Table 3.

Illustrative quotes of emergent barrier themes and their congruent Tailored Implementation for Chronic Diseases (TICD) domains.

Interview Findings: Pharmacist Perceived Remaining Barriers
(1) Unclear procedures outside the study setting (individual health professional factors; capacity for organizational change)
“No, I don’t know how to [request a test]. There seems to be some kind of system where you can order tests electronically, but I don’t have access to it anyway.” (P3:16) “Officially, a prescriber still has to request it and that is particularly irritating. I just want to arrange [requesting tests] myself.” (P12:9) “Can the pharmacist also request [PGx tests]? I have to say that the reimbursement policy is really unknown to me.” (P15:23) “... if there was clarity about reimbursement, what does it cost, which patients are eligible—sort of practical guidelines, that would be really useful.” (P14:16) “Requesting a test wasn’t really complicated at all. However, it is still unclear what [genes] to request; do we request the full profile or are you going to request one gene specifically?” (P5:38) “Well I know I can request a gene test in Leiden. If I request in Rotterdam, then the whole panel is tested. But how to make those choices, that is unclear to me.” (P10:30)
(2) Undetermined reimbursement for test and consult (incentives and resources; social political and legal factors)
“I don’t mind [the lack of reimbursement] in the experimental phase, but at a certain point, if it becomes more daily practice, then I think there must be something to compensate for [our time].” (P8:43) “If it starts becoming routine practice, then yes, I would think it would be logical to receive compensation for the consultation—that our time is reimbursed by the insurance.” (P9:28) “Well, what I really find a major obstacle is that we are not compensated for the consultations. When I look at how much energy we invest here, we get nothing at all for it. I think that is really a major obstacle because that is not feasible of course.” (P12:39)
(3) Insufficient evidence of clinical utility for PGx panel-testing (guideline factors)
“I still think so, yes, research has to show if it is at all cost-effective.” (P1:23) “The insurer is only thinking about cost-benefit ratios. So we should show that its cost-effective or cost-saving so that patients do not receive ineffective means. But of course, we hope to demonstrate that in the PREPARE study. Nonetheless, those [genetic testing] prices really have to really go down.” (P12:21) “We are still implementing in a research context, and investigating its added value. Similarly to implementing a new drug, it has to have demonstrated added value before prescribing it in the clinic. They must first prove that first.” (P5:53)
(4) Infrastructure inefficiencies (guideline factors; incentives and resources)
“Well, I think it’s really important that clear and practical guidelines are incorporated into our EMR.” (P15:26) “Not all recommendations are very clearly interpretable.” (P3:2) “The DPWG recommendations really help a lot, even though they are not always very clear. So for example ‘avoid clopidogrel’, well with TIA you do not have many alternatives than clopidogrel, and dipyridamole is unavailable at the moment - sometimes I want the guidelines to be more concrete.” (P15:9) “Well, what I find the biggest obstacle is the limited automation in the pharmacy system.” (P11:37) “The best thing would be if we received the data from the LSP from the lab, of course.” (P13:32)
(5) Healthcare Professional pharmacogenomics knowledge and awareness (professional interactions; individual health professional factors:)
“Well, I don’t think it’s very nice to say, but the GPs don’t know anything about it” (P5:15) “I notice that the GPs are not interested in the details, they want to act upon the results but are not interested in anything with CYPs, that’s my perception” (P12:13) “It really depends on the medical specialty, whether [PGx] is of interest to them. For example, the psychiatrists know quite a bit about [PGx], but I know how generalizable this is. On the other hand, I know a patient who was very proud of their PGx profile and showed it to their cardiologist, who had absolutely no idea what it was” (P8:31)

Quote (Pharmacist number: quote number)