Table 2. Exemplar Verbatim Quotes Organized Thematically and by Consolidated Framework for Implementation Research (CFIR) Domain
Intervention Component (CCM Domain)CFIR Domains
Patient BP self-monitoring and training (self-management support)Outer settingCostI've got several hundred people who have the [blood pressure] cuffs but a fair number of people who say ‘I can't afford a cuff.' (Clinic 1 provider)Intervention characteristicsImproves quality of careThe advantage would be getting patients under better control. (Clinic 4 provider)
AccuracyI think the challenge will be accuracy. Physicians would like to know the blood pressures they're getting from the patient's home are actually accurate. (Clinic 2 provider)Everything I've read is that patients that do monitor their own blood pressures statistically will take less medication than those that do not . . . So I support it. (Chain pharmacist)
I know when I bought my cuff . . . no one had taken the time to say this is how you put it on your arm and this is where it has to be. (Patient 2)I encourage patients all the time to take their blood pressure at home a lot and keep a record of it, because one blood pressure reading is pretty useless really. (Independent pharmacist)
Lack of patients' IT skillsNone of the old people [who] are concerned about their blood pressure know how to use the computer yet! (Clinic 4 provider)Empowers patientsThe whole idea of this outpatient clinical is that you can help people achieve their health goals by empowering them to take care of themselves and be more involved in the situation . . . I think home blood pressure monitoring is a perfect example of that and to me it's a steppingstone . . . if we can get people to do this with their hypertension, we can probably do asthma, we could probably do diabetes, we could probably do lipids. (Hospital pharmacist)
Characteristics of IndividualsInterpretationIf it's not done right . . . that might trigger some false decisions or questions . . . . Will somebody panic if it spikes? (Patient 4)It would encourage me to live better and make better choices with my diet and get more exercise, just to see those numbers go down to where they should be. (Patient 5)
Web pharmacist care (delivery system design change)Outer SettingQuestions about pharmacy selectionThe reality is you've got neighborhood pharmacies that are open 9 to 4, Monday through Friday, and not part of any sort of organized system, and then you've got big chain pharmacies that have the ability that patients can travel across the country and get their medications. So how do you pick and choose in a private practice setting? Which pharmacies do you work with? We need to leave it up to our patients which pharmacy they go to. (Clinic 2 provider)Intervention characteristicsEmpowers patientsI like the team approach, I really do, and I like feeling in control, like being a bigger player in my health. (Patient 2)
One of the things [the MDs in the clinic] all said to me was, there is such a big variation in what they perceive as the ability of a pharmacist from one pharmacist to the next, when you're talking about a retail pharmacist. (Integrated pharmacist)Patient convenienceIt's the way any of us would want to be treated if we're seeing somebody—we don't want to go in any more times than we absolutely have to, right? (Clinic 1 provider)
Lack of trustI don't feel like I have relationships with the pharmacists now. Because I don't use them, I don't call them for questions—there's other resources that I use. (Clinic 1 provider)Our type of patients would love [web-based collaborative care]. With the patients it's all about access, and access to the physicians is brutal—it's not good probably anywhere and it's definitely not good in this town. (Independent pharmacist)
[The big supermarket chain] basically rotates their pharmacists so the pharmacist one month may not be the pharmacist next month . . . I wouldn't have the [big drugstore chain] pharmacists doing this. For one of the reasons, I can't understand them most of the time . . . and they don't stay around very long. (Clinic 1 provider)I think it's easy access and I can get answers now instead of waiting until I go in to see the doctor, you know, a month down the road. (Patient 6)
Lack of financial incentive, lack of timePart of it is the financial issue because [clinic providers] get paid when the patient comes in to get their blood pressure checked and to get medicine changes and get control, that's how they make their money. (Clinic 3 provider)I always felt somewhat hesitant to call the doctor and say you know, I really like the medicine but yet maybe it's a little too strong. Having this opportunity to work with somebody and not calling the doctor and making an appointment and taking time out of my day to do that would be very beneficial. (Patient 2)
The barriers are obvious—time and money . . . . We don't have the time and we don't have the money. If we can solve those problems, I'm right on board. (Independent pharmacist)You don't have to make an appointment to come in and sit down for a couple hours to fix or to glitch some little thing if you need one day's worth of something different. Sounds good to me. (Patient 9)
Up until 6 weeks ago we were getting 500, 535 [prescriptions] a day . . . Monday through Friday, which doesn't lend itself to extra time. You know, time, time, time—I think that's probably everyone's constraint across the board. (Chain pharmacist)Saves staff time[Web-based pharmacist care is good.] I can see a huge benefit in that all the phone calls that our nursing staff receive constantly for refills and also for people with drug problems, a lot of that at least for hypertension would be redirected for this person and you'd never hear about it. It can potentially free the nursing staff up a little bit, not having to deal with all these phone calls. (Clinic 3 provider)
Intervention characteristicsConcerns about team roles and relationshipsA new person on board would be an adjustment. I'm not saying it couldn't be done, but it would be an adjustment. (Patient 1)Additional support for patientsOne other benefit is just potentially their access to a pharmacist . . . to ask questions. (Clinic 4 provider)
I take a lot of medications and they would have to have on this end, the pharmacy end, a list of that. They'd have to be aware of what else is going on besides just the blood pressure. (Patient 8)My experience is any time you give the patient more attention, they like it. (Hospital pharmacist)
The only negative I could see is where the physician and pharmacist explicitly disagree, like they're actually kind of in a battle about it. Then the patient may be a little bit neglected or think, well, what do I do? (Patient 5)Patients of mine who are not well controlled to this point have failed the current model a little bit . . . if I can't get them under control it usually means they're not taking their medicines or they're not coming to see me so another model may help remedy those two problems. (Clinic 4 provider)
Characteristics of individualsConcerns about collaborative practiceSome of my older partners . . . they're of that old framework that ‘I'm the doctor, I tell them what goes on, nobody else should be involved.' (Clinic 3 provider)Lots of patients will tell me they would rather talk to me than their doctor. Because they feel like I speak to them on their level and I take the time to listen to them. (Hospital pharmacist)
Those physicians who are not comfortable with a collaborative practice or a protocol probably aren't going to be interested in hearing what the pharmacist has to say. (Hospital pharmacist)Long-term cost savingsIt's worth the money if you have patients that are more engaged and have better health, then they're not in the hospital so much. So it's like if you can put in the investment up front, you will see the benefits down the road. (Hospital pharmacist)
You get the gamut of [doctors who] are all for [team care] to the ones that think they should still be going to their [patient's] house and checking their blood pressure once a week. (Independent pharmacist)One other thing that's value added from the pharmacist—sometimes you see blood pressure medicines written for where they haven't tried—you know they're writing for the drug reps and there's all this good medicine that's still out there that exists today that's cheap. And we should maximize some of that stuff, I mean that could be a value for people. (Chain pharmacist)
I'll also say that there are some patients that just don't . . . want anyone treating them besides the physician. (Integrated pharmacist)Characteristics of individualsCollaborative care benefitsI think most pharmacists will embrace it. I think they like the interaction and the clinical aspect of the work. (Hospital pharmacist)
There's going to be a certain percentage of people that are uncomfortable with the idea of working directly with a pharmacist. (Patient 2)If you can build the rapport with the physician . . . to establish a collaborative practice, I think the physicians are very comfortable with that. (Hospital pharmacist)
Patients love the attention and I think that they respond better . . . if I see this patient once a month and I'm reminding them or in the case of a two-way texting going back and forth . . . if they're involved, they're going to be getting much better results. (Independent pharmacist)
I think the patients would love it . . . they really trust us . . . sometimes they come right out and just say that they put more stock in what we have to say than the doctor. (Chain pharmacist)
High-quality careI've always felt like pharmacists had the potential to be a provider and this is going to give us one more arrow in the quiver, I guess, proving that in fact we can have an impact and do all of the things that so many studies have proven—we can reduce costs, we can improve care. (Independent pharmacist)
JNC-based protocols (decision support)Characteristics of individualsLow self-efficacyI would feel comfortable adding a second med or you know following those guidelines [protocols developed collaboratively], but when you get into the calcium channel blockers and stuff, then I would be like—you know, I got these readings and I'm a little nervous—but I have confidence, obviously, except to the calcium channel blockers. (Chain pharmacist)Outer settingLiability protectionLiability is obviously a little bit of an issue [for pharmacists doing collaborative care], but protocols give you a lot of protection against that. (Independent pharmacist)
Concerns about protocolAs long as I had a lot of say in the protocol, and it's not even so much for accelerating as much as it would be starting new medicines . . . . I don't want a calcium channel blocker started on the patient who has severe constipation. I don't want a beta blocker started on the patient who's got a heart rate of 45—you guys know, the list goes on. (Clinic 4 provider)Intervention characteristicsStandardized careIf you have a protocol and everybody's voted on it, you follow the protocol. If there's a question there, you always can go to the doctor. (Clinic 1 staff)
What they have nowadays is the MAs aren't supposed to give telephone advice . . . but with the protocol, the doctors have approved it already, so that opens the MAs up so they can give that information. (Clinic 1 staff)
Characteristics of individualsHigh self-efficacyI think if there was a written protocol . . . if the patient meets certain guidelines, changing the medication is not going to be that big of a deal or talking with them about what's going on in their day to day life. It's not going to be a big deal for us to do that and then notify the physician. (Clinic 4 staff)
Use of email or websites to support communication about BP (clinical information systems, delivery system design change, self-management support)Outer settingLack of financial incentiveIf I spend half of my day on the E-mail, and I don't get paid for it, I can't keep this building open. We have bills to pay. (Clinic 3 provider)Outer settingIT access, competenceI do think that most patients that have the savvy to use the Internet and the technology, I think if they have E-mail, I think they think it's fun. (Hospital pharmacist)
Lack of IT access, competenceThere's definitely still a type of population we're talking about in this type of [rural] area, a big void in IT prowess. (Independent pharmacist)Intervention characteristicsIncreases efficiencyWith the patient portal the advantage is I would type that into that system, the patient picks it up off that system, they could message me back, I have documentation that they received the result, which we obviously don't with a letter-based system, and there's a feedback loop that could be picked up presumably, either by the nurse or myself, regarding their questions or concerns. (Clinic 1 provider)
I read that 75% of . . . adults in America have access to the Internet. I'm not sure if ours is that high . . . I'm not sure that everyone has the Internet or certain patient groups, I mean the age in the study, the ages range from 25 to 75, certainly that younger crowd I think is very in tune. As you get up into the upper ages I think some are and some aren't [laughs] and maybe they have access and they just aren't able to use it. (Hospital pharmacist)When they communicate with us now, on occasion we'll have to call them for questions or—so I can't just, I can't shoot an E-mail back and say you know, I gave you the wrong number or I need more information. You have to call, so, it probably would be good. (Chain pharmacist)
Characteristics of individualsIncreases workloadI think [patient e-mail] would just be a bad idea. Because some patients . . . are very needy. And they'll just show up at the window and just expect to get right in, and if they had [the doctor's] E-mail, that wouldn't be a good thing . . . he has enough as it is . . . I think there should be a boundary. (Clinic 3 staff)Improves quality of careI think actually [electronic communication[ would improve patient care and I think it would probably enhance visits. (Clinic 4 provider)
Are we going to get a bunch of . . . E-mails that say I stubbed my toe, what would you like me to do? . . . We're replacing the phone with the E-mails . . . how many E-mails are we going to get in a day? (Clinic 1 staff)I think with the medical home model, some of the newer stuff that's coming out with health care reform . . . the part that's appealing is sort of the asynchronicity of the clinic visit. Being able to still have everyone on page in between the clinic visits. (Hospital pharmacist)
I think [patients using E-mail] might have a tendency to make the load bigger because we have quite a few needy patients. (Clinic 1 staff)Inner settingIT readily available[Re: E-mail communication with patients:] We've got a network that could certainly handle that volume. (Clinic 1 provider)
There could be a little thing on our dashboard that comes up from E-mails . . . I think it would be very easy to incorporate that into the web page we already have. (Clinic 4 staff)
Characteristics of individualsMore convenience for patientsWhat I think happens is patients, they encounter a problem, they try to get in to see the physician, it's a week and a half away. By the time they get in here it's no longer a problem . . . so it would be really nice to have them sit down and E-mail and say I just tried to take this medicine and I feel a little sick—is that normal? (Clinic 3 provider)
I would be very open to [having E-mail exchanges with patients] because I'd rather . . . because a lot of people just don't answer their phone. (Clinic 1 staff)
I think E-mail connection would be very helpful, especially for the younger generation. Not so much the senior population because they don't really do the computers so much. But I think having an E-mail access would really provide for more connections. (Clinic 1 staff)
We have a patient who's really uncontrolled and she's been having to come in at least a couple times a week, you know, phone calls back and forth, and I think if she could E-mail me, that would make it easier for me. I think that would be easier for her not having to come in here. (Clinic 3 staff)
Empowers patientsIf I was to look at it just me, I would be ‘oh boy, this is going to be overwhelming and I'm going to need more help.' But I know that's coming. And so I can look at it from a perspective of what's going to help the patient and what's going to help them long term? I think that's probably why I'm open to it. I think they'll have a feeling of maybe control knowing that they can kind of take some ownership of their own health first of all but then have that connection with—maybe not necessarily the doctor but somebody who has the doctor's ear. And that just gives them a sense of security that ‘okay, if I do my effort and do my part and submit this information, then we can work together and get something that's going to make me healthier.' (Clinic 3 staff)
Neutral effect on workloadIt's not going to be any different from patients calling us and saying hey, guess what my blood pressure is this—what can I do about it. But it's not going to be all drawn out into a big long story. (Clinic 4 staff)
Reduces patient costsIt would also help with cost and nonadherence. A lot of people's hesitation about coming in is cost . . . . You tell them come back in a week or a month or 3 months, and they don't . . . . And so they become noncompliant. (Clinic 3 staff)
Identification of patients with uncontrolled BPInner settingIT issuesNo—we cannot [identify patients with uncontrolled BP]. We're using an electronic record that allows essentially no useful reporting. (Clinic 1 provider)
  • BP, blood pressure; CCM, Chronic Care Model; IT, information technology; JNC, Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High BP.