" Telepharmacy is a branch of telemedicine that integrates pharmacy software, remote controlled dispensing units and telecommunications technologies to enable the provision of pharmaceutical services from a distance "
Through the use of state-of-the-art telecommunications technology, pharmacists are able to provide pharmaceutical care to patients at a distance. Telepharmacy expands access to quality health care to communities nationwide , primarily in rural, medically-underserved areas.
Through the North Dakota Telepharmacy Project , a licensed pharmacist at a central pharmacy site supervises a registered pharmacy technician at a remote telepharmacy site through the use of video conferencing technology. The technician prepares the prescription drug for dispensing by the pharmacist. The pharmacist communicates face-to-face in real time with the technician and the patient through audio and video computer links. The North Dakota Telepharmacy Project is a collaboration of the NDSU College of Pharmacy, Nursing, and Allied Sciences, the North Dakota Board of Pharmacy, and the North Dakota Pharmacists Association. North Dakota was the first state to pass administrative rules allowing retail pharmacies to operate in certain remote areas without requiring a pharmacist to be present.
As of September 2008, seventy-two pharmacies are involved in the North Dakota Telepharmacy Project, twenty-four central pharmacy sites and forty-eight remote telepharmacy sites. Of the seventy-two pharmacies involved, fifty-one are retail pharmacies and twenty-one are hospital pharmacies. Thirty-four counties (64%) in North Dakota are involved in the project and two in Minnesota.
Approximately 40.000 rural citizens have had their pharmacy services restored, retained, or established through the North Dakota Telepharmacy Project since its inception. The project has restored valuable access to health care in remote medically underserved areas of the state and has added approximately 12 $ million in economic development to the local rural economy including adding 40-50 new jobs. Licensed pharmacists provide traditional pharmacy services, including drug utilization review , prescription verification, and patient counseling to a remote site via telepharmacy technology.
Retaining the active role of the pharmacist helps assure the delivery of safe, high quality pharmacy services that can be at risk when the pharmacist is left out as in the case of internet and mail-order pharmacies.
Telepharmacy ? A Promising Alternative for Rural Communities
Although the scope of telemedicine encompasses many fields of technology, it most commonly describes the practice of medicine using videoconferencing, telephones, and the Internet. Telepharmacy, a more recent concept, is analogous to telemedicine. The National Association of Boards of Pharmacy defines telepharmacy as "the provision of pharmaceutical care through the use of telecommunications and information technologies to patients at a distance." Already, telepharmacy has had a significant impact, and its influence is beginning to show promise in a particularly underserved population? rural communities.
Rural communities have been losing vital access to health care for several years, at least in part due to the disappearance of local pharmacies . In fact, some rural pharmacies have become increasingly difficult to sustain . Older pharmacists working in these communities cannot find their replacements because of the overall nationwide pharmacist shortage and because salaries for new pharmacists have become too competitive. Why have mail-order pharmacies and rural health clinics not filled this ever-increasing gap? They have to some extent, but both of these alternatives fail to provide an essential pharmacy service " interaction with a pharmacist " .
Telepharmacy provides pharmacists with a means to counsel patients, perform druguse review, and verify prescriptions reliably for patients located at a distance from the pharmacist .
How Does Telepharmacy Work ?
Small pharmacies or clinics in remote, isolated areas are connected to a central pharmacy (models have included both retail and hospital central pharmacies) through novel software, videophone systems, and automated dispensing machines. Patients bring their prescriptions to the remote sites, which are staffed by either pharmacy technicians or nurses, depending on whether the rural site is a pharmacy or a clinic. The central pharmacist provides oversight via teleconferencing systems and processes the prescription faxed from the rural site. Then, the pharmacist releases several items at the rural site, including the prescription label and the prepackaged medication from the automated dispensing machine. The pharmacy technician scans the bar code matching the prescription with its label, attaches the label, and dispenses it to the patient . Finally, the central pharmacist conducts a 2-way video consultation with the patient.
Does Telepharmacy Result in Better Care ?
For eight years, our telepharmacy has helped to improve care for patients at about 30 remote village clinics spread across more than 100.000 square miles in south central and western Alaska. The practice has made medications more readily available to treat patients for more conditions . It also has prevented medication errors and established standard reporting procedures for them. It also improved inventory management and the security of narcotics and controlled substances.
Before we instituted the telepharmacy solution, it wasn't possible to consistently deliver quality pharmaceutical care . Some challenges were limited access to villages by boat or small plane, the itinerant nature of many patients and an absence of pharmacists in the field because low prescription volumes in each village didn't warrant the salary expense.
As a result, our ambulatory care clinic on the hospital campus could not reconcile patient medication histories with village medical records.
Medication-use practices weren't always evidence-based . Medication errors weren't tracked. Clinic staff ordered medications from multiple sources. And even though our pharmacists tried to reach patients by phone to discuss their medications, we rarely completed such contact.
Response to product recalls also was slow, and wastage of expired drugs was high. The U.S. Drug Enforcement Administration also was concerned about narcotic discrepancies, losses and thefts and limited accountability.
Our telepharmacy helps care for isolated pockets of Alaskan Natives and transient international fishermen- about 25,000 prescriptions annually. It is a small part of what our facility pharmacy does. Yet the gains signify the usefulness of the process for rural areas, especially with some of the safety elements we've instilled, such as bar-code scanning of prescription labels and of prepackaged medication in the automated dispensing devices at the clinics, and video teleconferencing equipment (so that pharmacists can consult with patients at the clinics when they are issuing their prescriptions) .
Approximately 40% of our telepharmacy interventions lead to clinical improvements in several medication management areas, including drug order clarification, dose/interval changes, drug duplication, drug therapy recommendations, start/stop medication or change in drugs. Additionally 38.7 % of the interventions led to safety improvements, including better monitoring for drug allergies, drug interactions, contraindications and improved weight-based dosing .
(No pre-telepharmacy measurements were available for benchmarking, so our percentages reported reflect the absolute number of interventions divided by the number of prescriptions.(
Most of what we dispense is for acute care. Yet telepharmacy allows us to expand the formulary to include small supplies of certain medications to treat patients for cancer pain or for chronic illnesses such as diabetes, hypertension and epilepsy-in case weather impedes flights and therefore medication deliveries.
Our Web-based telepharmacy uses the PickPoint LxS dispensing cabinet [PickPoint Corp.], which holds up to 121 rows of prepackaged items . It allows us to collaborate with clinics that don't report to us, and that have no pharmacists and few physicians among them. Our Anchorage-based physicians visit the villages and the community health aides whom they supervise quarterly . The aides care for patients daily; that includes the writing of prescriptions from limited formularies for which they have been trained and are authorized. They fax the prescriptions to our central pharmacy. Our pharmacists do clinical reviews, check against patients' electronic medical records, and confirm that aides are practicing within the scope of standing orders approved by their supervising physicians .
Our results are clear: Telepharmacy can help remote hospitals deliver high-quality pharmaceutical care, despite staffing and resource challenges .
Advantages And Disadvantages Of A Tele-Pharmacy
This concept for delivering medicines through a tele-pharmacy is being tested for operation in remote areas as well as in emergency and urgent care facilities. The main aim of tele-pharmacies is to provide maximum coverage in areas with few pharmacies and increase the revenue for pharmacy operators.
The major advantage of a tele-pharmacy is that it provides the much-needed consultation for patients living in remote areas. In the absence of any pharmacy in these areas, patients lose access to vital health care services, which leads to medication errors, drug overdose, and adverse reactions due to multiple drug interactions. Even though pharmacists are not physically present in their area, patients can access consultation with a registered pharmacist and get their prescription verified through video conferencing.
The second advantage of a tele-pharmacy is that it is highly cost-effective. With the rising pay scale of pharmacists, it might not be financially viable to support a full pharmacy in all rural areas. Thus hiring a single pharmacist for multiple areas can save the pharmacy thousands of dollars each year.
The third advantage is customer satisfaction, especially people living in remote areas. Earlier, these patients had no access to a pharmacy near them and could not afford the medication from other areas.
The main disadvantage of a tele-pharmacy lies in the lack of complete control in dispensing medications for the patients. Although the pharmacy technicians at these pharmacies are supervised by a registered pharmacist at all times, there is still the risk of violation of regulations.
The use of unauthorized drugs or dispensing of drugs without proper prescription is hard to control compared to regular pharmacies.
Another factor that is proving to be a hurdle in promoting more tele-pharmacies is that most places in the United States have not yet adapted to the concept of tele-pharmacies. It will be a challenging and time-consuming task to review the laws and set up rules and regulations for tele-pharmacy operations in all the states in the coming years.
As suggested earlier, the primary advantage of telepharmacy is that pharmacists can provide high-level pharmaceutical care services in rural environments that have lost or are losing access to health care services. Access to a pharmacist is essential in rural areas because there are risks inherent in medicationuse systems that do not include a pharmacist. These risks include increased medication errors and drug interactions, unresolved adverse effects, and potential therapeutic interchanges not used.
Furthermore, telepharmacy can save money. One report showed that the cost of equipment and a pharmacy technician is about 15%, compared with opening a new store and staffing with a pharmacist. Telepharmacy uses the skills of one pharmacist for multiple sites without the additional expense of hiring a pharmacist for a rural site. Also, telepharmacy can eliminate an underused inventory in a rural setting. The automated dispensing machine could dispense only the most used medications and could enhance inventory control and record keeping.
Improved access to medications in rural areas has led to another advantage for telepharmacy systems: patient satisfaction. An assessment of one telepharmacy program revealed that >75% of the patients were satisfied with their communication with pharmacists through videoconferencing.6 Patients benefited financially from this program too, as 63% responded that they would have difficulty affording their
medications if their telepharmacy program did not exist. Another study showed that telepharmacy counseling via compressed video was more effective than using package insert instructions to explain the metered-doseinhaler technique.
In contrast, one of the biggest disadvantages is that laws that regulate pharmacy operation in most states still do not address the growing telepharmacy industry. By 2004, only 15 states had approved telepharmacy regulations or pilot projects. Twenty states at that time were actively investigating regulations, and 15 states had no activity centered on developing regulations for telepharmacy. Unfortunately, this is not an easy fix. Complex issues must be resolved before laws can be created in many states.8 For example, the act of a pharmacy technician giving a medication to a patient in a remote setting could describe an illegal dispensing action. Programs have successfully petitioned, however, to their respective state boards of pharmacy that each patient would receive pharmacist counseling through 2-way videoconferencing.
Although telepharmacy is a great concept, it is sometimes challenging to put into practice. One pharmacist overseeing several rural pharmacy sites could significantly increase workload, and management may involve timeconsuming travel requirements to the rural sites ? especially when the pharmacy law dictates a monthly on-site visit. During the on-site visit, managers perform several duties such as restocking the automated dispensing machine, training or retraining personnel and patients at the site, and monitoring inventory. Finally, the startup of a telepharmacy takes considerable time, effort, and money. One article suggests that a rural pharmacy filling 30 prescriptions per day would take approximately 3 years to break even .
Considerations for Implementing Telepharmacy
Would telepharmacy be a promising alternative for providing medication access to the rural population in your area? Before launching a campaign for your hospital or retail pharmacy to develop fledgling rural outposts, there are a few considerations that will require an action plan. Here are some points to consider:
? The community itself should have a sufficient need for these services. Is there already a well-established rural pharmacy within the community, or have these pharmacies closed without a replacement? Do many residents use mail-order services? These needs can be analyzed succinctly through questionnaires that have already been developed.9
? Do laws and regulations already exist for the state in question, or do these laws need to be developed ? State laws usually require remote telepharmacy sites to have a license and program in place to receive thirdparty reimbursement and are sometimes very specific regarding the physical location and establishment of such a pharmacy.
? Inventory and technology will be key considerations when designing the site. Adequate space should be available for the computer, video equipment, and dispensing machine, as well as communication needs with the central pharmacy.
? Consider the unique environment ? and skills needed ? when hiring the central pharmacist and rural-working pharmacy technicians. Also, other personnel may be needed such as a courier for transport between the pharmacies and an accessible expert in information technology.
? Do not forget the patients and local physicians. Remember that rural patients and physicians will not be familiar with such an advanced system for providing pharmaceutical care and may require additional education and training .
Points To Consider Before Setting Up A
Tele-Pharmacy
Setting up a tele-pharmacy is different from setting up regular pharmacies or drug stores. It has to function under the laws of the state, and a license program must be in place. Second, trained pharmacy technicians have to be hired who are aware of the rules and regulations. Third, the inventory has to be adequately managed to make sure that while the vital medications are in stock, the pharmacy is not overstocked with drugs that are not much in demand.
The need of a tele-pharmacy in a particular area has to be first established. Physicians and other medical workers have to be notified of the availability of these services to make sure it is fully utilized.
Conclusions
The application of telepharmacy in rural hospitals varies across the United States but is not widespread , and many states have not defined regulations for telepharmacy in hospitals .
The implementation of telepharmacy services in a multihospital health system expanded hours of service , improved the speed of processing of physician medication orders, and increased clinical pharmacy services and cost avoidance. Surveys of health care staff found that telepharmacy services were well received .
