The Operational Risk Management (ORM) Approach to Medication Adherence

Medication non-adherence is a critical issue in healthcare, contributing to approximately 125,000 deaths and $100 billion in costs annually in the United States alone, particularly for chronic diseases. Some of you may have a military background and are familiar with operational risk management (ORM). ORM has been successfully deployed by the US military at the tactical level to minimize risks to an acceptable level. Tactical ORM includes the ABCD approach--Assess, Balance Resources, Communicate, and Do and Debrief—healthcare providers can systematically tackle adherence barriers. Over the next 4 posts I will discuss how to apply ORM to medication adherence. I welcome your feedback. By using the ABCD model healthcare providers can pinpoint along the ABCD path where improvements need to be made.

A: Assess
The first step to apply ORM to medication adherence is to Assess the patient for medication adherence. The minimum healthcare outcomes should include the degree of non-adherence, and the dimension of intentional or unintentional non-adherence. There are several methods to assessing this risk. Analyzing prescription refill patterns provides an objective measure of adherence. For example, frequent gaps between refills may indicate unintentional non-adherence due to forgetfulness or financial constraints, while consistent early refills might suggest hoarding or intentional overuse. Tools like smart pill bottles or medication event monitoring systems (MEMS) track the exact timing and frequency of dose-taking. These devices offer real-time data, revealing unintentional non-adherence (e.g., missed doses) or intentional patterns (e.g., skipping doses on weekends), and are ideal for patients with complex regimens. Measuring drug levels in blood or urine provides a direct assessment of adherence. For instance, low levels of an antihypertensive medication might indicate non-adherence, whether intentional (due to side effects) or unintentional (due to missed doses). In controlled settings, such as nursing homes or clinical trials, observing patients taking their medication can confirm adherence. This method is expensive and less practical. There are validated tools that can explore adherence barriers in depth.like the MMAS-8, a widely validated 8-item self-report scale, and the gold standard for measuring medication-taking behavior. It categorizes adherence as low, medium, or high and distinguishes between intentional non-adherence (e.g., deliberately skipping doses due to side effects or beliefs) and unintentional non-adherence (e.g., forgetting doses or logistical challenges).

If you haven’t uncovered the degree of medication non-adherence and the intentional or unintentional domain of non-adherence then you need to redo the assessment.

​By starting with a detailed assessment, providers can lay the groundwork for tailored interventions, addressing both intentional and unintentional barriers. Stay tuned for the next post, where we’ll explore how to “Balance Resources” to support these efforts. For more on MMAS-8 and MAAP, visit www.moriskyscale.com.

​Disclaimer: Use of the MMAS-8 requires permission due to copyright protection. Contact Dr. Donald Morisky via www.moriskyscale.com for licensing details.