**4. Discussion**

This qualitative study explored pharmacy technician perspectives of their role in ABM and found that they felt the program increases adherence and convenience for patients, but there were hurdles to e ffective implementation remaining. Establishing the role of the technician in ABMS services is critical as pharmacist-extender involvement in clinical service delivery is associated with a service implementation success, for frequent and diverse clinical service o fferings, and improved quality of work life for both pharmacists and pharmacy technicians [17–24]. However, integration of technicians into advanced or clinical support roles can prove challenging [21,24–26]. Understanding their unique perspectives on these new roles can be instrumental in designing training programs and assisting pharmacy leadership in the selection of technicians for these advanced roles [27].

Some important takeaways were uncovered in this exploratory study related to technician work life. The semi-structured interviews found that technicians felt their help to patients was appreciated. This team member buy-in of the ABM process is key for pharmacists to leverage the workflow efficiencies generated to enable clinical interventions such as CMR [17]. Downstream, this may have important implications for technicians' perceived quality of work life (QOWL), which has previously reported to be low among pharmacy technicians practicing in a community pharmacy [25,28,29]. Moreover, such advanced roles may decrease technician turnover and further improve QOWL, as lack of career advancement is a known QOWL issue among pharmacy technicians [28].

Evaluation of the content within the Adaptability and Relative Priority constructs found that siloed prescriptions in the ABM portal could be a source of time-consuming erroneous fills. Housing the platform used for ABM within the pharmacy managemen<sup>t</sup> system or enabling dynamic profile updating is necessary. The ABM interface must reflect the most current version of the patient profile to ensure that erroneous fills do not occur. This is a patient care concern that reduces pharmacy team support. Also, the report that too little time was budgeted to implement the program and complete other duties that must take priority worsened technician perceptions of the program. To prevent this, it is critical that new projects are integrated into existing workflows appropriately through accurate modeling of the workforce hours required.

The Champion construct emerged during the interviews as a successful aspect of implementation. Pharmacy technicians who recognized the importance of the program and took initiative to implement it were associated with success. By tailoring each ABM encounter to the specific needs of the patient, these champions generated more process buy-in from patients and team members. This generated synergy and reduced unnecessary prescription fills. Interviews found the champions were well-informed about the intervention process and felt comfortable integrating it into workflow. Our study indicates that empowering technicians on the local level to take initiative when patients are struggling with a high volume of prescriptions and poor adherence is an e ffective approach to circumventing the ine fficiencies around the automated enrollment processes.

The variability in training reported by technicians is another barrier to implementation identified. Some team members felt that although they had a grea<sup>t</sup> explanation of ABM conceptually, they had little exposure to the actual interface. Training specific to the ABM user interface is needed to ensure the success of the program. Hands-on training will reduce the likelihood of erroneous fills and wasted time in the enrollment process.

Significant improvements to the ABM program may be made to better patient care and increase efficiency in the business operations of pharmacies that implement it. E ffective implementation of medication synchronization core components within ABM is key to ensure that this program is effective. These components include the identification and enrollment of patients, inclusion of a medication review and patient assessment, the alignment of refills, a formal process for preparation of medications, and the delivery of medications and other services [7,30]. There is support in the literature for implementing a vaccination assessment program with ABM also. The CMR component of ABM has been proven to detect medication errors and successfully promote vaccination for patients [31]. The patients who benefit most are older adult patients with multiple medications, or have a chronic condition such as diabetes, COPD, or asthma [32]. The medical complications associated with medication nonadherence are worsening. Without proper management, nonadherence will continue to increase hospitalizations and raise costs in the health care system. This study contributes important data on pharmacy technicians, an understudied stakeholder whose perspectives are key to e ffectively implement patient care initiatives in a community pharmacy [7,30].
