperable medication list exists, and a medication management system has been constructed so that pediatric patients and caregivers are better able to administer medications in a timely fashion, monitor for and report side effects. To accomplish this vision, we begin by collecting data from parents, schools, and health professionals from the community to better understand the current state of medication management.
The figure above summarizes the results of our assessment phase. Medication management does not take place in isolation from other activities of daily living. The current (and future) medication management system can be characterized as an “open system” from a systems theory perspective, as described by Norbert Weiner, where there is “an interdependence between the several organized parts but in which this interdependence has degrees.” In this system, there is interplay between the environment and its capabilities or rules, the child’s own developmental/behavioral capabilities, and the social structure that surrounds the child. The largest gap identified in this system is, in fact, the gap between the child’s own capabilities and the degree to which the child is allowed to assume any degree of self care.
This observation of the gap between the role a child can and does play in medication management is apparent to all, but in effort to protect the child, is not considered possible in 2007. It was clear to those
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My-Medi-Health
Vanderbilt University Design Team
Design Phase Report of uss thinking about the role of the personal health record of the future that consumer activation needed to include empowering children, and that the original idea of the project was even better rationalized given our discoveries during the assessment phase.
Based on our assessment phase, the tasks in the table below needed to be addressed by our design.
Tasks Caregivers impacted
I need to never forget to administer a dose Patient, all caregivers
I need to learn more about medications
I want to get involved in the care
I need to protect this child from herself
I ask what to do and to expect
I call the parents for new symptoms or missed doses
I communicate with the health care team if necessary
I need to learn more about this disease
Patient, school, friends, parents
Patient, friends, siblings, family
Admin, school
Friend’s parents/ relatives
School
School
School, friends, siblings
Conceptually, our design focuses on the need to involve the child in ensuring that she receives the right dose of the right medication at the right time and in the right way. In an idealized scenario, the child would have access to a device that was not stigmatizing, but that was able to provide a visual or auditory prompt to self-administer a specific medication at a pre-specified time (or after a specific event.) This system would log any administration events and pass that information to caregivers, as well as provide opportunities for the child or others to log if a side effect occurs. This device would be integrated with a
PHR that was used to set up a dosing schedule, download medication-specific data (such as the picture and name of the medication to administer, as well as side effects to look for in age-appropriate language), and communicate between the patient and other caregivers using a messaging standard.
After careful consideration, our team has chosen to expand the functionality of an existing web-enabled cellular phone into what we term a “Pillsberry” that is capable of intelligently administering medications, monitoring for side effects, and communicating health concerns with caregivers. Stigmatization will be minimized by creating specific “skins” into which a Pillsberry can be placed. For the very young child, this skin might resemble a Teddy bear, as shown below.
As is evident from the idealized scenario described above, our design assumes significant challenges to the personal health record of the future. However, it is our belief that only a subset of these challenges needs to be assessed during this prototype phase. Therefore, our prototype will allow interactive testing and evaluation of a functional prototype of a MediTeddy using a cell phone
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My-Medi-Health
Vanderbilt University Design Team
Design Phase Report
•
•
• and a PHR designed to support the ability to:
• create a medication schedule define a social network and assign levels of detail to members. review a schedule and specific medication information on the Pillsberry
Audit activities performed on the Pillsberry
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My-Medi-Health
Vanderbilt University Design Team
Design Phase Report
The focus of the My-Medi-Health project is to invent a future where a totally interoperable medication list exists, and a medication management system has been constructed so that pediatric patients and caregivers are better able to administer medications in a timely fashion, monitor for and report side effects. Our initial vision recognized a gap in this last mile of the medication use system, but this recognition was surmised from a national consensus without input from parents, school nurses, and patients. Therefore, the first aim of the project was to better articulate the user’s needs and constraints.
This project utilized three methods to articulate the current problem in terms of negative aspects, positive aspects, and gaps: facilitated group discussions, site visits, and blogging.
The Vanderbilt Project HealthDesign development (VPHD) team partnered with a convenience sample of teachers, school nurses, and parents, to form a group named “Team Medi.” Team Medi met for two facilitated group discussions, which were focused on:


 validating/expanding an initial set of medication management scenarios, and constructing a future world with optimal medication management
Each discussion was held on a work evening for 2 hours. Audio recording of the discussion was reviewed by one of our development team members, who constructed field notes of key ideas based on these discussions.
To gather additional data from school officials, a subset of the VPHD received permission to visit a variety of schools and day cares within 40 miles of campus, encompassing two counties. Each site visit lasted approximately an hour, during which a set of questions were addressed (Appendix __.) As the site visitors toured the facility, a member of the site visit team took pictures of every knowledge source, cabinet, or device involved in the medication management
Medication management does not take place in isolation from other activities of daily living. The current
(and future) medication management system can be characterized as an “open system” from a systems theory perspective, as described by Norbert Weiner, where there is “an interdependence between the several organized parts but in which this interdependence has degrees.” In this system, there is an interplay between a child’s environment and its capabilities or rules, the child’s own developmental/behavioral capabilities, and the social structure that surrounds the child. Current conditions have been assessed using facilitated group discussions, site visits, and home visits, so that each of these areas would be included in our analysis. As of April 4, 2007, we have conducted one group discussion and three site visits, with two additional group discussions, 3 site visits, and 5-10 home visits remaining.
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My-Medi-Health
Vanderbilt University Design Team
Design Phase Report
User
The table below summarizes our user role matrix. This draft version will be refined as we complete site visits, home visits, and additional group meetings. In this table, “yes” and “some” refer to capabilities and current conditions. For example in our facilitated group discussion, teachers mentioned that some children in class remind other children when it is time receive medications. Other children are more distant. Some friends’ parents get very involved if the child spends a lot of time with them, while other parents prefer to keep some distance between their neighbors and associates.
It is striking that the current model does not provide children with many opportunities for self care, even though teachers and health professionals believe that children can be involved as early as the first grade.
Yes No ?? No Some Some Yes Some Some Child with chronic illness
Parent
Siblings
Friends
Friends’ parents
School/ day care teacher/ admin
School nurse
Relatives, parent’s friends
Pharmacists
Yes Yes
Yes No
Some Yes
Some No
Yes
Yes
Yes some Yes
No No No No Some Some Yes Some no
Yes No Some Some Some Yes Yes Some some
Yes some Some Yes Yes some Yes Yes yes
Yes yes
Yes No
Yes Yes
Some Yes
Yes Yes
Yes
Some Some Yes
No
Yes Some Yes yes
Some Some Some Some
No
Yes
No
Yes
Some Some
No yes yes
Group discussion has verified that interactions between 4 main groups impact the current system of medication management, as described below:



The child
Social support (parents)
Environment (schools, day cares)
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My-Medi-Health
Vanderbilt University Design Team
Design Phase Report

Teachers (other potential caregivers)
Within each of these domains, although there are many dimensions of interest to medication management, our discussions have focused on the dimension of capability
, defined as “having traits conducive to or features permitting [performance or accomplishment]”
( http://www.webster.com/capability ).
Persona
Dee Pendent

Characteristics

A young child with a chronic illness

The child of a supportive family

Not yet capable of self care; willing to let siblings, friends and adults guide his medical care.

Dee is old enough to read, but he likes to play simple video and computer games.
Doogie
Studious

A precocious twelve year old who is doing well in all classes, despite his chronic disease

Last year, Doogie won the regional science fair with minimal help from his father.

Doogie does not have very many friends his age, and loves technology and gadgets.

Doogie hopes to one day become a research scientist so that he can find a cure for his disease
Betty
Bindermom

36 year old woman married to a successful attorney named Bob.

Ever since she attended a Franklin Covey planning workshop ten years ago, she can’t seem to let go of her paper-based day timer.

She knows how to use the internet and chairs the local Cystic fibrosis support group

Betty is resistant to change her organizational system that seems to work for her.

She volunteers at her children’s schools and coaches the girl’s soccer team.
Steve A.
Stressedman

A recently divorced single father of one seven year old daughter named
Sandy, who has a chronic illness.

Steve works as a sales associate for a cell phone company and his boss, Mr.
P. Turbd is not understanding when Steve has to leave work early or in the middle of the day to take Sandy to her doctor’s appointments.

Steve relies on busses to get Sandy to school, and has before and after school care every day for her so that he can work his usual 12 hour day.

Steve uses a computer at work, a laptop at home, and a Blackberry.

Steve has been depressed and started therapy to help him cope with the
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My-Medi-Health
Vanderbilt University Design Team
Design Phase Report divorce. Steve feels like he would lose his job if the school wasn’t so supportive.
K. Autic.
Day Care

A low-income based family urban day care center.

Due to a high turnover of burned out employees, there is poor continuity of care for the children from month to month.

Many behavioral problems from the children left there by young, lowfunctioning parents prevent the staff from teaching the core content of their
Federally-funded programs.
 The most advanced piece of technology is the secretary’s personal cell

Medication administration happens because of the amazing cooperation of the teachers and willingness to step in when the unexpected happens
Martha’s
Holiday
Elementary

Based on the principles from the Martha Stewart Living Magazine

Aesthetically beautiful, technologically advanced private school located at the edge of an exclusive residential neighborhood.

The tuition at MHES is $27,500 per student and many parents are involved in the school as volunteers.
 It is the most “wired” elementary school in the state.

Two full time nurse practitioners

All students have access to the best education, library, science research, mental and health care services, cafeteria staffed with culinary experts and organic food sources, as well as personal fitness trainers and life coaches.

No student is left behind at MHES.
Mr. Germx
Mrs. E. M.
Tee

A very good, thorough teacher who has taught for years and been rewarded for excellence.

Does not like illness—has been known to send children with a cough to the nurse and then home

Will not administer medications—is afraid he doesn’t know what to do, and doesn’t want that additional responsibility

An extremely capable teacher who has taught for years
 “gets in there” and does what is needed for her students. Last year she made a ramp to help her wheelchair-bound child get to and from the back door.

She often patches her kids up on the playground when they get injured.

She has no problem administering medications, having done it for her 9 children at different times in the past.
Site visit and group discussion data strongly suggested that the challenges in the current environment are the combination of Stressed Steve Dee Pendent, and Mr. Germx, which we are not going to address in this project. Rather we heard from our site visits that the schools have an interest in involving the child more than they do taking on new technology to streamline their own processes. In addition, we found
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My-Medi-Health
Vanderbilt University Design Team
Design Phase Report that by involving the child, we could potentially impact many of the differing challenging personas. For example, if the child is capable of self-administering medications, many of the issues in schools without nursing are minimized, such as the need to store and monitor the supply of medications for some children, or the concerns of Mr. Germx for that child. Stressed Steve would not have to communicate as much information to the school, because the personal health record and Pillsberry communication would allow the interested school officials to understand what the medication is, what the indications for dosing are, and other details that schools currently request of parents.
Team Medi has defined some specific capabilities that, when provided to users will have positive and negative implications. The table below lists many of the tasks that My-Medi-Health will need to support, and the caregivers most likely to benefit from them.
Tasks Caregivers impacted
I need to never forget to administer a dose
I need to learn more about medications
I want to get involved in the care
I need to take/give my medications on time
I educate everybody
I need to protect the child from herself
I ask what to do and to expect
I call the parents if a dose is missed, or if there is a side effect
All caregivers
School*, friends, parents
Friends, siblings, family
Patient, school
Patient, family, pharmacists, clinicians
Admin, school
Friend’s parents/ relatives
School
I communicate with the health care team if necessary
I need to learn more about the disease of the child
School
School, friends, siblings
Based on our work to date, our information architecture is described in the table below. This table is a direct outgrowth of the user role matrix above.
School workers/ admin Patients Parents/Friends/Siblings
Medication list
Administration schedule
X
X
X
X
X
X
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Vanderbilt University Design Team
Design Phase Report
X
X
X Alerts
Administration regulations
Potential side effects
Authentication
Medication information
(picture of pill, name)
X
X
X
The figure below depicts the results of our workflow analysis.
X
X
X
X
X
X
X
This figure shows many of the roles (as thoughts) and actions (as assertions) that we have encountered.
It also points out potential negatives, such as only giving appropriate information to friends’ parents, and the danger of stigmatizing children by having them leave class or lunch to receive a medication.
Based on the feedback from our scenario, it would be ideal for My-Medi-Health to feature:

Tools that remind users to take doses

Systems to help users learn more about medications

Tools that ensure that the right medication is given in the right dose is given to the right patient, at the right time
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My-Medi-Health
Vanderbilt University Design Team
Design Phase Report

Tools that help patients self administer medications

Online connections to the actual prescription

Tools to assist with communication between schools, parents, children, and clinicians

Tools to provide information about potential side effects, even for medications not being administered by the school or day care

Tools to allow reporting of any potential side effects
We plan to present our initial vision to families during our second Team Medi meeting on April 8, 2007.
Two components of this future capitalize on lessons learned thus far from our group discussions and site visits. First, the child is often the stakeholder with the least resources provided for self care. Literature about the care of children with asthma and diabetes suggest that self care is associated with improved perception about control over the disease. Therefore, our initial vision of MediTeddy—a device that supports child self care—has persisted. Our initial conceptualization has, however, some potential concerns, including the need to avoid stigmatizing a child. It is likely that our next round of work will establish a more accepted look-and-feel for an aid that does what MediTeddy was initially predicted to do.
One new feature of a child appliance for medication management is the goal of actually allowing children to carry their medication and to take it when convenient. Site visits to an elementary school have disclosed that some children prefer to “sneak” to the nurses office between classes or before lunch.
We envision a future device that allows children to safely and securely self-medicate, while communicating both non-compliance and other information back to school and family stakeholders. In a world with this appliance, children could take a dose of medications with them to a friends’ house, or even manage medications at camp safely. This appliance would have to ensure the right dose at the right time, but this could be accomplished using a “tamagachi”-like system that is aware of date, time, who is holding it, etc.
A second potentially useful system would simulate the current processes for monitoring children scheduled to take medications, but would also decrease nurse documentation and would provide a mechanism to communicate about side effects and other information. We have called this a Medi-Dex, to draw a similarity between it and a card catalogue used for keeping address information handy. This idea has received mixed reviews in early discussions, but will be more formally addressed at the third
Team Medi meeting.
The goal of this design, based on user input is to:
 provide accurate and timely information about when children should take their medications, what side effects to look for, how to administer medications properly
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Vanderbilt University Design Team
Design Phase Report
 adhere to all federal, state, and corporate regulations with regard to medication delivery and event reporting.
The successful completion of this project must account for the realities of the current system, and mitigate the consequences of this system. First, medication management is dependent on the developmental and self-care potential of the child. Our focus group recognizes that children between the ages of 9 and 13 may be have some issues related to their social network, fear of stigmatization, desire to “fit in” or other similar concerns. Focus group members also noted the difficulties associated with families with little access to computer technology, or with families that are less interested in being empowered to assist with medication management. Rather, they recognized that the design challenge could target younger children and their day care and elementary school settings.
Our meetings with users have corroborated our initial intuition about the current problem. Focus group members identified workflows for medication management that acknowledged “just in case” rather than
“just in time” information dissemination, reliance on conservative and generally duplicative approaches
(phone calls, emails, notes to parents and nurses) to communicate problems, and the use of large teams to ensure that no doses are forgotten. They recognize that there is a gap between the idealized approach to delivering medications and the current approach.
MediTeddy (in whatever form is most appropriate for young school aged children) will combine alerts, reminders, text messaging with medication delivery and monitoring. Text messaging could be used by the child to report a side effect, such as a tic or itching after taking a medication. Alerts can be used to remind a child (through a vibration in the pocket) about an upcoming dose. Medication delivery using a secure two-key approach could trigger communication that removes some of the duplicity from nursing documentation. Other aspects will be discussed with Team Medi in an upcoming meeting.
It is Friday evening, and Kenny, a very capable 5 year old, along with his mother, has just completed an encounter with his physician, whom Kenny calls Dr. Chris. Kenny is to begin a new medication that must be taken three times a day on an ongoing basis. Before the visit is over, Kenny, his mother, and
Dr. Chris discuss the medication. Dr. Chris interacts with his computer, and as Kenny and his mother ask questions, he makes sure the answers are in a message he will send to them and to their PHR.
Finally, Dr. Chris reminds Kenny and his mother to take this medication right after eating, on a full stomach. Dr. Chris asks Kenny when he has lunch at school. He doesn’t remember, but his mother says it is around 11:45. They agree the lunch dose should be taken around 12:30 each day. This information is entered in the PHR Medication Scheduler.
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My-Medi-Health
Vanderbilt University Design Team
Design Phase Report
Dr. Chris has already worked with the mother to identify people likely to care for Kenny before, during, and after school. As he finishes, he asks Kenny’s mother if she would like to send a filtered message to the list, letting them know that Kenny is on a new medication and that this medication can cause abdominal pain if taken on an empty stomach, as well as decreased appetite and vomiting in some children (and other side effects that are common.) She agrees to send that information to her network.
QuickTime™ and a
TIFF (Uncompressed) decompressor are needed to see this picture.
QuickTime™ and a
TIF F (Uncompressed) decompressor are needed to see this picture.
That evening, Kenny and his mother are at dinner when Kenny’s MediTeddy begins to purr and vibrate. Kenny says “I have to take that new medicine.”
Kenny is very capable of self-administering medication, so he goes to his
MediTeddy, looks at the picture on the screen—which is showing the pill he must take now. Kenny’s mother gives him a dose before bed and logs the time into the MediTeddy. Kenny’s PHR is updated and an automated notification is set on the MediTeddy to remind Kenny to ask his Mom about the next dose due on Saturday morning.
Monday morning, his mother takes him to school. She has already used the “electronic message to school” feature on Kenny’s MediTeddy, notifying the school nurse and teacher of a new medication.
The school nurse gets more medical information from Dr. Chris and the MediTeddy than the teacher because this is how Kenny’s mother wants to filter the PHR. Kenny’s MediTeddy has been pre-loaded with a dose of the medication and is set to notify him to take a dose after lunch time. MediTeddy vibrates, and lights up, right before lunch. One of Kenny’s classmates sees it and can remind Kenny, who is throwing paper at a classmate, that his teddy lit up. Kenny stops to go take his medication.
School regulations require that a school official and the student both unlock the MediTeddy, so Kenny goes to the teacher on lunch patrol, who sees that Kenny has a MediTeddy and that it is awating Kenny to take a medication. The screen clearly shows that the reminder is for a lunchtime dose. The teacher enters the school password, and then Kenny enters his using the onscreen keyboard. The MediTeddy drawer opens, revealing a pill that looks like the one on the screen. Kenny takes the medication on time.
He presses the “done” button and Kenny’s PHR is updated with dose and time. Kenny’s Mom checks the PHR from her work computer and is relieved to see that he took the medication on time.
One day, Kenny is invited to go to a friend’s house after school. His mother calls the friend’s father to tell him about the medications that must be taken with each meal, but not to worry because Kenny’s
MediTeddy has been pre-loaded and set to notify Kenny when the doses are due. Kenny is capable of self-administering the medication and will ask for a glass of water. The friend’s father doesn’t have to follow-up with Kenny to make sure that he has taken the medication. When Kenny receives the reminder, he uses only his password, and the drawer opens up, revealing the medication. Kenny has been instructed to show the pill to a parent, so he takes it to the father and shows him the pill and the onscreen image before taking the medication. Again, Kenny presses the “done” button and Kenny’s mother knows he has taken the medication on time.
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Vanderbilt University Design Team
Design Phase Report
During our second facilitated group discussion, we asked the members of Team Medi the following question:
It
’s in a time FAR FAR AWAY…
What has been done to make medication management better?
Pictured below is a design by one of our Team Medi members. To the left, we have summarized the needs and negative aspects that must be negated, with a “Y”es by all those satisfied by this design. This design incorporates most of what we had envisioned in MediTeddy. If we add to this design medication administration functionality, recognition of environmental rules and regulations, an ability to educate the child about his or her medications (such as by showing a picture, as described above,) the notion of different looks (dolls, phones, bears, etc) so that the device is not stigmatizing at any young age, and we assume all communication is fed into the PHR, we will have accomplished all user needs defined during our assessment phase.
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Dose reminder
Medication education
Peer/friend involvement
Med administration tool
Rules-responsive
Communicate with parents
Communicate with health care team
Non stigmatizing
Promotes self care
Care management
Communicate with Schools
Disease Education FAQ
Filtering Function (Parents)
School Education of Child
N
Y
N
N
Y
Y
Y
N
N
Y
Y
Y
Y
Y
The fundamental design incorporates a new communication device, similar to today’s
Blackberry, but with some environmentallyaware functionality (such as disabling noise and the ability to place a call while in a specific location.) Of note, Disney Mobile has begun creating a similar type of tailoring for its cell phone network. Finally, we have added the idea of secure storage to the device, ideally suited for holding up to three doses of medication in its three individually controlled drawers. We have called this device a Pillsberry.
MediTeddy becomes nothing more than a formfitted covering (skin) around this Pillsberry, which supports both individual identification through a subscriber identification module (SIM) card. This card allows any SIM capable device to support messaging, alerts/ reminders, and calling. In some class settings, the SIM card
My-Medi-Health
Vanderbilt University Design Team
Design Phase Report
Barbie 2020 (This idea was lifted from a 6 year old!)
Barbie says, "Time to go check your blood sugar!";
"102-Great! I'm going to text message Dr. Russell.";
"You ate 60 grams of carbs, so you get 4 units of insulin. I'll store that info and your Mom will know."
Another comment at bottom of page "Disney-
Mickey". A parent described recently visiting
Walt Disney World and using a portable Mickey that discussed area attractions with child.
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My-Medi-Health
Vanderbilt University Design Team
Design Phase Report could be loaded into a device that allows a teacher to assume the role of the child without having to use her own phone.
Our prototype architecture is driven by the scenario described above. To accomplish this goal, we have decomposed the scenario into a series of lists. This architecture is in a very organic stage and will be defined in more detail as we determine the “art of the possible.”
Patient 1.
Receive an alert (audible, visible, and tactile ideally) and appropriate text image when medication is due
2.
Be able to retrieve a medication from a locked storage container that
Caregiver
Pillsberry
Resources communicates with (or is attached to) a cell phone
1.
Be allowed to enter a code to unlock storage container. Ideally this function should be either location or time-dependent.
2.
Audit medication activity (missed doses, etc.)
3.
Communicate with parent? Transfer communication authority by permission?
1.
Provide alerts (as described above) at a specific time or after a specific event
2.
Communicate audit information to prototype PHR application
3.
Supporting secure storage approach (allowing password based lock/unlock)
4.
Adhere to classroom, school etiquette and rules
1.
Prototype PHR (described below)
2.
Medline Plus
3.
Drug knowledgebase
4.
Communication filtering system
5.
Social network preference database
6.
Environmental rule base (turn off audible alarm at school)
PHR
Locations
Processes to support
1.
Scheduling
2.
Sending messages to Pillsberry
1.
Home
2.
Outdoors
3.
Public spaces (schools)
1.
Dose reminder
2.
Medication education
3.
Peer/friend involvement
4.
Medication administration
5.
Rules adherence
6.
Communication/filtering
7.
Care management
8.
Disease education
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Dependencies
My-Medi-Health
Vanderbilt University Design Team
Design Phase Report
9.
Child education
1.
Ability to create a medication schedule
2.
List of side effects for each medication
3.
Ability to download schedule to Pillsberry
4.
Audit of activities
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