Groupthink and the echo chamber phenomenon meant Brexit came as a shock to many. Innovators focused on the problem of medication adherence would be wise to avoid that same groupthink tendency.

Miranda Newbery

Unlikely as it may seem, medical device design has a lesson to learn from the United Kingdom's European Union referendum.

The Brexit result caught many offguard as even the pollsters failed to predict a country so divided. There were divisions between age groups, geographic regions, and socioeconomic groups. The government, public, and even those at the forefront of the "Leave" seemed shocked by the outcome. Tellingly, one friend posted on Facebook, "Social media really does create a bubble: when virtually 100% of your Facebook and Twitter feed say they're going to vote one way, you tend to fall into a false sense of security."

That's where the link to medical device design comes in. This warning of the misleading power of groupthink--where the people we communicate with most see things as we do and blind us even to the existence of other perspectives--should be heeded.

As a human factors and user researcher primarily for medical devices I often come across discrepancies in needs and conflicting design requirements across various user groups. I believe it is best to move away from a one-size-fits-all solution to provide a range of solutions for different patient groups. As the lines between medical devices and consumer healthcare blur, our need to understand end users and ensure inclusion of multiple different patient groups, including the ones who do not pop up in our own social bubble, becomes even more important.

Medication adherence solutions are a great example of the need for broader thinking. It is well documented that a large number of people do not take their medication as prescribed.  Typically, the reasons in the literature for nonadherence include forgetfulness, concern about side effects, cost, lack of belief in effectiveness, not understanding their medication, or logistical issues accessing the medication. Other studies have found that as many of 45% of non-adherence cases are intentional rather than forgetful. Technology is now providing a number of ways of both pushing reminders and tracking whether medication is taken as prescribed.

A search for "medication reminder" apps brings up hundreds of free and purchasable solutions. But these medication reminders will only be effective if forgetfulness is the issue. Other apps employ a subtler approach for improving adherence. Mango Health provides a slick interface with information about possible food interactions, social networks and the chance to be rewarded for improving your adherence.

Technology is not limited to your phone; it can, for example, be found embedded in medication packaging. Smart blister packs or smart pill boxes provide methods of tracking usage and feeding back performance in the same way the wearables market enables people who are interested in quantifying and follow their actions. Glow Caps incorporates smart packaging with reminders and a larger social network, playing into the idea that people may be more likely to take their medication if it benefits someone else (e.g. a grandchild), and SmartInhaler attaches to an inhaler and reminds users to use it if they haven't taken their medication.

These solutions do not work if the person taking the medication wants to be willfully noncompliant. For example, by taking the medication out of the packaging, they can "trick" the monitoring device. Proteus has developed a smart pill that transmits to a wearable sensor definitively proving medication has been taken. The wearable sensor provides the option to also monitor additional health signs. AiCure is a smart-phone based app that "watches" users place tablets inside their mouth and confirms that the tablet has been ingested. The technology obviously provides good methods of monitoring for clinical studies or scenarios where treatment success and outcome are linked directly to proper adherence--organ transplants, for example--but for someone who takes medication regularly, this technology removes any patient-doctor trust and moves into more of a surveillance role.

Fundamentally, all of these solutions require something in the environment prompting a user to take medication at the appropriate time. But we know that people make life-changing decisions based on very different priorities and perceptions about risk and benefit. People are not always rational nor are they always predictable. So, adherence solutions need to think more widely about methods of engagement. 

I have come across many people who are not interested in being reminded to take their medication. Many of the baby boomers I have interviewed said their preference was to rely on an active mind. The need to remember their medication therefore was seen as a useful task and outweighed any perceived benefit of having a reminder tell them what to do.

Many people who do take their medication fit this into a regular event. For example, they associate their morning coffee, which they know they won't forget, with the medication. They use their own habits to include a new medical regimen. Patient Partner  approaches adherence through individual styles of thinking and scenario-based games that allow users to reflect on their own adherence behaviours. This is potentially the beginning of a more tailored approach to individual motivators in taking medication.

Each of these solutions is separate from the actual drug regimen. Some injectable medication is moving toward less frequent administration (weekly, fortnightly, and even monthly) which in all likelihood would have to be used alongside various daily medications, each with different side effects or requirements. PillPack helps with the logistics of complicated medication schedules by providing all medication in pre-filled envelopes labelled with time and date information. But, how someone chooses to adhere to their regimen may be as complex and emotionally laden as weighing personal preferences on perceptions of immigration, governance, and the economy. Further work is needed to understand how drug formulations can affect adherence.

Adherence is not just about taking medication, but also about remembering to bring lifesaving medical devices such as EpiPens® or inhalers with you. The Veta Smart Case for EpiPen links to your phone and will remind you if you leave the house without your EpiPen and when it needs replacing, and will alert emergency contacts if the case is opened (indicating use and therefore medical assistance required). The Veta Smart Case seems to strike the balance of smart monitoring and careful reminders when needed but is for a more acute and sporadic treatment compared to regular, long-term medication.

The debate leading up to the UK referendum had many unpleasant tactics on both sides and the various experts supporting "Remain" were judged to be bullies and naysayers by the "Leave" group. Our next generation of adherence technologies will need to heed this warning, lest patients mistake them for condescending experts or all-knowing superpowers. The adherence solutions of tomorrow will need to know how to work with us and all our mental vagaries: when to nudge gently, when to be more persuasive, and maybe sometimes when to just let us make our own mistakes.

Miranda Newbery is the founder of Inspired Usability, an independent human factors and user research consultancy specializing in medical devices and drug combination products.

[Image courtesy of EVERYDAYPLUS/FREEDIGITALPHOTOS.NET. Headshot courtesy of BRENDAN HOPKINSON]