Project Description

SYDE 461 FYDP, SYDE 2023

Team 21

Sammy Robens-Paradise

Hussein Nagri

Aliya Rajwani

Joshua Wilkinson

Friday, September 23rd, 2022.

• Project Description
  • I Introduction
  • II Situation of Concern
  • III Problem Focus
  • IV Needs Assessment and Prior Art
  • V Ethical Implications of the Project
  • VI Project Objectives and Outcomes
  • VII Systems Design Engineering Approach
  • VIII Resource Management
  • IX References

I Introduction

Waiting is a near-universal experience in our society. Whether it be traffic or waiting at the doctor’s office, it is one of the most frustrating civil experiences [1]. Pharmacies are no exception. Individuals must often wait for long periods to pick up their prescriptions. In a survey conducted by a pharmacy in Phoenix Arizona, over 60% of customers estimated their wait times in their community pharmacies to be over 20 minutes [2]. These wait times can cause great frustration as a task that people plan to occupy a few minutes of their day can completely disrupt their, and others’ schedules.

The history of prescription pickups in North America can be traced to the early twentieth century when technology did not yet exist to notify customers of real-time pharmacy wait times. Civilians would get prescribed certain medication by visiting a doctor and would then go to a pharmacy to obtain said prescription [3]. To this current day, a similar set of operations exists. While the technology currently exists to make live updating possible, it is yet to be implemented on a large scale.

The stakeholders that feel the pain of having to wait for their prescriptions the most are those who need to pick up their prescriptions but may not need to speak with the pharmacist. This includes people like older adults, those with disabilities, caregivers, and those with diseases such as diabetes or chronic illnesses who are familiar with the medication that they intend to pick up or are seeking repeat prescriptions (refills). Some individuals have enough instruction from their doctors on the usage of these medications, and would not need to see pharmacists either [11].

These wait times can be attributed to understaffed pharmacies which results in a given pharmacy not having enough capacity to serve a large number of customers at once [4]. The overlying problem also lies in the disorganized workflow that exists in pharmacies. Having a process where pharmacists must deal with all customer service situations, where the prescription pickup process could be semi-automated also contributes to the inefficient workflow in the prescription pickup process.

To address the aforementioned challenges, a self-sustaining service that would reduce wait times for individuals in pharmacies who need prescription refills is required. This would not only reduce wait times for individuals who only need to pick up prescriptions, but would also allow the pharmacists to focus more on customers who need consultations without having to worry about it causing longer wait times for individuals in the queue.

II Situation of Concern

The problem space revolving around pharmacies that our project is exploring is the long wait times commonly experienced by patients at retail pharmacies. These long wait lines can cause inconveniences to other shoppers, people picking up their prescriptions, and pharmacists as well. For example, it can cause people to avoid picking up medication, cause backlogs and make it a challenge to deliver proper care to the patients that need it.

This problem is characterized by many factors that exist in Canada, such as the shortage of pharmacists [5]. As Canada’s population continues to grow the need for effective medicare will continue to increase[6]. This is demonstrated by a yearly increase in prescription purchases by Canadians over the last two decades. Canadians experienced a mean increase in prescription spending of 5.3% [7]. This characterizes a growing need for prescriptions over time.

Most retail pharmacies have limited hours of operation, meaning individuals need to pick up prescriptions within a restricted time frame. However, a recent study demonstrating that pharmacists could alleviate overcrowded emergency rooms has inspired some healthcare systems in Canada to explore additional responsibilities for pharmacists, further increasing the workload experienced by pharmacists [8]. A restricted time frame for working hours for pharmacists and an additional workload can cause pharmacists to be extremely occupied, resulting in longer wait times at pharmacies.

Within this problem space, another common issue is that patients are uncomfortable when talking to pharmacy staff about their medications. This problem can be categorized specifically as individuals who prefer to not talk about sensitive drug usage. For example, 46% of men admitted to being embarrassed talking about health concerns with a professional [9]. Women may also feel uncomfortable when speaking with health professionals. For example, women are twice as likely to be misdiagnosed when speaking to healthcare professionals, than men [10]. Moreover, transgender individuals also tend to disengage from previously used health care services, and talking with pharmacists can cause these individuals to not feel comfortable [12]. These situations can cause many groups of people to feel uncomfortable when discussing their health circumstances.

These problems contribute to the larger problem which is the long wait lines for pharmaceutical services. These problems are attributed to a lack of efficient service delivery strategies at pharmacies. If these problems go unsolved, it will lead to many repercussions. For example, the frustration of waiting in long lines can cause people to not want to pick up their prescriptions. A delay in the prescription pickup has its problems such as resulting in health issues, auto prescription overload, and many more.

Ultimately, the situation impact statement is to design a product that will be used by prescription owners, pharmacists, pharmacy technicians, and patients who are not picking up prescriptions to automate the prescription pickup process which will reduce time spent unnecessarily waiting.

III Problem Focus

The specific problem that the project will address to have the largest impact on the problem space is the long wait times experienced by individuals that simply need to pick up prescriptions. The result of these long wait times can cause frustrations, which can be minimized by offering a faster approach with prescription pickups [15]. As a result, the specific need that the project will prioritize is the time of both pharmacists and individuals who are picking up their prescriptions, creating a more efficient prescription pickup process.

With the apparent problem existing at many pharmacies across the country, many solutions can be implemented to decrease the effects of this problem. The biggest problems are the high influx of people needing prescriptions, combined with the staffing shortage at pharmacies. This in turn leads to long wait times at pharmacies. As an identified requirement is efficiency and keeping it in mind, increasing the number of pharmacists or building more pharmacies would not be the most efficient solution. Adding more pharmacists would increase everlasting variable costs for pharmacies, and adding more pharmacies would result in a large initial cost. These are resources that not everyone may have.

Instead, having a more organized and automated prescription pickup method would allow pharmacists to have more time to make medications instead of performing customer service-related tasks. Moreover, the people who need to speak to pharmacists for problems with their medications, or questions related to their medications will not feel the need to be rushed because of a long line or busy pharmacy. This will also allow people who pick up prescriptions to have easier access to their medications, without the wait times associated with existing prescription pickups.

Ultimately, by working towards solving the bigger problem in the problem space which is the long wait times in pharmacies, a number of other issues will also be bettered in the process.

IV Needs Assessment and Prior Art

Addressing inefficiencies in pharmacies affects two main user groups which constitute a large portion of the Canadian population. The first group is pharmacists and staff working at community pharmacy facilities, the second and much larger cohort consists of Canadian patients who are required to pick up prescriptions from community pharmacies, especially at high-traffic locations with increased wait times.

Pharmacists provide a variety of services to meet patient needs. Outpatient wait times at community pharmacies are already significant. The role of Canadian pharmacists is also evolving, and this shift is resulting in an expanded scope of responsibilities that these healthcare professionals are required to handle. In many jurisdictions, pharmacy practices are moving beyond the traditional medication dispensary model, to handle consultative services, expanded health care delivery and even diagnose and prescribe medicines for small ailments [8]. These changes emphasize the need for a solution to alleviate over-burdened community pharmacists and ever-increasing patient wait times.

The effects of these wait times on patients are significant. Pharmacists are responsible for helping patients navigate a complex and costly health care system, concerning medications. With a high workload, they’re unable to spend adequate time where patient care requires it. Demographic shifts have led to a population where older adults now outnumber children under 15 years of age [9]. Interactions with these groups often involve developing individualized patient-focused clinical plans, providing comprehensive medication reviews, and renewing and adapting prescriptions. However, the Ontario Pharmacy Evidence Network uncovered that time-constraint challenges and high pharmacy workloads are responsible for the lack of documented follow-up and an inability to deliver medication reviews: two services that the older demographic greatly benefits from [10]. Furthermore, 1 in 5 Canadians are immigrants with mixed education and language ability [9]. In these cases, additional time and focus are vital to ensure patient health and safety. These two growing patient demographics must be supported to ensure their safety and decrease the future load on the Canadian healthcare system resulting from improper patient care [11].

Another negative impact of high wait times for medicine pickups is prescription abandonment. This takes place when a prescription is filled by a pharmacy but the patient does not pick it up. Abandonment differs by prescription type with a rate of 21.3% on brand-name medications in the United States, and 8.1% for generics [12]. While these statistics are likely different in the Canadian market a similar phenomenon is likely. An observational study analyzing the impact of a contactless prescription kiosk implemented in American pharmacies reported that these prescription abandonment rates were lower for patients using the kiosk method compared to patients using the traditional pharmacy counter. This study’s findings demonstrate the importance of addressing this problem to ensure patient health and safety, and once again, reduce the future load on the Canadian healthcare system [12].

The impacts of high patient wait times and pharmacists’ increasing workload are recognized, and existing solutions have been implemented attempting to address these challenges. However, these solutions have either not been widely adopted because of their inefficiencies, or do not address the Canadian market. One relevant solution is automated dispensing machines. These are computerized drug storage and dispensing devices used in healthcare settings such as hospitals and nursing homes. They have been adopted in many American facilities at the point of care rather than in a pharmacy. This is because the rate of return of incorporating these existing systems in pharmacies is not high enough to justify a system overhaul. There is a high magnitude of change required at the point of prescribing as well as in the prescription preparation workflow [13]. The socialized nature of the Canadian healthcare system makes this too costly and time-consuming of a solution so it is unideal for widespread adoption in pharmacies. Furthermore, this solution does not have enough of an impact on pharmacist workload; they are still required to input and approve prescriptions through the system and continue to touch base with patients to ensure delivery instructions are understood. Another solution that addresses the problem space is the pharmacy kiosk model. This approach allows pharmacy staff to maintain control of filling and checking prescriptions and handles prescription storage, tracking, pickup, and payment. An initial analysis of the solution revealed that the user experience is suboptimal, the authentication system is bulky and time-consuming, and the user interface is outdated [14]. Furthermore, the system is only available in the US and is not currently adapted to the Canadian healthcare system.

Both these approaches fail to address all the concerns outlined in the Situation of Concern, leaving a gap in the Canadian healthcare market and an opportunity to improve patient care. Pharmacists’ evolving roles combined with the shortage of Canadian pharmacists following the COVID-19 pandemic, emphasize the importance of an end-to-end solution to resolve long wait times, high workloads and contactless healthcare delivery.

V Ethical Implications of the Project

A solution to optimize the dispensation and delivery of medication using technology in a pharmaceutical setting will carry ethical implications. Many of these are not dissimilar from the ethical implications that automating industries face. Most notably, the loss of production and administrative jobs continues to take place as part of the technological and automation revolution [15]. By introducing job-assistive technology or systems into a workplace designed to improve efficiency, employers may see the implementation of such technology as an opportunity to cut costs first, rather than allow the system to aid in the generation of additive revenue.

For example, employers may try to implement the solution as a replacement for pharmacists or pharmacy technicians, and attempt to cut costs by having fewer trained individuals available. Given that both patients and pharmacy practitioners are considered to be our primary users, this would be an unintended consequence of the solution. The ethical dilemma arises if the system can be utilized in such a way to achieve an aim that was not envisioned by its creators. To ensure that the solution cannot feasibly be used to achieve anything other than its intended goal of generating additional revenue for pharmacies reducing wait times for patients and reducing stress on pharmacy practitioners, it is the responsibility of designers to construct a solution that is only economically implementable in its intended use case as an assistive solution to optimize tasks for users.

Ethical implications aside, automating aspects of the pharmacy experience for both patients and practitioners will have an impact on society. This may be even more true in a country like Canada, with nationalized healthcare. Poor medication adherence is known to coordinate with decreased health outcomes and higher rates of hospitalization [17]. According to the World Health Organization, “Increasing the effectiveness of adherence interventions may have a far greater impact on the health of the population than any improvement in specific medical treatments” [17]. Automating aspects of perception pickup were shown to increase access to medicine and was correlated with a decreased prescription abandonment rate at pharmacies that implemented a medication dispensing kiosk [16]. It then stands to reason that the implementation of a system optimizing prescription pickup and re-fills while simultaneously increasing accessibility to pharmacy services could result in a better bill in health at the population level. This could be especially true for low-income individuals who often work hourly jobs and are often unable to take time off of work to visit a pharmacy during its normal operating hours. An automated medication dispensation system may increase their accessibility to medication, improving quality of life.

While a 2021 study published in the _Journal of the American Pharmacists Association _found that patients who used a remote kiosk to receive medicine instead “at the counter” were equally satisfied with the two variants of services, the study was conducted on a limited scale in California [16]. As a result, it is hard to predict the general acceptance that patients may have in Canada. More specifically, patients who prefer, or require person-to-person contact may feel discriminated against as they may not be able to or want to use the automated system. Because of this, it is important to give patients a path to easily opt-in or out of the service. While the goal of the solution is to free-up service providers to better assist these patients of higher need, the patients may feel that they are being relegated to a slower, more arduous process of medication dispensation.

While hard to quantify, there is also a common undertone of mistrust that individuals (often older adults) feel about the role technology plays in their everyday interactions. These qualms often have to do with the association between a loss of personal privacy and technology. The implementation of new technology could cause degradation of trust between the aforementioned cohort of patients and their pharmacists, likely resulting in decreased quality of care. To counter this, it would be the role of designers to ensure that the privacy of information is not only compliant with local and federal privacy law but educate users about the security of their interaction with the system. It would again be important to give such users the ability to opt in or out of the service as they desire.

In general, the implementation of a solution to increase access to medication, while optimizing the workflow of pharmacists and pharmacy technicians could have long-term effects on the health and wellbeing of a population. Early data suggests that optimization can contribute to increased medication adherence and give pharmacies using such technology a competitive advantage [16]. Many individuals already use automated systems such as airport kiosks, or grocery self-checkout stations making the cognitive load required to operate a similar automated solution small relative to other possible approaches to the problem. To validate these early findings, it will remain important to monitor user feedback and satisfaction with the designed solution.

VI Project Objectives and Outcomes

There are several objectives of the project. Given the scope and allotted time for the project, objectives are rooted in the goal of providing insight into the quantified viability of the solution. This scope limitation is intentional. This is because there are still considerable unknowns that cannot be accounted for at this stage in the design process. By limiting the objective scope, we increase the likelihood that we will be able to draw actionable insights from solution evaluation.

It is possible to describe objectives in a binary state. For example, if the objective is to have patients wait less time at the pharmacy, then even a small change (seconds) could be considered a fulfilled objective. However, this tells us very little about the true viability of the solution. To address this shortcoming, objectives are to be evaluated on discrete, or continuous scales rather than binary indicators.

The goal is to design a cost-efficient solution that improves both patient and practitioner experience at community pharmacies. This involves several objectives and associated outcomes described below

Objective 1: It must be possible to demonstrate that the design solution is economically feasible for community pharmacies to implement. That is to say, it must be possible to demonstrate that the solution has a greater than 80% probability of yielding a return on investment of 7% or more 3 years post-implementation, per conventional investment criteria [18]. The objective payback period of 3 years is calculated as the initial cost of the solution implementation divided by the predicted average annual cash flow increase.

Outcome: Added financial incentives for pharmacies may contribute to the continued operation and establishment of community pharmacies, which have been linked to the overall health of a given population [20].

**Objective 2: **The system should be easily adoptable by target users. It must be possible to demonstrate that typical patrons (patients) of community pharmacies can use the system to their benefit and do so quickly. It must be possible to demonstrate that target users can use the system to their satisfaction without any outside education or guidance other than notification of the existence of the solution. This is critical to ensure that there is a reduction in non-necessary interactions between pharmacists, pharmacy technicians and patients.

Outcome: Patients will be able to quickly adopt the system without outside intervention meaning that they can immediately begin reaping the benefits of the solution. This means the solution must be self-explanatory and have easily followable instructions. Pharmacists will also benefit immediately because they will experience a reduced workload. After all, a proportion of applicable inquiries will be directed towards the system rather than themselves.

Objective 3: It must be possible to demonstrate that the solution can visibly reduce patient wait times for medication dispensation, prescription drop-off and additional services at community pharmacies.

Outcome: A leading cause of patient dissatisfaction with pharmacy services is excessive wait times with some patients experiencing between 90 and 120 minutes of wait for pharmacy services [20]. Reducing wait time by a significant amount is predicted to increase patient satisfaction and reduce the likelihood that patients will avoid filling, or renewing prescriptions due to poor experience.

Objective 4: It must be possible to show that the solution will reduce cashier-related work that pharmacists and pharmacy technicians experience during their workdays. This reduction should be substantial enough that practitioners indicate that it will improve their satisfaction with their workflow as well as provide the opportunity for practitioners to deliver elevated care to patients who require it. This may be increased medication consultation when required or the delivery of medical treatment and prescriptions for minor ailments.

Outcome: As a direct outcome pharmacy practitioners may experience higher job satisfaction since they would be required to do less cashier-related work, which many pharmacists dislike [21]. More indirect is the notion that patients would receive a higher quality of care since pharmacists would have more time to dedicate care to those who need it since they are spending less time facilitating customer service transactions such as prescription refills and drop-offs.

VII Systems Design Engineering Approach

The overarching engineering approach in creating a solution for our problem space will revolve around the Iterative design process. This will help guide data and user research-driven iterations in our prototypes and will allow for mistakes to be caught early and improved upon. The general flow of the Iterative design process follows the general steps which will be explained in further detail:

1. Understand the problem
2. Prototype a solution
3. Validate the solution
4. Improve design
5. Repeat step 1.

Understand the Problem: This first stage involves understanding the existing problems, the requirements the solution must incorporate, and the different types of users/those who are affected. This can be aided by various tools learned through SYDE design courses, which include creating a Situation of Concern, Systems Diagram, Personas, and User Journey Maps. The user-centric design principles will also help guide the understanding of our problem. Understanding the primary, secondary, and tertiary users of our problem will be critical in designing a solution that is conscious to all those who are affected by it. In our problem space, this would involve gaining perspective and insight of pharmacists and pharmacy patients, our primary users, through primary research. This involves conducting interviews, providing questionnaires/surveys, and having conversations with these users to understand their pain points, perspectives, and feedback. Secondary research through platforms like Statista, provided by the University, will allow for supplemental research to fill out gaps in knowledge or for gathering insight from larger studies. This will be especially useful in understanding key trends or characteristics of general user preferences and the pharmacy industry in general. We will lastly need to define the metrics and benchmarks that complement our design requirements to measure the effectiveness of our prototypes. In our problem space, this could include average patient wait times, the peak number of patients in line, etc.

_Prototype a Solution: _Once the problem is scoped out, users are identified, and project requirements are understood the data must then be analyzed and a prototype designed accordingly. In the early design iterations, the main focus will be on identifying optimal user flows for both pharmacists and patients. It will be critical to iterate quickly and receive feedback without committing unnecessary effort in building a too technical solution early on. This means that early prototypes will be low fidelity and will involve markup or sketched solutions, through tools like Figma, which will allow user feedback and usage patterns to be collected in a short amount of time. This can also provide insight into how the designs will affect performance metrics such as wait time. The quick iteration of the first few prototypes will allow us to optimize our limited time with users and guide our decisions in building higher fidelity prototypes.

For instance, a solution involving automated prescription pickup boxes can first be experimented with users scanning a mock QR code and picking up an over-the-counter drug stored behind a makeshift box. This low-fidelity prototype would allow the user flow and pain points to be identified before any technical direction is decided. In future design iterations, this stage would involve higher fidelity prototypes that draw on findings from previous research and design validation. In further design iterations, we will pull technical knowledge from our collective experience working in Software Development and UI/UX, as well as concepts from technical electives such as Interface Design, Cognitive Ergonomics, and SYDE design courses.

_Validate the Solution: _After designing each prototype, the original hypotheses that inspired the design will be validated with user testing. In our problem space, this will take the form of experimenting with different user flows in the pharmacy, and interviewing pharmacists and patients about their experiences interacting with our prototype. This will also be an opportunity for us to refine our prior research and assumptions, tweak personas, and alter user journey maps. We intend on collecting this primary user feedback through local partnerships with community pharmacies, interviews with different user groups, and surveys.

Our initial goal will be to partner with the SLC pharmacy throughout the research and prototype validation stages. This will allow us to collect performance metrics and evaluate the effectiveness of different designs. This statistical data will be critical in conjunction with user feedback and testimonials in formulating a holistic understanding of our prototype. These performance metrics will also allow us to target several different design changes in future iterations to improve specific aspects of the solution.

_Improve Design: _Once the effectiveness of a prototype is concluded, the final stage is to improve the design, targeting areas of poor performance and pain points throughout the user flow as revealed from testing. Improving the design of a particular feature can be done through additional research, investigating how other designs have addressed the particular issue. Additional feedback from pharmacists and users on how they would prefer a particular pain point or feature to be changed can be invaluable as well. Improving the design can also involve creating higher fidelity prototypes of working aspects, for instance creating a working frontend out of Figma mockups. This final stage blends back into the initial stage of understanding the problem and involves understanding the new problems or aspects of the existing problem that emerged through the design iteration.

VIII Resource Management

To implement a solution to this challenge we have identified a project advisor with experience working in a community pharmacy, who can provide insight into the problem space. The project advisor will meet with the team biweekly to ensure we’re making progress with our project and are dressing the correct concerns. Throughout the iterative design process, we will require access to pharmacists and patients to collect user research and perform design validation. The solution will likely consist of both software and hardware. The software component will require web development skills, and likely utilize backend/infrastructure services like Google Firebase, Heroku, or Supabase. For website hosting, Netlify, Heroku or Vercel provide generous free tiers which will meet the needs of our solution. If our application needs scalability, these services offer payment tiers which can scale based on usage.

In terms of hardware, we will likely need access to 3D printers for creating the physical aspect of the prototypes as well as f microcontrollers or Raspberry PIs to interface with our software components. The University of Waterloo provides 3D printers and team members have access to off-campus 3D printers as a redundancy. Wood and cardboard will be useful for early prototypes and can be constructed at the E5 machine shop. It will be important to verify the availability of the machine shop and book time slots in advance. Team members have microcontrollers from previous course work and Raspberry PIs are available for purchase online or at computer shops.

The materials required for the hardware/firmware aspects of our project are low in cost and have utility after the project. The solution will likely require motors, cables and auxiliary hardware components such as resistors and diodes, all of which can be easily obtained at a computer store, or online at a low cost. It will be advantageous to order and check availability for the firmware items in advance to avoid bottlenecks in the development of prototypes.

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