“Esteam” is a proposed health website focused on promoting medication adherence among depressed individuals which I designed with a team of University of Michigan students as a part of a class on consumer health technology. This page documents the evolution of our design, from a general application broadly targeted toward medication adherence, to a website focusing on medication adherence for depressed individuals.

To access our functional digital prototype of Esteam, click here

Team members: Patrick Albertus, Selwyn Kancharla,Stacey Matlen, and Wenbo Yang

Choosing a Health Topic

Our team initially decided to focus on medication adherence as a general health focus after finding that only 50% of individuals take their medication as prescribed (CDC, 2013). This non-adherence leads to approximately 25%-50% of treatment failures and 33%-69% of hospitalizations (Brown & Bussell, 2011; Osterberg & Blaschke, 2005), with 125,000 deaths attributed to non-adherence annually (CDC, 2013).

We focused on individuals with chronic disease as our intervention focus, with older adults as our primary target because of their higher disease burden.

Data sources:

Brown, M. T., & Bussell, J. K. (2011). Medication adherence: WHO cares? Mayo Clinic Proceedings. Mayo Clinic, 86(4), 304–314. doi:10.4065/mcp.2010.0575

CDC. (2013). Medication Adherence.

Osterberg, L. ., & Blaschke, T. (2005). Adherence to medication. New England Journal of Medicine, 4 Suppl 1(5), 43–46. doi:10.1056/NEJMra050100

Persona Creation

After conducting background research on the reasons for medication non-adherence and attributes of our target population, I created a primary and secondary persona of "Harry" and "Sally" to focus our design efforts.

Using our personas as our focus, each team member created a rough vision of what our website or app might look like, focusing on the needs of our personas. Above is a proposed sitemap I created.

When then came together to discuss our ideas and refine the core elements necessary for our website or app. In this meeting, we determined that a website would be more appropriate to serve the needs older adults, both because of higher usage rates for desktop computers and laptops in this demographic over smartphones and because of the higher accessibility of websites for older adults.

Paper Prototype

We then distilled the core elements of our app into a series of screen sketches. Using these as a guide, we created a paper prototype.

Pivoting

After receiving feedback on our design, we realized that the needs of individuals with different chronic diseases are too diverse to be well served by a single website. Accordingly, we conducted further research and decided to change directions to focus on individuals with a single chronic disease. We chose depression and medication adherence in this population because we felt that a social support network developed through a website could address many of the issues related to medication non-adherence referenced in the literature which could be intervined on through information and social support provided through a website. These issues for medication non-adhrenence included: treatment of an asymptomatic disease, side effects of medication, patients' lack of belief in treatment, patient's lack of insight into their illness. (Osterberg & Blaschke, 1990).

Source:

Osterberg, L., & Blaschke, T. (1990). Adherence to medication. Journal of Human Hypertension, 4 Suppl 1, 43–46. doi:10.1056/NEJMra050100

Scenarios

Following the feedback from our second round paper prototype, we created a number of scenarios to help us determine the functional areas which we needed to add and areas of our site which needed to be revised to meet the needs of our target population.

Here we are sketching screens which needed to be revised based on our feedback.

Wireframes

Using the insights from our group session, each of us developed wireframes for the primary pages of our website.

High-Fidelity Digital Prototype

With these sketches and our previous paper prototype, my teammate, Selwyn Kancharla, created a functional digital prototype of our website. We decided to call our site "Esteam" to emphasize the team-based elements of the app which utilizes social support to promote medication adherence in depressed individuals. It does this by placing depressed individuals into teams of individuals suffering from depression which act as medication adherence support network through the website.

To access our functional digital prototype of Esteam, click here.

Onboarding

We envision the Esteam website exhisting as a module embedded as a component of an individual's personal health record (PHR) which interfaces and extracts information from their electronic health record (EMR). Such an interface would be provided through a person's insurance or through a health maintenance organization (HMO). We envision that depressed individuals would be prescribed the website after being screened during medical visits.

The above screen represents what a person would see during their first-time set-up after logging in.

When onboarding users are asked to identify their values so that they can be matched with individuals with similar values when support groups are formed on the website.

Here, users identify what they feel is their purpose. This purpose is later used as a cue to help connect a user's reasons for taking their medication and link their purpose adherence goals.

Users reconfirm their medication list which is imported from their electronic medical record.

The website includes a questionnaire which is modeled on stages of change theory. Users identified as being in the "maintenance stage" of medication adherence are asked by our system if they would like to be a mentor on Esteam. Mentors provide information and emotional support to individuals attempting to adhere to their anti-depressant medication.

As a last step of the on boarding process, individuals are notified that the conversations they post on the main forum will be visible to the other members which are placed on their support team. This is to ensure that people are fully aware of the information they may be disclosing to others.

Home Page

We wanted the Esteam website to be focused on social interaction to build a network of social support support to encourage medication adherence. Accordingly, many of the features on the homescreen emphasize connecting individuals through conversation and meaningful interaction, while providing the tools to track medication adherence.

Your Esteam Team

A user's "Esteam Team" is a group of nine other users that are also struggling with depression and antidepressant medication adherence. They are matched with the user based on the values the user selected during onboarding, and represent individuals at different stages of change as evaluated in the onboarding questionnaire. One of the group members is designated as a "mentor." Mentors are individuals who are at the maintenance stage of change (they have successfully adhered to their medications for at least 6 months) and provide experienced information and emotional support to members of the team struggling to adhere to their antidepressant medications. Likewise, purpose of this group is to provide the user with social support and normalize the process of taking antidepressant medication. The overall goal for this support is to move users through the stages of behavioral change into a stable maintenance phase medication adherence.

All group members are anonymous and represented only by a screen name and an avatar. By clicking on avatar icons, users can see the values these users selected as important during onboarding and directly message them. The Esteam Team list is pervasively present on the right side of the screen throughout the site to emphasize that they are always there to support the user.

Discussion Section

The discussion section occupies the central portion of the home screen. This is a place for members to post messages and interact with each other to foster community and support. Daily topic questions focusing on medication adherence will be placed at the top of the section to help guide conversations, but input on the message board beyond this will be left to users. However, our company will monitor the threads and may occasionally remove posts which are abusive or violate the spirit of the website.

Navigation Bar

From the top navigation bar the user can access stories, the doc blog, or their inbox (described in the following screenshots).

Top Dashboard

• Values

Located at the upper left, the values listed here are the same ones that the user chose during the onboarding process. We placed these next to the medication adherence tracing function so that the user will subconsciously connect these core aspects of themselves with their larger reason for taking their antidepressant medication.

• Weekly Medication Tracker

This circle provides a way for users to see how their medication adherence is progressing and self-monitor. The circle is divided into seven parts for each day of the week. When the users take all of their medications, the day will be colored green, most of their medications will be colored yellow, and none of their medications will be colored red. Within the circle is a graphic of the user's purpose, which was selected during the onboarding process to additionally reinforce their reason for taking their medication. Detailed graphs of the user's progress can be accessed by the user by clicking this icon.

The user's medication adherence will be tacked through daily pop-up prompts which ask the users which medications they have taken.

• Upcoming Medications

Next to the medication tracking circle is a list of the upcoming medications that the user needs to take that day. The medication turns green when it is within an acceptable range to take, red if the user has missed the medication, and is checked off when the user logs taking the medication.

• Feeling Tracker

Adjacent to the medication list is the feeling tracker. This allows the user to select from a drop-down menu how they are feeling that day. We collect this data so that it can be displayed in the detailed graph screen to show the users how their medication adherence relates to their overall mood over time.

• Talk Now

Through this button users can access a trained health coach to discuss any issues they may be experiencing. We also have the option within this portal to access immediate help if an individual is experiencing suicidal thoughts.

Stats

If users click on their weekly medication tracker, they can view pie charts documenting trends in their moods and their medication adherence. By seeing the connecting between more positive mood states and medication adherence, we hope to encourage adherence behavior.

Stories

Stories are provided by Esteam website users and curated by our staff with an emphasis on stories of users which have benefited from taking their medication, are living more fulfilling lives as a result of their medication, and those that highlight individuals overcoming the emotional or cognitive barriers related to medication adherence.

Not all stories from users will be specifically about medication or depression. Although we considered filtering stories to only address depression and medication adherence, we decided that it was important for user-generated content to encourage participation by drawing members in with stories they are naturally interested in reading. Video, audio, and textual stories will all be mixed and presented in this section.

Doc blog

In this section, our staff of physicians would provide articles addressing trending discussion topics, stories, or questions submitted directly by users. We created this is as a reliable information resource, a safe space for users to ask questions they may not feel comfortable asking physicians in person, and as a way to normalize how other users have similar questions and concerns.