title: Medication Management: The Macrocognitive Workflow of Older Adults With Heart Failure.
abstract: BACKGROUND
  Older adults with chronic disease struggle to manage complex medication regimens. Health information technology has the potential to improve medication management, but only if it is based on a thorough understanding of the complexity of medication management workflow as it occurs in natural settings. Prior research reveals that patient work related to medication management is complex, cognitive, and collaborative. Macrocognitive processes are theorized as how people individually and collaboratively think in complex, adaptive, and messy nonlaboratory settings supported by artifacts.
  
  
  OBJECTIVE
  The objective of this research was to describe and analyze the work of medication management by older adults with heart failure, using a macrocognitive workflow framework.
  
  
  METHODS
  We interviewed and observed 61 older patients along with 30 informal caregivers about self-care practices including medication management. Descriptive qualitative content analysis methods were used to develop categories, subcategories, and themes about macrocognitive processes used in medication management workflow.
  
  
  RESULTS
  We identified 5 high-level macrocognitive processes affecting medication management-sensemaking, planning, coordination, monitoring, and decision making-and 15 subprocesses. Data revealed workflow as occurring in a highly collaborative, fragile system of interacting people, artifacts, time, and space. Process breakdowns were common and patients had little support for macrocognitive workflow from current tools.
  
  
  CONCLUSIONS
  Macrocognitive processes affected medication management performance. Describing and analyzing this performance produced recommendations for technology supporting collaboration and sensemaking, decision making and problem detection, and planning and implementation.
authors.affiliation: Vanderbilt School of Nursing, Vanderbilt University, The Center for Research and Innovation in Systems Safety (CRISS), Vanderbilt University Medical Center, Nashville, TN, United States.
authors.forename: Robin S
authors.identifier: http://orcid.org/0000-0003-0497-952X
authors.initials: RS
authors.lastname: Mickelson
authors.forename: Kim M
authors.identifier: http://orcid.org/0000-0003-0094-3677
authors.initials: KM
authors.lastname: Unertl
authors.forename: Richard J
authors.identifier: http://orcid.org/0000-0002-3603-6158
authors.initials: RJ
authors.lastname: Holden
keywords: aged; cognition; medication adherence; medication therapy management; workflow