Table 1.

Components of RightRx development and implementation

Component	Preliminary Plan	Adaptations
Baseline assessment
1. Workflow and gap analysis	Estimation of the amount of missing information in the documented community drug list at admission compared to population-based dispensing data22	Workflow analysis of the number of tasks and time per task required for medication reconciliation among different units to address opportunities for improvement in efficiency 18
Data feeds
2. External integration to obtain provincial dispensing data, prescribers, and pharmacist information	Agreement with the provincial insurer, the Régie de l'assurance-maladie du Québec (RAMQ), provided a real-time web service for obtaining data on all prescriptions dispensed, prescribing physicians and dispensing pharmacies for all consenting patients and all medical services Algorithms were used to process raw prescription data to prepopulate the community drug list (US patent US8010379B2)	A system monitoring and alert system was added to detect breaks in the RAMQ web service and hospital data feeds and a protocol to communicate with end users
3. Communication with community-based prescribers and pharmacies	Contact information was obtained by linking the provincial data to the licensing rosters of the College of Physicians and Order of Pharmacists for the community-based prescribers and pharmacies to facilitate communication of changes in community-based medication	Verification of physician and pharmacy contact information The text of the letter communicating changes in medication was modified based on calls from community physicians who indicated that they were not the primary care physician, but had prescribed for the patient in the past
4. Drug knowledge module requirements	A commercial drug knowledge database was used to map drug identification numbers in the community drug list to generic molecules, and text strings in the hospital drug information to standardized text strings for the name of the same molecule	Frequent drug sentence orders for dose-based prescribing were incorporated to improve the efficiency of data entry
Interface development
5. Role-based workflow and user interface	Different profile settings were set up for various types of clinicians to tailor to their specific workflow needs and the provincial and hospital legal and professional regulatory requirements	Pharmacists’ notes on medication adherence were displayed directly under the medication so physicians who were making prescribing decisions could easily see this information Nurse practitioner role added to be inclusive of all users, and to reflect each user’s authority and responsibilities appropriately
6. User-centered design and feedback	Drug monographs and pharmacy/physician coordinates were included for each community drug to facilitate communication PDF documents automatically generated and saved once a best possible medication list is generated, review/transfer order is updated, or discharge prescription is finalized to improve and facilitate documentation Action buttons for efficiently continuing, stopping, or modifying each drug, with results appearing in the order summary as actions were taken	A “garbage can” icon added to facilitate deletion of medications when appropriate A free-text information box added on the Prior to Admission tab for notes
Functionalities development
7. Prior to admission functionalities	Designed to suit multiple encounters for the same patient; can be used in preop clinics, the emergency department, and inpatient units linked using the same encounter number Can be used to generate admission orders for community medication to be continued and modified and for new medications	Change from product-based prescribing to generic molecule and dose-per-administration prescribing to improve ease of prescribing and patient safety
8. In-hospital/transfer medication reconciliation functionalities	Alignment of community and hospital medication and grouping by therapeutic class, ordered by clinical importance One-click action bar to stop, modify, or continue community medications that may not have been ordered at admission and/or transfer	Change from product-based prescribing to generic molecule and dose-per-administration prescribing to improve ease of prescribing and patient safety Pharmacist recommendation printout added to allow better documentation of pharmacists’ recommended changes
9. Discharge functionalities	Discharge tab shows the original community drug list lined up against the current hospital medications to allow easier adjudication of medication changes in hospital Finalized discharge prescriptions are printed, signed, scanned, and given to patients A letter summarizing the changes is faxed to each of the community-based dispensing pharmacies and prescribing physicians identified from the dispensing data	Change from product-based prescribing to generic molecule and dose-per-administration prescribing to improve ease of prescribing and patient safety Discharging physicians were not comfortable represcribing drugs that were started by others in the community, even if they were the prescribing physician during the patient’s hospital stay. Two versions of a “continue as previous” functionality were developed as part of the action-bar options to accommodate differing interpretations of the discharging physician’s obligations by provincial medical licensing bodies
Deployment, implementation, and adoption
10. System deployment	Thorough pretesting of new features within the development environment Pilot rollout to a small group of users for testing Deployment of upgrades during the day when development and hospital teams work	Changed to after-hours deployment of upgrades to avoid interference with clinicians during the busiest work period Option to roll back to an earlier version was added if major workflow or patient safety “bugs” were encountered in the production environment
11. Implementation model/strategy	Stakeholder engagement/champion selection Workflow analysis and integration (unit process plan) Logistics Communications and change management planning Training and education Support, monitoring, and evaluation	Wide-screen display monitors were purchased for RightRx units to minimize the need for scrolling and improve efficiency in conducting medication reconciliation activities Training was changed from group presentations to small group and one-on-one hands-on training to accommodate the frequent turnover and busy activities of residents and pharmacists who were the major users Training was done by hospital pharmacy and physician champions Clinical champions joined the sprint planning meetings to determine the most important priorities
12. Adoption	Senior hospital and clinical unit leadership Clinical champions existed at the unit level Field staff provided ongoing training and feedback to the scientific and development team about technical, usability, and professional issues	Clinical champions joined the sprint planning meetings to determine the most important priorities Weekly adoption rates were analyzed, and the development team responded to modify the application and system to address priority issues