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Developing a medication communication framework across continuums of care using the Circle of Care Modeling… Kitson, Nicole A; Price, Morgan; Lau, Francis Y; Showler, Grey Oct 17, 2013

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RESEARCH ARTICLE Open AccessDeveloping a medication communicationframework across continuums of care using theCircle of Care Modeling approachNicole A Kitson1*, Morgan Price1,2, Francis Y Lau1 and Grey Showler2AbstractBackground: Medication errors are a common type of preventable errors in health care causing unnecessarypatient harm, hospitalization, and even fatality. Improving communication between providers and betweenproviders and patients is a key aspect of decreasing medication errors and improving patient safety. Medicationmanagement requires extensive collaboration and communication across roles and care settings, which can reduce(or contribute to) medication-related errors. Medication management involves key recurrent activities (determineneed, prescribe, dispense, administer, and monitor/evaluate) with information communicated within and betweeneach. Despite its importance, there is a lack of conceptual models that explore medication communicationspecifically across roles and settings. This research seeks to address that gap.Methods: The Circle of Care Modeling (CCM) approach was used to build a model of medication communicationactivities across the circle of care. CCM positions the patient in the centre of his or her own healthcare system;providers and other roles are then modeled around the patient as a web of relationships. Recurrent medicationcommunication activities were mapped to the medication management framework. The research occurred in threeiterations, to test and revise the model: Iteration 1 consisted of a literature review and internal team discussion,Iteration 2 consisted of interviews, observation, and a discussion group at a Community Health Centre, and Iteration3 consisted of interviews and a discussion group in the larger community.Results: Each iteration provided further detail to the Circle of Care medication communication model. Specificmedication communication activities were mapped along each communication pathway between roles and to themedication management framework. We could not map all medication communication activities to the medicationmanagement framework; we added Coordinate as a separate and distinct recurrent activity. We saw many examplesof coordination activities, for instance, Medical Office Assistants acting as a liaison between pharmacists and familyphysicians to clarify prescription details.Conclusions: Through the use of CCM we were able to unearth tacitly held knowledge to expand ourunderstanding of medication communication. Drawing out the coordination activities could be a missing piece forus to better understand how to streamline and improve multi-step communication processes with a goal ofimproving patient safety.Keywords: Medication management, Communication, Action research, Circle of care modeling* Correspondence: nkitson@uvic.ca1eHealth Observatory, Health Information Science, University of Victoria, STNCSC, PO Box 3050, Victoria, BC V8W 3P5, CanadaFull list of author information is available at the end of the article© 2013 Kitson et al.; licensee BioMed Central Ltd. This is an open access article distributed under the terms of the CreativeCommons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, andreproduction in any medium, provided the original work is properly cited.Kitson et al. BMC Health Services Research 2013, 13:418http://www.biomedcentral.com/1472-6963/13/418BackgroundMedication errors are a common type of preventable er-rors in health care causing unnecessary patient harm,hospitalization, and even fatality [1,2]. The estimatedrate of preventable Adverse Drug Events, caused bymedication errors, is 1.5 million per year in the UnitedStates [2]. There is a link between medication errors andmedication communication [2,3]; communication be-tween providers and between providers and patients,within and across care settings, have been identified assources of medication error [1,2,4-9]. Improving com-munication is a key aspect of decreasing medication er-rors and improving patient safety [2,4,10].Medication management requires extensive collabor-ation and communication across roles and care settings[2,10-13], which can reduce (or contribute to) medication-related errors [2,3]. Medication management involves keyrecurrent activities: determine need; prescribe; dispense;administer; and monitor/evaluate with information com-municated within and between each activity [2,14-17];medication communication is therefore embedded withinthe framework; whereas, our research seeks to draw itout. The medication management framework is presentedin Figure 1.Despite its importance, communication is often anembedded component (not the focus) of models that ex-plore medication management workflow [14,18], includ-ing describing: medicine pathways [14,15]; e-prescribing[16,17]; and patient safety [2,10]. For instance, of the sixconceptual models discussed in Liu’s [10] critical reviewof models to improve patient safety, only one focusedspecifically on medication management across the con-tinuum of care (the Australian Pharmaceutical AdvisoryCouncil’s (APAC) Partnership Model) and one on medi-cation communication specifically (the MedicationCommunication Model). The APAC Partnership Model[14] outlines nine components for achieving continuity inmedication management across the continuum of care.These components are comprised within a medicationmanagement cycle and are: decision to prescribe medi-cine; record of medicine order/prescription; review ofmedicine order/prescription; issue of medicine; provisionof medicine information; distribution and storage; admin-istration of medicine; monitor for response; and transferof verified information. This model focuses primarily onmedication communication between medication manage-ment cycles, rather than the communication within thecycle (e.g., between each component). The MedicationCommunication Model [18] is built from a concept ana-lysis from the literature. The model focuses on three di-mensions of face-to-face medication communication:antecedents (sociocultural and environmental factors); at-tributes (Who is speaking? Who is silent? What is said?What are the prioritized aspects of patient care? What isthe body language? What are the actual words used?); andoutcomes or consequences (the beneficial or unwanted ef-fects of communication) [18].While there have been studies on team communica-tion within healthcare departments (for instance, oncol-ogy [11,19], Emergency Department [12], Intensive CareUnit [13]), or focusing on specific communication inter-actions (like between the patient and providers [19,20]),there are fewer studies that explore healthcare com-munication across the continuum of care or acrossthe patient’s circle of care. The interdisciplinary teamcommunication framework [11] helps fill this gap asit explores healthcare communication structures, pro-cesses, and outcomes across continuums of care forpalliative care delivery, which can be used to informthe design of Health Information Systems to supportcommunication. In this framework: ‘structure’ refersto the internal (e.g., membership, policies) and external(e.g., contacts, services) structures and their communica-tion channels; ‘process’ refers to care planning, informa-tion exchange, teaching, decision making, negotiation,and leadership; and ‘outcomes’ refers to discharge-based(e.g., discharge planning) and patient-based (e.g., satisfac-tion, goal achievement) outcomes [11].Our research focuses on medication communicationacross continuums of care. The medication managementframework was used as the foundation for categorizingmedication communication activities within the patient’scircle of care. This paper presents a medication commu-nication framework built on the findings gathered fromMonitor/EvaluateDetermine Need Prescribe Dispense AdministerFigure 1 Medication management framework adapted from [2,14-17].Kitson et al. BMC Health Services Research 2013, 13:418 Page 2 of 10http://www.biomedcentral.com/1472-6963/13/418creating a Circle of Care model that explores medicationcommunication.MethodsApproachThe Circle of Care Modeling (CCM) approach was usedto build a model of medication communication activitiesacross a patient’s circle of care. CCM positions the pa-tient in the centre of his or her own healthcare system,their circle of care; providers and other roles are thenmodeled around the patient as a web of relationships.CCM has been used successfully by our team to exploreopportunities to improve: continuity of care [21,22]; per-sonal health records (unpublished); and rural patient at-tachment issues [23]. In this study, CCM was used toidentify roles, and medication communication pathwaysand activities within the patient’s circle of care, to high-light gaps and challenges, and reason about possible im-provements. Our analysis of these activities was bothdeductive, as we mapped to existing medication manage-ment activities, and inductive, as we drew out specificcommunication activities not reflected in the medicationmanagement framework.The research occurred in three iterations: Iteration 1developed an initial Circle of Care medication communi-cation model based on a review of the literature; Iteration2 gathered field data at a Community Health Centre(CHC) with an integrated pharmacy; and Iteration 3 gath-ered data within a broader urban community. The Circleof Care medication communication model was revised ineach iteration.Iteration 1: TheoreticalParticipants and recruitmentNone.Data collectionThe research team conducted a literature scoping reviewin December 2010 to explore medication communica-tion pathways and activities. Medline, CINAHL, andGoogle Scholar were searched from 1998–2010 usingthe following search terms: medication communication,medication management, medication error, patient safety,and/or ambulatory care. The articles were included if theydescribed medication communication pathways and/oractivities between care providers or patients. Forty-fivearticles were retrieved. An internal discussion with fivemembers of the research team (one physician, two regis-tered nurses, and two health informaticians) exploredadditional medication communication pathways and ac-tivities. In this context, a pathway is the direction of com-munication between individual roles (the part someoneplays in the patient’s circle of care); communication fromnurse to doctor and doctor to nurse represents twopathways. Activities refer to medication communica-tion activities using the activities reflected in the medica-tion management framework as an initial basis foridentification and classification (e.g., prescribe, dispense,administer).Data analysisWe drew medication communication activities and path-ways from the literature to create an initial Circle of Caremedication communication model. Additional pathwayswere added after a team discussion. The team discussionvalidated the draft Circle of Care medication communica-tion model and informed the development of a medicationcommunication framework. This information was used asa basis for creating patient personas (simulated patientcases) to discuss with participants in subsequent researchiterations.Iteration 2: Integrated community health centreParticipants and recruitmentRecruitment occurred at a single inner city integratedCommunity Health Centre (CHC) and included patientsand care providers. Patients were recruited by a posterin the waiting room; interested patients identified them-selves to the research nurse who asked further questionsfor eligibility: a patient at the CHC for at least one year,currently taking at least three prescribed medicationsdispensed by the CHC pharmacy (compliance and otherfactors were not part of the inclusion criteria). Patientparticipants were provided a gift card for participation.Provider participants were recruited by the CHC managerand included family physicians, registered nurses, phar-macy employees, and Medical Office Assistants (MOAs).MOAs are administrative office assistants in a medical orhealthcare environment. Provider participants identifiedthemselves to the researchers directly and chose to partici-pate in an interview, observation, and/or discussion.Data collectionWe used mixed methods, including: observation, patientinterviews, provider interviews, and provider discussion.Observation occurred with consenting patients andcare providers within the CHC. Observation of patient/clinician interactions focused on medication communica-tion only and took approximately ten minutes per patient;the researcher left the room when asked. Clinician obser-vation occurred in three-hour time blocks. No patientidentifiable information was documented. Detailed noteswere taken on medication communication and includedroles (e.g., doctor, patient), medication communication ac-tivity (e.g., request new prescription), and communicationpathway (e.g., patient→ physician). Patient interviewsconsisted of semi-structured questions to explore theroles and content of medication communication. ProviderKitson et al. BMC Health Services Research 2013, 13:418 Page 3 of 10http://www.biomedcentral.com/1472-6963/13/418interviews were structured around two patient personasthat were developed after Iteration 1 to highlight commonmedication communication scenarios and challenges. In-terviews were audio-recorded and detailed notes weretaken. No personal information was recorded. The one-hour provider discussion was characterized by active dis-cussion with multiple roles and perspectives; the groupreviewed the model to confirm accuracy, and discussedpotential local (internal) improvements to medicationcommunication. The discusison was audio-recorded anddetailed notes were taken.Data analysisObservation notes were reviewed to identify specificcommunication pathways and activities between roles.Interviews were transcribed and thematically coded,along with the detailed notes. Several elements wereextracted including roles, pathways, recurrent medica-tion communication activities, and challenges encoun-tered in medication communication. The observationsand interviews collectively were used to inform theCircle of Care medication communication model. Recur-rent medication communication activities were mappedto the medication management framework. The discussionaudio-recordings and detailed notes were also thematicallycoded as above. Multiple perspectives (patients, providers)served to triangulate the findings. The findings from iter-ation 2 were used to inform iteration 3.Iteration 3: CommunityParticipants and recruitmentA standard recruitment letter was sent to physician officesand community-pharmacies listed in the 2011 Physicianand Surgeons Directory for Victoria, Saanich and the GulfIslands (excluding the Gulf Islands). Research assistantsfollowed up with potential participants in person and viafax. Community Nurses were recruited through Homeand Community Care (HCC) at Vancouver Island HealthAuthority (VIHA).Data collectionIn this iteration, one-hour interviews were conductedwith providers only. Interviews were structured aroundtwo patient personas (simulated patient cases) to stimu-late discussion about medication communication activ-ities across circles of care. One patient persona wasreused from Iteration 2; whereas, a second one was cre-ated to better reflect a typical patient seen in the com-munity (rather than the inner city CHC). Interviewswere audio-recorded and detailed notes were taken. Thetwo-hour discussion involved bringing together providersfrom both iterations two and three to discuss the Circleof Care medication communication model and medica-tion communication framework developed during theproject, and to identify opportunities to improve medi-cation communication. There were no observation ses-sions in iteration 3. The discussion was audio-recordedand detailed notes were taken.Data analysisAs in Iteration 2, the rich set of data from interviewsand the discussion were translated visually into a refinedand expanded rich Circle of Care medication communi-cation model. Recurrent medication communication ac-tivities were mapped to the medication managementframework.Synthesis of findingsData collection activities and analyses were iterative, andused to inform the medication communication frame-work and the Circle of Care medication communicationmodel. Each of the iterations built upon the findings ofthe preceding iteration(s), with Iteration 2 informed bythe findings of Iteration 1, and Iteration 3 informed bythe combined findings of Iterations 1 and 2. These itera-tive findings collectively contributed to what we knowabout medication communication within and betweenroles in the patient’s circle of care. The combined findingsfrom Iterations 1, 2, and 3 are presented in the Resultssection below.Ethics approval was granted by the University ofVictoria (UVic), protocol number: 11–093 and UVic/Vancouver Island Health Authority, protocol number:J2011-54.Patient personas and the interview question tool arefreely available at http://ehealth.uvic.ca/initiatives/pro-jects/pharmacy.php.ResultsParticipantsThe research occurred from April 2011 to May 2012. Atotal of 39 patients and community care providers(representing 8 roles) participated in the research; someparticipants were involved in multiple activities (e.g., ob-servation, interview, and discussion). The breakdown ofparticipant roles by data collection method is presentedin Table 1.The medication communication frameworkWhile the five medication management categories (deter-mine need, prescribe, dispense, administer, monitor/evalu-ate) had alignment with communication activities, not allcommunication activities could be mapped directly to themedication management framework (Figure 1). Our re-search highlighted Coordinate as a separate and dis-tinct recurrent activity. We observed many instancesof specific roles (e.g., MOA, HCC liaison, HCC nurse,pharmacy technician) coordinating medication informationKitson et al. BMC Health Services Research 2013, 13:418 Page 4 of 10http://www.biomedcentral.com/1472-6963/13/418between providers, and between providers and patients.The medication communication framework is presentedin Figure 2.Medication communication activities are definedbelow: Determine need involves communication aroundactivities to determine the need for medication, e.g.,a doctor and patient discussing the patient’scomplaint; Prescribe focuses on communication aroundprescribing activities, e.g., a patient and doctordiscussing the details of a new prescription; Dispense focuses on communication arounddispensing activities, e.g., a pharmacist and physicianresolving an alert for a duplicate medication; Administer involves communication aroundmedication administration activities, e.g., apharmacist and patient discussing medicationadministration instructions;Table 1 Breakdown of participant roles for Iterations 2 or 3Iteration 2 Iteration 3Role Observation Interview Discussion Interview DiscussionFamily Physician 2 3 4 5 2Home and Community Care Nurse 0 0 0 3 1Medical Office Assistant 3 2 5 1 2Community Health Centre Nurse 2 2 3 0 1Patient 3 6 0 0 0Pharmacist 1 1 1 4 2Pharmacy Technician 2 1 2 1 1Specialist Physician 0 0 0 3 1Administrator 0 0 1 0 0Total 13 15 16 17 10Figure 2 Medication communication framework.Kitson et al. BMC Health Services Research 2013, 13:418 Page 5 of 10http://www.biomedcentral.com/1472-6963/13/418 Monitor/Evaluate focuses on communicationaround medication monitoring and evaluation,e.g., a patient and Home and Community Carenurse discussing medication compliance. Themonitor/evaluate activity was often used to informthe other medication communication activities formedication decision-making; and Coordinate communication focuses on thecoordination of medication information betweenroles, e.g., an MOA transmitting a request forinformation between a pharmacist and a familyphysician.The number of roles, number of pathways, and list ofsub-activities for each of these medication communica-tion activities is in Table 2.CoordinateWe identified 36 communication pathways between 15roles for the Coordinate medication communication ac-tivity. However, given the structure of our research enquiry(for instance, extended observation of MOA medicationcommunication activities) this paper focuses more specific-ally on our coordinate communication activity findings inthe context of the MOA role. We observed MOAs as in-formation conduits, transmitting medication informationin support of medication management in the patient’s cir-cle of care.Coordinating activities include: relaying messages be-tween care providers and relaying messages between pa-tients and care providers; requesting or transmittingpatient information for current or historical medicationrecords; requesting and confirming appointments andreferrals; and requesting, confirming, or alerting roles ofthe status of medication coverage. While the content ofwhat these roles communicate falls within other medica-tion communication activities (e.g., prescribing, dispens-ing, monitoring), their responsibility is to facilitate thecoordination of this information between roles (e.g., be-tween a family physician and a pharmacist). Figure 3highlights the MOA pathways for the coordinate com-munication activity within the Circle of Care medicationcommunication model.Figure 3 highlights the coordinate communicationactivity in the Circle of Care Model. There are 36 dir-ect and 22 indirect pathways between 15 roles: thepatient; physicians (family physician, specialist phys-ician, walk-in clinic physician, previous provider) andtheir Medical Office Assistants; nurses (HCC, CHC);pharmacist; family member; home lab; and the Payor.Additional roles and pathways could exist. Direct path-ways represent those roles MOAs have direct commu-nication with to coordinate medication information.Indirect pathways indicate those connections that canbe made between roles as a result of the coordinatingactivity. For instance, a walk-in clinic physician can com-municate with a patient’s family physician that a new pre-scription was provided; this information is transmitted viathe walk-in clinic physician’s MOA and the family physi-cian’s MOA.Interestingly, we observed fewer coordinate communi-cation pathways in the integrated clinic versus the non-integrated clinics. In a non-integrated clinic, the pharmacyis off-site and coordination is regularly required to linkthe family physician and pharmacist together to confirm,for instance, current medications as reflected in the elec-tronic provincial medication repository or to discuss a dis-pensing alert (e.g., for a contraindicated medication). Inthe integrated clinic with a pharmacy on-site, however,conversations between the pharmacist and family phys-ician generally occur directly in the pharmacy or clinichallway.Circle of Care medication communication modelThe medication communication activities were mappedalong pathways between roles. This is illustrated bythe Circle of Care Medication Communication Model(Figure 4). The Circle of Care medication communi-cation model grew from an initial 50 communicationpathways between 11 roles from the literature to anintricate web of 252 communication pathways between50 roles (doctor to nurse, nurse to doctor counts as 2pathways). In order to capture communication path-ways between providers and sites, we made a distinc-tion between, for instance, the patient’s primaryfamily physician, and a family physician at a walk-inclinic. Similarly, we captured the pharmacy staff atthe patient’s primary pharmacy, as well as a secondarypharmacy.In terms of roles and medication communication path-ways, 11 of the 50 roles communicated with more than5 other roles, they are: patient (34 other roles), familyphysician (28), pharmacist (22), HCC nurse (15), MOA(13), specialist physician (12), CHC nurse (12), familymember (8), hospital ward doctor (8), hospital wardnurse (7), pharmacy technician (7), and EmergencyRoom (ER) doctor (6). These roles largely had pathwaysthat interconnected with each other. Most roles (39 of50) shared communication pathways with 5 or fewerroles. Examples of these roles are HCC home workers,case workers, support groups, and laboratory techni-cians. These pathways primarily connected with the pa-tient, family physician, pharmacist, and MOA.The combined list of roles and communication path-ways for all medication communication activities, alongwith roles and communication pathways for specificmedication communication activities, are provided asonline Additional file 1 and Additional file 2.Kitson et al. BMC Health Services Research 2013, 13:418 Page 6 of 10http://www.biomedcentral.com/1472-6963/13/418DiscussionThe medication communication frameworkThe Circle of Care medication communication modelplaces the patient at the centre of his or her own circleof care; family members, providers, and other roles arethen modeled around the patient as they collectively en-gage in medication communication activities. The deduct-ive and inductive data analysis helped us to recognize,draw out, and classify recurrent medication communica-tion activities, and related roles and pathways within thecircle of care. In addition to the activities that could bemapped to the medication management framework(determine need, prescribe, dispense, administer, monitor/evaluate), we identified Coordination of medication infor-mation as a key recurrent activity that may have been pre-viously overlooked.There are similarities and differences between our medi-cation communication framework, Manias’ MedicationCommunication Model [18], and Kuziemsky’s interdiscip-linary team communication framework [11]. In terms ofthe Medication Communication Model [18], our researchexplored some of the sociocultural and environmental fac-tors (antecedents) influencing medication communicationand outcomes of current (and potentially future) practice;in particular, we explored gaps in medication communica-tion, underlying challenges, and potential opportunities toimprove (these were out of scope for this paper). We alsoexplored the attributes of ‘who is speaking to whom aboutwhat’ when it comes to medication communication; how-ever, we did not specifically explore body language, theaspect of silence, or the actual words used. Another differ-ence is that our framework incorporates both asynchron-ous and synchronous communication pathways; whereas,the Medication Communication Model focuses on face-to-face communication. In terms of Kuziemsky’s inter-disciplinary team communication framework [11], ourframework incorporates aspects of internal and exter-nal structure (members of the care team, procedures, con-tacts) and communication channels. There is alignmentbetween the interdisciplinary team communication pro-cesses, and the medication communication activities weidentified (e.g., care planning and teaching are part of com-municating about Determine Need). Unlike Kuziemsky,however, our enquiry did not explore discharge planningspecifically. Similarly, our outcomes were focused on im-proving patient safety through improved medication com-munication; whereas, Kuziemsky’s framework looked atTable 2 Roles, pathways, and sub-activities formedication communication activitiesCommunicationactivityRoles Pathways Sub-activitiesDetermine need 20 54 •Discuss complaint•Discuss social context•Discuss non-medicinal andmedicinal options•Discuss plans and goals•EducatePrescribe 16 46 •Confirm patient identity•Provide medication information•Request, prepare, confirm, alertprescription/renewal•Request, confirm emergencysupply of medications•Review coverage•Request, discuss restrictions•Review prescribing alertsDispense 14 36 •Confirm patient identity•Provide medication information•Confirm medication availability•Request, prepare, confirm, alertdispensing•Review coverage•Request, discuss restrictions•Review, notify dispensing alertsAdminister 12 28 •Provide medicationadministration instructions•Schedule medicationadministration•Request, prepare, modify, clarifyDelegation of Task (for Home andCommunity Care)Monitor/Evaluate 47 200 •Confirm, request, review currentmedication details•Confirm, request, review pastmedication details•Discuss medication compliance•Request, provide, confirm allergyinformation•Discuss experience of side effects•Review medication efficacy•Request, confirm appointment•Request, order, review tests•Review self-monitoring•Confirm, request, review caretransitionsCoordinate 15 36 •Request, confirm appointmentsand referrals•Request, transmit patientinformationTable 2 Roles, pathways, and sub-activities formedication communication activities (Continued)•Relay messages betweenpatients and care providers•Request, confirm, alert coverageKitson et al. BMC Health Services Research 2013, 13:418 Page 7 of 10http://www.biomedcentral.com/1472-6963/13/418broader patient- and discharge-based outcomes. Themedication communication framework we created candraw from both the Medication Communication Modeland interdisciplinary team communication framework toadd further depth and breadth to our understanding ofmedication communication within teams and across thecontinuum of care.Implications for practice and researchThis research can help improve medication communica-tion activities within and between provider practices toimprove quality of patient care. Practitioners can drawfrom the medication communication resources we devel-oped as a guide to: identify specific coordination activities(and the roles responsible for them) within their organiza-tions as they relate to medication communication; and toexplore potential consequences (both good and bad) ofchanging existing medication communication practices.The guides can also be used broadly as a basis for identify-ing the opportunities to improve medication communica-tion activities across the patient’s circle of care.Researchers can help fill a gap in knowledge by design-ing future studies to explore medication communicationacross the continuum of care; these studies can expand,validate, and revise the resources we provide in thispaper, including exploring the differences in medicationcommunication pathways between integrated and non-integrated clinics. We have only scratched the surface toexplore the coordinating activity for medication commu-nication; additional studies could provide further insight.The use of observation was an essential component ofbeing able to unearth this tacitly held knowledge [24].Figure 3 A view of the Circle of Care Model that highlights only the coordinate communication activity. Solid lines represent directpathways of communication; whereas dotted lines reflect indirect connections. Abbrev: Medical Office Assistant (MOA); Home and CommunityCare (HCC).Kitson et al. BMC Health Services Research 2013, 13:418 Page 8 of 10http://www.biomedcentral.com/1472-6963/13/418Organizational communication practices are interactiveand socially embedded [25]; indirect pathways, such asthose reflected in the coordinate communication activity(and other tacit day-to-day activities), may be taken forgranted, but could be equally important in terms of theirpotential for error or improvement.Contribution to new knowledgeThis patient-centric research contributes to the know-ledge of what is known about medication communica-tion across the continuum of care. We built a medicationcommunication framework, a Circle of Care medicationcommunication model, and a taxonomy of medicationcommunication; future studies can expand, validate, andrevise these resources. Further, this research fills a gap inknowledge by drawing attention to the ‘coordinate com-munication’ activity. This activity has the potential to betaken for granted as it can represent an embedded processthat can be institutionalized over time.LimitationsThis study was limited to community providers andpatients within one city. Further, observation of com-munication activities occurred within the CommunityHealth Centre only and not within the larger commu-nity itself. We used a limited set of simulated patientcases (three). Additional cases or characteristics couldreveal other communication pathways and activitiesnot yet represented in the model, for instance, furtherexploring transitions between the community, acutecare, and long-term care facilities. This study was ex-ploratory and qualitative; we did not attempt toquantify the frequency or impact of the various com-munication activities.ConclusionsThrough the use of an exploratory approach, Circle ofCare Modeling, we were able to unearth tacitly heldknowledge to expand our understanding of medicationcommunication across the continuum of care. Thisknowledge can be used to improve the quality of patientcare through the identification and improvement ofmedication communication gaps and the design ofhealth information systems (HIS). Drawing out the co-ordinate communication activities in the medicationcommunication framework could be a missing piece forus to better understand how to streamline multi-stepprocesses. Better understanding of this activity couldalso help us anticipate some of the unintended conse-quences of improvement processes, for instance, if tacitactivities are not taken into account.ConsentWritten informed consent was obtained from the patientfor the publication of this report and any accompanyingimages.Additional filesAdditional file 1: Supplementary materials: Taxonomy of medicationand communication activities.Additional file 2: Supplementary materials: Medicationcommunication activities - roles and pathways.FamilyPhysicianPatientDetermine NeedPrescribeAdministerMonitorMonitorCoordinateDetermine NeedMonitorCoordinateFigure 4 Circle of Care medication communication model.Kitson et al. BMC Health Services Research 2013, 13:418 Page 9 of 10http://www.biomedcentral.com/1472-6963/13/418Competing interestsThe authors declare that they have no competing interests.Authors’ contributionsNK carried out the fieldwork and drafted the manuscript. MP and FLconceived of the study. MP designed and coordinated the study, anddrafted the manuscript. GS engaged in the initial literature review andparticipated in persona design. FL provided detailed feedback to themanuscript. All authors read and approved the final manuscript.AcknowledgementsThank you to Mingquan Yang, RN, and Michael Bowen, MSc for theircontributions to this study. Thank you to the patients and community healthcare providers for participating in this study. We gratefully acknowledgefunding through the PhORSEE committee and the BC College ofPharmacists.Author details1eHealth Observatory, Health Information Science, University of Victoria, STNCSC, PO Box 3050, Victoria, BC V8W 3P5, Canada. 2Department of FamilyPractice, University of British Columbia, 3rd Floor David Strangway Building,5950 University Boulevard, Vancouver, BC V6T 1Z3, Canada.Received: 3 April 2013 Accepted: 30 September 2013Published: 17 October 2013References1. 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