Co-Designing Decision Support for People taking Multiple Medicines
Within the decision support programme, we are very aware that engagement and shared ownership healthcare professionals and citizens are essential to create tools that they will use and which will improve care.
We are currently developing decision support for polypharmacy (people taking multiple medicines), with a strong focus on co-design with users, based on the Scottish Approach to Service Design . The key stages in this development are:
Understanding the problem
The national polypharmacy guidance highlights the imperative to find new, more effective ways of caring for people with multiple morbidities and resulting polypharmacy. Between 2015 and 2035, the proportion of the population of 35 years and above with four or more conditions is expected to increase from 9.8% to 17.0%. Most healthcare research and guidelines focus on single conditions, so are often not fit for purpose for these complex care needs. The consequence can be inappropriate prescribing of multiple medicines, evidenced by European data showing that 50% of hospital admissions for adverse drug events occurring in people over 65 taking 5 or more medicines are preventable.
Given the limitations of traditional research and guidance for people taking multiple medicines, we need a new real-world evidence approach and a personalised paradigm of care based on Realistic Medicine principles.
Our user research to generate this real world evidence involved interviews, focus groups, use of storytelling and scenarios, with healthcare professionals and patients. This uncovered a wide range of challenges and needs arising from overly complex medication regimes, often for the most vulnerable people. Many innovations were suggested to improve their experience of care and help them to feel more involved and in control of decisions about their medicines.
Defining the focus
With the support of the national Polypharmacy Working Group, we were able to crystallise out two top priorities from the user research:
1) Embed decision support prompts based on the national polypharmacy guidance within the primary care electronic health record systems, so that it is integrated into clinician workflow.
2) Create shared decision aids that enable citizens to engage with health professionals in discussing options for their medicines and also non-pharmaceutical options for managing their conditions.
We created mock-ups and early prototypes as a basis for user workshops to get more detailed insight into how to develop solutions that would meet their needs. This stage highlighted some critical issues. For example, after seeing initial proposals, clinicians pinpointed as a top priority was to have pro-active decision support at the point of prescribing, rather than at the point of opening the patient record. They also highlighted the need for an integrated ‘once for Scotland’ approach that joins up different elements of polypharmacy support being developed in different parts of Scotland. Patients highlighted that they wanted an interactive, personalised solution that allowed them to focus on information about their specific medicines.
We are using an agile development approach, engaging with users as we build packages of functionality and user interface, so that their input and user experience are constantly guiding the process.
Creating a culture of readiness for implementation
We are on track for completing technical development of polypharmacy decision support for integration into primary care E H R systems by spring 2020, to be followed by CE marking.
Early adopter Boards have come forward to take the lead on future roll-out of polypharmacy decision support. This will start on a small-scale and build through iterative cycles of implementation and evaluation towards organisation-wide adoption. Work is about to start with these Boards to gauge state of readiness for implementation, identify key barriers and enablers, and define a combined implementation and evaluation plan.
The co-design process is both challenging and rewarding. It has taken our developments in some new directions that we didn’t initially anticipate. Most of all, our work is kept on-track and motivated by the positive feedback from users as they see their ideas turn into working reality, and they begin to see how these solutions will make a genuine impact in improving care.