Safety, Convenience, and Compliance: The 'Cardinal' Rules of Package Design at Cardinal Health

By Patrick Henry

Most consumers don't know, nor do they really need to, that something more than merchandise awaits them each time they visit their local pharmacies for prescription (Rx) drugs or over-the-counter (OTC) medications. That invisible but ubiquitous influence is the presence of Cardinal Health, a pharmaceutical industry giant with a hand in almost everything having to do with the development, manufacturing, promotion, and distribution of the products that consumers rely upon to cure their ills or keep them in the pink of health.

A $75 billion global enterprise that ranks 16th among the Fortune 500, Cardinal Health delivers many different kinds of technical and logistical support to pharmaceutical manufacturers, medical suppliers, chain and local pharmacies, hospitals, physicians, and other providers of health care solutions. No small part of this activity is Cardinal Health's array of packaging services, which include both the design and the production of packages with stringent requirements for safety, utility, and end-user convenience.

Committed to fully integrated operation, Cardinal Health relies on its own network of printing plants and package fabrication centers to develop packages that typically must do more than simply dispense medications. Packages for Cardinal Health customers frequently have to ensure "patient compliance"—in lay terms, getting consumers to stick to their prescribed drug-taking routines. A package containing an Rx or OTC medication also should be as child-resistant as it is senior-friendly, enabling older adults to easily access the medicine while defending the package against innocent but potentially life-threatening attacks by little fingers.

These weighty responsibilities are borne by a small but thoroughly capable package development team at the packaging services facility of Cardinal Health on Red Lion Road in Philadelphia. Michael Bergey, the packaging services group's vice president for business development, says that in addition to the skills of four full-time packaging engineers, the group can draw on dedicated package design expertise at six other packaging plants in New Jersey, Illinois, and Puerto Rico. Cardinal Health also has packaging design resources at plants in the UK, Ireland, and Germany.

Cardinal Health relies on its own network of printing plants and package fabrication centers to develop packages that typically must do more than simply dispense medications.

Special services for special needs

Renard Jackson, executive vice president for packaging services, says the group is structured to supply packages developed by Cardinal Health as well as packages designed by the customers themselves. This includes primary and secondary packaging as well as labels, inserts, and outserts. Designing, prototyping, and sampling also are among the services provided to contract packaging customers such as large and mid-tier pharmaceutical and biotech companies.

Given the special needs of these customers, says Victor Gherdan, packaging engineering supervisor, the group's skill set generally is more focused on industrial design than on graphic design. This doesn't mean, however, that Cardinal Health doesn't have the same appreciation of a package's appearance as any other purveyor of products for a mass audience. In fact, at least half of the company's design workload is aimed at packages for the OTC market, which, according to Bergey, "is a particular challenge because of the enhanced focus on graphics, color, and the other elements of shelf presence."

"The design features associated with pharmaceutical packaging can be looked at in two major categories: communicating the customer's marketing message, and package functionality," says Bergey. "Marketing is all about brand image and shelf presence. Cardinal Health works closely with its customers to understand the marketing message, and to make sure that packages are properly designed to convey the message to the consumer."

Nevertheless, planning for functionality—the set of structural characteristics that assures the safety of a package while making it convenient to use—typically is the starting point. "If there is a requirement for a child-resistant, senior-friendly (CRSF) design, this must be known at the very start of any package design project," says Bergey, who calls designing packaging for this kind of functionality "an absolute strength at Cardinal Health." It's a strength based upon insight. According to Jackson, an understanding of the "psyche" of end-users is what enables the design group to create CRSF packaging that also encourages compliance.

Dealing with the "dichotomy"

Making a package both child-resistant and senior-friendly, says Jackson, is "a real dichotomy" that tests the design group's awareness of people's physical capabilities both in the mornings and the evenings of their lives. Because a child of two to four years may have roughly the same strength as an elderly person with an impairment, making the package too strong for the toddler would defeat half its purpose. By the same token, making a package accessible to adults must not diminish child resistance—a condition defined according to strict standards of the U.S. Consumer Product Safety Commission.

Gherdan says that one way to address the dichotomy is to create packaging that requires a level of dexterity—simultaneous opening actions using both hands—that most small children don't possess. Experience has shown that although youngsters might be strong enough to open certain packages, their fingers aren't nimble enough to perform two opening motions at once. However, because that still leaves them the option of using teeth or fingernails to get at the contents, it's also necessary to specify packaging materials tough enough to defeat these childishly destructive attempts.

Jackson says that all of these principles were applied in the design of the Pill Calendar(TM), a slide-card package consisting of foil-covered blisters in a paperboard folder with a built-in plastic "trigger." The Pill Calendar is child-safe because dispensing tablets from it takes two grown-up hands: one to pull the plastic trigger, exposing the foil; and the other to push the medication through the foil by pressing the blister. Releasing the trigger secures the package again.

The Rx barrier pack, a blister card with a plastic shield over a cavity containing the product, achieves CRSF-ness in a different way. Here the user must press the shield to access and dispense the contents—a single-motion manipulation that a disabled adult can manage, but not a child.

"Pill Calendar" tells you when

Besides satisfying safety and accessibility requirements, the team's other overriding design goal is designing packages in ways that help users stick to their medication routines. "Giving you a prescription product isn't enough—we want to help you take that medicine," says Jackson. This means focusing primarily on the packaging psyches of the elderly, as 70% of prescription medications are taken by seniors who typically are using four or five products—a tough regimen to follow at any age.

The Pill Calendar aims to streamline the routine with its seven-day, four-week format and a set of removable labels that serve as day markers for starting the course of medication. After the user has affixed the appropriate label to the first blister, he or she can tell at a glance whether the current day's pill still needs to be taken.

At least one scientific study appears to indicate that the Pill Calendar's compliance-prompting features can yield benefits that go well beyond convenience and ease of use. Jackson says that Ohio State University's College of Pharmacy conducted a 12-month trial in which a group of about 140 people aged 65 years and older were divided into two sections: one whose members received a medication for high blood pressure in the Pill Calendar; and another whose members were given the same product in ordinary brown vials. Members of both groups were monitored by their physicians every six months and made monthly visits to their pharmacists, who counted their pills and tracked their refill intervals.

The research found, according to Jackson, that the test subjects taking their medicine from the Pill Calendar showed "a significant increase in the percentage of refills on time, as well as a significant reduction in diastolic blood pressure levels."

Exceeding elders' expectations

Older consumers' dependence on the life-extending properties of their medicines in no way implies that they are passive about the ways in which pharmaceutical products are delivered to them. As the aging portion of population grows, says Gherdan, its members are becoming more demanding: "They want convenience, and they expect quick results." This means that packages designed for this prime consumer segment must achieve a seamless blend of functionality and clarity—and that is where good graphic design enters the picture.

"Package graphics can help with patient compliance by making instructions for use easier to understand," Bergey says. "Copy space on a label or carton is always at a premium, and it's always a balancing act to get the marketing message and compliance enhancing text all on the same package, in the proper place where the information can be utilized to its fullest advantage." Gherdan observes that a package can encourage compliance both structurally, by arranging the pill cavities in dosage sequence; and graphically, by distinguishing, for example, between the A.M. dose and the P.M. dose.

The reference to balancing compliance features and marketing objectives is a clear indication that Cardinal Health takes the latter just as seriously as the former. "This aspect of package design is more typically driven by the package designer, and utilizing unique functionality is one of the best ways for customers to differentiate their products through packaging alone," Bergey says. "In conventional carton design, elements such as fifth panel displays, unique open/close/reopen features, tamper evidence, and other shelf presence enhancements are a few of the ways to give the customer an advantage over the competition."

According to Bergey, the Cardinal Health design team proved itself equal to the challenge when a customer, a large pharmaceutical company, tasked it with design and contract packaging for a branded line of oral film strip products. The customer wanted the package not only to have "an overwhelming shelf presence" to differentiate it from competitive brands, but also to promote the product line's unique delivery technology.

The solution, says Bergey, was a reverse fifth-panel design that presented the fifth panel and the carton panel as one large printed surface facing the consumer on the store shelf. "Feet" were added so that the package could stand upright, further enhancing shelf presence. The carton's end flaps closed in reverse order so that flap edges would not interfere with loading the carton onto the store shelf. Finally, a reclosing tuck feature was added to the carton's glued end to make the multidose package reclosable.

Cardinal Health has the design, printing, labeling, and contract manufacturing resources to take any innovative package from conception to product launch.

Won't hurt to raise these blisters

As the market for pharmaceutical products of all kinds continues to expand, Cardinal Health anticipates plenty of opportunity to apply its expertise in developing safe, convenient, compliance-prompting packaging. Bergey says that the company sees blister card delivery systems as particularly well poised for growth. Several patented and proprietary Cardinal Health blister card designs are available now, and several more are undergoing CRSF testing. Gherdan says that packages for hospital dispensing and physician sampling are other solutions for which demand is rising.

Such opportunities are not easy to exploit, even for a company with Cardinal Health's resources and capabilities. "Industry pressures are tremendous, especially in the OTC area," says Bergey. "Many times we have found ourselves designing packaging concurrently with the automated high-speed equipment that will run it. This creative pressure is further intensified by new substrates and laminate structures that our customers are always asking us to quantify."

One way in which the packaging design team of Cardinal Health deals with the pressure is by interacting regularly through its recently developed World Wide Design Team Internet portal, an interactive space accessible only to members of the team. The group also holds monthly teleconferences and annual face-to-face meetings to share information about industry trends and best practices for package design, materials, and procedures.

Good pharmaceutical package design will always be a moving target, but it is a discipline that Cardinal Health has embraced as a matter of course. "We are always looking back at existing package design improvements, while continuously looking forward at the next proprietary package in development," Bergey says. "As customer needs change, existing package features may need to change as well."