January/February 2017

Telepharmacy's Clinical Benefits
By Mark D. Coggins, PharmD, CGP, FASCP
Today's Geriatric Medicine
Vol. 10 No. 1 P. 8

The benefits of telepharmacy are many, including easy access to health care services for patients in remote locations, economic aspects, patient accommodation, and reducing the paucity of pharmacies and pharmacy services. The concept necessarily involves challenges, not the least of which entail legal, financial, and logistical considerations.

The use of technology to deliver health care, health information, or health education to distant populations often living in medically underserved rural communities or those having problems accessing health care professionals and health care services defines telehealth. It is intended to improve a patient's health by permitting two-way, real-time interactive communication between a patient and a health care provider who are geographically separated.1

Telepharmacy is the application of telehealth technology to the provision of pharmaceutical care to patients at a distance.2 Advancements in telehealth technologies including videoconferencing, faxes, the internet, and electronic health information systems such as electronic health records have made information more readily available to pharmacists. These technologies enable pharmacists to contribute in new and innovative ways to improve medication use across health care settings, including community pharmacy sites, hospitals, nursing homes, and other medical care facilities.3

Common telepharmacy activities being conducted remotely by pharmacists include dispensing medications, performing drug review and monitoring, verifying oral and sterile compounding, assessing and counseling patients, consulting with other clinicians, and providing medication therapy management (MTM) services.1

MTM services, whether provided in person or via telepharmacy, include medication therapy reviews, pharmacotherapy consults, anticoagulation management, health and wellness programs, and many other clinical services. MTM services help patients receive the best benefits from their medications by actively managing drug therapy, improving medication compliance, and identifying, preventing, and resolving medication-related problems.1

Telepharmacy Models
Telepharmacy dates back to the last quarter of the 19th century when the telephone—a new invention—was first installed in a pharmacy, and remains essentially unchanged to this day, with pharmacists using the telephone to counsel patients regarding medications or provide drug information to prescribers and other health professionals. It should be noted that these interactions have historically occurred between pharmacists and others within the same community.1

As technology has advanced, a number of different types of telepharmacy models have been developed. A number of these models have shown good user satisfaction among patients and clinicians receiving these services, improved medication-related patient safety, and improved clinical outcomes.1

Traditional Telepharmacy Model
In 2001, North Dakota became the first state to pass regulations allowing retail pharmacies to operate without requiring a pharmacist to be physically present. The next year, state agencies and grants established the North Dakota Telepharmacy Project to save rural independent North Dakota pharmacies from closing as their owners retired and new graduate pharmacists were being lured to other states by higher salaries. The loss of these pharmacies and pharmacists resulted in many communities losing local access to their first-contact health care professional.2

In this program, a licensed pharmacist at a central site communicates with remote site pharmacy technicians and patients through videoconferencing. A 2004 study of the program found that telepharmacy delivered the same quality of pharmacy services as traditional facilities. Although regulations of telepharmacy practice vary widely across states, the success and expansion of this program became an inspiration and model for programs and laws in other states.2

A typical telepharmacy modeled after North Dakota practices involves identifying a location where patients receive medications from remote sites with complete inventories of prescription and nonprescription drugs maintained by pharmacy technicians. Depending on specific state regulations, the pharmacy technician's duties may include the following:

• maintaining drug inventory;

• taking original prescription orders by phone;

• preparing prescriptions for dispensing by a pharmacist including order entry, filling, billing, and labeling prescriptions; and

• establishing the audio and video link connection for patients to communicate directly with the pharmacist, who provides a private consultation.

The pharmacist is ultimately responsible for ensuring prescription orders have been properly prepared and for dispensing medications. The pharmacist can monitor a technician's activities and ensure accuracy by examining digital pictures of the completed prescription via videoconferencing equipment. The pharmacist also reviews a patient's medication profile for drug interactions and other potential medication-related problems. Once the pharmacist has approved the prepared prescription, the pharmacy technician offers the patient a private consultation room for counseling by the pharmacist on the proper use of the medication. Patient education counseling is provided by the pharmacist via live videoconferencing.2

In September 2002, Texas Tech University unveiled the first telepharmacy project in Texas, creating a link between a remote private clinic in Turkey, Texas, and Lubbock's Texas Tech School of Pharmacy, 75 miles away. This telemedicine system enables pharmacists in Lubbock to counsel patients remotely and visually oversee the dispensing of prescriptions. Based on their knowledge of the drugs most commonly prescribed by the clinic's physicians, drugs are prepackaged and made available to the Turkey clinic. The videoconference link is established to create a long-distance pharmacy for the purpose of writing the prescription. In the process, residents of the Texas panhandle community are spared untold miles and hours of driving time to the nearest retail pharmacies, and their drug treatment can begin more promptly after medication is prescribed.4

Remote Consultation Telepharmacy Site
When a telepharmacy is a short distance from the central pharmacy, the pharmacist may choose to develop a remote consultation site where there is no drug inventory and no requirement for a registered pharmacy technician. The pharmacist fills prescriptions at the central pharmacy, and a courier makes deliveries twice a day to the telepharmacy, which is a general merchandise store. Patient counseling by the pharmacist occurs by way of videoconferencing.2

Automated Dispensing Systems
Automated dispensing of medications by pharmacies occurs via remotely operated automated dispensing systems, which include a live audio-video link with a pharmacist to provide pharmacy services at the point of care in hospital emergency departments (EDs), specialty clinics, employer-based health clinics, and other deployment settings to improve compliance and adherence with patients' drug therapy.2

Hospital Telepharmacy
Following successful implementation of telepharmacy pilot programs in North Dakota, services were expanded to hospital settings to provide supervisory pharmacist oversight to remote rural hospital pharmacies via telepharmacy technology, including audio, video, and computer links and scanned electronic images. Using this telepharmacy technology, a pharmacist supervises a pharmacy technician in processing medication orders for patients at a remote telepharmacy site. A pharmacy technician obtains the medication order from the nursing station or physician, enters the order into the computer, prepares the product for dispensing by the pharmacist (ie, product selection, labeling, and billing), and then the pharmacist performs a final check of the product, releases the medication to the nursing station, and provides professional consultation to the patient, nurse, or physician, if needed.

Through use of a wireless telepharmacy cart, access to a pharmacist and pharmacy services can be available to potentially any rural hospital 24 hours a day, seven days per week, at any location within the hospital, ED, nursing station, patient bedside, or pharmacy. Real-time pharmacy oversight of the medication order entry and use process in hospitalized patients is recognized as a key component of high quality medication safety practices, and there is an opportunity in North Dakota to extend this level of coverage to all critical access hospitals willing to participate.

The project also provides quality assurance monitoring to ensure optimum patient safety through medication error tracking and other quality assurance measures. The North Dakota Telepharmacy Project now supports more than 50 remote retail and hospital pharmacy sites throughout the state.2

The Community Health Association of Spokane, a network of community health centers in Spokane, Washington, launched a telepharmacy program in 2001. The program delivers remote medication dispensing and health counseling to patients at six urban and rural clinics; remote site personnel are connected to pharmacists at the base site by videoconferencing. A survey found that most patients at the remote sites agreed or strongly agreed that they would have had difficulty affording their medications without this program.5

The Alaska Native Medical Center, a hospital in Anchorage, Alaska, providing telehealth services to native Alaskan populations, established a telepharmacy program in 2003 to improve its pharmaceutical services in rural native settlements. The American Society of Health-System Pharmacists gave the program its 2006 Award for Excellence in Medication-Use Safety, concluding that the use of telepharmacy had improved access to pharmaceutical care and enabled pharmacists to monitor medication safety and encourage medication adherence, as well as make pharmacy care more cost-effective.6

In addition, the US Navy Bureau of Medicine operates a large-scale telepharmacy program for the use of service personnel. After piloting the program in 2006 at Naval Hospital Pensacola in Florida and Naval Hospital Bremerton in Washington, the Navy expanded it to more sites throughout the world in 2010. This program represents the largest implementation of telepharmacy to date.7

As technology use expands and evolves, telepharmacy will continue to play a significant role in optimizing pharmacy operations, reducing costs, and improving patient care.

— Mark D. Coggins, PharmD, CGP, FASCP, is vice president of pharmacy services for Diversicare, which operates skilled nursing centers in 10 states. He was nationally recognized by the Commission for Certification in Geriatric Pharmacy with the 2010 Excellence in Geriatric Pharmacy Practice Award.

References
1. Stratton T. Review of research on telepharmacy. http://www.smgebooks.com/telemedicine/chapters/TELMED-16-03.pdf. Published May 20, 2016. Accessed November 21, 2016.

2. Telepharmacy. North Dakota State University website. https://www.ndsu.edu/telepharmacy/ 

3. Pedersen CA, Schneider PJ, Scheckelhoff DJ. ASHP national survey of pharmacy practice in hospital settings: monitoring and patient education — 2015. Am J Health Syst Pharm. 2016;73(17):1307-1330.

4. Telemedicine. Texas Tech University Health Sciences Center website. https://www.ttuhsc.edu/telemedicine/otherprojects.aspx

5. Clifton GD, Byer H, Heaton K, Haberman DJ, Gill H. Provision of pharmacy services to underserved populations via remote dispensing and two-way videoconferencing. Am J Health Syst Pharm. 2003;60(24):2577-2582.

6. 2006 awards recipients. ASHP Foundation website. http://www.ashpfoundation.org/MainMenu
Categories/Awards/AwardforExcellenceinMedicationUseSafety/2006AwardsRecipients.aspx

7. Traynor K. Navy takes telepharmacy worldwide. Am J Health Syst Pharm. 2010;67(14):1134-1136.