An electronic pillbox intervention designed to improve medication safety during care transitions: challenges and lessons learned regarding implementation and evaluation

Abstract

Background: Adverse drug events are common during transitions of care. As part of the Smart Pillbox study, a cluster-randomized controlled trial of an electronic pillbox designed to reduce medication discrepancies and improve medication adherence after hospital discharge, we explored barriers to successful implementation and evaluation of this intervention.

Methods: Eligible patients were those admitted to a medicine service of a large teaching hospital with a plan to be discharged home on five or more chronic medications. The intervention consisted of an electronic pillbox with pre-filled weekly blister pack medication trays given to patients prior to discharge. Pillbox features included alarms to take medications, detection of pill removal from each well, alerts to patients or caregivers by phone, email, or text if medications were not taken, and adherence reports accessible by providers. Greater than 20% missed doses for three days in a row triggered outreach from a pharmacist. To identify barriers to implementation and evaluation of the intervention, we reviewed patient exit surveys, including quantitative data on satisfaction and free-text responses regarding their experiences; technical issue logs; and team meeting minutes. Themes were derived by consensus among the study authors and organized using the Consolidated Framework for Implementation Research.

Results: Barriers to implementation included intervention characteristics such as perceived portability issues with the pillbox and time required by pharmacists to enter medication information into the software; external policies such as lack of insurance coverage for early refills and regulatory prohibitions on repackaging medications; implementation climate issues such as the incompatibility between the rushed nature of hospital discharge with the time required to deploy the intervention; and patient issues such as denial of previous problems with medication adherence. We founds several obstacles to conducting the study, including patients declining study enrollment and limited attempts by the hospital to streamline logistics by building the intervention into usual care. Several solutions to address many of these challenges were implemented or planned. Despite these challenges, many patients with the pillbox were pleased with the service and believed the intervention worked well for them.

Conclusions: In this evaluation, several barriers to implementing and conducting a study of the effectiveness of the intervention were identified. Our findings provide lessons learned for others wishing to implement and evaluate HIT-related interventions designed to improve medication safety during care transitions.

Trial registration: Clinicaltrials.gov NCT03475030.

Keywords: Care transitions; Health information technology; Implementation science; Medication safety.

Conflict of interest statement

Hareesh Ganesan, BSE, Emily Cerciello, BS, Janan Dave, BS, and Rahul Jain, BS were employees of Towerview during the study period.

© 2022. The Author(s).

Figures

Fig. 1

Smart pillbox. Top figure illustrates the closed pill box. Middle figure illustrates insertion of the blister pack into the pill box. Bottom figure illustrates a patient removing pills from one of the wells

Fig. 2

Medication Adherence Reports. Top figure illustrates a sample adherence report (trend graph) by week. Bottom graph illustrates a “heat map” with number of doses removed and mean timing of removal for each administration day and time over the course of one month

Fig. 3

Flow diagram of intervention patients. Abbreviations: HCP: healthcare proxy; PCP: primary care provider