Priyesh Tiwari National Institute of Health Innovation, University of Auckland (Thursday, 2.30, Science 1) See the related video: http://www.slideshare.net/secret/KJSonpE9wa38K5 Quality use of medication by older people is becoming an important challenge with the demographic shift and increasing burden on our healthcare system. There is a significant emphasis on improving medication adherence as well as safety. We developed an automated dialogue system for residents of an Aged Care Facility (ACF) who were on multiple medications to help them manage their medications better. The dialogue was delivered spoken as well as via a written display over a touch screen mounted on a robot. Each session assisted the identified users in finding the right medication, and taking the right dose at the right time through the right route. It also included dialogues on side effects monitoring and other essential drug information. The data on the robot were exchanged wirelessly with a remote health record (called Robogen) in real time. The sessions were video logged, researcher notes and semi-structured interviews were conducted to elicit acceptance and usability information. Six participants interacted over a two-week period. Most users found the system easy to use and helpful and demonstrated evidence of task mastery by the 3rd or 4th sessions. We conclude that such a system can be used to enhance quality of use of medication by the elderly, but we need to better understand and address user behaviour while designing such system.

1. Comprehensive Support for
Self Management of Medications
By The Elderly
Testing a Networked Robot
Priyesh Tiwari, Jim Warren, Karen Day, Chandan Datta
University of Auckland

3. Background & Rationale
• Ageing of populations
• Multiple chronic condition and practice of
polypharmacy in elderly
• Medication errors and ADEs common cause of
morbidity in elderly
• Medication safety for elderly is a priority for
National Quality Improvement Program

4. Searching for solutions
• Shrinking healthcare workforce and increasing
cost of personal support
• Simply pushing adherence may not necessarily
be safe for very elderly
– Need to address medication safety, monitor and report ADEs,
build skills for quality use and improve communication between
patients and their providers
– Use of pillboxes and simple reminders therefore is limited
• Standard desktops and mobile phones pose
usability challenge for elderly
• There is room for innovation
How could a social robot help?

5. Earlier work:
Action research Cycle 1
A qualitative study to
Safety arrive at a theoretical
framework*
Empower- *Tiwari P, Warren J, Day K,
ment Can a Robot Facilitate Medication
Information Sharing in an Aged Care
Collabor- Facility? : Health Informatics Society
Usability of Australia
ation

6. Action Research Cycle 2
Established the usability of a
automated dialogue system and
a touch-screen interface
mounted on a robot
Tiwari P, Warren J, Day K, MacDonald B, Jayawardena
C, Kuo I, et al., editors. Feasibility study of a
robotic medication assistant for the elderly.
Australasian User Interface Conference; 2011;
Perth: CRPIT.
Tiwari P, Warren J, Day K. Empowering Older Patients
to Engage in Self Care: Designing an Interactive
Robotic Device. Proceedings of the 2011 Annual
AMIA Symposium; Washington DC, (2011)

7. AR cycle 3 - Modules tested
Medication reminder Testing long term usability :
Visiting residents of a retirement
Medication education home once in a day over 2 weeks
Average age of 6 83-92 yrs. (Mean 80.5
respondents years)
Screening for side Gender distribution 3 Males
effects 3 Females
Meds organized as 3 Loose medications
2 Pill Box
Measuring BP and 1 Sachets
SPO2

8. Dialogue delivery
Back & quit buttons
Dialogue display
Options Menu
with soft buttons
Speakers
Dual dialogue output: Written as well as Spoken

9. Testing a real prescription
WEB
SERVICES
MEDICATION MANAGEMENT ROBOGEN
MODULE Web based application on
The system reads prescription secure server
from web server in real time Stores prescription information
Starts the dialogue sequence and customized information for
according to schedule constructing dialogues
Users respond by touching soft Logs fine grained data coming
buttons on the screen from MMM
Communicated with Robogen Medication use and
in real time reading prescription Monitoring data displayed as
information and sending user weekly reports.
responses. CDA architecture intends
Can send text alert to caregiver interoperability
in real time

10. Robogen
Dashboard for Healthcare Providers

11. Converting a prescription
into a dialogue
Example Prescription by a Physician Example Reminder dialogues –
Mr. Joe Bloggs, 20.09.2011 21.09.2011
Med: Furosemide 40 mg Tablets Qty: - 8.30 AM (Breakfast time dialogues)
30 Please find the “sachet” that reads “Mr.
Sig: Take 1 tablet every morning Joe Bloggs”, “Wednesday 21st
Sachet September” and “Breakfast time”
Med: Metoprolol 47.5 mg Tablets
Qty: 30 “Take out” “2” “Pills” “and swallow
Sig: Take 1 tablet every morning whole with a large glass of water”
Bottle - 1.30 PM (Lunch time dialogues)
Med: Poly-Tears eye drops Qty: 1
Please find the “bottle” that reads
Sig: Instill 2 drops 3 times a day in
“Poly-tears”.
each eye
Box “Instill” “2” “drops” “into each eye”
Med: Paracetamol 500 mg Tablets
Qty: 200 *inverted commas represent placeholders for
Sig: Take 2 tabs as needed upto 4 each unit of dialogue constructed from
times a day Robogen

12. Methods
• Video recording and analysis
• Questionnaire analysis
• Structured interview with grounded
analysis of script
• Field notes

13. Results: Video analysis
User No. Total No. Of Success of Appropriatene Backtracking, Response to Medication Non-technical
Interactions medication ss of dialogue getting stuck or side effects information errors
intake (out of to actual needing help question accessed / observed at
total no of activity demonstrated any point
interactions)
1 9 9/9 8† day 1 1 1‡
2 5 5/5 4§ day 1, 2,3 1 1
3 8 8/8 8 day 1 1
4 8 8/8 8 0 1 1║
5 7 6*/7 7 0 1
6 8 6*/8 8 day 1 1 1¶
*Had taken medications before our arrival ‡ Loose medication was found in the pillbox,
†Error in capturing “before breakfast” medication ║We missed to record supplements,
§Unclear instruction when to swallow pills ¶Prompted name of brand was different

14. Ratings on a questionnaire
1= Poor, 2 =Average, 3 = Good, 4 = Excellent
USER No.
4 1
Ratings
2
3 3
4
2
5
6
1
1 2 3 4 5 6 7 8 9
Number of Interactions

15. Structured Interview
Yes No Not Other
Question Researcher Comments (Field notes)
sure
Was your prescription information on the 5 0 1 0 Participant on Sachets have many pills packaged
together and find it difficult to remember and correlate
robot correct?
Did you access educational details about 0 6 0 0 None of the participants remembered having accessed
medication education module despite being
your medications on the robot? demonstrated in the beginning and therefore
unsurprisingly did not find it useful.
Did the robot have correct educational 1 0 5 0 Most participants did not access the details despite
being available as an option, hence unsure about it.
information about your medications?
Did the robot help you to remember your 0 6 0 0 When one is prepared to receive visitors and a robot,
little chances that they will forget. Anyways, the
medications participants were independent living people who were
managing themselves without reminding.
Did the robot ask you about the side 1 5 0 0 Despite being asked on multiple occasions participants
did not remember it. Perhaps because we did not
effects of your medications? specify this was a side effect question.
Did you find the side effect monitoring 1 0 5 0 Since most of the participants did not acknowledge
remembering it they were not sure about its
questions helpful? helpfulness, but the one who remembered it found it
helpful
Would you like to change the number of 0 6 0 0 The participants thought this was an appropriately
delivered content
steps or instructions being given in
medication management module?

16. Some comments
• “I have enjoyed it immensely-cannot speak too highly of its wide applications,
and am desirous of having one myself. For me a brief reminder would be
sufficient, but I am not sure if Mrs. …. Living next doors would make much
sense of it”.
• “I thought it was quite well done- but I missed to find out more about the
actual medications, that would have been helpful if I knew it was there”.
• “Entering my name was hard on the robot as my hands are shaky”.
• “My grandsons think it's a hoot that grandma's doing robot research. I found it
quite entertaining, and looked forward to the visit each morning”.

17. Observations
• Automated dialogues correctly displayed the medication information
from Robogen and successfully logged participant activity back
• Participants successfully completed the task on 5-9 days over two
weeks
• The satisfaction ratings after each session did not drop over the
duration of trial

18. Observations
• The participants enjoyed interactions in general
• The task performance time steadily improved showing task mastery
after 3-4 sessions
• The participants did not access the passive option of education
about their medications
• They did not find the side effect monitoring questions noticeable or
intrusive
• Appreciation of fun factor that transforms the monotony of a daily
chore

19. Discussion
• Significance 1. Develops understanding & Deeper insights
– Medication management is a variable and constantly changing task
– Users personalise a prescription uniquely
– It is difficult to navigate this complexity and maintain relevance for deploying
automated assistance
– Frail and challenged patients need longer handholding and may be unsuitable for
such intervention
• Significance 2: Demonstrates a method
– It was possible to create a fine grained accurate dialogue to meet personal
variations
– It was possible to share the information both ways, in real time with a web server.
This could in turn communicate with a PHR or EHR in future.

20. Discussion
• Limitations
– The results of this research are limited by its small sample size
– Presence of researcher and Hawthorne effect could make
results difficult to generalise
• Future work
– Lessons learnt in this phase would inform refinement of module
design
– The next action research cycle examines longer-term use of the
robot without as much direct supervision by the researchers

21. Conclusion
• It is possible to create a collaborative information sharing system Meting
both patients and providers preferences
• Older people can successfully navigate through a touch screen based
system to assist them with a complex self-care task
• It is possible to unobtrusively query clinically relevant symptoms and
side effects, without raising patient’s anxiety
• Merely providing an option to access drug information may not work for
older people. Personalised dialogues may be more effective.

22. drpriyeshtiwari@gmail.com
THANK YOU
ACKNOWLEDGEMENTS – NZ KOREAN CENTRE FOR
HEALTHCARE ROBOTICS, ETRI KOREA, NIHI