Community pharmacists’ and residents’ decision making and unmet information needs when completing comprehensive medication reviews

SCIENCE AND PRACTICE Journal of the American Pharmacists Association xxx (2019) 1e10

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RESEARCH

Community pharmacists’ and residents’ decision making and unmet information needs when completing comprehensive medication reviews Kacie L. McPherson, Omolola A. Adeoye-Olatunde*, Jayna M. Osborne, William R. Doucette, Stephanie A. Gernant, Heather Jaynes, Shobha Phansalkar, Alissa L. Russ-Jara, Margie E. Snyder a r t i c l e i n f o

a b s t r a c t

Article history: Received 30 July 2019 Accepted 12 December 2019

Objective: To (1) characterize community pharmacists’ and community pharmacy residents’ decision making and unmet information needs when conducting comprehensive medication reviews (CMRs) as part of medication therapy management and (2) explore any differences between community pharmacists and community pharmacy residents in CMR decision making and unmet information needs. Design: Thirty-to 60-minute semistructured interviews framed using a clinical decisionmaking model (CDMM) were conducted with community pharmacists and residents. Setting and participants: Participants were recruited from practice-based research networks and researchers’ professional networks. Eligible participants had completed or supported the completion of at least 2 CMRs in the last 30 days. Outcome measures: Two researchers independently coded transcripts using a combination of inductive and deductive methods to identify themes pertaining to community pharmacists’ and residents’ decision making and unmet information needs in the provision of CMRs. Discrepancies among researchers’ initial coding decisions were resolved through discussion. Results: Sixteen participants (8 pharmacists and 8 residents) were interviewed. Themes were mapped to 5 CDMM steps. Participants primarily used subjective information during “case familiarization”; objective information was secondary. Information used for “generating initial hypotheses” varied by medication therapy problem (MTP) type. During “case assessment,” if information was not readily available, participants sought information from patients. Thus, patients’ levels of self-management and health literacy influenced participants’ ability to identify and resolve MTPs, as described under “identifying final hypotheses.” Finally, participants described “decision-making barriers,” including communication with prescribers to resolve MTPs. Although pharmacist and resident participants varied in the types of MTPs identified, both groups cited the use and need of similar information. Conclusion: Community pharmacists and residents often rely primarily on patient-provided information for decision making during CMRs because of unmet information needs, specifically, objective information. Moreover, confidence in MTP identification and resolution is reduced by communication challenges with prescribers and limitations in patients’ ability to convey accurate and necessary information. © 2020 American Pharmacists Association®. Published by Elsevier Inc. All rights reserved.

Disclosure: Margie E. Snyder is serving as a paid consultant to Westat, Inc, for the evaluation of the Centers for Medicare and Medicaid Services Part D Enhanced Medication Therapy Management program. The remaining authors declare no relevant conflicts of interest or financial relationships. Funding: Purdue College of Pharmacy, Lilly Endowment, Inc, and Hook Drug Foundation; The Indiana Clinical and Translational Sciences Institute funded in part by The National Institutes of Health, National Center for Advancing Translational Sciences, Clinical and Translational Sciences Award (TL1TR001107); and Agency for Healthcare Research and Quality (K08HS022119).

Previous presentation: The results of this study have been reported at a poster presentation at the Great Lakes Pharmacy Residency Conference in West Lafayette, April 25, 2018, and at the American Pharmacists Association Annual Meeting and Exposition in Nashville, March 17, 2018. * Correspondence: Omolola A. Adeoye-Olatunde, PharmD, MS, Hook Drug Foundation Fellow in Community Practice Research, Department of Pharmacy Practice, Purdue University College of Pharmacy, 575 Stadium Mall Dr., West Lafayette, IN 47907. E-mail address: [email protected] (O.A. Adeoye-Olatunde).

https://doi.org/10.1016/j.japh.2019.12.009 1544-3191/© 2020 American Pharmacists Association®. Published by Elsevier Inc. All rights reserved.

SCIENCE AND PRACTICE K.L. McPherson et al. / Journal of the American Pharmacists Association xxx (2019) 1e10

Key Points Background:
Medication therapy management services, including comprehensive medication reviews (CMRs), are provided to patients to identify and resolve medication-therapy problems, and community pharmacists and community pharmacy residents are common providers of these services.
To date, the information perceived by community pharmacists and residents as needed when conducting CMRs is unknown and might differ between them. Findings:
Patients provide important information that is used by community pharmacists and residents for decision making during CMRs. However, the process used by participants for decision making, including the reliance on patients, was often the result of unmet information needs.
To optimize the identification and resolution of most types of medication-therapy problems, both pharmacists and residents expressed a desire for more objective patient data from medical records (e.g., laboratory data, medication lists, or diagnoses), improvement in communications with prescribers, and improvement in patients’ abilities to convey pertinent information.

Background Medication therapy management (MTM) aims to optimize medication use in accordance with evidence-based guidelines and is “distinct from but can occur in conjunction with the provision of a medication product.”1 Following the inception of Medicare Part D, the Centers for Medicare & Medicaid Services (CMS) requires Medicare Part D plans to offer MTM to select beneficiaries, including those taking multiple medications for 2 or more chronic conditions, with medication costs exceeding a threshold that is set annually by CMS.2 Part D MTM includes an annual, direct MTM provider-to-patient or caregiver comprehensive medication review (CMR).2 A CMR is a “systematic process of collecting patient-specific information, assessing medication therapies to identify medication therapy problems (MTPs), developing a prioritized list of MTPs, and creating a plan to resolve them with the patient, caregiver and prescriber.”3 MTPs can be grouped into 4 broad categories related to a medication’s indication, effectiveness, safety, and adherence.4 Improvement in MTPs, such as improved medication adherence, has been observed among patients enrolled in MTM services.5,6 For example, a 12-month study concluded

2

that patients who received MTM services had a statistically significant reduction in medication- and health-related problems compared with those who did not receive MTM services.5 Similarly, another study has suggested that participating in MTM services reduces the risk of mortality compared with not participating in these services.7 The potential positive impacts of MTM on patient care are dependent on the MTM provider’s ability to detect and resolve MTPs. With regard to the providers of MTM, all Part D plans report utilizing pharmacists.8 More specifically, our team recently analyzed Part D MTM claims data that were newly made available to researchers and found that approximately 23,000 CMRs (approximately 1 in 5) were completed by community pharmacists in 2014.9 Given that the percent of Part D plans reporting community pharmacist utilization for MTM (via contracts with MTM vendors) more than doubled from 2014 to 2018, the number of CMRs provided annually by community pharmacists is likely much larger.8,10 However, although community pharmacists made more MTP recommendations to prescribers, they resolved fewer MTPs than other types of pharmacists providing CMRs.9 Given the important role that community pharmacists play in MTM delivery nationally and the need to improve MTP resolution, insights into community pharmacists’ decision making and unmet information needs regarding the detection and resolution of MTPs during MTM has important implications for practice and policy. Previous research has explored community pharmacists’ decision making for prescription verification,11 “complex” clinical scenarios encountered during prescription dispensing,12 over-the-counter medication recommendations,13 and adverse drug event detection.14 In addition, pharmacists’ unmet information needs pertaining to the provision of other patient care services, such as transitions of care,15 pharmacogenomics,16 and interventions to improve CMS Stars Ratings measures,17 have been identified. However, to our knowledge, community pharmacists’ decision making and unmet information needs pertaining to MTM delivery, particularly CMRs, have not been studied. This is important because of the unique nature of MTM delivery by community pharmacists. For example, community pharmacists are typically providing recommendations about identified MTPs rather than implementing therapy changes through collaborative drug therapy management (CDTM) agreements, as is often the case for pharmacists practicing in other settings.18 In addition, community pharmacists are typically located at a physically distant location from prescribers. Moreover, patients eligible for MTM are typically determined by the payer, such as a specific Part D plan, and not by the pharmacist.2 In addition, the experience level of community pharmacists providing MTM varies. Although various organizations offer MTM training or certificate programs, no national, uniform, educational, or certification requirements for MTM delivery exist. Similarly, community pharmacists often engage community pharmacy residents in providing MTM.19 Community pharmacy residencies are a key path by which new PharmD graduates receive advanced training in patient care services, such as MTM.19 However, previous research has documented differences in expert and novice clinical decision makings.20 With regard to MTP detection, Kwint et al.21 found that less experienced community pharmacists identified vastly fewer

SCIENCE AND PRACTICE CMRs: Decision making and unmet information needs

MTPs during medication reviews than experienced pharmacists. More recently, our team observed a greater reliance by novices on MTM alerts for MTP detection.22 To our knowledge, despite the important role of community pharmacy residencies in preparing MTM providers, community pharmacy residents’ decision making and unmet information needs regarding MTM have also not been studied. Objectives To (1) characterize community pharmacists’ and community pharmacy residents’ decision making and unmet information needs when conducting CMRs as part of MTM and (2) explore any differences between community pharmacists and community pharmacy residents in CMR decision making and unmet information needs.

members throughout Minnesota.24-27 PBRN leaders sent an e-mail invitation to their membership rosters, inviting interested members to contact the researchers by e-mail to schedule time to discuss further. In addition to recruitment from PBRNs, researchers’ community practice professional networks were elicited to identify additional potential participants. These recruitment avenues were used to identify a purposeful sample of participants. Specifically, to be eligible, participants had to be practicing community pharmacists or community pharmacy residents (“residents”) who reported completing at least 2 CMRs within the previous 30 days. This was to ensure that participants had sufficient familiarity with CMRs to describe their decision-making processes and unmet information needs. Any pharmacists and residents contacting the researchers but ultimately not participating were not tracked.

Methods Conceptual framework The clinical decision-making model (referred to throughout this paper as CDMM) developed by Abuzour et al.23 describes prescribing decision-making processes of pharmacists and nurse practitioners through the following steps: case familiarization, generating initial hypotheses, case assessment, final hypotheses, and decision making. This model was selected to frame our inquiry because the steps seemed to reasonably align with those taken during the conduct of CMRs; moreover, the model was identified during the investigators’ literature searches during study planning. For the purposes of applying CDMM to this research focused on CMR provision as a part of MTM, case familiarization was operationalized as the process of becoming familiar with the patient receiving CMR by gathering the patient’s medical history, disease state(s), medication use, and any other appropriate information before the patient’s appointment. Generating initial hypotheses was defined as the development of a list of potential MTPs (e.g., potential medication nonadherence) based on the information gathered. Case assessment referred to further information gathering during CMR appointment to either confirm or deny the hypotheses generated. The results of the assessment then led to final decision making about MTPs and steps for resolution. We applied CDMM to the development of the interview guide and during data analysis to characterize themes regarding decision making and unmet information needs for CMR provision. For the purposes of this study, “unmet information needs” were defined as any information perceived as needed or desired by the participant for CMR delivery and not currently available to the participant. Design, setting, and participants The Indiana University Institutional Review Board approved this descriptive, exploratory, qualitative study. Two practice-based research networks (PBRNs) were used for recruitment purposes: the Medication Safety Research Network of Indiana (Rx-SafeNet) and the Minnesota Pharmacy Practice-based Research Network (MPPBRN). Rx-SafeNet comprises approximately 145 community pharmacy locations throughout Indiana, and MPPBRN has 366 pharmacist

Pilot testing and data collection Before data collection, 1 researcher (KLM) received training in data collection methods by researchers (MES and OAA) experienced in conducting semistructured interviews. KLM then conducted pilot interviews with 3 pharmacists from January to February 2018 to ensure face validity of the interview guide. Minor modifications (e.g., wording of questions) were made to the interview guide according to feedback. The final interview guide (Appendix 1) consisted of 4 broad questions, with several draft probing questions employed when needed; these questions were regarding the community pharmacists’ and residents’ perceptions regarding information used during the 5 stages of the CDMM from Abuzour et al.23 as the model applies to identifying and resolving MTPs during a CMR. KLM scheduled and conducted all interviews by phone, and interviews lasted approximately 30-60 minutes. Phone interviews were chosen for convenience. Basic demographic data were collected at the end of the interview. On completion of the interview, participants were offered a $15 gift card.

Data analysis Audio recordings were transcribed verbatim by a health care transcription service. The transcriptions were coded using the qualitative data management software MAXQDA (versions 12 and 2018) to determine common themes among interviews.28 Any notes taken by the researcher during interviews were not transcribed or coded. Two researchers (KLM and JO) coded transcripts independently and maintained an audit trail to document key decisions.29 Coding and discussion of discrepancies were performed on 1 transcript before continuing to the next. Discrepancies among researchers’ coding were discussed until consensus was reached. Themes were determined inductively after line-by-line coding; after this, themes were mapped to the 5 CDMM constructs through discussion among 4 researchers, including the 2 coders and 2 researchers with more qualitative research experience. Member checking was not performed, and no formal assessment of intercoder reliability was conducted. Demographic data were summarized with descriptive statistics computed using SPSS version 24.30 3

SCIENCE AND PRACTICE K.L. McPherson et al. / Journal of the American Pharmacists Association xxx (2019) 1e10

Table 1 Participant demographics Characteristic Age (y), median (range) Sex, n (%) Female Ethnicity, n (%) Not Hispanic/Latino Race, n (%) White/Caucasian Pharmacy degree, n (%) PharmD Y licensed, n (%) 0e9  10 Additional education/degree(s) completed, n (%)a PGY-1 residency Master’s degree Bachelor’s degree Certification(s) obtained, n (%)a Board Certified Pharmacotherapy Specialist Board Certified Ambulatory Care Pharmacist APhA Pharmacist and Patient-Centered Diabetes Care cert APhA Immunization cert APhA Medication Therapy Management cert Site of employment, n (%) Chain pharmacyb Independent pharmacyc Hospital outpatient pharmacy

Pharmacists n ¼ 8

Pharmacy residents n ¼ 8

Total N ¼ 16

33 d 5 d 8 d 8 d 8 d 5 3 d 4 1 0 d 1 1 0 8 4 d 3 4 1

25 (24e33) d 7 (87.5) d 8 (100.0) d 8 (100.0) d 8 (100.0) d 8 (100.0) 0 (0) d 0 (0) (all in progress) 1 (12.5) 3 (37.5) d 0 (0) (not eligible) 0 (0) (not eligible) 2 (25.0) 7 (87.5) 4 (50.0) d 6 (75.0) 2 (25.0) 0 (0)

d d 12 d 16 d 16 d 16 d 13 3 d 4 2 3 d 1 1 2 15 8 d 9 6 1

(25e43) (62.5) (100.0) (100.0) (100.0) (62.5) (37.5) (50.0) (12.5) (0) (12.5) (12.5) (0) (100.0) (50.0) (37.5) (50.0) (12.5)

(75.0) (100.0) (100.0) (100.0) (81.3) (18.7) (25.0) (12.5) (18.8) (6.3) (6.3) (12.5) (93.8) (50.0) (56.3) (37.5) (6.3)

Abbreviations used: APhA, American Pharmacists Association; cert, certification. a Not mutually exclusive. b Chain pharmacy includes community and grocery store pharmacy settings. c As defined by the National Association of Chain Drug Stores, independent pharmacy includes independent chain (4 or more locations) and independent community (fewer than 4 locations) pharmacies.

Results Participant characteristics In total, 16 participants were interviewed, including 8 community pharmacists and 8 residents. All participants were white (Caucasian), and all possessed a PharmD degree.

Pharmacists were slightly older than pharmacy residents and had more experience with MTM provision (Tables 1 and 2). The availability of worksite information sources (Table 2) varied among participants; most participants (56.3%) reported having access to an affiliate university library database, and only 18.8% of participants reported having access to an electronic medical record (EMR). The interviews were conducted

Table 2 Pharmacist and pharmacy resident comprehensive medication review experience and worksite resources Characteristic Experience providing CMRs (y), n (%) 0e3 4e7 8e11 CMRs per mo, n (%) 0e9 10e19  20 Information sources available at worksite, n (%)a Clinical pharmacology MicroMedex LexiComp Facts and comparisons (Online) University library database Otherb,c

Pharmacists n ¼ 8

Pharmacy residents n ¼ 8

Total N ¼ 16

d 2 (25.0) 4 (50.0) 2 (25.0) d 3 (37.5) 4 (50.0) 1 (12.5) d 3 (37.5) 4 (50.0) 4 (50.0) 6 (75.0) 2 (25.0) 5 (62.5)

d 8 (100.0) 0 (0) 0 (0) d 4 (50.0) 3 (37.5) 1 (12.5) d 2 (25.0) 1 (12.5) 2 (25.0) 2 (25.0) 7 (87.5) 6 (75.0)

d 10 4 2 d 7 7 2 d 5 5 6 8 9 11

(62.5) (25.0) (12.5) (43.8) (43.8) (12.5) (31.3) (31.3) (37.5) (50.0) (56.3) (68.8)

Abbreviation used: CMR, comprehensive medication review. a This was a free-response item in which participants reported information sources available at their worksite. Data are provided for the 5 most frequently reported sources by pharmacists with the exception of data for “University library database,” which was the most frequently reported resources by residents. Data are not mutually exclusive. b Other reported resources included DynaMed, UpToDate, Pregnancy and Lactation, Natural Database, Trissels, Pharmacist Letter, Merck Manual, ClinicalKey, and electronic medical record (EMR). c EMR: 3 pharmacists and no residents reported having an EMR available at their worksite (18.8%).

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SCIENCE AND PRACTICE CMRs: Decision making and unmet information needs

Table 3 Emergent themes by step of the clinical decision-making model and supporting participant quotations Step in CDMM

Case familiarization

Generating initial hypotheses

Themes

Explanation

Participant quotations Community pharmacists

Residents

Subjective information was the primary information type used, whereas objective information (e.g., laboratory data or progress notes) was a secondary type, with objective information confirmed through discussions with the patient Information used to generate initial hypotheses varied by MTP type

Regardless of access to specific information, participants felt it was necessary to confirm the accuracy of data with the patient

“I go through the med list, and first and foremost, just make sure that every med has an indication.” “So, if I had the labs, that would be amazing, but most of the time I don’t.”

“I think the patient’s history is really important to see, so if there is a ‘dose too low’ Alert, for example, looking back and seeing if they have tried a different dose that is higher.”

When available, the medication list would be used to assess adherence. Laboratory data would be used to assess for safety and effectiveness. Tertiary references, such as guidelines, would be used to assess indication, safety, and effectiveness Some participants would wait to generate hypotheses until after case assessment (speaking with the patient)

“I will also double check through guidelines that I may not be as familiar with.” “I usually will go to Lexicomp. I feel like Lexicomp has the most comprehensive information…”

“I think asking the patient about side effects, that gives us a lot of information…”

“I will typically end up finding another one drug therapy problem or two, just [by] interviewing the patient…”

“Unless you ask the right question of the patient, you don’t always get all of the information that you need to maybe identify a drug therapy problem.” “I think a lot of time it is just communication with [the patient]. Sometimes it is... how do you feel like [your disease state management] is going?”

“…Speaking with the patient can largely influence my identification of drug related problems, especially in regards to safety… without talking to a patient and hearing about the side effects they are experiencing…, it is hard to… know what drug related problems need addressed.” “…because a lot of drug therapy problems is dependent on what the patient is able and willing to tell you.”

Not all hypotheses regarding potential MTPs were generated before patient interaction

Case assessment

Information unavailable from readily accessible sources (e.g., prescriptionfulfillment software) was sought from patients

When objective information is unavailable, subjective information is gathered and used to identify MTPs

Identifying final hypotheses

Patients’ level of selfmanagement and health literacy influenced participants’ ability to identify and resolve MTPs

If the patients were unable to provide information, participants may not necessarily be able to finalize or resolve MTPs or even determine if an MTP is a “true” problem

Decision making

Communication with prescribers was a barrier to resolve MTPs

Challenges with prescriber communication created inefficiencies and reduced participants’ ability to resolve MTPs

“I can make fantastic sound medication-related recommendations… but I rely on the provider to take my recommendations, because I can’t change a prescription… so my confidence is a lot less that the [recommendation] actually gets done.”

“I know there’s probably always going to be certain things that patients are not willing to tell providers and so there is always the potential that you are going to miss at least a few [drug problems]” “I think it would be much better if we had some direct contact with a prescriber, so we could address a lot of these issues”

Abbreviations used: CDMM, clinical decision-making model; MTP, medication therapy problem.

in spring 2018; this represented the approximate threequarters completion point of the residency for resident participants.

Themes by step in CDMM Themes are described below and summarized with additional representative quotations provided in Table 3.

Step 1, case familiarization Subjective information was the primary information type used, whereas objective information (e.g., laboratory data or progress notes) was secondary type, with objective information confirmed through discussions with the patient Minimal case familiarization occurred before CMR with the patient because most participants had limited objective information (i.e., information obtained from the medical record, such as laboratory data or progress notes) available to them. 5

SCIENCE AND PRACTICE K.L. McPherson et al. / Journal of the American Pharmacists Association xxx (2019) 1e10

Moreover, participants felt the need to verify the accuracy of any objective information gathered from the patient during CMRs. For example, “[if the patient says] they are taking something one way and the provider says something different” participants would “go with what the patient says since they are the one who is actually taking the medication at home.” Objective information was then used as a secondary source when available. With regard to unmet information needs, most participants wanted access to additional patient-specific objective information, such as EMR access to view laboratory data and provider notes. In addition, participants reported that it would be helpful if they had access to patients’ health insurance formularies and co-pay information. Finally, given the emphasis on using information provided by the patients themselves, some participants commented on the logistics of obtaining patient-specific information, expressing a desire to have a specific support person (i.e., “a scheduler”) make initial calls to patients, schedule CMRs, and gather initial information. - “I go through the med list and first and foremost just make sure that every med has an indication.” - “So, if I had the labs, that would be amazing, but most of the time I don't.” - “I think it would be great to have access to lab work, like if it was possible to just have all of the information that the prescriber has, you know through their EHR.” - “I wish I could have access to the electronic medical records so that I can see from their doctor their pertinent labs.”

Step 2, generating initial hypotheses Information used to generate initial hypotheses varied by MTP type and not all hypotheses regarding potential MTPs were generated before patient interaction Information used to generate initial hypotheses pertaining to efficacy- and safety-related MTPs included clinical practice guidelines or tertiary drug information references (e.g., Facts and Comparisons and LexiComp). In addition, these information sources were used for identifying indication-related MTPs. However, other information sources, such as the community pharmacy’s prescription-fulfillment software, were used. Potential adherence-related MTPs were identified primarily using the community pharmacy’s prescriptionfulfillment software. However, particularly for indication and adherence-related MTPs, participants emphasized a need to confirm the information gathered from these sources with the patient during CMRs. Participants expressed that MTPs were not confirmed as “true problems” until discussed and verified by the patient. Some participants even noted that they would generate no hypotheses regarding MTPs until case assessment (i.e., step 3, CMR) was performed directly with the patient. - “When I start going through the problem list, I will start pulling in each med per problem and that is when I will start to identify missing therapies.” - “We just use our judgement as far as if we should address that [MTM alert regarding potential MTP] with the patient or if it is truly…valid…” - “I can also then compare it [each medication on medication list] to how it is actually taken…and also asking why it is being taken, and from there we typically then discover 6

what kind of drug therapy issues the patient may be experiencing and we talk about what their goals are.”

Step 3, case assessment Information unavailable from readily accessible sources (e.g., prescription-fulfillment software) was sought from patients Case assessment (i.e., CMR appointment) was used to either gather information, such as objective information, which was unavailable during case familiarization (step 1), or to verify previously gathered information with the patient. Examples of information gathered from patients during this step included medication indications, laboratory results, and history of medication-related adverse effects. During case assessment, participants’ hypotheses regarding MTPs sometimes changed after talking with the patient because patients “have more accurate information than what [the participants] may have.” However, participants also noted that patients are often “familiar with monitoring parameters and benchmark numbers that they need to hit, but they have no idea what they are.” - “When you speak with the patient, you verify, you take their history of what they have been on, what they have tried before, what their symptoms are and what the control is currently.” - “If they need additional drug therapy, that usually comes up, I feel like, when I am in with the patient... we usually discover either that they have an untreated condition or... I mean it just kind of depends on the situation.”

Step 4, identifying final hypotheses Patients’ levels of self-management and health literacy influenced participants’ abilities to identify and resolve MTPs Some participants reported feeling “fairly confident” overall in their ability to identify all MTPs during a CMR. However, several unmet information needs were identified. For example, many participants felt more confident in identifying MTPs when working with patients with common disease states such as diabetes, hypertension, and dyslipidemia but felt less confident when working with patients with uncommon disease states. In addition, participants reported a lack of confidence in their ability to ask correct questions or phrase questions in a way that allowed patients to give them all the information that they needed to identify MTPs. Moreover, it was noted by a few participants that the more confident patients were in their own care, the more confident pharmacists or pharmacy residents felt in being able to identify MTPs. - “If the patient is not very knowledgeable about their disease state or not able to tell me about it, or is unable to recall anything about their past medication history, it does make it pretty difficult, if not impossible, to perform an accurate medication review.” - “But there is always some problems and some things that unless you ask the right question of the patient, you don't always get all of the information that you need to maybe identify a drug therapy problem. So I would say that I don't catch all of them, but I would say most of them.”

SCIENCE AND PRACTICE CMRs: Decision making and unmet information needs

Therefore, after case assessment, participants expressed that their final assessment in determining “true” MTPs could be problematic if patients could not provide necessary information when the information needed could not be gathered from other sources. Participants expressed that without the patient providing sufficient information, some MTPs could not be identified or confirmed. If an MTP could not be identified or confirmed, a resolution or recommendation to the prescriber to resolve the MTP could not be made. - “You can't tell them to change their blood pressure medications if you don't even know what the patient's blood pressure is.” - “I find that a lot of medication problems, it takes a while to kind of get them to come out and it is not necessarily when you are asking them about it, but as you are talking to the patient, they may remember something that they then give information on.” - “I know there’s probably always going to be certain things that patients are not willing to tell providers and so there is always the potential that you are going to miss at least a few [drug problems]”

Step 5, decision making Communication with prescribers was a barrier to resolve MTPs Barriers to the resolution of MTPs pertained to communication challenges with prescribers and the inefficiencies and extra time spent as a result. In particular, participants emphasized the difficulties in resolving MTPs owing to a lack of response from prescribers after sending medication-related recommendations, the inability to determine the best method (i.e., facsimile, voicemail, or letter) for communicating with prescribers, and challenges in the chain of communication (i.e., needing to communicate with prescribers through their support staff as opposed to direct communication between the pharmacist and prescriber.) - “I think we can identify problems and I think we are pretty well prepared as far as tertiary resources go, but I think actually getting those changes to be made after completing the CMR, actually having the follow through, is the biggest thing that we have an issue with.” - “I think it would be much better if we had some direct contact with a prescriber so we could address a lot of these issues.” - “I can make fantastic sound medication-related recommendations… but I rely on the provider to take my recommendations, because I can’t change a prescription… so my confidence is a lot less that the [recommendation] actually gets done.” Overall, participants generally felt confident in their ability to identify MTPs but less confident that they could actually resolve those problems. Community pharmacists versus residents Pharmacists more commonly discussed strategies for identifying indication-related MTPs, such as identifying

needed medications or unnecessary medications; however, residents were more apt to describe approaches for identifying effectiveness- and adherence-related MTPs. Despite these differences, both the groups of participants described similar decision-making processes and unmet information needs when addressing specific types of MTPs. Discussion This study extends the literature on MTM delivery by community pharmacists by providing insight into the decision-making processes and unmet information needs of community pharmacists and community pharmacy residents conducting CMRs. These findings could be used by multiple MTM stakeholders, such as pharmacy educators, residency program directors, CMS, and informatics professionals, in the development of policies, trainings, clinical tools, and technologies that support the identification and resolution of MTPs identified during MTM delivery by community pharmacists. Improved MTP resolution by community pharmacists providing MTM has been identified as an opportunity9 and could result in better patient outcomes and improved Part D plan performance on CMS Star measures, such as those pertaining to medication adherence.31 The overarching theme from this study was pharmacists’ and residents’ primary reliance on patient-provided information to identify and resolve MTPs during a CMR. For some MTP types, such as adherence, participants expressed that patients were the optimal information source for making their assessments. The importance of information obtained during patient interviews in MTP identification has been noted previously. A study from the Netherlands determined that about a quarter of MTPs identified during home medication reviews were identified during patient interviews as opposed to during a review of clinical records.32 Similarly, our team’s recent research (M.E. Snyder et al, unpublished data, 2019) found that about half of MTPs identified during CMRs were found with the assistance of MTM alerts and about half were found without the assistance of MTM alerts. However, the process used by participants for decision making, including the reliance on patients, was often the result of unmet information needs. Specifically, to optimize the identification and resolution of most types of MTPs, both pharmacists and residents expressed a desire for more objective patient data from medical records (e.g., laboratory data, medication lists, or diagnoses), improvement in communications with prescribers, and improvement in patients’ ability to convey pertinent information. A desire for more objective data during MTM has been noted previously. A recent survey reported that more than 25% of respondents indicated that they needed to know nutrition and biometric wellness assessment information and point-ofcare testing results to provide MTM.33 In addition, a recent pilot study found that community pharmacists were able to identify more MTPs when they had access to medical records.34 However, we found that fewer than 20% of participants had access to an EMR. Furthermore, recent work has noted that when EMRs are accessible by pharmacists, they must be designed with both types of end users (physicians and pharmacists) and their respective clinical decision-making processes in mind and that doing so could improve

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collaborations.35 In summary, if community pharmacists and community pharmacy residents have access to medical record information, MTPs can be more readily identified and help supplement, confirm, or disconfirm information provided by the patient. These findings emphasize a need for national policies supporting pharmacists’ inclusion in health information exchange (HIE) and aligns with findings from other recent work from our research group.22 The Pharmacy Health Information Technology Collaborative continues to advocate for such policies.36 However, pharmacists in the previous pilot study noted that although they were confident in MTP identification when accessing medical records, they lacked confidence in MTP resolution.34 This was consistent with our current findings described herein; pharmacists and residents were generally confident in their ability to identify MTPs but in the final step of CDMM, they were less confident in their ability to resolve MTPs because of difficulties in prescriber communication. Pharmacists have noted “lack of time” and “physician attitudes” as the greatest barriers for delivering MTM services.37 In addition, challenges with pharmacist-prescriber communication have been reported by pharmacists providing similar medication review services the United Kingdom and Australia.38-40 In fact, many of the challenges with medication use review (MUR) delivery in the United Kingdom described in a recent review article39 mirrored those faced in MTM delivery. As stated by those authors, “Many of these challenges are not exclusive to the MUR service, or even to the community pharmacy setting. Nonetheless, by identifying and exposing such challenges, an opportunity exists for policymakers and commissioners to seek to improve this service to patients.” Similarly, understanding the role that pharmacist-prescriber relationships play specifically in pharmacists’ unmet information needs for MTM is informative. Our findings suggest that, in addition to incentives for HIE, stakeholders should consider models for MTM delivery by community pharmacists, in which prescriber engagement and the use of CDTM agreements to support MTP resolution are rewarded. Additional research is needed on effective strategies for engaging prescribers and facilitating HIE for MTM. This research and evaluations of any new policies to support pharmacist-prescriber collaboration and HIE, such as through routine pharmacist access to EMRs, should examine effects on pharmacists’ abilities to both identify and resolve MTPs during MTM and any unintended consequences. Examples of specific research questions to explore in future research include “does the number and type of MTPs identified by community pharmacists during CMRs and resulting prescriber recommendations and acceptance of recommendations change when pharmacists have routine access to EMRs?” and “what, if any, unintended consequences (e.g., care fragmentation or double documentation) occur from community pharmacist participation in HIE?” Owing to the heavy reliance on the patient for information, improving patient engagement and preparation for CMR is important. Challenges, such as health literacy, pertaining to obtaining health information from patients have been described.41 Understanding the extent to which patients serve as a reliable and engaged source of health information, specifically for CMRs, warrants further research. This could facilitate education and preparation instructions provided to patients before MTM appointments and additional

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enhancements to the CMS’s standardized format, building off the findings of a recent beneficiary survey.42 Moreover, pharmacists might benefit from further training in strategies for eliciting information from patients. We were surprised to find that community pharmacists and residents seemed to use similar decision-making processes for MTM and expressed similar unmet information needs. Our previous mixed-methods research found that novice MTM providers, particularly pharmacy interns, relied more heavily on MTM alerts in the identification of MTPs.22 However, few pharmacy residents were included in that sample. Unfortunately, it is possible that the experience level of the pharmacists and residents in the current investigation was too similar with regard to CMR case volume and years of providing CMRs to identify nuanced differences, and this should be considered a limitation of this research. Therefore, further research to fully elucidate any differences in decision making and unmet information needs between these groups is needed. In addition, the residents were all interviewed at approximately three-quarters of the way during their programs. Future research could include interviewing residents at various stages of residency training to gain further insights into how decision making evolves during residency and the influence of specific training experiences. In addition, pharmacists and residents expressed a desire in having a specific support person gather initial information from patients. A systematic review of recent studies described the use of pharmacy technicians in components of MTM delivery, such as medication reconciliation and documentation.43 Furthermore, Adeoye et al.44 found that compared with pharmacists, pharmacy technicians held more positive perceptions of MTM delivery in regard to having adequate time and support for their role in MTM delivery. Given that support staff are increasingly being involved in MTM, with increased involvement expressed as desirable during study interviews, future research exploring the decision-making processes and unmet information needs of student pharmacists and pharmacy technicians related to their roles in MTM delivery would be valuable.

Limitations This study applied the CDMM designed by Abuzour et al.,23 which was developed from independent prescribing pharmacists’ and nurses’ experiences. Abuzour et al.’s23 use of the hypothesis-generating step refers to diagnosing medical conditions, whereas the current work explored community pharmacists who were “diagnosing” MTPs. Applying CDMM elucidated community pharmacists’ and residents’ steps for decision making with notable overlap among strategies for case familiarization and assessment because of the reliance on the patient for information. Applying a different decisionmaking model to the development of our interview guide and possibly the organization of findings could have resulted in different conclusions. However, after this project was launched, Wright et al.45 published a CDMM describing “secondary beneficent” services provided by pharmacists, wherein the pharmacist decision making helps the decision making of another “primary” provider.45 This model aligns well with how we operationalized CDMM for MTM, and we believe that our

SCIENCE AND PRACTICE CMRs: Decision making and unmet information needs

findings would have been similar had the Wright et al.45 model been available and known to us at the time of study design. Similarly, because only pharmacists and pharmacy residents practicing in the community were interviewed for this study, our findings may not always be transferable to pharmacists providing MTM services in inpatient or other health care settings. In addition, although the number of participants was sufficient to identify the themes described herein, thematic saturation might not have been met. It is unknown if additional themes, more nuanced subthemes, or further insights into any differences between pharmacists and residents could have emerged if further interviews had been conducted. Unfortunately, pragmatic constraints (i.e., the number of participants recruited during the time allotted for data collection) prevented further interviews from being conducted. In addition, we did not attempt to probe into whether decision making was described by participants “in general” or using specific patient examples or whether differences in themes existed when participants described CMRs conducted for patients receiving all pharmacy services versus patients receiving MTM only. Finally, reflexivity is an important consideration in qualitative research.29 All of the authors directly involved in the analysis and interpretation of interview data were pharmacists and student pharmacists with varying levels of experience. The first author, who conducted the interviews, was a community pharmacy resident at the time of data collection and was mentored by 2 senior investigators with both community pharmacy residency training and experience with qualitative research. Our interpretations could have differed if we had different education and training experiences. Conclusion This study extends the literature on MTM delivery by community pharmacists by providing insight into the decision-making processes and unmet information needs of community pharmacists and community pharmacy residents conducting CMRs. Patients were the primary information source used by community pharmacists and residents to identify MTPs when conducting CMRs. Reliance on the patient for information was partly because of unmet information needs, such as a desire for more patient-specific, objective information owing to inconsistent access to medical records. MTP resolution was often challenging because of inadequate communication with prescribers. Participants desired improved pharmacist-prescriber communication to facilitate the timely resolution of MTPs. Acknowledgments The authors thank Rx-SafeNet, MPPBRN, and investigators’ professional network for their assistance with recruitment for this study. In addition, the authors thank the preceptors and residents of the Purdue Research Project Development Program 2017-2018 who provided feedback throughout the completion of this study. References 1. Bluml BM. Definition of medication therapy management: development of profession wide consensus. J Am Pharm Assoc (2003). 2005;45(5): 566e572.

2. Centers for Medicare and Medicaid Services. CY 2019 medication therapy management program guidance and submission instructions. Available at: https://www.cms.gov/Medicare/Prescription-Drug-Coverage/Prescription DrugCovContra/Downloads/Memo-Contract-Year-2019-Medication-TherapyManagement-MTM-Program-Submission-v-040618.pdf. Accessed November 13, 2018. 3. American Pharmacists Association and National Association of Chain Drug Stores Foundation. Medication therapy management in pharmacy practice: core elements of an MTM service model. 2.0 version. Available at: https://www.pharmacist.com/sites/default/files/files/core_elements_ of_an_mtm_practice.pdf. Accessed June 24, 2018. 4. Cipolle RJ, Strand LM, Morley PC. Pharmaceutical Care Practice: The Clinician’s Guide. New York, NY: McGraw Hill; 2004. 5. Moczygemba LR, Barner JC, Gabrillo ER. Outcomes of a Medicare Part D Telephone Medication Therapy Management program. J Am Pharm Assoc (2003). 2012;52(6):144e152. 6. Brummel A, Carlson AM. Comprehensive medication management and medication adherence for chronic conditions. J Manag Care Spec Pharm. 2016;22(1):56e62. 7. Hui RL, Yamada BD, Spence MM, Jeong EW, Chan J. Impact of a medicare MTM program: evaluating clinical and economic outcomes. Am J Manag Care. 2014;20(2):e43ee51. 8. Centers for Medicare and Medicaid Services. medicare part D medication therapy management (MTM) programs. Fact sheet: summary of 2018 MTM programs. 2018. Available at: https://www.cms.gov/Medicare/ Prescription-Drug-Coverage/PrescriptionDrugCovContra/Downloads/CY2 018-MTM-Fact-Sheet.pdf. Accessed January 14, 2019. 9. Adeoye OA, Farley JF, Coe AB, et al. Medication therapy management delivery by community pharmacists: insights from a national sample of Medicare Part D beneficiaries. J Am Coll Clin Pharm. 2019;2(4):373e382. 10. Centers for Medicare and Medicaid Services. Medicare Part D Medication Therapy Management (MTM) programs. Fact sheet: summary of 2014 MTM programs. Available at: https://www.cms.gov/Medicare/ Prescription-Drug-Coverage/PrescriptionDrugCovContra/Downloads/ CY2014-MTM-Fact-Sheet.pdf. Accessed July 9, 2019. 11. Nusair MB, Guirguis LM. How pharmacists check the appropriateness of drug therapy? Observations in community pharmacy. Res Social Adm Pharm. 2017;13(2):349e357. 12. Gregory PA, Whyte B, Austin Z. How do community pharmacists make decisions? Results from an exploratory qualitative study in Ontario. Can Pharm J (Ott). 2016;149(2):90e98. 13. Sinopoulou V, Summerfield P, Rutter P. A qualitative study on community pharmacists’ decision-making process when making a diagnosis. J Eval Clin Pract. 2017;23(6):1482e1488. 14. Phansalkar S, Hoffman JM, Hurdle JF, Patel VL. Understanding pharmacist decision making for adverse drug event (ADE) detection. J Eval Clin Pract. 2009;15(2):266e275. 15. Brühwiler LD, Hersberger KE, Lutters M. Hospital discharge: what are the problems, information needs and objectives of community pharmacists? A mixed method approach. Pharm Pract (Granada). 2017;15(3):1046. 16. Romagnoli KM, Boyce RD, Empey PE, Adams S, Hochheiser H. Bringing clinical pharmacogenomics information to pharmacists: a qualitative study of information needs and resource requirements. Int J Med Inform. 2016;86:54e61. 17. George DL, Smith MJ, Draugalis JR, Tolma EL, Keast SL, Wilson JB. The use of think-aloud protocols to identify a decision-making process of community pharmacists aimed at improving CMS star ratings scores. Res Social Adm Pharm. 2018;14(3):262e268. 18. American College of Clinical Pharmacy, McBane SE, Dopp AL, et al. Collaborative drug therapy management and comprehensive medication management-2015. Pharmacotherapy. 2015;35(4):e39ee50. 19. American Pharmacists Association. Accreditation standard for postgraduate year one (PGY1) community-based pharmacy residency programs. Available at: https://www.ashp.org/-/media/assets/professionaldevelopment/residencies/docs/pgy1-community-based-pharmacy-2017. ashx. Accessed July 9, 2019. 20. Persky AM, Robinson JD. Moving from novice to expertise and its implications for instruction. Am J Pharm Educ. 2017;81(9):6065. 21. Kwint HF, Faber A, Gussekloo J, Bouvy ML. Completeness of medication reviews provided by community pharmacists. J Clin Pharm Ther. 2014;39(3):248e252. 22. Snyder ME, Jaynes HA, Gernant SA, Lantaff WM, Hudmon KS, Doucette WR. Variation in medication therapy management (MTM) delivery: implications for health care policy. J Manag Care Spec Pharm. 2018;24(9):896e902. 23. Abuzour AS, Lewis PJ, Tully MP. A qualitative study exploring how pharmacist and nurse independent prescribers make clinical decisions. J Adv Nurs. 2018;74(1):65e74. 24. Snyder ME, Frail CK, Seel LV, Hultgren KE. Experience developing a community pharmacy practice-based research network. Innov Pharm. 2012;3(2). Article 78.

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25. Seel LV, Hultgren KE, Snyder ME. Establishing the Medication Safety Research Network of Indiana (Rx-SafeNet): perspectives of community pharmacy employees. Innov Pharm. 2012;3(2):79. 26. Kozak MA, Gernant SA, Hemmeger HM, Snyder ME. Lessons learned in the growth and maturation stages of a community pharmacy practice-based research network: experiences of the medication safety research network of Indiana (Rx-SafeNet). Innov Pharm. 2015;6(2). Article 203. 27. Minnesota Pharmacy Practice-Based Research Network. Welcome to the Minnesota Pharmacy practice-based research network. Available at: http:// www.mpha.org/associations/9746/files/PBRN/index.html. Accessed July 9, 2019. 28. VERBI software GmbH. MAXQDA. 2018. Available at: https://www. maxqda.com/contact/verbi-software. Accessed January 11, 2020. 29. Ulin PR, Robinson ET, Tolley EE. Qualitative Methods in Public Health: A Field Guide for Applied Research. San Francisco, CA: Jossey-Bass; 2005. 30. IBM. IBM SPSS software. Available at: https://www.ibm.com/analytics/ us/en/technology/spss/. Accessed July 9, 2019. 31. Academy of Managed Care Pharmacy, American Pharmacists Association. Medicare star ratings: stakeholder proceedings on community pharmacy and managed care partnerships in quality. J Am Pharm Assoc (2003). 2014;54:228e240. 32. Kwint HF, Faber A, Gussekloo J, Bouvy ML. The contribution of patient interviews to the identification of drug-related problems in home medication review. J Clin Pharm Ther. 2012;37(6):674e680. 33. Casserlie LM, Mager NA. Pharmacists' perceptions of advancing public health priorities through medication therapy management. Pharm Pract (Granada). 2016;14(3):792. 34. Gernant SA, Zillich AJ, Snyder ME. Access to medical records’ impact on community pharmacist-delivered medication therapy management: a pilot from the medication safety research network of Indiana (Rx-SafeNet). J Pharm Pract. 2018;31(6):642e650. 35. Mercer K, Burns C, Guirguis L, et al. Physician and pharmacist medication decision-making in the time of electronic health records: mixedmethods study. JMIR Hum Factors. 2018;5(3):e24. 36. Pharmacy Health Information Technology Collaborative. Integrating pharmacists into health information exchangeseupdate version. Available at: http://www.pharmacyhit.org/pdfs/workshop-documents/WG3Post-2018-01.pdf. Accessed February 18, 2018. 37. Blake KB, Madhavan SS. Perceived barriers to provision of medication therapy management services (MTMS) and the likelihood of a pharmacist to work in a pharmacy that provides MTMS. Ann Pharmacother. 2010;44(3):424e431. 38. Stewart D, Whittlesea C, Dhital R, Newbould L, McCambridge J. Community pharmacist led medication reviews in the UK: a scoping review of the medicines use review and the new medicine service literatures [e-pub ahead of print]. Res Social Adm Pharm https://doi.org/10.1016/j. sapharm.2019.04.010. Accessed January 11, 2020. 39. Latif A. Community pharmacy medicines use review: current challenges. Integr Pharm Res Pract. 2017;7:83e92.

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40. Costa D, Van C, Abbott P, Krass I. Investigating general practitioner engagement with pharmacists in home medicines review. J Interprof Care. 2015;29(5):469e475. 41. Irizarry T, DeVito Dabbs AD, Curran CR. Patient portals and patient engagement: a state of the science review. J Med Internet Res. 2015;17(6): e148. 42. Brandt NJ, Cooke CE, Sharma K, et al. Findings from a national survey of medicare beneficiary perspectives on the Medicare Part D Medication Therapy Management standardized format. J Manag Care Spec Pharm. 2019;25(3):366e391. 43. Gernant SA, Nguyen MO, Siddiqui S, Schneller M. Use of pharmacy technicians in elements of medication therapy management delivery: a systematic review. Res Social Adm Pharm. 2018;14(10):883e890. 44. Adeoye OA, Lake LM, Lourens SG, Morris RE, Snyder ME. What predicts medication therapy management (MTM) completion rates? The role of community pharmacy staff characteristics and beliefs about medication therapy management. J Am Pharm Assoc (2003). 2018;58(4S):S7eS15.e5. 45. Wright DFB, Anakin MG, Duffull SB. Clinical decision-making: an essential skill for 21st century pharmacy practice. Res Social Admin Pharm. 2019;15(5):600e606. Kacie L. McPherson, PharmD, Clinical Pharmacy Specialist, Pain Management, VA Northern Indiana Health Care System, Fort Wayne, IN, and at time of study, PGY-1 Community-based Pharmacy Resident, Topeka Pharmacy and Purdue University, Topeka, IN Omolola A. Adeoye-Olatunde, PharmD, MS, Hook Drug Foundation Fellow in Community Practice Research, Department of Pharmacy Practice, Purdue University College of Pharmacy, IN Jayna M. Osborne, PharmD, PGY-1 Resident, Indiana University Health, Bloomington, IN, and at time of study, Student Pharmacist, Purdue University College of Pharmacy, West Lafayette, IN William R. Doucette, PhD, Division Head and Professor, Departments of Pharmacy Practice and Science and Division of Health Services Research, University of Iowa College of Pharmacy, Iowa City, IA Stephanie A. Gernant, PharmD, MS, Assistant Professor, School of Pharmacy, University of Connecticut, Storrs, CT Heather Jaynes, RN, MSN, Research Nurse, Department of Pharmacy Practice, Purdue University College of Pharmacy, IN Shobha Phansalkar, BSPharm, PhD, Assistant Professor, Department of General Medicine and Primary Care, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA Alissa L. Russ-Jara, PhD, Assistant Professor, Department of Pharmacy Practice, Purdue University College of Pharmacy, IN Margie E. Snyder, PharmD, MPH, FCCP, Associate Professor, Department of Pharmacy Practice, Purdue University College of Pharmacy, IN

SCIENCE AND PRACTICE CMRs: Decision making and unmet information needs

Appendix 1. Verbal interview format “Thank you for participating in this study. As discussed before, this interview is being conducted to gather information needs while completing a comprehensive medication review. The interview has 2 components: a verbal interview, which will be recorded, followed by a brief survey, which will not be recorded. The brief survey will be right after the verbal interview. The total interview experience should not take longer than 1 hour. The verbal interview will be recorded on a device

that I will need to have my phone on speaker for. There is no one else in the room. The survey will gather some basic demographic information. The information gathered from this interview is confidential; however, if you do not feel comfortable answering any question at any point in time, you can refuse to answer. There are no right or wrong answers to these questions. If, at any time, you wish to stop and discontinue the interview, please let me know. During the recorded interview, I am asking that you refrain from using names and other specific identifiers. This is to

Supplemental Table 1. Semi-structured interview guide. Decision-making steps Case familiarization

Item

Questions

Main questions

When you open a new comprehensive medication review (CMR) case, walk me through the steps you take to familiarize yourself with the case? - In what ways do you approach the case? - What, if any, patient-specific information do you look for? Where do you get this information? How readily available is it? (What additional information, if any, would you want to have?) - What, if any, disease state or general drug information do you look for? Where do you get this information? What resources do you use? How readily available is it? (What additional information, if any, would you want to have?) - If you ever come across a disease state you are not familiar with, how, if at all, do you update yourself on this topic? - Where are all the places you look to find a complete list of the patient’s medications? - In situations where you are not familiar with a medication, how, if at all, do you go about familiarizing yourself with the drug? - In general, what resources, if any, do you use to complete a CMR? Resources could include primary, secondary, tertiary resources, and other health care personnel. - What is the first thing you look for? - Where do you start your work up? What is your approach to identifying potential medication-therapy problems (MTPs) before speaking with the patient (or caregiver)? - What role does information about the patient play? - What role, if any, does other information sources play? - How does it vary by different MTPs? - How relevant or irrelevant are the alerts or targeted medication reviews (TMRs) in the platforms to the topics you feel you need to discuss with patients? Once you start speaking with the patient, how does this further influence, if at all, your identification of medication-related problems? - When you begin a CMR, what type of information do you ask the patient (or caregiver)? - Compare and contrast alerts in the medication therapy management platform versus medication-related problems you typically discover when conducting a CMR. - How does this information impact your ability to detect different types of medication-related problems? - What questions, if any, do you ask the patient to help you better understand how their disease state is being treated? - If the patient cannot answer your questions, how does this, if at all, affect how you complete the CMR? At what point in the CMR do you feel you are finished identifying medicationrelated?

Follow-up/probes

Generating initial hypothesis

Main questions Follow-up/probes

Case assessment

Main questions Follow-up/probes

Final hypothesis and decision making

Main questions

Follow-up/probes

- What resources do you use, if any, to ensure your recommendations or findings during the CMR are accurate? - How do those resources vary, if at all, from the resources you used with the initial patient assessment and work up? - Once you’ve identified all the medication-related problems that you feel you are going to, how confident, or not confident, are you that you’ve found them all? Why is that? - How, if at all, does your confidence vary by medication-related problems? - How confident, or not confident, are you that you’ve resolved them all? Why is that?

“Again, I would like to thank you for participating in this study. The first section of the interview process is over.” dshuts off recorderd “I have now shut off the recorder.”End of verbal interview 10.e1

SCIENCE AND PRACTICE K.L. McPherson et al. / Journal of the American Pharmacists Association xxx (2019) 1e10

preserve confidentiality. He or she or job titles such as pharmacist, physician, or technician will be fine. In addition, please refrain from chewing gum, eating, or drinking during the recording portion of the interview. During the interview, to reduce feedback or the noise you may hear during recording, I will have my voice muted while you are responding to my questions. Please note there may be some time between your response and my comments. I will still be on the phone. Simply muted. The interview will last about 30-60 minutes. I will start the interview by asking you if it would be ok to start the recording. When we are done, I will tell you when the interview is finished and when the recorder is shut off. What questions do you have so far?” “If there are no further questions, with your permission, may I start the recording of the initial portion of this interview process?” This is study id _ _ and today is _ _ _.

Demographic survey 1) Age (years): __________ 2) Sex: a. Male b. Female c. Prefer not to answer 3) Ethnicity: a. Not Hispanic/Latino b. Hispanic/Latino c. Prefer not to answer 4) Race: a. White/Caucasian b. Black/African American c. Asian d. American Indian/Alaska Native e. Native Hawaiian or other Pacific Islander f. More than one race g. Prefer not to answer 5) Job title: a. Pharmacy technician (go to question 10) b. Student pharmacists/intern (go to question 10) c. Pharmacy resident d. Pharmacist 6) Pharmacy degree completed: a. BS b. PharmD c. Both BS And PharmD

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7) Year first licensed as a pharmacist in any state: 8) Additional education and degree completed (check all that apply): a. PGY-1 residency b. PGY-2 residency c. Fellowship d. Masters e. PhD f. Other _____________ g. None 9) Pharmacist-specific certifications obtained (check all that apply): a. Board Certified Pharmacotherapy Specialist b. Board Certified Ambulatory Care Pharmacist c. Board Certified Geriatric Pharmacist d. Other:___________ e. None 10) Certifications obtained (check all that apply): a. Certified Diabetes Educator b. APhA Pharmacist and Patient-Centered Diabetes Care Certificate c. APhA Pharmacy-Based Lipid Management Certificate d. APhA Immunization Certificate e. APhA Medication Therapy Management Certificate f. Other:___________ g. None 11) Site of employment: a. Chain community pharmacy (CVS Health, Walgreens, Rite Aid) b. Chain mass merchant pharmacy (Walmart, Meijer) c. Chain grocery store pharmacy (Kroger, Giant Eagle) d. Independent community pharmacy (fewer than 4 locations) e. Hospital outpatient pharmacy f. Compounding-only pharmacy g. Other:____________ 12) How long have you been providing comprehensive medication reviews (CMRs) as part of mediation therapy management (MTM) in community pharmacies? (Years) 13) Approximately, how many CMRs do you conduct or assist with per month? 14) What MTM platform do you use? 15) List all resources you have available to you at your work site: _________________________________________________ 16) Other comments about background, training, or experience providing CMRs: __________________________________________________