Table 2 Major themes, descriptions, and participant quotations categorized as potential barriers and facilitators for PatientToc™ Implementation^a

 1. Lack of existing integrations among technology vendors and/or concerns about the feasibility/effectiveness of future integrations of existing pharmacy technology with PatientToc™.

Some pharmacy staff expressed concerns about integrating PT with dispensing systems (both pharmacy types) or electronic health records (health system pharmacies).

Adaptability, Cosmopolitanism, Networks & Communications, Compatibility, Available Resources, External Change Agents

“Firewalls are a big concern with integrating [PT]... with multiple software … dispensing software, outpatient clinic software and inpatient software.” – Health system pharmacy (staff)

 2. Some sub-groups of patients (e.g., older adults, those with arthritis, those who do not physically come in to the pharmacy, those who prefer paper over technology) might be challenged to use PatientToc™.

Some pharmacy patients expressed concerns over technological complexity, managing PT, and seeing how it meets a need for them while pharmacy staff described concerns due to patient age and co-morbidities and needing to walk patients through it (both pharmacy types).

Relative Advantage, Complexity, Design Quality & Packaging, Patient Needs & Resources, Structural Characteristics, Culture, Compatibility, Engaging, Intervention Participants

“There would be some people who would be... you know, we have a pretty elderly clientele. They would look at something like this and say, no, thank you.” – Independent pharmacy (staff)

 3. PatientToc™ could be difficult to incorporate into pharmacy workflow due to space (e.g., small waiting areas, shared space) or staffing (e.g., time required, possible need for additional staff, competing demands) constraints.

Some pharmacy staff expressed concern with available space for pharmacy patients to use PT while many pharmacy staff noted a potential need for additional staff time due to constraints and competing demands (both pharmacy types).

Structural Characteristics, Patient Needs & Resources, Implementation Climate, Compatibility, Available Resources

“Some of your elderly population come in with their cell phones and they are using them for things, or they are calling in or using the internet to call in the refills, but then there are other ones that absolutely won't use our automated system and want to talk to somebody all the time, so I think those people would probably need more help and from a workflow standpoint, I don't know how much extra time we would have to walk them all the way through... so that would be a concern.” – Health system pharmacy (staff)

 4. Data security concerns (e.g., privacy of information provided in PatientToc™ by patients, mistrust of technology, uncertainty regarding where the information is sent) could limit uptake of PatientToc™ by pharmacy patients.

There are some concerns that patients might resist or not trust technology due to concerns with privacy and/or a general mistrust in technology (all primary care practices and pharmacy types) (primary care and pharmacy staff and patients).

Adaptability, Complexity, Patient Needs & Resources, Intervention Participants

“I like to talk face-to-face. I don’t trust these things… Everybody can get your information on them.” – Independent pharmacy (patient)

“There is always some reluctance to everything, because everyone... now they have everyone afraid about data... so everyone is like, what are you going to do with my data? What are you going to do with my data? You know, so that is going to be your biggest challenge... everyone is like, oh you are going to get rich off my data, you know, I mean... just the fact that the media has sort of undermined the credibility… everybody is a suspect now.” – Primary Care (staff)

 1. Pharmacy teams are generally willing to try new things, like PatientToc™, if it will help advance their number one goal of improving patient care.

There is general optimism for PT and expected buy-in from pharmacy staff in trying new things that will benefit and be perceived to be of value to patient care (both pharmacy types) (pharmacy staff).

Evidence Strength & Quality, Culture, Implementation Climate, Organizational Incentives & Rewards, Learning Climate, Readiness for Implementation, Knowledge & Beliefs About the Intervention, Individual Stage of Change, Individual Identification with Organization

“I think most of us are pretty open to trying new things. Um... I think on a more global scale, it sort of matches with what independent pharmacy is trying to do, which is to provide a better patient experience, you know, and that is sort of an all-encompassing thing from [the] start of getting the [medication] orders, getting orders changed when they need to be, to actually providing real caring consults for people.” – Independent pharmacy (staff)

 2. Pharmacy leadership is respected and generally strong communication across team members is present, which would support PatientToc™ implementation.

There is a strong sense that leadership is supportive and respected and motivation to do well was noted with many sites. Teamwork is reflected in regularly scheduled meeting times (all primary care practices and pharmacy types) (primary care and pharmacy staff).

Networks & Communications, Leadership Engagement, Individual Identification with Organization, Opinion Leaders

In specific, pharmacy staff generally view technicians as equals and have a good understanding of roles (both pharmacy types), and there is evidence of strong pharmacy-patient relationships in which patients feel motivated to help the pharmacy (both pharmacy types) (pharmacy patients).

“I think that helps because I am here on a daily basis and not only do I help in, you know, improving numbers, but I also help in other areas of the workflow… and then just building the rapport with the team, knowing that, you know, I hear them on a daily basis and they can come to me with anything, open door policy, and just... yeah, I have a good rapport with my team.” – Primary Care (staff)

“Well, we all do our huddles. The pharmacist is very encouraging and very helpful, and so, like after the huddle, everyone just feels pumped, and so, ... it feels... because we all get together and we talk about how we could all improve within the pharmacy...” – Health system pharmacy (staff)

 3. Measures of importance to pharmacy teams (e.g., Medicare Star ratings, CPESN USA metrics, patient satisfaction, medication adherence) align with those expected to be impacted by PatientToc™ and measured by the research team.

Most pharmacy staff expressed agreement that there are multiple sources of alignment with quality performance metrics of importance to the pharmacy and PT that also align with research plans and objectives (both pharmacy types) (pharmacy staff).

Evidence Strength & Quality, Costs, External Policies & Incentives, Relative Priority, Goals & Feedback, Reflecting & Evaluating

“…system-wide it would help out a lot. I mean, at our site, we do adherence, but I don't know if we do as much as all the other sites just because of our patient population, so I guess it would align with our [company] pharmacy overseeing umbrella goals very well.” – Health system pharmacy (staff)

“So, I think one big thing we talk about is like Star measures and the quality measures. So, …if this could help us with that, um, that would be a big driver to help implement it.” – Health system pharmacy (staff)

 4. Most stakeholders (pharmacists, pharmacy staff, and patients) felt PatientToc™ was easy to use, felt training requirements would be minimal, and offered limited suggestions for improvement.

Most pharmacy participants felt PT flowed and worked well and generally felt confident in their ability to use it with any improvements for suggestion likely feasible (both pharmacy types) (pharmacy staff and patients).

Complexity, Design Quality & Packaging, Access to Knowledge & Information, Self-Efficacy

“I think, honestly, you’ve overcome all the barriers as far as navigating the tablet. I don’t think you could make it any more simple.” – Independent pharmacy (staff)

“…it’s just the print was just right, the lettering was easy to read, the font was okay and the colors were right, the display was easy at a glance you could understand it, so...Even if you are not computer literate, it might take you a minute, but you could figure it out eventually.” – Independent pharmacy (patient)