Designing a computerized decision support system for asthma chronic disease management in community pharmacies

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Aim: Herein, we sought to adapt and optimize the eAMS for implementation in community pharmacy practice. Methods: We iteratively developed a system prototype (the eAMS- Pharm ) with input from clinical pharmacists, and asthma, knowledge translation, and eHealth experts. After face-validation by three external community pharmacists, we used a rapid-cycle development process for optimization of system functionality/design, content, and user workflows. This involved a sequential and repeated three-stage process: (1) system prototype demonstration and testing in 90 minute, semi-structured virtual focus groups with target end-users; (2) analysis of focus group findings; and (3) corresponding modifications to the prototype, then re-testing in another focus group. This process continued until we reached pre-defined stopping criteria. We used a questionnaire to gather demographic information and further usability data and feedback. Community pharmacy team members were recruited from an existing pharmacy database. Results: Stopping criteria were met after six focus group cycles with 28 participants [23 (83%) pharmacists, 4 (14%) registered pharmacy technicians/assistants, and 1 (3%) pharmacy student]. User feedback and corresponding system improvements spanned usability, workflow, and prescriber communication domains. The optimized system consisted of a pharmacy portal with a patient dashboard, patient and provider versions of a point-of-care questionnaire, an interactive CDSS producing guideline-based recommendations, automated documentation, and pre-formatted prescriber communications. The System Usability Scale score was 82.9 ± 16.8 (maximum 100), and user responses to Likert scale-based assessments of eAMS-Pharm format, content, workflow, impact, and overall impressions were highly favorable. Conclusion: We built and optimized a chronic disease CDSS for use in community pharmacies, identifying and addressing pharmacy-specific barriers to implementation. The system achieved a high system usability score and highly favorable ratings for perceived system benefits, likelihood of clinical use, and patient benefits. The eAMS-Pharm can now be evaluated for uptake, care impact, and outcome impact in real-world settings. Our findings surrounding users’ usability, workflow, and content preferences, and our unique development strategy, can also inform future pharmacy-based chronic disease CDSS design. clinical decision support system asthma care chronic disease management pharmacy practice Figures Figure 1 Figure 2 Figure 3 Figure 4 INTRODUCTION Significant gaps exist between optimal, guideline-directed medical care and the care that patients actually receive in the real-world, most prominently in chronic diseases [1–5]. These care gaps result from several barriers, including the rapid pace of scientific advancements outstripping providers’ available time [6], and the corresponding increasing complexity of chronic disease care. With rising uptake of electronic tools in healthcare settings, computerized clinical decision support systems (CDSSs) may present a generational opportunity to address chronic disease care gaps by bridging the critical knowledge and time barriers faced by today’s primary care providers [7,8]. However, access to primary care remains severely limited in modern health systems [9]. At the same time, the pharmacy profession is undergoing an unprecedented expansion in the scope of care delivery in many countries worldwide [10]. As highly trained and accessible front-line healthcare professionals, pharmacists see patients up to ten times more frequently than patients see their family physician [11]. Pharmacist-led clinical interventions have already been shown to improve outcomes in chronic disease populations such as diabetes [12], hypertension [13], and those at risk for cardiovascular disease [14]. As pharmacists engage in a broader spectrum of chronic disease care, there is a growing need for empowerment, by equipping pharmacists with timely and accurate knowledge, delivered through simple, efficient, and integrated workflows – capabilities that computerized clinical decision support systems (CDSSs) are designed to provide. Asthma exemplifies a chronic disease with persistent care gaps, with only 15% of patients receiving formal assessment of disease control, 15% receiving guideline-based pharmacotherapy escalation, virtually no patients receiving a self-management asthma action plan, and only half of those with severe disease receiving referral to specialist services [5,15]. The Electronic Asthma Management System (eAMS) is an evidence-based CDSS designed for clinic-based providers, demonstrated to effectively bridge these care gaps in real world primary care clinics [16], updated with each new guideline iteration, and used widely in clinic settings. Aim We sought to adapt and systematically optimize the eAMS for implementation in community pharmacy practice. Herein, we report findings from that process, which provide insights into ideal design and workflow considerations for chronic disease CDSSs in pharmacies. METHODS The eAMS consists of a CDSS integrated within the primary care electronic medical record system. It was developed through iterative feedback from primary care physicians, asthma educators, pulmonologists, and patients with asthma, and tested and refined in large primary care group practice settings [16]. The tool receives and processes data from a patient questionnaire to present asthma guideline-based [17] decision support for the provider at the point-of-care, including asthma control level, corresponding medication optimization recommendations, an auto-populated, personalized asthma action plan (AAP), and a prompt to refer to specialty care for severe asthma (if applicable). It also features a registration-only patient smartphone/tablet app or PC-based portal where patients (aged ≥ 16 years) can access and complete the patient questionnaire, see their AAP after approval, and access self-directed web-based education. Using this clinic-based tool as our model and applying an integrated knowledge translation framework featuring end-user engagement in content and design formulation [18], we employed a 2-step process to adapt system functionality, content, and workflows for pharmacy settings, to develop the Electronic Asthma Management System for Pharmacies (eAMS-Pharm). Step 1: eAMS-Pharm Prototype Development We started by building a prototype of the system by adapting the eAMS. This process entailed a detailed analysis of the eAMS with input from the co-investigator team (composed of five clinical pharmacists, the asthma/knowledge translation expert physician who led eAMS development, and two team members who led prior eAMS clinic implementations), to identify user end-points, workflows, and information flows that would require adaptation for community pharmacy settings. The group suggested required changes to each element, which were then translated to the core software development team. The software team made corresponding changes, presented them serially to the co-investigator group, and iteratively improved the system based on co-investigator feedback. Each system change was tested extensively, using a database of 258 real-world clinical scenarios to ensure that workflows and system advice remained accurate and guideline concurrent. We utilized a simplified version of the eAMS patient-facing questionnaire, which was co-developed with [19] and validated in patients with asthma [16,20,21]. Finally, this prototype was tested by three practicing community pharmacists (face validation), who provided further iterative feedback, enabling additional system refinements. Step 2: Rapid Cycle Design Process Using the refined eAMS-Pharm prototype, we then conducted optimization of system functionality/design, content, and user workflows through a rapid-cycle design process. This involved identifying and addressing target end-user preferences and practical concerns via incremental analysis [18,22], through a sequential and repeated three-stage process: (1) system prototype demonstration and testing focus groups with target end-users; (2) analysis of focus group findings for emergent and critical findings (see definitions below); and (3) corresponding modifications of the prototype, before re-testing in another focus group. Focus Groups Participants and Recruitment Based on our previous work [20,21], we estimated that 3-6 focus group rounds involving 4-6 participants per round (25-30 participants in total) would be required. Participants were recruited by email invitation (inviting pharmacists with prior clinical experience in asthma), through the University of Toronto Faculty of Pharmacy Clinical Preceptor Database, which consists of registered pharmacists from across Ontario working full-time with at least 2 years’ practice experience, and through snowball recruitment through participants’ networks. We included any of the following community pharmacy team members: registered pharmacists, registered pharmacy technicians, pharmacy assistants, and pharmacy students. We employed purposive sampling to achieve participant heterogeneity with respect to sex, years in practice, and pharmacy business model. Focus group participants received a $100 honorarium for their time. Focus Group Structure Each focus group was 90-minutes in duration, held virtually, facilitated by two moderators with facilitating/interviewing experience, and attended by a pharmacist co-investigator (TN). Sessions employed a semi-structured format, following a moderator script. Participants completed an electronic questionnaire collecting demographic data and system feedback immediately after the focus group. The moderator script and questionnaire were reviewed by all investigators and an external qualitative research expert, then piloted in a mock focus group with fellow researchers to ensure clarity and appropriate duration. Focus Group Content Following introductions, participants were explained the background, purpose, and core workflow of the eAMS-Pharm, followed by a live demonstration of the prototype (with any changes incorporated from previous cycles). The focus group script elicited user preferences and recommended changes across functionality (e.g., format, design), content (e.g., feature optimization and additional features required), and workflows (e.g., usability). Individual participant suggestions/opinions were reflected to other participants to elicit group preferences on suggested changes. Issues with divergent opinions from prior focus groups were specifically raised in subsequent focus groups until there was a clear directional consensus. In cases where critical system changes had been suggested in prior rounds, mockups were sometimes presented in subsequent focus groups for further feedback, before finalizing system changes. The post-focus group questionnaire consisted of demographic questions and Likert scale-based assessments of eAMS-Pharm format, content, workflow, impact, and overall impressions. The System Usability Scale (SUS), a validated, 10-item Likert scale questionnaire used widely to assess perceived usability of a system or tool, was administered as a measure of global system usability [23]. Analysis Rapid-Cycle Analysis Focus groups were audio-recorded, anonymized, and transcribed verbatim. After each session, each moderator reviewed transcripts, field notes, and the post-focus group questionnaire to identify quotes referencing functionality, content, and/or workflow-related issues, along with potential solutions suggested by focus group participants. These quotes were organized into categories, then first reviewed by the moderator and the pulmonologist/knowledge translation expert (SG) to identify emergent findings and possible critical changes, and then re-reviewed with the pharmacist/pharmacy science expert (JK) to reach a final consensus on emergent/critical findings. A priori, we defined critical changes as those that all participants in a single focus group or most participants across multiple focus groups agreed to and/or that the investigator team and moderators agreed were likely to be broadly representative, required a change to address, and were feasible to implement. Emergent findings were those expressed by more than one participant across a single focus group or across two or more focus groups which were not deemed by co-PIs, the analyst and/or the moderator to meet the threshold for a critical change. Emergent findings could be considered critical changes after appearing in two or more focus groups. Critical changes were implemented after each focus group cycle (with retesting after any system changes). Our pre-set stopping criterion was three rounds and until no new critical changes emerged from a single focus group cycle [20,21]. Questionnaire Analysis We provide quantitative summary statistics of questionnaire data, including the summative SUS score and graphical representation of Likert-scale responses. RESULTS Step 1: eAMS-Pharm Prototype Development The eAMS-Pharm prototype was developed collaboratively, then further improved after real-world face-validation (above). It consisted of: 1) a pharmacy portal providing a) access to a dashboard of all registered patients (with ability to email/text any patient a link to the full length patient questionnaire), b) ability to register new patients, c) access to an alternative short (7-question) questionnaire to complete with patients at the point-of-care, and d) an interactive CDSS that processes questionnaire data in real-time to categorize disease control and exacerbation risk, provide corresponding pharmacotherapy adjustment guidance, a summary note, an asthma action plan, and a prescriber letter with sign-back request (or a pharmacist prescription if sign-back was not needed); 2) a full-length patient-facing questionnaire accessible through a publically available website; and 3) a patient portal where patients who choose to register can access and complete the full length patient questionnaire, see their latest asthma action plan (once approved by the provider), and access educational content (e.g. audio/visual glossary, inhaler videos, etc.) (Figure 1). Compared to the eAMS used in clinic settings, changes made during eAMS-Pharm prototype development included: 1) creating a publicly available version of the patient questionnaire, whereby patients no longer had to register for the portal in order to access the system (to reduce barriers to questionnaire completion and improve efficiency in the busy pharmacy environment); 2) creating a short questionnaire version for a pharmacy team member to complete with the patient at the point-of-care (to enable the pharmacy team to make use of the system even if the patient had not self-completed the questionnaire); and 3) adding an option to output a pre-formatted letter addressed to the patient’s primary prescriber, indicating prescription change request(s), justifications, and a copy of the AAP (if applicable), for approval and sign-back (because pharmacists in most jurisdictions do not have authorization to make all inhaler changes independently). Step 2: Rapid-Cycle Design Process Participants We conducted six sequential focus group cycles until stopping criteria were met. These included 28 pharmacy team members, consisting of: 23 (83%) pharmacists, 3 (11%) pharmacy technicians, 1 (3%) pharmacy assistant, and 1 (3%) pharmacy student (Table 1). Among pharmacists, 8 (35%) were pharmacy owners/associates and 3 (13%) were pharmacy managers. Table 1. Focus group participant background and demographic information (n = 28) Characteristic Number (%) Sex Male 12 (43) Female 16 (57) Age in years ≤24 01 (4) 25-30 06 (21) 31-40 11 (40) 41-50 04 (14) 51-60 06 (21) Role in pharmacy Pharmacist 23 (82) Pharmacy Technician/Assistant 04 (14) Pharmacy Student 01 (4) Highest level of education Completed college 3 (11) Completed university (e.g. BSc, BScPhm) 14 (50) Completed a PharmD 9 (32) Completed any other post-graduate program (e.g. MSc, PhD) 2 (7) Time since completing most recent degree Less than 5 years ago 08 (29) 5-10 years ago 05 (18) 11-15 years ago 04 (14) 16-20 years ago 03 (11) 21-25 years ago 02 (7) More than 25 years ago 06 (21) Pharmacy type Chain 12 (42) Banner 1 (4) Independent 9 (32) Academic Pharmacy 5 (18) Outpatient Hospital Pharmacy 1 (4) Monthly Pharmacy Prescription Volume ≤1000 9 (33) 1001-2000 2 (7) 2001-3000 4 (14) 3001-4000 4 (14) 4001-5000 2 (7) >5000 7 (25) Rapid-Cycle Analysis We summarize and categorize critical findings from focus groups, and corresponding changes made to the eAMS-Pharm in Table 2. Table 2. Critical Findings and Corresponding System Modifications Category and Subcategory Critical Finding Requiring Action Corresponding System Modifications System Usability (a) Patient Identifiers (FG5) Requirement to quickly differentiate patients with similar names Addition of date of birth as a patient identifier in the main pharmacy dashboard, below first name/last name (b) System Instructions (FG3, FG5) User confusion about the purpose and expected results of certain clickstreams Addition of specific reasoning and expected outcomes for each relevant system workflow; editing to improve clarity (c) Medication History (FG1, FG2) Concern regarding difficulty in entering current patient medications (including concerns about accuracy of data in the pharmacy management system) Addition of a visual aid at the point of patient medication entry with images of all asthma medications, to assist in confirming medications at the point-of-care (d) Insurance Coverage Information (FG1) Desire to know which therapeutic options were covered by public insurance Addition of visual indicators indicating public drug coverage at the point of medication change selection in the CDSS (e) Warning Fatigue (FG5) Concern that red text used in warnings was alarming, and that frequency of warnings would result in warning fatigue Modification of less essential warnings to black text, reduction in warning text length, elimination of certain warning messages System Workflow (a) Remaining Action Alerts (FG4, FG5) Desire to quickly identify patients requiring further pharmacy team and/or prescriber actions Addition of a column containing color-coded follow-up flags with “due dates” in the main pharmacy dashboard (b) Follow-Up Reminders (FG5) Desire to create a self-reminder for pharmacy team members to follow-up with certain patients after system use Addition of a column with a clickable calendar for setting a follow-up reminder date (c) Prescriber Disagreement Management (FG5) Need for ability to document and discard prescription change recommendations and/or asthma action plan if the prescriber disagrees Addition of a button to discard current recommendations/action plan after prescriber sign-back, and automated documentation for this workflow (d) Reset Functionality (FG5) Need to reset the system (i.e. start from beginning) in instances where the system recommendation is rejected by the patient/prescriber and/or the pharmacy team wants to re-initiate patient questionnaire Addition of a “Restart” button and corresponding functionality next to each patient name in the main pharmacy dashboard (e) Documentation/Billing (FG1, FG3, FG5) Desire for automatically generated documentation for medico-legal and billing purposes Modification of the automated system usage summary note and prescriber letter to meet medico-legal requirements for pharmacy documentation, documentation of patient consent, and documentation required for billable services (including pharmacy billing codes) Prescriber Communication (a) Customized Messaging (FG2, FG5) Need to address prescriber letter to a specific prescriber, and desire to include a custom message Addition of an optional free text field to add letter addressee, and optional text box for inclusion of any desired customized messaging (b) Pharmacy Role Justification (FG4, FG5) A desire to alter tone of prescriber letter to indicate the pharmacy’s role in, and qualifications for, shared care Inclusion of wording such as “our mutual patient” and addition of pharmacy team member credentials within prescriber letter (c) Communication Formatting (FG3, FG5) Concern that busy prescribers may overlook key information in the prescriber letter Changing prescriber letter title to specify that new prescriptions were being requested; addition of key pharmacy information to letter header; use of bold face to emphasize key action points (e.g. prescription changes); relocation of key information (e.g. patient name) to more prominent areas; cutting text (d) Information Prioritization (FG3) Preference to prioritize the action item (e.g. prescription change request) within prescriber letter Modification of prescriber letter to include the prescription change request on page 1, while simplifying and moving the change request justification to page 2 (e) Facilitating Prescriptions (FG1, FG5) Concern that providers would not recall required public insurance coverage codes for certain medications Automated addition of special public insurance code checkboxes with description/expiry to prescriber letter, where applicable (f) Enabling Prescriber Documentation in Cases of Disagreement with Pharmacy Recommendations (FG5) Need to enable prescribers to indicate any disagreement with prescriber letter medication change recommendations and/or asthma action plan medication recommendations Modification of prescriber letter to include a “disagree” option next to each medication Figures 2 and 3 display serial changes made to the eAMS-Pharm main pharmacy dashboard and prescriber letter, based on focus group findings. Questionnaire Analysis Feedback questionnaires were received from all pharmacy team members involved in the focus groups. The mean System Usability Scale (SUS) score was 82.9 ± 16.8 (maximum score: 100). Figure 4 presents focus group participants’ responses to Likert scale-based assessments of eAMS-Pharm format, content, workflow, impact, and overall impressions. Responses were similar across pharmacy types. DISCUSSION We applied a systematic, theory-based approach to optimize an existing asthma CDSS (the eAMS ) used in primary care clinics, to align with the environment, workflow, and differing needs and preferences of community pharmacy teams. The system achieved a high system usability score and highly favorable ratings for perceived system benefits, likelihood of clinical use, and patient benefits. Most changes and adaptations identified and made would be applicable to other pharmacy-based care of chronic disease. CDSSs have been studied extensively in primary care [24]. Pharmacists have also used such systems to support drug safety [25] and are now more frequently using them to prescribe for acute self-limiting conditions [26,27]. However, pharmacists are also increasingly being called upon to co-manage chronic illnesses [12–14], and although CDSSs would be ideally suited to tackle the greater knowledge gaps, complexity and time required, little is known about the availability, ideal design, and effectiveness of such systems in pharmacies [28]. A prior systematic review of pharmacy CDSSs concluded that existing systems were prone to failure due to a lack of sociotechnical considerations for managing workload and workflow, and that research in community pharmacy CDSSs was “limited and disjointed,” with insufficient focus on factors enabling optimization of CDSS utilization [28]. Indeed, the broader CDSSs literature has found that these systems are underused when not designed with their intended end-users in mind [29], which has been a key factor limiting their clinical impact [24]. Accordingly, pharmacy team user preferences for chronic disease CDSS content and design identified herein fill a gap in the literature which can inform future system design, across diseases. System Usability. Many user requirements and corresponding changes made during our rapid-cycle design process centered on system usability. For example, changes made to improve and facilitate patient identification within the system will likely improve user efficiency, and mirror priorities identified for an acute lower back pain pharmacy CDSS [27]. Similarly, user-directed tailoring of system warnings will help to reduce warning fatigue, associated with override rates as high as 88% in pharmacy drug interaction warning systems [28] and over 90% in the physician ambulatory setting [30,31]. Users were also concerned about their ability to accurately identify patients’ current medications. Although these data should be retrievable in the pharmacy management system (PMS), studies show that up to 43% of patients frequent multiple pharmacies [32], rendering an accurate current medication use history (a requirement for accurate chronic disease CDSS guidance) a challenge in jurisdictions that do not share a single health record. Given that inhalers come in distinct shapes and sizes that are often recognizable to patients, participants recommended an integrated visual medication chart for point-of-care use. This is akin to online “pill identifier” [33] systems and AI-supported medication image recognition tools [34] which fulfil the same purpose for pills, and thus should be a feature of any future CDSS targeting a disease treated with oral medications. The fact that this gap had not been identified by our prototype development team highlights the importance of including diverse interprofessional pharmacy team members (including technicians and assistants) in the design of any future pharmacy CDSS. Finally, users requested integrated coverage information for public drug formularies. Indeed, prior studies of prescriber-facing CDSSs have shown that this improves medication accessibility and reduces cost burden [35]. Although jurisdictional differences in public drug coverage will often require correspondingly tailored CDSS content, the addition of easily accessible formulary information reduces the likelihood of selecting CDSS-recommended medications that some patients will not be able to procure. System Workflow. We made several adaptations to the intrinsic workflows within the eAMS-Pharm prototype to meet the needs of various patient/pharmacist encounter types that occur within community pharmacies. Focus group participants indicated concerns that they could easily lose track of various patients for whom they used the system, and particularly patients for whom prescriber approval was pending. Accordingly, we designed a flag-based visual reminder system to indicate which patients had prescriber or pharmacist actions remaining. This is in line with preferences identified in a previous study of an acute self-limiting low back pain [27] CDSS in community pharmacies, and aligns with recommendations for visual progress indicators in CDSS design [36]. Relatedly, participants wished to identify patients who could benefit from a follow-up assessment, and to set a self-reminder to initiate this follow-up. This was achieved through the addition of a follow-up calendar, with date selection resulting in the appearance of a visual date reminder in the pharmacist dashboard. Unlike minor and/or acute ailments that are currently more commonly managed in pharmacy settings, transition to chronic disease care will indeed require a shift towards repeated serial touchpoints to enable iterative therapeutic optimization [37]. In a prior review of pharmacy-initiated diabetes medication reviews [38], only 17.5% of patients received follow-up care after the initial assessment, demonstrating the need for such functionality in CDSSs. Next, users indicated the importance of facilitating documentation and clinical billing workflows in order to offset the time required to use the CDSS itself. Given the high patient throughput and importance of limiting patient wait times in the community pharmacy model, automation of downstream tasks such as documentation and billing will likely be critical determinants of CDSS uptake, both for point-of-care efficiency, and to incentivize use by increasing chances of remuneration [25]. As artificial-intelligence-based systems for pharmacy documentation and billing workflows become more mature, they may be integrated with CDSSs to further facilitate these tasks. Prescriber Communication. In all focus groups, participants noted the importance of managing and preserving their relationships with prescribers, particularly given that sending chronic disease care recommendations represents a paradigm shift. Specific feedback on the prescriber communication letter led to numerous adjustments, including changes to formatting, information ordering, and edits for readability and clarity. Users also requested a free-text field to add customized messages to prescribers, which they envisioned often using to justify their clinical intervention. Similarly, they valued the credibility afforded by citing the evidence-based guidelines upon which the CDSS was based, information about the origins and development of the CDSS itself, and a summary of the patient’s guideline-based disease control level that triggered the prescription change request. Although existing standards are available to guide pharmacists in physician communication surrounding routine tasks such as renewal requests[39], our findings provide novel insights into preferences for the more sensitive task of communicating chronic disease care recommendations. In fact, physician surveys have identified positive attitudes towards collaborative care with community pharmacists, and particularly their roles in patient education, drug safety, and adherence [40]. Collaborative models in which pharmacists and physicians communicate regularly have also been shown to enhance patient outcomes, particularly in ambulatory and chronic care settings [14,40,41]. In the context of the alarming gaps in primary care access in the community [9] and the corresponding regulatory changes to expand pharmacists’ scope of practice, pharmacists do self-perceive the importance of their evolving role in clinical care [42–44]. However, studies have also suggested that pharmacists are concerned that physicians perceive them to have a more perfunctory role as dispensers of medication [45]. This indicates the importance of careful user-centered and user-preference sensitive design for any pharmacist-initiated chronic disease treatment recommendations, to address perceived and real barriers to physician acceptance. In acknowledging and systematically addressing the above concerns in our tool design through our rapid-cycle design process, we achieved high user ratings across content, format, and usability domains of the eAMS-Pharm (Figure 4). This was reflected in our high System Usability Scale (SUS) score (83/100), which is well above the mean SUS score of 68 across 500 systems, and corresponds to a qualitative rating between “Good” and “Excellent” along with high overall acceptability [46]. Correspondingly, a vast majority of participants (86%) were confident in their ability to use the tool, including both ensuring that most patients would complete the patient-facing questionnaire (86%) and consistently completing corresponding decision support steps (86%). More broadly, all participating pharmacy members believed that pharmacists have a role to play in chronic disease care, and almost all believed that the tool would enhance their ability to provide better care. Most (89%) also endorsed that patients would perceive that they received better care from the pharmacy as a result of the eAMS-Pharm, whereby customer satisfaction and resulting loyalty enhance the business case for system use. The SUS results suggest that, from the users’ perspective, the system is not only effective and efficient but also delivers a favorable user experience. The main limitation of the current study is the use of focus groups with a simulated use environment for system feedback. Although we achieved stopping criteria and had high user ratings, a follow-up study will be required to assess how this translates to real-world uptake and benefit in the complex pharmacy setting. Our sample represented diverse sex, age, and work experience subgroups, and a wide range of pharmacy throughputs (by prescription volume). In terms of pharmacy business model representation, most participants were from chains and independents, with fewer from banner, hospital, and academic pharmacy models (this is reflective of the current Canadian pharmacy landscape). Accordingly, further research is needed to ensure that our findings reflect the priorities of pharmacy team members in the latter settings as well. CONCLUSION The convergence of increasing use of CDSSs in healthcare with a growing role for pharmacies in complex chronic disease care creates an urgent need for chronic disease CDSSs with high levels of acceptability and usability for pharmacy team members. Although existing pharmacy CDSSs have had limited uptake due to suboptimal design [25,28], we demonstrated that a clinic-based asthma CDSS can be successfully adapted to pharmacy settings by applying user-centered design principles and stakeholder engagement (co-development), along with rapid-cycle iteration. Not only can these methods be emulated in future system development, but through this process, we also generated important insights regarding content, format, and workflows required to overcome uptake barriers that may be applicable across chronic disease CDSSs for pharmacies. CDSS developers can use our findings to guide system design and development, before testing chronic disease CDSSs prospectively for uptake, and impact on care processes and patient outcomes. Declarations FUNDING DECLARATION Funding statement: This work was funded by the Unity Health Toronto Research Innovation Council Award, University of Toronto Dalla Lana School of Public Health New Initiatives and Innovation Award, Canadian Foundation for Pharmacy Innovation Fund. COMPETING INTERESTS Author SG led the original eAMS development and has eAMS intellectual property rights. Other authors declare no conflicts of interest. AUTHOR CONTRIBUTIONS Tony Ning (Conceptualization, Data acquisition, Data Curation, Analysis, Writing – original draft, Writing – review and editing); Terry Li (Data acquisition, Data Curation, Analysis, Writing – review and editing); Jamie Kellar (Methodology, Data Curation, Writing – review and editing); Mina Tadrous (Writing – review and editing); Natalie Crown (Writing – review and editing); Lisa Dolovich (Writing – review and editing); Samir Gupta (Conceptualization, Data Curation, Supervision, Writing – review and editing, funding acquisition) DATA AVAILABILITY The datasets generated and/or analysed during this study can be made available upon reasonable request and ethics approval. Ethics approval The study was approved by the research ethics board at the University of Toronto (#46441) and each participant provided written informed consent. CONSENT TO PARTICIPATE Informed consent was obtained from all individual participants included in the study. 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Canadian Thoracic Society 2021 Guideline update: Diagnosis and management of asthma in preschoolers, children and adults. Can J Respir Crit Care Sleep Med. 2021;5:348–61. https://doi.org/10.1080/24745332.2021.1945887 Johnson K, Ewigman B. Using Rapid-Cycle Research to Reach Goals: Awareness, Assessment, Adaptation, Acceleration. 2015 [cited 2025 Oct 9]. https://www.semanticscholar.org/paper/Using-Rapid-Cycle-Research-to-Reach-Goals%3A-Johnson-Ewigman/a2d2b2e33007984e85c9c7cab5e52157a7a0d1f2. Accessed 9 Oct 2025 Gupta S, Lam Shin Cheung V, Kastner M, Straus S, Kaplan A, Boulet L-P, et al. Patient preferences for a touch screen tablet-based asthma questionnaire. J Asthma Off J Assoc Care Asthma. 2019;56:771–81. https://doi.org/10.1080/02770903.2018.1490750 Gagné M, Lam Shin Cheung J, Kouri A, FitzGerald JM, O’Byrne PM, Boulet L-P, et al. A patient decision aid for mild asthma: Navigating a new asthma treatment paradigm. Respir Med. 2022;201:106568. https://doi.org/10.1016/j.rmed.2021.106568 Lam Shin Cheung V, Kastner M, Sale JE, Straus S, Kaplan A, Boulet L-P, et al. Development process and patient usability preferences for a touch screen tablet-based questionnaire. Health Informatics J. 2020;26:233–47. https://doi.org/10.1177/1460458218824749 Kitzinger J. Qualitative Research: Introducing focus groups. BMJ. British Medical Journal Publishing Group; 1995;311:299–302. https://doi.org/10.1136/bmj.311.7000.299 Brooke J. SUS—a quick and dirty usability scale. In: Jordan PW, Thomas B, Weerdmeester BA, et al. (eds) Usability evaluation in industry. London: Taylor and Francis, 1996, pp. 189–194. Kwan JL, Lo L, Ferguson J, Goldberg H, Diaz-Martinez JP, Tomlinson G, et al. Computerised clinical decision support systems and absolute improvements in care: meta-analysis of controlled clinical trials. BMJ. British Medical Journal Publishing Group; 2020;370:m3216. https://doi.org/10.1136/bmj.m3216 Curtain C, Peterson GM. Review of computerized clinical decision support in community pharmacy. J Clin Pharm Ther. 2014;39:343–8. https://doi.org/10.1111/jcpt.12168 MAPFlow Inc. MAPflow - Efficient and Effective Minor Ailment Prescribing [Internet]. 2023. https://www.mapflow.ca/ Cutler TW, et al. An Electronic Clinical Decision Support System for the Management of Low Back Pain: Intervention Development and Mixed Methods Usability Evaluation. JMIR Med Inform. 2020;8:e17203. https://doi.org/10.2196/17203 Moon J, Chladek JS, Wilson P, Chui MA. Clinical decision support systems in community pharmacies: a scoping review. J Am Med Inform Assoc JAMIA. 2023;31:231–9. https://doi.org/10.1093/jamia/ocad208 Kouri A, Yamada J, Lam Shin Cheung J, Van de Velde S, Gupta S. Do providers use computerized clinical decision support systems? A systematic review and meta-regression of clinical decision support uptake. Implement Sci. 2022;17:21. https://doi.org/10.1186/s13012-022-01199-3 Isaac T, Weissman JS, Davis RB, Massagli M, Cyrulik A, Sands DZ, et al. Overrides of medication alerts in ambulatory care. Arch Intern Med. 2009;169:305–11. https://doi.org/10.1001/archinternmed.2008.551 Chui M. Evaluation of Online Prospective DUR Programs in Community Pharmacy Practice. J Manag Care Pharm. Academy of Managed Care Pharmacy; 2000;6:27–32. https://doi.org/10.18553/jmcp.2000.6.1.27 Look KA, Mott DA. Multiple pharmacy use and types of pharmacies used to obtain prescriptions. J Am Pharm Assoc JAPhA. 2013;53:601–10. https://doi.org/10.1331/JAPhA.2013.13040 Drug I.D. - UpToDate® Lexidrug TM [Internet]. [cited 2025 Aug 11]. https://online-lexi-com.myaccess.library.utoronto.ca/lco/action/drugid. Accessed 11 Aug 2025 Liu C, et al. Identification of medications using artificial intelligence: recent advances and challenges. NPJ Digit Med [Internet]. 2019; https://doi.org/10.1038/s41746-019-0086-0 Fischer MA, et al. Impact of Electronic Prescribing With Formulary Decision Support on Medication Cost and Use. JAMA Intern Med [Internet]. 2008; https://doi.org/10.1001/archinte.168.3.243 Nielsen J. Enhancing the explanatory power of usability heuristics. Proc SIGCHI Conf Hum Factors Comput Syst [Internet]. New York, NY, USA: Association for Computing Machinery; 1994 [cited 2025 Sept 11]. p. 152–8. https://doi.org/10.1145/191666.191729 MacCallum L, Dolovich L. Follow-up in community pharmacy should be routine, not extraordinary. Can Pharm J CPJ. 2018;151:79–81. https://doi.org/10.1177/1715163518756586 Erratum to “Uptake of Community Pharmacist-Delivered MedsCheck Diabetes Medication Review Service in Ontario between 2010 and 2014”: Canadian Journal of Diabetes 2017;41:253-258 Lori MacCallum BScPhm, PharmD, CDE; Giulia Consiglio BSc, MSc; Linda MacKeigan BScPhm, PhD; Lisa Dolovich BScPhm, PharmD, MSc. Can J Diabetes. Elsevier; 2019;43:453. https://doi.org/10.1016/j.jcjd.2019.06.007 Model Standards of Practice for Pharmacists and Pharmacy Technicians in Canada - NAPRA [Internet]. [cited 2025 Aug 11]. https://www.napra.ca/publication/model-standards-of-practice-for-pharmacists-and-pharmacy-technicians-in-canada/. Accessed 11 Aug 2025 Tannenbaum C, Tsuyuki RT. The expanding scope of pharmacists’ practice: implications for physicians. CMAJ. CMAJ; 2013;185:1228–32. https://doi.org/10.1503/cmaj.121990 Kucukarslan S, Lai S, Dong Y, Al-Bassam N, Kim K. Physician beliefs and attitudes toward collaboration with community pharmacists. Res Soc Adm Pharm RSAP. 2011;7:224–32. https://doi.org/10.1016/j.sapharm.2010.07.003 Schindel TJ, Yuksel N, Breault R, Daniels J, Varnhagen S, Hughes CA. Perceptions of pharmacists’ roles in the era of expanding scopes of practice. Res Soc Adm Pharm. 2017;13:148–61. https://doi.org/10.1016/j.sapharm.2016.02.007 Manolakis PG, Skelton JB. Pharmacists’ Contributions to Primary Care in the United States Collaborating to Address Unmet Patient Care Needs: The Emerging Role for Pharmacists to Address the Shortage of Primary Care Providers. Am J Pharm Educ. 2010;74:S7. https://doi.org/10.5688/aj7410s7 Cunha Leal MLG, Rodrigues AR, Bell V, Forrester M. Exploring the Evolving Role of Pharmaceutical Services in Community Pharmacies: Insights from the USA, England, and Portugal. Healthcare. Multidisciplinary Digital Publishing Institute; 2025;13:1786. https://doi.org/10.3390/healthcare13151786 Salim AM, Elgizoli B. Exploring self-perception of community pharmacists of their professional identity, capabilities, and role expansion. J Res Pharm Pract. 2016;5:116–20. https://doi.org/10.4103/2279-042X.179574 PhD JS. Measuring Usability with the System Usability Scale (SUS) – MeasuringU [Internet]. 2025. https://measuringu.com/sus/ Additional Declarations Competing interest reported. Author SG led the original eAMS development and has eAMS intellectual property rights. Other authors declare no conflicts of interest. Cite Share Download PDF Status: Published Journal Publication published 27 Apr, 2026 Read the published version in International Journal of Clinical Pharmacy → Version 1 posted Editorial decision: Revision requested 10 Mar, 2026 Reviews received at journal 06 Mar, 2026 Reviewers agreed at journal 20 Feb, 2026 Reviews received at journal 19 Feb, 2026 Reviewers agreed at journal 06 Feb, 2026 Reviewers invited by journal 23 Jan, 2026 Editor assigned by journal 23 Jan, 2026 Submission checks completed at journal 23 Jan, 2026 First submitted to journal 19 Jan, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8643015","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":580771599,"identity":"c0d08d90-28bd-420f-9bb7-b651305bf037","order_by":0,"name":"Tony Xin Ning","email":"","orcid":"","institution":"University of Toronto","correspondingAuthor":false,"prefix":"","firstName":"Tony","middleName":"Xin","lastName":"Ning","suffix":""},{"id":580771600,"identity":"668aed7c-2d2c-4493-a221-3e6be7404bd4","order_by":1,"name":"Terry Li","email":"","orcid":"","institution":"University of Toronto","correspondingAuthor":false,"prefix":"","firstName":"Terry","middleName":"","lastName":"Li","suffix":""},{"id":580771601,"identity":"dcabe793-80c2-4e23-8460-064819a5c56c","order_by":2,"name":"Jamie Kellar","email":"","orcid":"","institution":"University of Toronto","correspondingAuthor":false,"prefix":"","firstName":"Jamie","middleName":"","lastName":"Kellar","suffix":""},{"id":580771602,"identity":"97f488d8-d342-49bf-986a-1cef8c5d1cb3","order_by":3,"name":"Mina Tadrous","email":"","orcid":"","institution":"University of Toronto","correspondingAuthor":false,"prefix":"","firstName":"Mina","middleName":"","lastName":"Tadrous","suffix":""},{"id":580771603,"identity":"276eb234-b9dd-4c8d-abc8-ce0c3acee95e","order_by":4,"name":"Natalie Crown","email":"","orcid":"","institution":"University of Toronto","correspondingAuthor":false,"prefix":"","firstName":"Natalie","middleName":"","lastName":"Crown","suffix":""},{"id":580771604,"identity":"20150621-1322-4150-aef4-5d465d96ca5e","order_by":5,"name":"Lisa Dolovich","email":"","orcid":"","institution":"University of Toronto","correspondingAuthor":false,"prefix":"","firstName":"Lisa","middleName":"","lastName":"Dolovich","suffix":""},{"id":580771605,"identity":"c229999f-bc82-42d0-8d4a-feef836738a3","order_by":6,"name":"Samir Gupta","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABEElEQVRIiWNgGAWjYJCCA1Ca8QEDgwQYMTyAC+LTwsbAbABULwHWkpBwgIGHoF1sDGwgxYS1yLefTjxcwVCbuF2++Vk17w6LOoPbzQc/JP64w2DP3oBVi8GZ3A0HzzAcT9zZxmZ2m/eMhITBnWPJEgkJzxh4eLD7x4ABqKWB4VjihmMMQC1tQC03cgyAWg4z8EgkYHdY/1uYFvZvxRAt+Z9/4NPCcANsSw1QC48ZM9QWNry2GNwA2WJwwHhnW06x5Nw2CcmZN9LMLBLSDvPwnMHuF/n+3M0fGyrqZLczH9/44W1bHT/fjeTHNz7YHJZjb8ceYlC7DgPDAQoUoGYTisk6hBZ5fGaPglEwCkbBiAQA2DtnF9/Vs5UAAAAASUVORK5CYII=","orcid":"","institution":"St. Michael's Hospital","correspondingAuthor":true,"prefix":"","firstName":"Samir","middleName":"","lastName":"Gupta","suffix":""}],"badges":[],"createdAt":"2026-01-19 21:08:51","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8643015/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8643015/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s11096-026-02142-y","type":"published","date":"2026-04-27T15:57:17+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":102425644,"identity":"377ea67c-0357-43d8-8f8c-8065beeb387b","added_by":"auto","created_at":"2026-02-11 14:36:47","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":145930,"visible":true,"origin":"","legend":"\u003cp\u003eeAMS-Pharm prototype components and workflow. Data collected through the (short or full-length) patient questionnaire are processed in a cloud-based CDSS in real-time to produce guideline-based care advice for the pharmacy team member. After the user processes these recommendations, the system outputs a summary note for documentation and a prescriber letter and personalized asthma action plan for sign-back (if required). Upon receiving sign-back from the prescriber, a pharmacy team member approves new prescriptions and the asthma action plan, after which the patient can then access their asthma action plan in the patient portal (if they choose to create a portal account).\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8643015/v1/dda2289e60ff6bdb0e338495.jpeg"},{"id":102425645,"identity":"bf0963ba-40a8-47f1-a20f-42a33c073517","added_by":"auto","created_at":"2026-02-11 14:36:47","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":365216,"visible":true,"origin":"","legend":"\u003cp\u003eeAMS-Pharm Main Dashboard, highlighting areas that were changed based on critical findings from focus groups.\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8643015/v1/ebdaff590e604d3726a35f3a.jpeg"},{"id":102425646,"identity":"18922694-5cde-4a7f-a172-3d040e6858ae","added_by":"auto","created_at":"2026-02-11 14:36:47","extension":"jpeg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":681349,"visible":true,"origin":"","legend":"\u003cp\u003eeAMS-Pharm Prescriber Letter (page 1), highlighting areas that were changed based on critical findings from focus groups\u003c/p\u003e","description":"","filename":"floatimage3.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8643015/v1/c4dc4d3b842f9867880c9dff.jpeg"},{"id":102425669,"identity":"ae7c1b41-f1da-49b6-9d24-78099f8de9ab","added_by":"auto","created_at":"2026-02-11 14:37:17","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":35028,"visible":true,"origin":"","legend":"\u003cp\u003eeAMS-Pharm focus group feedback questionnaire responses (n = 28). Responses were entered on a five-point Likert scale labeled 1 (strongly disagree), 2 (disagree), 3 (neutral), 4 (agree), and 5 (strongly agree). In this figure, scores of 1 and 2 were considered “disagree”, and scores of 4 and 5 were considered “agree.” For each statement, each bar demonstrates the proportion of patients with each response. \u0026nbsp;\u0026nbsp;There was one missing response to question 3, and one missing response to question 7. Both were assigned a neutral score.\u003c/p\u003e","description":"","filename":"floatimage4.png","url":"https://assets-eu.researchsquare.com/files/rs-8643015/v1/b1365eac5462f0101e3fc458.png"},{"id":108438040,"identity":"5062eb6d-d1ec-4e22-95a0-775edfad0223","added_by":"auto","created_at":"2026-05-04 16:05:44","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1561663,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8643015/v1/7926abe0-c6f6-47da-9de4-0cf0c94b4278.pdf"}],"financialInterests":"Competing interest reported. Author SG led the original eAMS development and has eAMS intellectual property rights. Other authors declare no conflicts of interest.","formattedTitle":"Designing a computerized decision support system for asthma chronic disease management in community pharmacies","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eSignificant gaps exist between optimal, guideline-directed medical care and the care that patients actually receive in the real-world, most prominently in chronic diseases [1–5]. These care gaps result from several barriers, including the rapid pace of scientific advancements outstripping providers’ available time [6], and the corresponding increasing complexity of chronic disease care.\u003c/p\u003e\n\u003cp\u003eWith rising uptake of electronic tools in healthcare settings, computerized clinical decision support systems (CDSSs) may present a generational opportunity to address chronic disease care gaps by bridging the critical knowledge and time barriers faced by today’s primary care providers [7,8].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eHowever, access to primary care remains severely limited in modern health systems [9]. At the same time, the pharmacy profession is undergoing an unprecedented expansion in the scope of care delivery in many countries worldwide [10]. As highly trained and accessible front-line healthcare professionals, pharmacists see patients up to ten times more frequently than patients see their family physician [11]. Pharmacist-led clinical interventions have already been shown to improve outcomes in chronic disease populations such as diabetes [12], hypertension [13], and those at risk for cardiovascular disease [14]. As pharmacists engage in a broader spectrum of chronic disease care, there is a growing need for empowerment, by equipping pharmacists with timely and accurate knowledge, delivered through simple, efficient, and integrated workflows – capabilities that computerized clinical decision support systems (CDSSs) are designed to provide.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAsthma exemplifies a chronic disease with persistent care gaps, with only 15% of patients receiving \u0026nbsp; formal assessment of disease control, 15% receiving guideline-based pharmacotherapy escalation, virtually no patients receiving a self-management asthma action plan, and only half of those with severe disease receiving referral to specialist services [5,15]. The Electronic Asthma Management System (eAMS) is an evidence-based CDSS designed for clinic-based providers, demonstrated to effectively bridge these care gaps in real world primary care clinics [16], updated with each new guideline iteration, and used widely in clinic settings.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAim\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe sought to adapt and systematically optimize the eAMS for implementation in community pharmacy practice. Herein, we report findings from that process, which provide insights into ideal design and workflow considerations for chronic disease CDSSs in pharmacies.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cp\u003eThe eAMS consists of a CDSS integrated within the primary care electronic medical record system. It was developed through iterative feedback from primary care physicians, asthma educators, pulmonologists, and patients with asthma, and tested and refined in large primary care group practice settings [16]. The tool receives and processes data from a patient questionnaire to present asthma guideline-based [17] decision support for the provider at the point-of-care, including asthma control level, corresponding medication optimization recommendations, an auto-populated, personalized asthma action plan (AAP), and a prompt to refer to specialty care for severe asthma (if applicable). It also features a registration-only patient smartphone/tablet app or PC-based portal where patients (aged ≥ 16 years) can access and complete the patient questionnaire, see their AAP after approval, and access self-directed web-based education.\u003c/p\u003e\n\u003cp\u003eUsing this clinic-based tool as our model and applying an integrated knowledge translation framework featuring end-user engagement in content and design formulation\u0026nbsp;[18], we employed a 2-step process to adapt system functionality, content, and workflows for pharmacy settings, to develop the Electronic Asthma Management System \u003cem\u003efor Pharmacies\u003c/em\u003e (eAMS-Pharm). \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStep 1: eAMS-Pharm Prototype Development\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe started by building a prototype of the system by adapting the eAMS. This process entailed a detailed analysis of the eAMS with input from the co-investigator team (composed of five clinical pharmacists, the asthma/knowledge translation expert physician who led eAMS development, and two team members who led prior eAMS clinic implementations), to identify user end-points, workflows, and information flows that would require adaptation for community pharmacy settings.\u003c/p\u003e\n\u003cp\u003eThe group suggested required changes to each element, which were then translated to the core software development team. The software team made corresponding changes, presented them serially to the co-investigator group, and iteratively improved the system based on co-investigator feedback. Each system change was tested extensively, using a database of 258 real-world clinical scenarios to ensure that workflows and system advice remained accurate and guideline concurrent. We utilized a simplified version of the eAMS patient-facing questionnaire, which was co-developed with\u0026nbsp;[19]\u0026nbsp;and validated in patients with asthma [16,20,21].\u003c/p\u003e\n\u003cp\u003eFinally, this prototype was tested by three practicing community pharmacists (face validation), who provided further iterative feedback, enabling additional system refinements.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStep 2: Rapid Cycle Design Process\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eUsing the refined eAMS-Pharm prototype, we then conducted optimization of system functionality/design, content, and user workflows through a rapid-cycle design process. This involved identifying and addressing target end-user preferences and practical concerns via incremental analysis [18,22], through a sequential and repeated three-stage process: (1) system prototype demonstration and testing focus groups with target end-users; (2) analysis of focus group findings for emergent and critical findings (see definitions below); and (3) corresponding modifications of the prototype, before re-testing in another focus group.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eFocus Groups\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eParticipants and Recruitment\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eBased on our previous work\u0026nbsp;[20,21],\u0026nbsp;we estimated that 3-6 focus group rounds involving 4-6 participants per round (25-30 participants in total) would be required. Participants were recruited by email invitation (inviting pharmacists with prior clinical experience in asthma), through the University of Toronto Faculty of Pharmacy Clinical Preceptor Database, which consists of registered pharmacists from across Ontario working full-time with at least 2 years’ practice experience, and through snowball recruitment through participants’ networks. We included any of the following community pharmacy team members: registered pharmacists, registered pharmacy technicians, pharmacy assistants, and pharmacy students.\u0026nbsp;We employed\u0026nbsp;purposive sampling to achieve participant heterogeneity with respect to sex, years in practice, and pharmacy business model. Focus group participants received a $100 honorarium for their time.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFocus Group Structure\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eEach focus group was 90-minutes in duration, held virtually, facilitated by two moderators\u0026nbsp;with facilitating/interviewing experience, and attended by a pharmacist co-investigator (TN).\u0026nbsp;Sessions employed a semi-structured format, following a moderator script. Participants completed an electronic questionnaire collecting demographic data and system feedback immediately after the focus group. The moderator script and questionnaire were reviewed by all investigators and an external qualitative research expert, then piloted in a mock focus group with fellow researchers to ensure clarity and appropriate duration.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFocus Group Content\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eFollowing introductions, participants were explained the background, purpose, and core workflow of the eAMS-Pharm, followed by a live demonstration of the prototype (with any changes incorporated from previous cycles). The focus group script elicited user preferences and recommended changes across functionality (e.g., format, design), content (e.g., feature optimization and additional features required), and workflows (e.g., usability). Individual participant suggestions/opinions were reflected to other participants to elicit group preferences on suggested changes. Issues with divergent opinions from prior focus groups were specifically raised in subsequent focus groups until there was a clear directional consensus. In cases where critical system changes had been suggested in prior rounds, mockups were sometimes presented in subsequent focus groups for further feedback, before finalizing system changes. The post-focus group questionnaire consisted of demographic questions and Likert scale-based assessments of eAMS-Pharm format, content, workflow, impact, and overall impressions. The System Usability Scale (SUS), a validated, 10-item \u003cstrong\u003eLikert scale\u0026nbsp;\u003c/strong\u003equestionnaire used widely to assess perceived usability of a system or tool, was administered as a measure of global system usability [23]. \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAnalysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eRapid-Cycle Analysis\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eFocus groups were audio-recorded, anonymized, and transcribed verbatim. After each session, each moderator reviewed transcripts, field notes, and the post-focus group questionnaire to identify quotes referencing functionality, content, and/or workflow-related issues, along with potential solutions suggested by focus group participants. These quotes were organized into categories, then first reviewed by the moderator and the pulmonologist/knowledge translation expert (SG) to identify emergent findings and possible critical changes, and then re-reviewed with the pharmacist/pharmacy science expert (JK) to reach a final consensus on emergent/critical findings.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eA priori, we defined critical changes as those that all participants in a single focus group or most participants across multiple focus groups agreed to and/or that the investigator team and moderators agreed were likely to be broadly representative, required a change to address, and were feasible to implement. Emergent findings were those expressed by more than one participant across a single focus group or across two or more focus groups which were not deemed by co-PIs, the analyst and/or the moderator to meet the threshold for a critical change. Emergent findings could be considered critical changes after appearing in two or more focus groups. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCritical changes were implemented after each focus group cycle (with retesting after any system changes). \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOur pre-set stopping criterion was three rounds and until no new critical changes emerged from a single focus group cycle [20,21].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eQuestionnaire Analysis\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eWe provide quantitative summary statistics of questionnaire data, including the summative SUS score and graphical representation of Likert-scale responses.\u0026nbsp;\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003e\u003cstrong\u003eStep 1: eAMS-Pharm Prototype Development\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe eAMS-Pharm prototype was developed collaboratively, then further improved after real-world face-validation (above). It consisted of: 1) a pharmacy portal providing a) access to a dashboard of all registered patients (with ability to email/text any patient a link to the full length patient questionnaire), b) ability to register new patients, c) access to an alternative short (7-question) questionnaire to complete with patients at the point-of-care, and d) an interactive CDSS that processes questionnaire data in real-time to categorize disease control and exacerbation risk, provide corresponding pharmacotherapy adjustment guidance, a summary note, an asthma action plan, and a prescriber letter with sign-back request (or a pharmacist prescription if sign-back was not needed); 2) a full-length patient-facing questionnaire accessible through a publically available website; and 3) a patient portal where patients who choose to register can access and complete the full length patient questionnaire, see their latest asthma action plan (once approved by the provider), and access educational content (e.g. audio/visual glossary, inhaler videos, etc.) (Figure 1).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCompared to the eAMS used in clinic settings, changes made during eAMS-Pharm prototype development included: \u0026nbsp;1) creating a publicly available version of the patient questionnaire, whereby patients no longer had to register for the portal in order to access the system (to reduce barriers to questionnaire completion and improve efficiency in the busy pharmacy environment); 2) creating a short questionnaire version for a pharmacy team member to complete \u003cem\u003ewith\u003c/em\u003e the patient at the point-of-care (to enable the pharmacy team to make use of the system even if the patient had not self-completed the questionnaire); and 3) adding an option to output a pre-formatted letter addressed to the patient\u0026rsquo;s primary prescriber, indicating prescription change request(s), justifications, and a copy of the AAP (if applicable), for approval and sign-back (because pharmacists in most jurisdictions do not have authorization to make all inhaler changes independently).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStep 2: Rapid-Cycle Design Process\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eParticipants\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe conducted six sequential focus group cycles until stopping criteria were met. These included 28 pharmacy team members, consisting of: 23 (83%) pharmacists, 3 (11%) pharmacy technicians, 1 (3%) pharmacy assistant, and 1 (3%) pharmacy student (Table 1). Among pharmacists, 8 (35%) were pharmacy owners/associates and 3 (13%) were pharmacy managers.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1. Focus group participant background and demographic information (n = 28)\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 482px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCharacteristic\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNumber (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSex\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 369px;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026nbsp; 12 \u0026nbsp; (43)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 369px;\"\u003e\n \u003cp\u003eFemale\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026nbsp; 16 \u0026nbsp; (57)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge in years\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 369px;\"\u003e\n \u003cp\u003e\u0026le;24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026nbsp; 01 \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;(4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 369px;\"\u003e\n \u003cp\u003e25-30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026nbsp; 06 \u0026nbsp; \u0026nbsp; \u0026nbsp;(21)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 369px;\"\u003e\n \u003cp\u003e31-40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026nbsp; 11 \u0026nbsp; (40)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 369px;\"\u003e\n \u003cp\u003e41-50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026nbsp; 04 \u0026nbsp; \u0026nbsp; \u0026nbsp;(14)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 369px;\"\u003e\n \u003cp\u003e51-60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026nbsp; 06 \u0026nbsp; \u0026nbsp; \u0026nbsp;(21)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRole in pharmacy\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 369px;\"\u003e\n \u003cp\u003ePharmacist\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026nbsp; 23 \u0026nbsp; (82)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 369px;\"\u003e\n \u003cp\u003ePharmacy Technician/Assistant\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026nbsp; 04 \u0026nbsp; \u0026nbsp; \u0026nbsp;(14)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 369px;\"\u003e\n \u003cp\u003ePharmacy Student\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026nbsp; 01 \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;(4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\" valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHighest level of education\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 369px;\"\u003e\n \u003cp\u003eCompleted college\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; 3 \u0026nbsp; \u0026nbsp; \u0026nbsp;(11)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 369px;\"\u003e\n \u003cp\u003eCompleted university (e.g. BSc, BScPhm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026nbsp; 14 \u0026nbsp; (50)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 369px;\"\u003e\n \u003cp\u003eCompleted a PharmD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; 9 \u0026nbsp; \u0026nbsp; \u0026nbsp;(32)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 369px;\"\u003e\n \u003cp\u003eCompleted any other post-graduate program (e.g. MSc, PhD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; 2 \u0026nbsp; \u0026nbsp;(7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"6\" valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTime since completing most recent degree\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 369px;\"\u003e\n \u003cp\u003eLess than 5 years ago\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026nbsp; 08 \u0026nbsp; \u0026nbsp; \u0026nbsp;(29)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 369px;\"\u003e\n \u003cp\u003e5-10 years ago\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026nbsp; 05 \u0026nbsp; \u0026nbsp; \u0026nbsp;(18)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 369px;\"\u003e\n \u003cp\u003e11-15 years ago\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026nbsp; 04 \u0026nbsp; \u0026nbsp; \u0026nbsp;(14)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 369px;\"\u003e\n \u003cp\u003e16-20 years ago\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026nbsp; 03 \u0026nbsp; \u0026nbsp; \u0026nbsp;(11)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 369px;\"\u003e\n \u003cp\u003e21-25 years ago\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026nbsp; 02 \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;(7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 369px;\"\u003e\n \u003cp\u003eMore than 25 years ago\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026nbsp; 06 \u0026nbsp; \u0026nbsp; \u0026nbsp;(21)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"5\" valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePharmacy type\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 369px;\"\u003e\n \u003cp\u003eChain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026nbsp; 12 \u0026nbsp; (42)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 369px;\"\u003e\n \u003cp\u003eBanner\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; 1 \u0026nbsp; \u0026nbsp; (4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 369px;\"\u003e\n \u003cp\u003eIndependent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; 9 \u0026nbsp; (32)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 369px;\"\u003e\n \u003cp\u003eAcademic Pharmacy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; 5 \u0026nbsp; (18)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 369px;\"\u003e\n \u003cp\u003eOutpatient Hospital Pharmacy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; 1 \u0026nbsp; \u0026nbsp; (4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"6\" valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMonthly Pharmacy Prescription Volume\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 369px;\"\u003e\n \u003cp\u003e\u0026le;1000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; 9 \u0026nbsp; \u0026nbsp; \u0026nbsp;(33)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 369px;\"\u003e\n \u003cp\u003e1001-2000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; 2 \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;(7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 369px;\"\u003e\n \u003cp\u003e2001-3000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; 4 \u0026nbsp; \u0026nbsp; \u0026nbsp;(14)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 369px;\"\u003e\n \u003cp\u003e3001-4000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; 4 \u0026nbsp; \u0026nbsp; \u0026nbsp;(14)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 369px;\"\u003e\n \u003cp\u003e4001-5000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; 2 \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;(7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 369px;\"\u003e\n \u003cp\u003e\u0026gt;5000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; 7 \u0026nbsp; \u0026nbsp; \u0026nbsp;(25)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eRapid-Cycle Analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe summarize and categorize critical findings from focus groups, and corresponding changes made to the eAMS-Pharm in Table 2.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2. Critical Findings and Corresponding System Modifications\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"718\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCategory and Subcategory\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 255px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCritical Finding Requiring Action\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 274px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCorresponding System Modifications\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 718px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSystem Usability\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003e(a) Patient Identifiers\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(FG5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 255px;\"\u003e\n \u003cp\u003eRequirement to quickly differentiate patients with similar names\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 274px;\"\u003e\n \u003cp\u003eAddition of date of birth as a patient identifier in the main pharmacy dashboard, below first name/last name\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003e(b) System Instructions\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(FG3, FG5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 255px;\"\u003e\n \u003cp\u003eUser confusion about the purpose and expected results of certain clickstreams\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 274px;\"\u003e\n \u003cp\u003eAddition of specific reasoning and expected outcomes for each relevant system workflow; editing to improve clarity\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003e(c) Medication History\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(FG1, FG2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 255px;\"\u003e\n \u003cp\u003eConcern regarding difficulty in entering current patient medications (including concerns about accuracy of data in the pharmacy management system)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 274px;\"\u003e\n \u003cp\u003eAddition of a visual aid at the point of patient medication entry with images of all asthma medications, to assist in confirming medications at the point-of-care\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003e(d) Insurance Coverage Information (FG1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 255px;\"\u003e\n \u003cp\u003eDesire to know which therapeutic options were covered by public insurance\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 274px;\"\u003e\n \u003cp\u003eAddition of visual indicators indicating public drug coverage at the point of medication change selection in the CDSS\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003e(e) Warning Fatigue (FG5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 255px;\"\u003e\n \u003cp\u003eConcern that red text used in warnings was alarming, and that frequency of warnings would result in warning fatigue\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 274px;\"\u003e\n \u003cp\u003eModification of less essential warnings to black text, reduction in warning text length, elimination of certain warning messages\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 718px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSystem Workflow\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003e(a) Remaining Action Alerts (FG4, FG5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 255px;\"\u003e\n \u003cp\u003eDesire to quickly identify patients requiring further pharmacy team and/or prescriber actions\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 274px;\"\u003e\n \u003cp\u003eAddition of a column containing color-coded follow-up flags with \u0026ldquo;due dates\u0026rdquo; in the main pharmacy dashboard\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003e(b) Follow-Up Reminders (FG5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 255px;\"\u003e\n \u003cp\u003eDesire to create a self-reminder for pharmacy team members to follow-up with certain patients after system use\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 274px;\"\u003e\n \u003cp\u003eAddition of a column with a clickable calendar for setting a follow-up reminder date\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003e(c) Prescriber Disagreement Management (FG5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 255px;\"\u003e\n \u003cp\u003eNeed for ability to document and discard prescription change recommendations and/or asthma action plan if the prescriber disagrees\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 274px;\"\u003e\n \u003cp\u003eAddition of a button to discard current recommendations/action plan after prescriber sign-back, and automated documentation for this workflow\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003e(d) Reset Functionality (FG5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 255px;\"\u003e\n \u003cp\u003eNeed to reset the system (i.e. start from beginning) in instances where the system recommendation is rejected by the patient/prescriber and/or the pharmacy team wants to re-initiate patient questionnaire\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 274px;\"\u003e\n \u003cp\u003eAddition of a \u0026ldquo;Restart\u0026rdquo; button and corresponding functionality next to each patient name in the main pharmacy dashboard\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003e(e) Documentation/Billing (FG1, FG3, FG5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 255px;\"\u003e\n \u003cp\u003eDesire for automatically generated documentation for medico-legal and billing purposes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 274px;\"\u003e\n \u003cp\u003eModification of the automated system usage summary note and prescriber letter to meet medico-legal requirements for pharmacy documentation, documentation of patient consent, and documentation required for billable services (including pharmacy billing codes)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 718px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePrescriber Communication\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003e(a) Customized Messaging (FG2, FG5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 255px;\"\u003e\n \u003cp\u003eNeed to address prescriber letter to a specific prescriber, and desire to include a custom message\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 274px;\"\u003e\n \u003cp\u003eAddition of an optional free text field to add letter addressee, and optional text box for inclusion of any desired customized messaging \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003e(b) Pharmacy Role Justification (FG4, FG5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 255px;\"\u003e\n \u003cp\u003eA desire to alter tone of prescriber letter to indicate the pharmacy\u0026rsquo;s role in, and qualifications for, shared care\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 274px;\"\u003e\n \u003cp\u003eInclusion of wording such as \u0026ldquo;our mutual patient\u0026rdquo; and addition of pharmacy team member credentials within prescriber letter\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003e(c) Communication Formatting (FG3, FG5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 255px;\"\u003e\n \u003cp\u003eConcern that busy prescribers may overlook key information in the prescriber letter\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 274px;\"\u003e\n \u003cp\u003eChanging prescriber letter title to specify that \u003cem\u003enew\u003c/em\u003e prescriptions were being requested; addition of key pharmacy information to letter header; use of bold face to emphasize key action points (e.g. prescription changes); relocation of key information (e.g. patient name) to more prominent areas; cutting text\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003e(d) Information Prioritization (FG3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 255px;\"\u003e\n \u003cp\u003ePreference to prioritize the action item (e.g. prescription change request) within prescriber letter\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 274px;\"\u003e\n \u003cp\u003eModification of prescriber letter to include the prescription change request on page 1, while simplifying and moving the change request \u003cem\u003ejustification\u003c/em\u003e to page 2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003e(e) Facilitating Prescriptions (FG1, FG5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 255px;\"\u003e\n \u003cp\u003eConcern that providers would not recall required public insurance coverage codes for certain medications\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 274px;\"\u003e\n \u003cp\u003eAutomated addition of special public insurance code checkboxes with description/expiry to prescriber letter, where applicable\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003e(f) Enabling Prescriber Documentation in Cases of Disagreement with Pharmacy Recommendations (FG5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 255px;\"\u003e\n \u003cp\u003eNeed to enable prescribers to indicate any disagreement with prescriber letter medication change recommendations and/or asthma action plan medication recommendations\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 274px;\"\u003e\n \u003cp\u003eModification of prescriber letter to include a \u0026ldquo;disagree\u0026rdquo; option next to each medication \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eFigures 2 and 3 display serial changes made to the eAMS-Pharm main pharmacy dashboard and prescriber letter, based on focus group findings.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eQuestionnaire Analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFeedback questionnaires were received from all pharmacy team members involved in the focus groups. The mean System Usability Scale (SUS) score was 82.9 \u0026plusmn; 16.8 (maximum score: 100). Figure 4 presents focus group participants\u0026rsquo; responses to Likert scale-based assessments of eAMS-Pharm format, content, workflow, impact, and overall impressions. Responses were similar across pharmacy types.\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eWe applied a systematic, theory-based approach to optimize an existing asthma CDSS (the \u003cem\u003eeAMS\u003c/em\u003e) used in primary care clinics, to align with the environment, workflow, and differing needs and preferences of community pharmacy teams. The system achieved a high system usability score and highly favorable ratings for perceived system benefits, likelihood of clinical use, and patient benefits. Most changes and adaptations identified and made would be applicable to other pharmacy-based care of chronic disease.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCDSSs have been studied extensively in primary care [24]. Pharmacists have also used such systems to support drug safety [25] and are now more frequently using them to prescribe for acute self-limiting conditions [26,27]. \u0026nbsp;However, pharmacists are also increasingly being called upon to co-manage chronic illnesses [12–14], and although CDSSs would be ideally suited to tackle the greater knowledge gaps, complexity and time required, little is known about the availability, ideal design, and effectiveness of such systems in pharmacies [28]. A prior systematic review of pharmacy CDSSs concluded that existing systems were prone to failure due to a lack of\u0026nbsp;sociotechnical considerations for managing workload and workflow, and that research in community pharmacy CDSSs was “limited and disjointed,” with insufficient focus on factors enabling optimization of CDSS utilization\u0026nbsp;[28]. Indeed, the broader\u0026nbsp;CDSSs\u0026nbsp;literature\u0026nbsp;has found that these systems are underused when not designed with their intended end-users in mind\u0026nbsp;[29], which has been a key factor limiting their clinical impact\u0026nbsp;[24]. Accordingly, pharmacy team user preferences for chronic disease CDSS content and design identified herein fill a gap in the literature which can inform future system design, across diseases.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSystem Usability.\u003c/strong\u003eMany user requirements and corresponding changes made during our rapid-cycle design process centered on system usability. For example, changes made to improve and facilitate patient identification within the system will likely improve user efficiency, and mirror priorities identified for an acute lower back pain pharmacy CDSS [27]. Similarly, user-directed tailoring of system warnings will help to reduce warning fatigue, associated with override rates as high as 88% in pharmacy drug interaction warning systems [28] and over 90% in the physician ambulatory setting [30,31]. Users were also concerned about their ability to accurately identify patients’ current medications. Although these data should be retrievable in the pharmacy management system (PMS), studies show that up to 43% of patients frequent multiple pharmacies [32], rendering an accurate current medication use history (a requirement for accurate chronic disease CDSS guidance) a challenge in jurisdictions that do not share a single health record. Given that inhalers come in distinct shapes and sizes that are often recognizable to patients, participants recommended an integrated visual medication chart for point-of-care use. This is akin to online “pill identifier” [33] systems and AI-supported medication image recognition tools [34] which fulfil the same purpose for pills, and thus should be a feature of any future CDSS targeting a disease treated with oral medications. The fact that this gap had not been identified by our prototype development team highlights the importance of including diverse interprofessional pharmacy team members (including technicians and assistants) in the design of any future pharmacy CDSS. Finally, users requested integrated coverage information for public drug formularies. \u0026nbsp;Indeed, prior studies of prescriber-facing CDSSs have shown that this improves medication accessibility and reduces cost burden [35]. Although jurisdictional differences in public drug coverage will often require correspondingly tailored CDSS content, the addition of easily accessible formulary information reduces the likelihood of selecting CDSS-recommended medications that some patients will not be able to procure. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSystem Workflow.\u0026nbsp;\u003c/strong\u003eWe made several adaptations to the intrinsic workflows within the eAMS-Pharm prototype to meet the needs of various patient/pharmacist encounter types that occur within community pharmacies. Focus group participants indicated concerns that they could easily lose track of various patients for whom they used the system, and particularly patients for whom prescriber approval was pending. Accordingly, we designed a flag-based visual reminder system to indicate which patients had prescriber or pharmacist actions remaining. This is in line with preferences identified in a previous study of an acute self-limiting low back pain [27] CDSS in community pharmacies, and aligns with recommendations for visual progress indicators in CDSS design [36]. \u0026nbsp;Relatedly, participants wished to identify patients who could benefit from a follow-up assessment, and to set a self-reminder to initiate this follow-up. This was achieved through the addition of a follow-up calendar, with date selection resulting in the appearance of a visual date reminder in the pharmacist dashboard. Unlike minor and/or acute ailments that are currently more commonly managed in pharmacy settings, transition to chronic disease care will indeed require a shift towards repeated serial touchpoints to enable iterative therapeutic optimization [37]. In a prior review of pharmacy-initiated diabetes medication reviews [38], only 17.5% of patients received follow-up care after the initial assessment, demonstrating the need for such functionality in CDSSs. Next, users indicated the importance of facilitating documentation and clinical billing workflows in order to offset the time required to use the CDSS itself. Given the high patient throughput and importance of limiting patient wait times in the community pharmacy model, automation of downstream tasks such as documentation and billing will likely be critical determinants of CDSS uptake, both for point-of-care efficiency, and to incentivize use by increasing chances of remuneration [25]. As artificial-intelligence-based systems for pharmacy documentation and billing workflows become more mature, they may be integrated with CDSSs to further facilitate these tasks.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePrescriber Communication.\u0026nbsp;\u003c/strong\u003eIn all focus groups, participants noted the importance of managing and preserving their relationships with prescribers, particularly given that sending chronic disease care recommendations represents a paradigm shift. Specific feedback on the prescriber communication letter led to numerous adjustments, including changes to formatting, information ordering, and edits for readability and clarity. Users also requested a free-text field to add customized messages to prescribers, which they envisioned often using to justify their clinical intervention. Similarly, they valued the credibility afforded by citing the evidence-based guidelines upon which the CDSS was based, information about the origins and development of the CDSS itself, and a summary of the patient’s guideline-based disease control level that triggered the prescription change request. Although existing standards are available to guide pharmacists in physician communication surrounding routine tasks such as renewal requests[39], our findings provide novel insights into preferences for the more sensitive task of communicating chronic disease care recommendations. In fact, physician surveys have identified positive attitudes towards collaborative care with community pharmacists, and particularly their roles in patient education, drug safety, and adherence [40]. Collaborative models in which pharmacists and physicians communicate regularly have also been shown to enhance patient outcomes, particularly in ambulatory and chronic care settings [14,40,41]. In the context of the alarming gaps in primary care access in the community [9] and the corresponding regulatory changes to expand pharmacists’ scope of practice, pharmacists do self-perceive the importance of their evolving role in clinical care [42–44]. However, studies have also suggested that pharmacists are concerned that physicians perceive them to have a more perfunctory role as dispensers of medication [45]. This indicates the importance of careful user-centered and user-preference sensitive design for any pharmacist-initiated chronic disease treatment recommendations, to address perceived and real barriers to physician acceptance.\u003c/p\u003e\n\u003cp\u003eIn acknowledging and systematically addressing the above concerns in our tool design through our rapid-cycle design process, we achieved high user ratings across content, format, and usability domains of the eAMS-Pharm (Figure 4). This was reflected in our high System Usability Scale (SUS) score (83/100), which is well above the mean SUS score of 68 across 500 systems, and corresponds to a qualitative rating between “Good” and “Excellent” along with high overall acceptability [46]. Correspondingly, a vast majority of participants (86%) were confident in their ability to use the tool, including both ensuring that most patients would complete the patient-facing questionnaire (86%) and consistently completing corresponding decision support steps (86%). More broadly, all participating pharmacy members believed that pharmacists have a role to play in chronic disease care, and almost all believed that the tool would enhance their ability to provide better care. Most (89%) also endorsed that \u003cem\u003epatients\u003c/em\u003e would perceive that they received better care from the pharmacy as a result of the eAMS-Pharm, whereby customer satisfaction and resulting loyalty enhance the business case for system use. The SUS results suggest that, from the users’ perspective, the system is not only effective and efficient but also delivers a favorable user experience.\u003c/p\u003e\n\u003cp\u003eThe main limitation of the current study is the use of focus groups with a simulated use environment for system feedback. Although we achieved stopping criteria and had high user ratings, a follow-up study will be required to assess how this translates to real-world uptake and benefit in the complex pharmacy setting. Our sample represented diverse sex, age, and work experience subgroups, and a wide range of pharmacy throughputs (by prescription volume). In terms of pharmacy business model representation, most participants were from chains and independents, with fewer from banner, hospital, and academic pharmacy models (this is reflective of the current Canadian pharmacy landscape). Accordingly, further research is needed to ensure that our findings reflect the priorities of pharmacy team members in the latter settings as well.\u0026nbsp;\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eThe convergence of increasing use of CDSSs in healthcare with a growing role for pharmacies in complex chronic disease care creates an urgent need for chronic disease CDSSs with high levels of acceptability and usability for pharmacy team members. Although existing pharmacy CDSSs have had limited uptake due to suboptimal design [25,28], we demonstrated that a clinic-based asthma CDSS can be successfully adapted to pharmacy settings by applying user-centered design principles and stakeholder engagement (co-development), along with rapid-cycle iteration. Not only can these methods be emulated in future system development, but through this process, we also generated important insights regarding content, format, and workflows required to overcome uptake barriers that may be applicable across chronic disease CDSSs for pharmacies. CDSS developers can use our findings to guide system design and development, before testing chronic disease CDSSs prospectively for uptake, and impact on care processes and patient outcomes.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFUNDING DECLARATION\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFunding statement: This work was funded by the Unity Health Toronto Research Innovation Council Award, University of Toronto Dalla Lana School of Public Health New Initiatives and Innovation Award, Canadian Foundation for Pharmacy Innovation Fund.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCOMPETING INTERESTS\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAuthor SG led the original eAMS development and has eAMS intellectual property rights. Other authors declare no conflicts of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAUTHOR CONTRIBUTIONS\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTony Ning (Conceptualization, Data acquisition, Data Curation, Analysis, Writing – original draft, Writing – review and editing); Terry Li (Data acquisition, Data Curation, Analysis, Writing – review and editing); Jamie Kellar (Methodology, Data Curation, Writing – review and editing); Mina Tadrous (Writing – review and editing); Natalie Crown (Writing – review and editing); Lisa Dolovich (Writing – review and editing); Samir Gupta (Conceptualization, Data Curation, Supervision, Writing – review and editing, funding acquisition)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDATA AVAILABILITY\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and/or analysed during this study can be made available upon reasonable request and ethics approval.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was approved by the research ethics board at the University of Toronto (#46441) and each participant provided written informed consent.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCONSENT TO PARTICIPATE\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInformed consent was obtained from all individual participants included in the study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eWang J, Tan F, Wang Z, Yu Y, Yang J, Wang Y, et al. 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Respir Med. 2022;201:106568. https://doi.org/10.1016/j.rmed.2021.106568\u003c/li\u003e\n\u003cli\u003eLam Shin Cheung V, Kastner M, Sale JE, Straus S, Kaplan A, Boulet L-P, et al. Development process and patient usability preferences for a touch screen tablet-based questionnaire. Health Informatics J. 2020;26:233\u0026ndash;47. https://doi.org/10.1177/1460458218824749\u003c/li\u003e\n\u003cli\u003eKitzinger J. Qualitative Research: Introducing focus groups. BMJ. British Medical Journal Publishing Group; 1995;311:299\u0026ndash;302. https://doi.org/10.1136/bmj.311.7000.299\u003c/li\u003e\n\u003cli\u003eBrooke J. SUS\u0026mdash;a quick and dirty usability scale. In: Jordan PW, Thomas B, Weerdmeester BA, et al. (eds) Usability evaluation in industry. London: Taylor and Francis, 1996, pp. 189\u0026ndash;194.\u003c/li\u003e\n\u003cli\u003eKwan JL, Lo L, Ferguson J, Goldberg H, Diaz-Martinez JP, Tomlinson G, et al. Computerised clinical decision support systems and absolute improvements in care: meta-analysis of controlled clinical trials. BMJ. British Medical Journal Publishing Group; 2020;370:m3216. https://doi.org/10.1136/bmj.m3216\u003c/li\u003e\n\u003cli\u003eCurtain C, Peterson GM. Review of computerized clinical decision support in community pharmacy. J Clin Pharm Ther. 2014;39:343\u0026ndash;8. https://doi.org/10.1111/jcpt.12168\u003c/li\u003e\n\u003cli\u003eMAPFlow Inc. MAPflow - Efficient and Effective Minor Ailment Prescribing [Internet]. 2023. https://www.mapflow.ca/\u003c/li\u003e\n\u003cli\u003eCutler TW, et al. An Electronic Clinical Decision Support System for the Management of Low Back Pain: Intervention Development and Mixed Methods Usability Evaluation. JMIR Med Inform. 2020;8:e17203. https://doi.org/10.2196/17203\u003c/li\u003e\n\u003cli\u003eMoon J, Chladek JS, Wilson P, Chui MA. Clinical decision support systems in community pharmacies: a scoping review. J Am Med Inform Assoc JAMIA. 2023;31:231\u0026ndash;9. https://doi.org/10.1093/jamia/ocad208\u003c/li\u003e\n\u003cli\u003eKouri A, Yamada J, Lam Shin Cheung J, Van de Velde S, Gupta S. Do providers use computerized clinical decision support systems? A systematic review and meta-regression of clinical decision support uptake. Implement Sci. 2022;17:21. https://doi.org/10.1186/s13012-022-01199-3\u003c/li\u003e\n\u003cli\u003eIsaac T, Weissman JS, Davis RB, Massagli M, Cyrulik A, Sands DZ, et al. Overrides of medication alerts in ambulatory care. Arch Intern Med. 2009;169:305\u0026ndash;11. https://doi.org/10.1001/archinternmed.2008.551\u003c/li\u003e\n\u003cli\u003eChui M. Evaluation of Online Prospective DUR Programs in Community Pharmacy Practice. J Manag Care Pharm. Academy of Managed Care Pharmacy; 2000;6:27\u0026ndash;32. https://doi.org/10.18553/jmcp.2000.6.1.27\u003c/li\u003e\n\u003cli\u003eLook KA, Mott DA. Multiple pharmacy use and types of pharmacies used to obtain prescriptions. J Am Pharm Assoc JAPhA. 2013;53:601\u0026ndash;10. https://doi.org/10.1331/JAPhA.2013.13040\u003c/li\u003e\n\u003cli\u003eDrug I.D. - UpToDate\u0026reg; Lexidrug\u003csup\u003eTM\u003c/sup\u003e [Internet]. [cited 2025 Aug 11]. https://online-lexi-com.myaccess.library.utoronto.ca/lco/action/drugid. Accessed 11 Aug 2025\u003c/li\u003e\n\u003cli\u003eLiu C, et al. Identification of medications using artificial intelligence: recent advances and challenges. NPJ Digit Med [Internet]. 2019; https://doi.org/10.1038/s41746-019-0086-0\u003c/li\u003e\n\u003cli\u003eFischer MA, et al. Impact of Electronic Prescribing With Formulary Decision Support on Medication Cost and Use. JAMA Intern Med [Internet]. 2008; https://doi.org/10.1001/archinte.168.3.243\u003c/li\u003e\n\u003cli\u003eNielsen J. Enhancing the explanatory power of usability heuristics. Proc SIGCHI Conf Hum Factors Comput Syst [Internet]. New York, NY, USA: Association for Computing Machinery; 1994 [cited 2025 Sept 11]. p. 152\u0026ndash;8. https://doi.org/10.1145/191666.191729\u003c/li\u003e\n\u003cli\u003eMacCallum L, Dolovich L. Follow-up in community pharmacy should be routine, not extraordinary. Can Pharm J CPJ. 2018;151:79\u0026ndash;81. https://doi.org/10.1177/1715163518756586\u003c/li\u003e\n\u003cli\u003eErratum to \u0026ldquo;Uptake of Community Pharmacist-Delivered MedsCheck Diabetes Medication Review Service in Ontario between 2010 and 2014\u0026rdquo;: Canadian Journal of Diabetes 2017;41:253-258 Lori MacCallum BScPhm, PharmD, CDE; Giulia Consiglio BSc, MSc; Linda MacKeigan BScPhm, PhD; Lisa Dolovich BScPhm, PharmD, MSc. Can J Diabetes. Elsevier; 2019;43:453. https://doi.org/10.1016/j.jcjd.2019.06.007\u003c/li\u003e\n\u003cli\u003eModel Standards of Practice for Pharmacists and Pharmacy Technicians in Canada - NAPRA [Internet]. [cited 2025 Aug 11]. https://www.napra.ca/publication/model-standards-of-practice-for-pharmacists-and-pharmacy-technicians-in-canada/. Accessed 11 Aug 2025\u003c/li\u003e\n\u003cli\u003eTannenbaum C, Tsuyuki RT. The expanding scope of pharmacists\u0026rsquo; practice: implications for physicians. CMAJ. CMAJ; 2013;185:1228\u0026ndash;32. https://doi.org/10.1503/cmaj.121990\u003c/li\u003e\n\u003cli\u003eKucukarslan S, Lai S, Dong Y, Al-Bassam N, Kim K. Physician beliefs and attitudes toward collaboration with community pharmacists. Res Soc Adm Pharm RSAP. 2011;7:224\u0026ndash;32. https://doi.org/10.1016/j.sapharm.2010.07.003\u003c/li\u003e\n\u003cli\u003eSchindel TJ, Yuksel N, Breault R, Daniels J, Varnhagen S, Hughes CA. Perceptions of pharmacists\u0026rsquo; roles in the era of expanding scopes of practice. Res Soc Adm Pharm. 2017;13:148\u0026ndash;61. https://doi.org/10.1016/j.sapharm.2016.02.007\u003c/li\u003e\n\u003cli\u003eManolakis PG, Skelton JB. Pharmacists\u0026rsquo; Contributions to Primary Care in the United States Collaborating to Address Unmet Patient Care Needs: The Emerging Role for Pharmacists to Address the Shortage of Primary Care Providers. Am J Pharm Educ. 2010;74:S7. https://doi.org/10.5688/aj7410s7\u003c/li\u003e\n\u003cli\u003eCunha Leal MLG, Rodrigues AR, Bell V, Forrester M. Exploring the Evolving Role of Pharmaceutical Services in Community Pharmacies: Insights from the USA, England, and Portugal. Healthcare. Multidisciplinary Digital Publishing Institute; 2025;13:1786. https://doi.org/10.3390/healthcare13151786\u003c/li\u003e\n\u003cli\u003eSalim AM, Elgizoli B. Exploring self-perception of community pharmacists of their professional identity, capabilities, and role expansion. J Res Pharm Pract. 2016;5:116\u0026ndash;20. https://doi.org/10.4103/2279-042X.179574\u003c/li\u003e\n\u003cli\u003ePhD JS. Measuring Usability with the System Usability Scale (SUS) \u0026ndash; MeasuringU [Internet]. 2025. https://measuringu.com/sus/\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"international-journal-of-clinical-pharmacy","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ijcp","sideBox":"Learn more about [International Journal of Clinical Pharmacy](https://www.springer.com/journal/11096)","snPcode":"11096","submissionUrl":"https://submission.nature.com/new-submission/11096/3","title":"International Journal of Clinical Pharmacy","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"clinical decision support system, asthma care, chronic disease management, pharmacy practice ","lastPublishedDoi":"10.21203/rs.3.rs-8643015/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8643015/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eIntroduction: \u003c/strong\u003eWe previously built and validated the Electronic Asthma Management System (eAMS) - a clinic-based asthma computerized clinical decision support system (CDSS) which is in clinical use.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAim: \u003c/strong\u003eHerein, we sought to\u003cstrong\u003e \u003c/strong\u003eadapt and optimize the eAMS for implementation in community pharmacy practice.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e We iteratively developed a system prototype (the eAMS-\u003cem\u003ePharm\u003c/em\u003e) with input from clinical pharmacists, and asthma, knowledge translation, and eHealth experts. After face-validation by three external community pharmacists, we used a rapid-cycle development process for optimization of system functionality/design, content, and user workflows. This involved a sequential and repeated three-stage process: (1) system prototype demonstration and testing in 90 minute, semi-structured virtual focus groups with target end-users; (2) analysis of focus group findings; and (3) corresponding modifications to the prototype, then re-testing in another focus group. This process continued until we reached pre-defined stopping criteria. We used a questionnaire to gather demographic information and further usability data and feedback. Community pharmacy team members were recruited from an existing pharmacy database.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e Stopping criteria were met after six focus group cycles with 28 participants [23 (83%) pharmacists, 4 (14%) registered pharmacy technicians/assistants, and 1 (3%) pharmacy student]. User feedback and corresponding system improvements spanned usability, workflow, and prescriber communication domains. The optimized system consisted of a pharmacy portal with a patient dashboard, patient and provider versions of a point-of-care questionnaire, an interactive CDSS producing guideline-based recommendations, automated documentation, and pre-formatted prescriber communications. The System Usability Scale score was 82.9 ± 16.8 (maximum 100), and user responses to Likert scale-based assessments of eAMS-Pharm format, content, workflow, impact, and overall impressions were highly favorable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e We built and optimized a chronic disease CDSS for use in community pharmacies, identifying and addressing pharmacy-specific barriers to implementation. The system achieved a high system usability score and highly favorable ratings for perceived system benefits, likelihood of clinical use, and patient benefits. The eAMS-Pharm can now be evaluated for uptake, care impact, and outcome impact in real-world settings. Our findings surrounding users’ usability, workflow, and content preferences, and our unique development strategy, can also inform future pharmacy-based chronic disease CDSS design.\u003c/p\u003e","manuscriptTitle":"Designing a computerized decision support system for asthma chronic disease management in community pharmacies","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-11 14:36:42","doi":"10.21203/rs.3.rs-8643015/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-03-10T18:02:50+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-06T14:14:07+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"265996949446194281237992540898350876668","date":"2026-02-20T17:25:18+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-19T06:15:11+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"295335457437157865628633536958967937549","date":"2026-02-06T19:04:38+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-01-23T14:57:30+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-01-23T05:07:50+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-01-23T05:04:23+00:00","index":"","fulltext":""},{"type":"submitted","content":"International Journal of Clinical Pharmacy","date":"2026-01-19T21:01:43+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"international-journal-of-clinical-pharmacy","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ijcp","sideBox":"Learn more about [International Journal of Clinical Pharmacy](https://www.springer.com/journal/11096)","snPcode":"11096","submissionUrl":"https://submission.nature.com/new-submission/11096/3","title":"International Journal of Clinical Pharmacy","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"83bbc05b-7cd5-46c0-8e4c-a046cd48b9b1","owner":[],"postedDate":"February 11th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-05-04T16:05:39+00:00","versionOfRecord":{"articleIdentity":"rs-8643015","link":"https://doi.org/10.1007/s11096-026-02142-y","journal":{"identity":"international-journal-of-clinical-pharmacy","isVorOnly":false,"title":"International Journal of Clinical Pharmacy"},"publishedOn":"2026-04-27 15:57:17","publishedOnDateReadable":"April 27th, 2026"},"versionCreatedAt":"2026-02-11 14:36:42","video":"","vorDoi":"10.1007/s11096-026-02142-y","vorDoiUrl":"https://doi.org/10.1007/s11096-026-02142-y","workflowStages":[]},"version":"v1","identity":"rs-8643015","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8643015","identity":"rs-8643015","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}