Table 2 Supporting quotes from in-depth key informant interviews

 Relative advantage of Flu POCT service over other pharmacy services

“And out of the 15 (rapid influenza) tests that we did right then and there, nine, ten of them had never stepped foot in any of our stores...maybe that has that opportunity to bring in… new patients, new families into our business, and show them how we run a pharmacy.”

5

Independent

2

“Obviously the ability to be able to attract new [patients]... [influenza testing] was the first time they had come there. So that’s definitely going to give you an advantage in the market.”

6

Independent

2

 Complexity of Flu POCT service over other pharmacy services

“…once you get past that initially training, people become so much more comfortable.”

4

Chain

7

 Patient needs and resources

“The one positive thing about COVID is that it brought point of care testing more into the spotlight with pharmacies… Now, hopefully, COVID will bring patients into the pharmacy for the antibody testing. So, flu testing kind of hand in hand with that. Just marketing towards all of these different potentials that a pharmacy can offer. So, it kind of goes hand in hand and how they can complement each other.”

2

Chain

7

“The very first day we opened the flu testing in the previous year, we had 15 tests in the first day. We hadn’t advertised it. We didn’t tell anybody. We just had a little-bitty sign.... We had a clinic next door to us, like an urgent clinic, and they were overflowing. So, people just kind of randomly walked over. They didn’t want to wait. There was 30, 40 people in their lobby, and they saw that we were doing that. And we ended up having a line on our first day, first time doing it. People just totally blown away that we were able to do this...” (informant 5, independent, 2 years)

6

Independent

2

“…they all love it, because it’s a one stop shop, and it’s offered in a more timely fashion for them.”

3

Independent

<1 year

“We have some rural areas up in Northern Michigan that frankly don’t have enough providers to provide care for patients. A lot of patients don’t have primary care providers, so we really set out to fill that void. I certainly feel that we’ve done that.”

4

Chain

7

“I think just everybody being aware of the job that pharmacists and the pharmacy technicians, what we can do [would help]. A lot of people don’t realize the job and the qualifications that we have and are completely surprised by the things that we can do. And once they hear it by word of mouth, or any kind of advertising, they’re so excited about being able to come in for a short amount of time and get in, and get out with medicine if they test positive.”

5

Independent

2

“Because we’ve had to stay open this entire time so who’s going to provide those strep tests when other places are closing and patients don’t have anywhere to go to get a rapid strep test?”

4

Chain

7

 Pharmacy networks with other healthcare settings

“Working under a [collaborative practice agreement] with a pharmacist has not [historically] been respected as much as I wish it would be. It’s baby steps. The reason the flu thing was so readily accepted is because it’s a [collaborative practice agreement] for one drug.”

1

Independent

< 1 year

“There’s a little bit of competition obviously… but again, a lot of those clinics are dealing with shortened hours as well. So, they’re not open until 9:00 AM and they’re not always there the whole weekend. So, it’s really a niche we still fill…. In the beginning, so several years ago, we had a few physician offices that were a little uneasy about us providing this type of care in our pharmacies, but honestly after having personal conversations with them and really [explaining] ‘it’s much like vaccinations, right?’ We’re not taking a piece of the pie; we’re just trying to expand the offering.’ So, we haven’t had any issues like that in several years.”

4

Chain

7

“...we always do a follow-up with the individual’s primary care physician in addition to the collaborating physician. Any time that we not only prescribe a therapy to treat influenza based on a positive test, but anytime we would just test an individual, we would also reach out to the PCP just to let them know that the patient was in there and what our recommendation was.”

2

Chain

6

“I’ve got a physician who brings his five kids here every single time instead of taking them to his office or their pediatricians and stuff like that. They roll in, all five of them, once a month, once every six weeks, whatever, trying to get a test, because one of them is sick. And they would rather do it here, because it’s faster. And financially, better for them, as well.”

5

Independent

2

“We’ve had one office ask and say, “Hey, if you could please not do that for our patients, we’d appreciate that. We would rather see them.” We’ve had another office that refers them to us because if someone’s sick and potentially has the flu, they’re already going to have to come back to the drug store anyway so why should they even come into the office? So, some offices see that as competition, others would gladly rather have them come to us...”

6

Independent

2

 Peer pressure among pharmacy competition

“As an independent pharmacy we have to work very hard to differentiate ourselves. One big way we do that is in [patient] care, but then also in the services we offer… It gives us an advantage over the [other pharmacies] to get folks in the door and retained.”

3

Independent

< 1 year

“…we battle tooth and nail competing with [other pharmacies]. So, being able to provide another service [is part of the fight] we’re fighting every day. Trying to find the next thing, because reimbursements from insurance companies and from pharmacy benefit managers (PBMs) and everything right now for independent [pharmacies], it’s life or death. A lot of them are going under. We’ve seen 50% or so in the past 10 years have closed down ...So offering other services and expanding the scope of pharmacists is crucial to independent pharmacies.”

5

Independent

2

 External policies and incentives

“I guess referring to the [collaborative practice agreement], we had to create a collaborative practice agreement with a local physician that we did with our same physician that signs off on our immunizations. That was probably the biggest delay we had was just getting all of that signed and ready to go.”

1

Independent

< 1 year

 Network and communication within the pharmacy

“Meetings were important because all staff needs to be aware of the offering and be able to speak to it. But then also regional pharmacy leader would have calls with the pharmacist that were participating just to do a check in, to see what their barriers were, to make sure that everybody understood all the procedures that need to be in play. So, an open line of communication both between the overall leader and the pharmacist and those stores, and then also the pharmacist and the teams that they’re leading.”

2

Chain

6

“We disseminate information through email. … we push the information out that way to our managing staff who then tell their on-site staff. We try to have morning huddles every day for focus as well as any kind of new information we might be pushing out to get to our pharmacy technicians and some of the other staff at each store. So, we have a little bit of a flow that starts from upper management and kind of trickles down. Phone calls as well, but the easiest way to get things processed is through email.”

3

Independent

< 1 year

“So, at [our pharmacy chain] we have a clinical division, and then we have almost like a business division. I don’t even want to call them silos, because we work so closely together, but between business and clinical. In terms of implementation, I don’t think there was ever a question from the business side that this was the right thing to offer. We communicate it to both sides because we think it’s important for the entire leadership team to know what we offer”

4

Chain

7

 Culture of the pharmacy

“[We’re] highly efficient. We run one pharmacist and four technicians managing 500+ patients in a very different model; My whole model is just a different deal.”

1

Independent

< 1 year

“We’re all looking for ways to matter to our patients and to make sure we’re going above and beyond for them. …I think that [our pharmacy] has a great culture for implementation. …we have implemented transitions of care, we’ve implemented a new adherence packaging program, so our staff is always prepared and ready for new things. [The pharmacy staff] are very flexible, and I think there’s just a great culture for implementation within all the [pharmacies]. …I think also, the job satisfaction that goes into it for our pharmacists as well, has been a huge reward. So, this always sounds funny and a little weird saying, but we get excited when we get those positive tests. Not because someone’s ill, but because we can help someone. We found someone that needs therapy that, you know what? In a few days, they’re probably going to start to feel a lot better and maybe they wouldn’t have gotten that therapy had we not been available for the service. So incredibly rewarding.”

3

Independent

< 1 year

 Implementation climate of the pharmacy

“We’re very adaptive I guess at [our organization]. It doesn’t take months and months and months to make a change, if we need a change, we can get that approved and completed quickly.”

4

Chain

7

“[Flu POCT is] high priority... We are really working hard on how we expand, and both provide more services to our patients as well as looking to get reimbursed by insurances for that. So, we’re evaluating medical billing platforms currently to allow us to practice at the top of our license. There’s a whole lot of things that we’ve got going on, and I don’t need my pharmacists just spending all day staring at a computer and checking… You’re going to be able to come to [our pharmacy] for your prescriptions, testing supplies, and if you’re not feeling well, come over here and let us test you for Flu or Strep or whatever else you want to do. Save you some time and an office co-pay and get you out of there. I think it’s just another piece of the puzzle. I think with having those other services in place to free up pharmacists’ time, we have been doing Med Sync and tech product verification for so long that’s kind of just become part of our practice, and the pharmacists are having more and more time. So, don’t think it’s going to be a burden or an inconvenience to step away and spend a little bit of extra time with a patient.”

3

Independent

< 1 year

“So, I think if anything, the times we’re in right now, have made us see that this was the right thing to decide to do five or seven years ago. It’s going to make our clinical programs stronger because we’ve got to help our communities through this. …How do we fit it into this new realm of healthcare? I think there’s so much of that, the unknown right now, and while it’s a scary time, I think that pharmacy is going to actually come out stronger clinically because we have to.”

4

Chain

7

“…in pharmacy, we had just experienced initiating something new probably five years before that with vaccines, so it was just revisiting ‘ok, how are we going to adapt for change?’ It’s really change leadership [strategies], that we used more or less.”

4

Chain

7

“Anytime you add additional workload into a pharmacist day there’s always the initial stress of, ‘How do I do this,’ and ‘This is one more thing I need to do.’ But I think the satisfaction, once you can pull away from dispensing and really get that one-on-one time with a patient that the point of care testing offers, it’s very rewarding. I think it’s a good balance for pharmacists.”

2

Chain

6

 Pharmacy readiness for implementation

“When we were pitching the program [our top leadership] were full of recommendations. ‘Let’s get you in touch with marketing so we can make flyers about this service and get store posters out there letting the patients know.’ Of course, because you have to drive people in to get the tests. So, they were definitely supportive in that aspect, as pharmacy isn’t always used to creating and doing marketing pieces like that. So, we had to get in touch with other departments in the company.”

4

Chain

7

“…by the time the analyzers were actually received in stores, we were only just a matter of two, three weeks away from everything happening with COVID...that was one of the barriers, really just the timing of all the pieces coming together in an impactful way for this flu season.”

6

Independent

2

“So, word of mouth honestly goes a long way to be quite honest. Social media’s been huge. We had a big social media push in January. Someone got a test and they put it on social media and it just exploded. Media was everywhere. So, it’s funny what social media does to things. But when it came around this year, we started to press a little more... our goal was to kind of get going, get it spread out... we started with some advertising...We do radio commercials, we do billboards in town. All the old school stuff, it still works great where we’re at.”

4

Chain

7

“I thought it was a good refresher… I did feel compelled to do that, and there was a section in there on collaborative practice. The final section of it was collaborative practice agreements, new billing mechanisms, and doing clinical stuff and getting paid for it. That was helpful. So, I’d recommend that for anybody. That was good."

1

Independent

< 1 year

"[The pharmacists] got certified through a Point of Care Testing certification program. All the pharmacists in the company. And [a local University] facilitated and organized that.

3

Independent

< 1year

“[Pharmacy leadership] created an in-house training… We went through [a national point-of-care testing certificate course] Train the Trainer Training. That’s a lot of training there. They all had to go through [in-house training and national certification]. Every flu season is new because you haven’t tested people for potentially six months depending on flu activity. So, we like to do refreshers. Certain modules that they have to complete or videos they have to watch.”

4

Chain

7

 Planning

“Oh my goodness, we were pretty detailed with it. Lots of manuals, lots of policies and procedures, and entire things spelled out because it was so new to everyone. So, we had everything was spelled out.”

4

Chain

7

 Engaging

“I think I’d be here an hour telling you how much I love the fact that my technicians get to do this. It’s, again, phenomenal for me to watch them grow in their position, as well... With these technicians, it’s my job to train them to do exactly how I would do it, how I would approach things, how I would treat the patient... if you think about it, with an everyday patient picking up a prescription... the point of contact is that technician. So, they’re probably just as comfortable with that technician that’s always seeing them than they are anybody. So, to have that person... be able to sit back with them, take their temperature, go through questions and go through everything, the basic details on the data sheet, that’s more comfortable to them, and seeing someone they see every day. Or every time they come by the pharmacy.”

3

Independent

< 1 year

“I think that’s our biggest hurdle. Having everyone on board. In the pharmacies that have a pharmacist and technicians that are all about it, and pushing it, and helping, and providing it, and talking about it, and enjoying it. If you’re doing the testing and you’re bitter and you’re grumpy, people aren’t going to come back anyway, just because they don’t want to be around you. So having everyone on board, I think is the biggest hurdle for our pharmacy.”

5

Independent

2

 Executing

“...even with what we experienced with COVID-19 kind of putting a stop to it, we were still more than almost triple our numbers from the year before. And we thought we did great the year before. We were impressed with our first-year numbers. But to see, even being cut probably a couple months, we were over triple the amount of tests.”

2

Chain

6

 Reflecting and evaluating

“[Flu POCT implementation] weighs very high. It’s one of our goals for the year. So, doing more implementation of point of care testing will definitely be a high evaluator of my performance.”

2

Chain

6

“We probably should set better goals or set an additional number that we want to treat. Right now, it’s all passive in nature that they come to us after we promote it, but we really haven’t set any goals.

6

Independent

2

“We don’t necessarily have goals as far as a metric to hit. We put it out there that all stores will be trained coming into this flu season. But as far as specific goals, it really is going to depend on where you are and what the flu season looks like. So it’s hard to put a specific number when we don’t know what flu season may look like.”

2

Chain

6

“I think at least covering the cost, the expenses. Seeing that we are doing tests in every store to make it beneficial, not just as a monetary standpoint but also make sure that we’re serving our purpose of helping the community in identifying those cases. So I think a combination of, it’s not a money pit, and also that we truly are finding patients that can benefit from this program.”

4

Chain

7

“I think the return of investment is really important. We’re paying for our pharmacists to be trained. So if we can get enough tests, at least to break even on that training… I think even if it’s just increasing awareness that your pharmacy is somewhere where you go to get this type of service done, that adds a lot as well. I think both of those could be used to measure the overall success of this. And then also helping the patients of the community. If we can detect flu earlier than waiting for them to go see their PCP, overall, just trying to limit exposure rate in our communities is huge.”

2

Chain

6

“[Success is] being able to practice at the top of their license, being able to provide a high level of patient care and being able to bring in additional revenue streams.”

6

Independent

2

“Our goals were really to improve quality of health and expand services that were provided to the patients in certain communities, especially communities that maybe had lower amounts of PCP. We have some rural areas up in Northern Michigan that frankly don’t have enough providers to provide care for patients. A lot of patients don’t have primary care providers, so we really set out to fill that void. I certainly feel that we’ve done that.”

4

Chain

7

“We try to dig and dig and dig, whether it be in person, after the test, before the test, social media. Anything we possibly could to get as much data on how successful, or how appropriate, or how convenient, efficient that this process would be for our patients and for our communities…Was it worth it? Would people actually use it? Would it be helpful to them? …our goal was to kind of get going, get it spread out. It kind of got to where other people around the state, around the city were starting to think about doing it.” (informant 5, independent, 2 years)

5

Independent

2

“Patient dissatisfaction I think would be an unsuccessful marker. I guess my goal is not necessarily right now a certain number of tests, but it would just be good data collection and good reporting so I can see, of whatever test we end up doing, what it’s meant to the company and what it’s meant to the patients.”

3

Independent

0