JMIR Publications

ABSTRACT

Background:

Despite making great strides in improving the treatment of disease, the minimization of iatrogenic harm continues to be a major hurdle facing the healthcare system. Potentially inappropriate medications (PIMs) in older persons represent a prevalent source of harm to patients and are associated with increased rates of adverse events, hospitalizations, and increased healthcare costs. Deprescribing attempts to combat PIMs by systematically identifying and removing high risk medications from patients’ regimens. Attempts to operationalize deprescribing, however, have had mixed results. Complex contextual factors at play make the implementation process of these new interventions difficult. Abstraction hierarchy (AH), the first step in cognitive work analysis (CWA), is used by human factors practitioners to describe complex socio-technical systems. While initially intended for the nuclear power domain and interface design, AH has been used successfully to aid healthcare redesign of numerous systems such as design of decision support tools, mobile patient monitoring applications, and a telephone triage system.

Objective:

The aim of this manuscript is to refine our understanding about the primary care office in relation to a patient’s medication through the development of an abstraction hierarchy. Emphasis was placed on the elements related to medication safety in order to address the challenges of deprescribing in a more effective manner.

Methods:

The AH development was guided by the methodology used by seminal CWA literature. It was initially developed by two authors and later given feedback from an expert panel of clinicians, social scientists, and a human factors engineer. It was subsequently refined until an agreed upon AH was achieved. A means-ends analysis was performed and described for nodes of interest. The model represents the primary care office space through functional purposes, values and priorities, function-related purposes, object-related processes, and physical objects.

Results:

This model depicts the various components which must be balanced and coordinated to provide medical treatment with limited healthcare resources in order to ensure patient medication safety. Understanding of the complex activities that occur in a primary care office depicted in this model may define areas in which deprescribing activities can be successfully completed.

Conclusions:

After analysis of the generalized AH, recommendations for the development of an optimized medication management system in primary care were made. Numerous means-ends relationships can be identified using AH depending on the specific needs of the user. Individual practices can utilize the AH for clinic redesign to improve prescribing and deprescribing practices.