The Ask: How Might We improve the patient journey with prescription medication?
The Solution: Let's bring clarity to the complicated world of prescription drug pricing by providing patients with pricing data and empowering them to ask their doctor about cost.
The Client: RefillWise
The Class: Design Studio
The Program: SMU Masters of Arts in Design and Innovation
The Timeline: August '17 - December '17
For the Fall 2017 semester I worked as part of a team of graduate designers in the SMU Design and Innovation program to explore how we might improve the patient journey in regards to prescription medication. We partnered with a small DFW based pharmacy discount card company, RefillWise, as our client for this project. RefillWise believes that patients should not have to choose between their health and their finances, but that they too often do. They provide a discount card that can be used to reduce the cost of prescription medication at any major pharmacy nationwide, saving users an average of 40% per visit. They work primarily with un-insured and under-insured patients. Over the 16 weeks of the project we employed human-centered design methodology to this complicated problem, starting with empathy building research, insight generating synthesis, and solution driven prototyping. Through this process, we were able to uncover that patients, especially the un-insured/under-insured, have significant difficulty understanding the cost of their medication. They have no clue what a certain drug could cost them, and do not think to ask while in the prescriber's office. To address these needs we created a suite of print materials that encourage patients to ask questions about cost and an SMS based price lookup tool that allows patients to discover the price of their drug while they are still in the prescriber's office. Our prototype idea was so well received by RefillWise that we are currently in talks to continue our work on the project as an independent design team. As we hope to develop our prototype into a pilot and then into a scalable product, we anticipate having a real impact in the lives of the un-insured and in the performance of RefillWise as a business. Please read on below for an overview of the project and results or read the full report here.
Starting with such a broad research ask, how might we improve the patient journey in regards to prescription medication, we needed to get a better grip on the lay of the land, so we spent the first two weeks gathering and consuming as much secondary research as we possibly could. Through this initial phase, we were able to narrow our research focus down to the affordability of prescription medication and craft questions for in person, qualitative interviews and research activities.
Over the next six weeks we went out into the field to interview prescription users who have had significant barriers in the access of their medications and spoke with medical professionals who work in this field everyday. We wanted to determine the barriers that patients face, as well as how they overcome them. For this, we used a variety of research methods to get to the heart of the problem.
Research methods are human-centered design tools that emphasize and facilitate innovative solutions to the problems that people face by putting those people at the center of the design process. These methods are employed in the field, allowing design researchers to gain a deep understanding of the people that they are working with through a series of immersive, in-person experiences.
From this research experience, we found that patients commonly employ a common set of workarounds in order to make the system work for them. We chose to focus on understanding these workarounds to gain insight into how we could craft a solution for these patients so that they don't have to.
After focusing on analysis of workarounds, we interviewed six individuals specifcally attempting to understand how they use workarounds to circumvent the problems that they face in their healthcare journey. We found that all six participants resorted to physical and emotional support outside of the traditional systems, and all six had instances where they were forced to stretch their medication by taking less than was needed or stockpile their medication in case they are not able to pay for their medications in the future.
Having synthesized our data down to these set of workarounds, we moved into the ideation phase of the project, formulating a set of How Might We questions to guide brainstorming sessions. How Might We questions are simple, generative questions that we use in the process of human-centered design to facilitate ideation. Each word of the term is carefully crafted for the purpose of generating solution ideas. “How” implies that there is a way to solve the problem before us, a powerful mindset to get in when working in these sort of problem spaces. “Might” implies that the ideas we come up with may not actually solve the problem, this freedom to come up with half-baked or crazy ideas helps us get to the ideas that will actually work. “We” adds emphasis to the function of the design team in solving a problem and away from any one individual.
Along with these How Might We questions we developed a series of Design Principles, statements of truths that allow us to evaluate what potential ideas have merit and most align with our original research goals. The use of Design Principles is vital to the success of a final prototype, since they represent the totality of research performed. They take the descriptive data we have gathered over time and present it in a prescriptive way. Taking these principles and How Might We questions we were able to then move into a series of brainstorming sessions, idea selection, and storyboarding.
In order to answer these How Might We questions and gain a fresh perspective, we recruited a group of our colleagues who uninvolved in the project along with members from RefillWise to brainstorm potential solutions. We believe that it is helpful to include those who are unfamiliar with the project along with the client to think of solutions in a different way than we would have otherwise. After generating hundreds of potential solutions, we, as a team, selected the ideas which aligned with our design principles most closely, and which had the most potential for real impact.
After selecting the top twelve ideas, we took time to illustrate the ideas out in context with a series of storyboards. These storyboards brought our ideas to life, showing how they could work out in the context of a real situation with real people. They also helped us to visualize the similarities between our broad range of ideas and draw connections between them.
In the practice of human-centered design there is no substitute for testing prototype ideas in the field with real potential users. It is not enough to simply come up with an idea and analyze it within the walls of the designer’s studio. The team must go out into the field to seek feedback on the prototype ideas. With this in mind, we took our top storyboard ideas and created prototypes around them to test their effectiveness. The two ideas we moved forward with dealt with the issue of medication price transparency and patient empowerment.
We found that unlike other goods, such as a pair of shoes, where the buyer knows the price before hand, with medications the price is never known until the patient gets to the pharmacy. We heard many stories of patients who went to fill their prescription, but realized that they couldn’t afford the medication after learning of the price at the pharmacy counter. When this happens, many patients are forced to walk away from the pharmacy counter empty handed. This is a frustrating and humiliating experience that people go through everyday. From here, patients are forced to make a decision: Do they call their doctor’s office and wait to speak to the doctor until he or she is available again? Or do they forego taking the medication that was prescribed to them, altogether? We wanted to create a system that brings price transparency to patients in their doctor’s offices, moving that critical moment of price realization to an earlier point in the prescription process. If the patient realizes the financial burden of their medication earlier in the prescription process, the critical moment becomes less severe. It creates the opportunity for patients to tell their doctors that they won’t be able to afford their prescription, and talk about alternatives before the patient leaves their doctor’s office.
We also found that many patients do not ask their doctors about their medications. We found that many patients are embarrassed, or they don’t know the right questions to ask. We wanted to create an empowerment campaign, to allow patients to take back some power in their relationship with their doctor, and ask the questions that they need to ask to feel comfortable with their prescription medication. This would take the form of a suite of printed informational materials that would encourage patients to ask important health questions to their doctor.
Instead of taking these ideas, which were well supported by research, and building high fidelity versions of them from the start, we chose instead to build a series of smaller prototypes, each that would test a different set of assumptions inherent in our idea. Starting with the price transparency service, we knew that RefillWise had over a decade of prescription pricing data that they had collected from the millions of transactions they have processed. We also knew that many of the patients we were aiming to serve often did not have a smartphone or way to access the internet at all. Taking that one resource and one constraint, we decided that an SMS text service could help patients understand the cost of their prescription in the doctor's office. After doctors told their patients what they were going to be prescribed, the patient could text their prescription, and, in turn, receive the prices for those prescriptions at different major pharmacies, as well as the prices of the available generics.
This first prototype was actually just done through a Google voice number that participants were given. We set up sessions where we had a customer service agent at RefillWise on the phone with us while the patient would text in the name, dosage, and quantity of their medication. Then we would verbally communicate that on the phone to the agent, who would query the drug manually in their database, giving us the results once the information was found. We then typed that information back in and sent it to the patient. While this process was anything but efficient or scalable, it helped us understand a few key features of our service, namely: how fast the service needed to be, what information needed to be sent back, what sort of language the service needed to use, and what ways a patient would format their input information.
For the empowerment campaign idea, we quickly put together a pamphlet and card that patients could pick up in the waiting room, with simple steps to follow to receive the price of their prescription. We originally envisioned that patients could find the pamphlet in the waiting rooms at their doctor’s offices, read it while they were waiting, slip the card into their pocket, and feel more confident as they entered the exam room. The pamphlet included information on the cost benefits of using generics and why generics are as effective as brand name medications. It also included conversation prompts for patients to use, so that they could begin asking questions about their medications more comfortably and confidently.
We were able to perform extensive testing on both the empowerment campaign and the texting service, to reshape and refine the ideas that we produced. We found it very difficult to be able to test our ideas in the actual waiting and exam rooms, as many clinics we contacted were afraid of violating a patient's privacy. Thus, we resorted to asking for patient feedback in areas where we would not be invading on privacy. Eventually, we were able to speak with a few medical staff at a low cost community health clinic to receive feedback on the printed materials and texting service. We received helpful feedback on the visual design and content of the pamphlet and card which we were able to use to inform our future iterations. The biggest piece of feedback we received from the clinic, was the suggestion that we experiment with different formats besides just a pamphlet. The director of the clinic made the point that there are already stacks of pamphlets sitting around the waiting room, and that it would be hard for our information to get to patients in the current format. Taking all of this feedback, we were able to refine our existing prototypes and develop new ones for our final deliverables for the project.
Taking the findings from our prototype testing, we were able to create final products that can significantly reduce the burden of high cost prescription medications for the un-insured and under-insured. We found that using a poster was a better format for communicating messages empowering the patient because the poster can physically go into the exam room, where the patient needs those messages the most. We realized that including the instructions for the price lookup tool on the poster as well would put that information front and center during the office visit for the patient. We developed this along with making changes to the pamphlet in order to make it more accessible to our target audience.
While the first version of our price transparency prototype was successful in that we learned more about what the user experience should be, the prototype was still very low fidelity and ineffective at mocking up a truly automatic service. Since one of my teammates and I both came from a computer science background, we decided to go ahead and create a high fidelity version of the price transparency tool. Our vision was that a patient could text the hotline number with their medication, dosage, and quantity, and receive back the cost of the drug at major pharmacies along with available generics and their prices. While eventually we knew that we could query RefillWise data to find the price of any drug, for time's sake we only programmed the system to take in the drug "Lipitor". We chose to implement our service in Python using the Flask microframework and Twillio for messaging. Thanks to great technologies like these, we were able to spin up a price lookup tool run off of localhost in just a few days.
Over the next two weeks we spent time refining the service to be more user friendly and offer more features to the user, such as: handling spelling errors of individual terms through the use of a Levenshtein distance check ("liptar" or "lipitog" will work), allowing for sending query terms individually ("lipitor, 30mg, 30 tablets", or each term separately), and prompting patients to request a RefillWise card so that they can save more on their prescriptions. The code is hosted on GitHub (view here), the service is still running on AWS, and you can give it a try by texting "lipitor" to 214-214-4367!
We believe that good design does not exist in a bubble. While qualitative research and iterative prototyping are extremely important in solving tough problems, if the proposed solution is infeasible from a business or organizational perspective then designers have effectively failed at bringing value to the world. After creating and testing our product ideas with users we performed a brief competitor analysis and revenue projection to assess the viability of our proposed ideas.
RefillWise has two main competitors: GoodRx and Blink Health. While both of these offer the ability to look up the price of a drug, RefillWise’s current system and our proposed approach would target a different user segment. Both GoodRx and Blink Health are only available to users with Internet access, meaning that anyone seeking to use their services needs a smartphone or access to a computer. Neither offer much support services to users, as they focus on the transactional side of buying medication, not the patient experience. Additionally, Blink Health requires that patients have a form of electronic payment, such as a debit or credit card, in order to purchase medication through their platform. A large portion of low-income, uninsured, and undocumented Americans do not have consistent internet access, and are not eligible for a credit card or a bank account. Blink effectively bars them from utilizing their service. Both services are intended to be used after the patient leaves the doctor’s office, but what we have uncovered is that this point is too late in the process. The patient is no longer with their doctor, and will have to call back to their doctor for any potential alternatives. Often times, that call back may not even happen and the patient will choose to go without their medication. Our service is meant to be utilized while the patient is still in the exam room and while changes can still be made to the plan of care. We believe that RefillWise already excels in ways that its competitors do not: by providing empathy for those in need. However, there is significant opportunity to grow in ways that would put RefillWise ahead of the competition. Our proposed solution would make RefillWise truly superior to their two main competitors, delivering the right information in the right place at the right time through the right channel.
We believe that the price transparency and patient empowerment tool would also add value to the company as a whole. Building out this service and distributing it through the pamphlet and poster at clinics throughout America would bring more users into the RefillWise network at the same time as saving those users money. Patients who text the service in the doctor’s office are able to optionally receive a discount card and would be able to utilize the card at the pharmacy shortly after their medical visit. Since RefillWise makes money every time one of their users saves money, this could mean substantially more revenue for RefillWise. But exactly how viabile is this idea? With information provided to us by RefillWise and through research into other pharmacy discount card companies, we believe that our product could generate:
Projected Revenue Within the First Year
We did not get deep into the weeds of the capital budgeting process with NPV, IRR, hurdle rates, and other methods of analysis, but we did employ a simple model to make an estimate on the feasibility of this project. The data for this calculation came from RefillWise, industry databases, and data we gathered in the field. Put together they total the $190,000 in projected revenue.
Even though the projections are estimations, they illustrate that the price transparency service and the patient empowerment campaign we are proposing are not just great ideas, they are actually viable for RefillWise to implement. This new product could bring true value to thousands of Americans at the same time as building the value of RefillWise.
Over the course of our research, we saw an opportunity for RefillWise to empower patients and impact price transparency. Our team was able to pinpoint these specific areas through user-driven research and iterative prototyping. Again and again, we noticed that access to affordable medication surfaced as an issue for patients. We believe that our proposed solutions, the empowerment campaign and the texting service, offer a beneficial solution for both patients and RefillWise as a business. The empowerment campaign brings patients back into a seat of confidence and power with medical visits. The texting service allows patients to realize price in the doctor’s office, moving that critical moment to a point where it can still be addressed by the doctor. Both of these solutions address the real issues we saw in our research, driven to be useful products in the eyes of patients. Together, they offer a dynamic solution to issues that patients experience every day, all across the United States. RefillWise has the opportunity to bring these ideas to life, at a scale that would truly impact the patient experience. We sincerely hope that RefillWise will take our product ideas and continue to discover new findings about the patient journey and bring lasting benefit to those who need it.
To read the full report, view our document here
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