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Medication nonadherence has a significant impact on the health and wellbeing of individuals with chronic disease. Several mobile medication management applications are available to help users track, remember, and read about their medication therapy.
The objective of this study was to explore the usability and usefulness of existing medication management applications for older adults.
We recruited 35 participants aged 50 and over to participate in a 2-hour usability session. The average age ranged from 52-78 years (mean 67 years) and 71% (25/35) of participants were female. Each participant was provided with an iPad loaded with four medication management applications: MyMedRec, DrugHub, Pillboxie, and PocketPharmacist. These applications were evaluated using the 10 item System Usability Scale (SUS) and visual analog scale. An investigator-moderated 30-minute discussion followed, and was recorded. We used a grounded theory (GT) approach to analyze qualitative data.
When assessing mobile medication management applications, participants struggled to think of a need for the applications in their own lives. Many were satisfied with their current management system and proposed future use only if cognition and health declined. Most participants felt capable of using the applications after a period of time and training, but were frustrated by their initial experiences with the applications. The early experiences of participants highlighted the benefits of linear navigation and clear wording (eg, “undo” vs “cancel”) when designing for older users. While there was no order effect, participants attributed their poor performance to the order in which they tried the applications. They also described being a part of a technology generation that did not encounter the computer until adulthood. Of the four applications, PocketPharmacist was found to be the least usable with a score of 42/100 (
With training, adults aged 50 and over can be capable and interested in using mHealth applications for their medication management. However, in order to adopt such technology, they must find a need that their current medication management system cannot fill. Interface diversity and multimodal reminder methods should be considered to increase usability for older adults. Lastly, regulation or the involvement of older adults in development may help to alleviate generation bias and mistrust for applications.
As many as half of all prescriptions are not taken as prescribed, costing the US health system over US $100 billion per year [
For chronic conditions such as diabetes, hypertension, and dyslipidemia, up to one-half of individuals will stop taking a medication as prescribed within the first year [
The language of adherence is complex and evolving. Adherence generally refers to how a patient takes a medication in relation to the prescribed timing, dose, frequency, and duration of therapy [
The term “compliance” is often used interchangeably with adherence, but has fallen out of favor in recent years for its paternalistic implication that a good patient passively follows physician instructions [
Mobile health, or mHealth, applications offer one potential solution to help patients adhere to prescribed therapy. Over one-half of American adults own a smartphone and over one-third own a tablet [
For mHealth interventions to be both effective and accepted by end users, it is important to understand the differences between individuals who have, who will, and who will never adopt mHealth interventions. In the same way that there are barriers to medication adherence, there are also likely to be barriers to digital adherence. For example, user experience research has found users over age 50 can be easily frustrated by conceptual misunderstandings about the design of mobile devices [
Among the thousands of mHealth applications commercially available, many are designed to help individuals organize and manage how they take their medications. Adults over age 50 make up the majority of medication users [
We used a mixed-methods approach to examine the usability and user perceptions of commercially available mobile medication management applications at the University of Waterloo School of Pharmacy. We included a qualitative assessment of user experiences using a grounded theory (GT) approach, which is reported according to the consolidated criteria for reporting qualitative research (COREQ) [
We identified medication management applications by searching the Apples iTunes store using the terms “medication”, “prescription”, and “drug”. After exploring the descriptions of over 100 mobile applications, two researchers identified and downloaded 22 applications focused on helping consumers manage general medication therapy rather than medications related to a specific illness. The researchers independently explored the functionality of each application by entering a list of prescription and nonprescription medications, setting reminders, and reviewing the applications with friends and family members over age 50. After 2 weeks, the research team reconvened and chose five applications for the final review, each highlighting a different feature, such as appearance, reminders, drug information, drug interactions, and connectivity (
We chose MyMedRec (Version 1.0.4) for its simple features and linear data entry. MyMedRec was developed as a collaboration between the Institute of Safe Medication Practices Canada, Canada’s Research Based Pharmaceutical Companies (Rx&D), and several health professional association across Canada. We chose Pillboxie (Version 2.6) for its graphical interface. A registered nurse in the United States developed Pillboxie to be a virtual medicine cabinet. We chose DrugHub (Version 1.3) for its drug information feature. The Great-West Life Assurance Company, a large provider of health insurance in Canada, developed DrugHub as a service to the general public. We chose PocketPharmacist (Version 3.1.8, Danike, Inc.) for its drug interaction feature. A pharmacist in the United States designed PocketPharmacist to provide users with medication information and the ability to check multiple drugs for any interaction. Finally, we chose MediSafe (Version 2.3.2, MediSafe Project) for its cloud-synced, family-centered profile sharing features. MediSafe was designed in Israel. At the time of the study, MyMedRec, Pillboxie, DrugHub, and Pocket Pharmacist were available for the iOS system, and Pocket Pharmacist and MediSafe were available for the Android OS.
Features of the mobile medication management applications selected for review.
Full name | MyMedRec | Pillboxie | DrugHub | Pocket |
MediSafe |
Medication list | ✓ | ✓ | ✓ | ✓ | ✓ |
Reminder alarms | ✓ | ✓ | ✓ | ✓ | ✓ |
Drug information |
|
|
✓ | ✓ |
|
Drug interactions |
|
|
|
✓ |
|
Multiple user profiles | ✓ | ✓ |
|
✓ | ✓ |
Profile sharing via email | ✓ | ✓ | ✓ | ✓ | ✓ |
Sharing across multiple devices |
|
|
|
|
✓ |
Screenshots of the mobile medication management applications included in the assessment.
We included participants aged 50 years of age and over, who could speak and read English and who took some form of chronic medication. We did not require participants to have previous experience using a touchscreen device. We recruited participants by posting flyers and attending events at community centers and medical clinics.
Our sampling strategy reflected a GT approach to qualitative analysis [
Our final sample included 35 participants aged 52-78 years (mean 67 years), 71% (25/35) of whom were female (
We used a group-based assessment model to meet our objectives as it allowed us to test multiple participants at once while capturing moments of consensus, censoring, and dissonance among new, novice, and experienced mobile device users (
We began each session with a meal or light refreshments and a 10-minute discussion of what medication management meant to participants. Each participant was provided with a third generation Apple iPad and given a series of ordered tasks. Participants in the purposive sample worked from the simplest application to the most complex (MyMedRec, Pillboxie, DrugHub, PocketPharmacist). For the theoretical sample, we randomized the order of the applications to assess order effect. We also introduced styluses and gave participants access to smaller devices such as the Apple iPhone 4, Apple iPod Touch, and the Samsung Galaxy S3. We introduced the fifth application, MediSafe (Medisafe Project LTD), because it had a unique pillbox graphical interface and had more connectivity than the other study applications, but excluded it after one session because participants complained of several system errors.
For each application, we asked participants to complete a series of application-specific tasks that could include the following: (1) adding prescription, nonprescription, and natural medicines, (2) scheduling reminders, (3) recording when a dose was taken, (4) emailing profiles, (5) reading drug information, and (6) scanning for drug interactions. We provided each participant with a set of standardized medication bottles that represented a clinically significant drug-drug interaction: warfarin, aspirin, and St. John’s Wort; clarithromycin and atorvastatin; ramipril and ibuprofen; furosemide and ibuprofen; and levothyroxine and calcium carbonate [
We concluded each session with a 30-minute focus-group discussion. The guided discussion included questions on overall user experiences, ease of use, concerns over the potential for data input errors, perceived quality of the information provided, preferences for different features, and expected adoption by adults over age 50. On completion, participants were given a $10 gift card in appreciation for their time.
Participant characteristics (N=35).
Characteristic | Category | n (%) |
|
Median (range) | 67 (52-78) |
|
|
|
|
Male | 10 (29) |
|
Female | 25 (71) |
|
|
|
|
None | 4 (11) |
|
Heart disease | 7 (20) |
|
Cholesterol | 14 (40) |
|
High blood pressure | 15 (43) |
|
Thyroid disease | 5 (14) |
|
Bone and joint problems | 6 (17) |
|
Cancer | 2 (6) |
|
Diabetes | 7 (20) |
|
Kidney disease | 4 (11) |
|
Liver disease | 0 (0) |
|
Lung disease | 2 (6) |
|
Other | 10 (29) |
|
|
|
|
Prescription medications | 30 (86) |
|
Vitamins | 28 (80) |
|
Natural health products | 16 (46) |
|
Manage medications for others | 14 (40) |
|
|
|
|
High school | 9 (26) |
|
College | 13 (37) |
|
University | 7 (20) |
|
Graduate degree | 6 (17) |
|
|
|
|
< $20,000 | 2 (6) |
|
$20,000 - $49,999 | 10 (29) |
|
$50,000 - $79,999 | 10 (29) |
|
>$80,000 | 6 (17) |
|
Prefer not to say | 7 (20) |
|
|
|
|
Daily | 27 (77) |
|
Weekly | 3 (9) |
|
Monthly | 0 (0) |
|
Rarely | 1 (3) |
|
|
|
|
Daily | 10 (20) |
|
Weekly | 1 (3) |
|
Monthly | 0 (0) |
|
Rarely | 0 (0) |
|
|
|
|
Daily | 5 (14) |
|
Weekly | 3 (9) |
|
Monthly | 0 (0) |
|
Rarely | 0 (0) |
Study design.
Participant demographics and experiences were gathered using paper-based questionnaires and summarized using descriptive statistics. Participants were encouraged to write comments about their experience as they tried each application. Two researchers also recorded their observations of participant experiences, including questions asked, errors observed, and tasks users could not complete. Focus-group discussions were audio recorded. All data, including audio recordings, field notes, and participant comments, were transcribed and de-identified by a researcher and double-checked by a second researcher.
After each application, participants rated usability on a visual analogue scale (easy/difficult) and the 10-item SUS (
We used a GT approach as it allowed us to develop a theoretical interpretation of the meanings we observed older users attaching to mobile medication management applications without defining the phenomenon a priori [
Our data analysis, which began after the third session, followed three levels. For the first level of analysis (microanalysis), two independent researchers coded data by briefly summarizing each line of data. In the second level of analysis (axial coding), the two researchers organized the summaries into categories (
Categories and labels used to organize grounded theory analysis.
Category | Examples of descriptive summaries |
What does “medication management” mean? | -Remembering medications |
How did it feel to try the applications? | -Feelings: frustrating, challenging |
What was the easiest/most difficult application to use? | -Training would help make it easier |
What was the most/least preferred application? | -Not qualified to evaluate |
What features were liked? | -Graphics easier to understand than words |
What features were disliked? | -Ambiguous use of symbols |
What features were most surprising? | -Missing allergy–drug alerts |
How can/will the applications be used in real life? | -Uncertain if would ever use |
What is the willingness to pay for the applications? | -Willing to use more a difficult application if free |
How long would someone spend learning the applications? | -Willingness to spend time everyday |
Should physicians or pharmacists recommend the applications? | -All younger persons already own technology |
Should the applications connect with physician or pharmacist computer systems? | -Future connection “so cool” |
Should the applications be backed up? | -Expect backing up |
Based on the SUS scores (
Overall Systems Usability Scale scores for each application assessed.
Application | Mean SUS score (SD)a |
DrugHub (N=35) | 57.1 (22.2) |
MyMedRec (N=35) | 55.6 (22.4) |
Pillboxie (n=31) | 52.2 (18.1) |
PocketPharmacist (N=35) | 42.1 (18.7) |
MediSafe (n=4) | 40.0 (15.1) |
aSignificant difference between applications
Model depicting first time experiences of older adults using mobile medication management applications.
For participants, the early experience of learning to use a mobile medication management application was frustrating, overwhelming, and challenging but it was also fascinating, fun, and enlightening (
With a little bit of practice, with all of them, [it] would become a lot easier to like anything. You know, the first try at any of these, regardless whether you’re familiar with an iPod or an iPad, it does not go smoothly. They’re not terribly intuitive.
Early on, we observed that many participants were reluctant to learn by trial and error. They appeared to feel vulnerable or lost and often worried about making a mistake. Many spoke of trying not to break the device. We learned to start each session saying, “Don’t worry, you won’t break it” to encourage learning by trial and error. In describing the need for support, one participant explained,
there are a few steps missing I think in each of these [applications]…I didn’t know how to get from a certain screen to another, it wasn’t very evident, but once I was shown, I think it’s easy to use.
Eventually, within the 2-hour timeframe of each session, almost all participants became comfortable inputting information. The experience of learning the applications can be compared with the implementation of new technologies in other areas of life, including banking and transportation:
I guess while I was doing it, I kept thinking about ok, when I was first ordering airline tickets on the computer, or bus tickets on the computer, the difference after you’ve done it a few times as opposed to the first time, trying to figure out which buttons to hit.
However, some individuals had more difficulty than others, and would likely need significant support, both technical and emotional, to adopt the application into their lives. One participant who found the applications extremely difficult to use highlighted this challenge when he concluded,
I don’t want an app, I don’t ever want to see one in my house or anything because to me they’re just frustrating. Frustration devices.
When asked if they were willing to persist in using the applications, the opinion was divided between willingness to persevere until comfortable given a perceivable benefit, or only for 15 minutes due to impatience and lack of time.
I’d spend a bit of time, half an hour to an hour, not even an hour, half an hour to learn something like this, yes.”
Patient Need
The perceived usefulness of a mobile medication management application is closely related to the needs of the end user. Users who believed their current adherence strategies are sufficient are likely to consider the applications as less useful. One participant highlighted the importance of perceived usefulness by saying
I like things fast and dirty, I would just give up. Say forget it, I’ll just do it my old fashioned way.
Strategies for remembering to take medications included scheduling all medication doses at once, using a physical pillbox, wearing a digital watch with an alarm, and/or having a pharmacist who provides telephone refill reminders. Many also carried a written or printed list of medications in a wallet or purse. Participants would only speculate future use under the assumption of declining health, declining memory, or the need to manage medications for a relative.
I’m looking at it from the point of view of my mother when she was elderly. She was confined to a wheelchair and okay, she wasn’t computer literate. But had she been, you know, if she’d had it with her, in her chair, she could’ve looked at it and said ‘yeah hey I need to take this pill’ or there’s a reminder, or ‘no I can’t’, somebody’s making lunch for her, ‘no I can’t have grapefruit because I’ve taken Lipitor’ or something like that. I’m sure that kind of information would have been good. If you’re not terribly mobile, I think something like that, and in this day and age, as time goes on, people are much more computer literate and can handle these things much more easily and how do you say, you know, that would be much more useful, if you’re concerned, if you’re taking a lot of medications. Because I know some people who are taking seven or eight a day.
Most also felt it was only appropriate for health care professionals to recommend an mHealth application if they had used it themselves and if the patient was willing, needed it, and was technologically literate.
Participants summarize the experience of trying mobile medication management applications in one word.
Negative Words (Count) | Neutral Words (Count) | Positive Words (Count) |
Frustrating (5) | Different (1) | Fascinating (2) |
Challenging (3) | Perplexing (1) | Fun (2) |
Overwhelming (2) |
|
Enlightening (1) |
Stressful/nerve-wracking (2) |
|
Doable (1) |
Confusing (1) |
|
Interesting (1) |
Exhausting (1) |
|
Useful (1) |
Complicated (1) |
|
Informative (1) |
Mobile medication management applications can be conceptually separated into two categories: adherence (MyMedRec, Pillboxie) and information (DrugHub, PocketPharmacist). An “ideal" application was described as including both features:
I found MyMedRec covers everything, it’s ordered properly. But it did miss the other little features, the little pillbox [in Pillboxie] and then the [drug interaction] check [in Pocket Pharmacist] and then [DrugHub]. I guess it’s the access to the information and whether you could check interactions and things like that. If somehow you could incorporate that into the [MyMedRec] then it would be perfect.
In their daily lives, all participants sought information about their medications in order to stay aware and avoid adverse events. The drug information features were seen as providing background information on a new prescription, supplementing the information given by a health care professional, and satisfying curiosity.
For me, personally, I take a lot of pills everyday…I’ve got it so down and whenever I take a prescription, well the pharmacist is very good to go over things, but I always, always make a point of reading the literature when I get it.
While the most popular source of drug information was the pharmacist, some participants worried that too much information was dangerous and that the applications were replacing the expertise of the pharmacist. Given the choice, participants preferred an in-person conversation for important information:
Something like drug interactions? I don’t want to be bothered by anything like that. I mean I know I should, but I want my pharmacist to say to me when I go in, don’t take this or do take that. You know what I mean? I didn’t go to school, I don’t want to have the responsibility of worrying about that...
When asked to estimate the cost of applications, most participants valued drug information applications over adherence applications. Participants who had purchased applications expected to pay less than Can $5 (or often nothing at all), but those who had never purchased an application expected to pay up to Can $100 or a monthly fee. Most did not take into consideration the cost of the device itself.
There was a competing relationship between functionality and complexity. The “ideal” application may actually be two applications, one for adherence and another for information. Separating the features into two applications would maximize the functionality of both features rather than trying to do both incompletely.
I think there’s two parts of it. There’s reminding people to take the medication but then there’s the whole information side with what’s working with what. So it almost seems like you should have two apps.
For many participants, linear navigation was preferred. Participants commonly struggled with going “back and forth”, essentially, moving forward to enter a medication into their profile and once completed, going back to enter a new medication (
I’m impatient as hell. So when it comes to an app, it’s got to be simple. See…it wasn’t easy for me to find the prompts, you know, partly from [my] glasses, but also I’m impatient and I quit looking. And I said ‘Oh I’ve spent all this time entering the stuff but if I put CANCEL, does that mean it’s gone?
Similarly, the first screen a user saw with PocketPharmacist contained both a menu and submenu. Participants expressed feeling overwhelmed by the amount of information being presented all at once. Many first time users struggled with basic touchscreen features, such as accessing and using the keyboard and employing application-specific gestures. One participant felt this should be standardized,
So ultimately, you’d want a universal language, and a universal kind of, you know, this is where the back button is, this is where the forward button is. But if that doesn’t happen, then every app has its own unique way.
Application actions and features identified by participants as being nonintuitive or difficult to interpret.
Action/feature | Description of challenge |
|
|
|
|
Cancel | The word “cancel” typically means “undo” but many participants felt it implied finality and described how they “cancel” social or service contracts such as memberships, subscriptions, and appointments. |
Scrolling | Without a scrollbar, participants rarely looked for additional information. |
Audio reminders | The audio alarms were inaudible to many participants, especially males. |
Autocorrect | When typing, many participants focused on the keyboard and missed the autocorrect feature that would change drug names or dosage units (eg, “mcg” to “mg”). |
Inconsistent terminology | Inconsistent terminology led participants miss features. For example, reminder features were called “schedule,” “dose reminder,” or “first dose” in each application. |
Sample text | Greyed text was used to provide examples of data that could be entered into a field, but participants typically misinterpreted the grey text to be the information of another user. |
Peripheral buttons | Participants associated a black frame as being outside of the application and noninteractive, thus overlooking peripheral buttons completely. |
One of the challenges faced by participants was that the adherence features we examined (dose reminders, refill reminders) made assumptions about the end user. For example, the reminder strategies (alarms, notification boxes) assumed users were “attached” to mobile devices. Participants said, for example,
Like, [young people] live with their cell, live with their Blackberry, and that becomes, you know what I mean. Like, I could see, even obviously, when those kids get to be 50, they will still be attached to the hip with those Blackberries.
Comparing the use of the applications on the tablet to the smartphone, one participant noted,
Reminders would probably be the best [feature] but it would be inconvenient unless I had one of the other devices that you could carry in your pocket or your shirt pocket or a woman could carry in her purse. (Male, Group 4).
This is an important distinction because though the tablets are less portable, they are more accessible to individuals with age-related vision loss. In one case, a participant with severe low vision noted that touchscreen devices were surprisingly accessible,
I was always afraid to even look at them or try them, because I just thought that I wouldn’t be able to see, so why even bother. But I was surprised…yeah.
The participants, as older adults, also described how they power off devices between use to conserve battery power or save it for emergencies.
These tablet things, they’re not plugged in, so, most of the time…you tend to turn them off to conserve the battery and maybe they could be designed so that they automatically turn themselves on, give a signal, and then go back to rest.
The reminder strategies also assumed users were physically able to hear alerts. In every session, we observed at least 1 participant, often male, who could not hear the alarms going off in the room.
But some people may be hearing impaired and you know, maybe that could be accommodated, I’m not sure how. [Male, Group 8].
Finally, participants worried that adherence strategies that required users to maintain a medication administration record were easily fallible.
With your daily plastic, you can see that you took it, with this thing, you may have put in that you took two pills…but you got distracted, so how do you know you took two?…It’s not physical, you can’t see it, as you get older. I mean, there’s two sides. You forget to take things or you know, things like that, I don’t know, it’s too easy to screw up.
We asked 35 adults aged 50 and over to spend 2 hours trying popular medication management applications on mobile devices. Most were new and novice users and we found that the currently available applications were not designed with older users in mind. Without simple and targeted design, the current applications are unlikely to be considered useful, usable, or accessible for a large proportion of individuals who need to take chronic medications.
Dr Everett Koop famously said, “Drugs don’t work in patients who don’t take them”. Similarly, mobile medication management applications will not work for users who do not use them. Reminders offered the clearest example of the gap between design and the older end user. One-half of prescriptions are not taken as directed [
The Technology Acceptance Model, which was introduced by Davis in 1986 [
In a study of the factors that impact patient acceptance of online self-management technology, Or et al [
We were able to speak with 3 of the 5 creators of the medication management applications tested. None had conducted usability testing in adults 50 and older. A tendency to target designs toward younger adults perpetuates the notion of the “digital divide” or “digital disengagement”, where developers assume older adults lack the technological access and literacy of younger generation [
While we need to recognize that many older users are technologically savvy, Hawthorn [
To improve usability, it would be helpful for developers to provide clear instructions and describe important buttons or features for first time users (eg, “The area where you list all the medications you take is called the
Often, mHealth applications do not follow guidelines or include features considered essential for prevention and public health [
A strength of our study is that it reflects the experiences of first-time users. The rationale was that, in the real-world setting, many new users would try several medication management applications before choosing one to use or would be prescribed a mobile application that they had not used previously. However, the 2-hour format meant some features of each application could not be explored. In some cases, participants assumed certain features were missing. In each case, we demonstrated the feature in question to gather any additional feedback. During the discussions, application names and features were often confused with one another so we tried to ensure we regularly revisited each application to clarify which application was being discussed.
In future studies, participants should be given a device for a longer time period to examine the effects of daily use. Previous studies have found SUS scores to increase with the degree of experience with a program prior to usability testing [
Though older adults make up the majority of medication users, mobile medication management applications are often designed for younger populations. The result is that age-related physical changes, such as hearing or vision loss, and the use of nonintuitive design features limit the usefulness of the applications for older users. When developing mobile interventions to improve medication use and adherence, designers, programmers, and developers need to consider older adults as potential high-impact end users and include this population in the design process. For older adults, standard features such as reminders may be poorly suited to most mobile devices, whereas applications that provide high quality information on side effects or drug interactions may be more desirable. Considering that the industry is not currently regulated, the focus also needs to be on building applications that limit the risk of errors and omissions.
Systems Usability Scale used to compare selected medication management applications.
consolidated criteria for reporting qualitative research
grounded theory
Systems Usability Scale
Thank you to Mrs Erin Harvey, the statistics consultant at the University of Waterloo, and to the cities of Kitchener and Waterloo for providing recruitment support.
Conflicts of Interest: None declared.