Rural Idaho Hospitals Look to Telepharmacy to Offer Better Healthcare Services

George Prentice of the Boise Weekly details the use of two machines in Idaho's rural Adams County Health Center named Beatrice and Norman that dispense drugs approved remotely by a pharmacist in Ontario, Oregon. Live video via Skype allows for remote patient consultations should the patient want it. From the article:

You can't believe how thrilled our providers are," said Langston-Groves. "We had this installed here after obtaining a special order from Gov. Otter."

The success in Council has led Langston-Groves to consider duplicating their effort to nearby Valley County where, by all accounts, the need is as great.

...

But administration at McCall Memorial, which just three months ago joined the St. Luke's network of hospitals, isn't so sure they want to see a low-cost clinic near their turf. Two weeks ago, hospital administrators told the McCall Star News that "adding more medical providers could damage our long-term financial viability." But officials back-pedaled a bit when BW asked about the proposal.

"We're going to do a formal assessment to determine the need," said Lee Rhodes, CEO of St. Luke's McCall.

"I really hope the hospital doesn't try to shut this effort down," said Backus. "With these hard times and people struggling as much as they are, I don't know why folks aren't jumping at this. There's no way that a low-cost clinic in Donnelly is going to be, in any way, competition toward a large medical facility in McCall."

Considering that McCall is less than 13 miles away from Donnelly, I don't think it's a big logical leap to worry about considering what the McCall Memorial "administrators" said. Hopefully they will put peoples needs before their own profits...

New Study: 24/7 Order Review by Telepharmacists Reduces Medication Errors

There's a new study in AJHP where pharmacists from Tinity's Mercy Medical Center in Dubuque, Iowa reviewed 58% of the orders at 7 Critical Access Hospitals starting in the Summer of 2008:

Purpose. The implementation of a telepharmacy service to provide round-the-clock medication order review by pharmacists is described.
Summary. Seven critical access hospitals (CAHs) worked collaboratively as part of a network of hospitals implementing the same electronic health record (EHR), computerized prescriber-order-entry (CPOE) system, and pharmacy information system to serve as the health information technology (HIT) backbone supporting round-the-clock medication order review by pharmacists. Collaboration permitted standardization of workflow policies and procedures. Through the HIT backbone, both onsite and remote pharmacists were given access to the medication orders, the pharmacy information system, and other patient-specific clinical data in patients' EHRs. Orders are typically reviewed within 60 minutes of when they are entered into the system. The reviewing pharmacists have remote access to the EHRs in each CAH. After completing the clinical review, the pharmacist selects the appropriate medication to dispense from the CAH's formulary. If the medication order is not made using the CPOE system, the order is scanned into a document and sent via e-mail to remote pharmacists. The pharmacist enters the necessary information into the EHR and pharmacy information system. The medication order review process from this point forward is identical to that used for medications ordered via CPOE. The new medication order is then entered into the EHR, and the CAH nurse can proceed with the order.
Conclusion. The implementation of a telepharmacy model in a multihospital health system increased access to pharmacy services, allowing for round-the-clock medication order review by pharmacists.

You can read the full text here. A few interesting details: At a charge of $4 per order (wow, that seems expensive!), "the volume of and costs for medication orders reviewed remotely varies widely among the seven CAHs, from approximately 700 orders ($2,800) to over 2300 orders ($9,200) per month." Also, for the CAHs without CPOE, nurses scanned the order sheets which were then emailed to the remote pharmacists, but "Messages are sent without leaving the internal network to which the CAHs and MMC-Dubuque belong and therefore do not require Privilege Management Infrastructure encryption."

Central Order Entry Site Makes 24/7 Review Affordable for 9 North Dakota Critical Access Hospitals

In the July-August 2010 edition of the Journal of Pharmacy Technology, Charles Peterson, David Scott, Ann Rathke, Patricia Killingsworth and George Hill describe a telepharmacy model where a central site processes orders for 9 North Dakota CAHs, where 24/7 pharmacist review of medication orders was not affordable before:

Background: Smaller, critical access hospitals continue to be challenged in finding sufficient pharmacist staffing to deliver quality pharmacy services. Innovative solutions are being explored, including use of technology, to address the problem of access to pharmacy services in remote rural areas.

Objective: To describe a new telepharmacy model that is being developed in North Dakota; the model establishes a central order entry site (COE site) that provides 24-hour pharmacist staffing and telepharmacy services to rural critical access hospitals within the state.

Methods: Nine rural hospitals in North Dakota established a contractual agreement with a pharmacist-staffed COE site in Fargo to obtain pharmacist staffing and pharmacy services via telepharmacy delivery.

Results: All 9 rural hospitals receiving telepharmacy services from the Catholic Health Initiatives (CHI) COE site are critical access hospitals with 25 beds or less and an average of 6625 community population (range 470–16,010); 9986 doses filled per month (range <100–21,000);

CONCLUSIONS: A telepharmacy model that involves a COE site that provides 24-hour pharmacist staffing with pharmacists who are highly trained and skilled in use of telepharmacy technology and dedicate their full-time jobs to delivery of telepharmacy services to remote rural hospitals is an affordable means of delivering pharmacy services to these hospitals.

Recent Telepharmacy Study Round-Up

Jayashri Sankaranarayanan published a Viewpoint in Medscape today, about a study in the Journal of the American Pharmacists Association from August 2009 called "Exploring the formation of patient satisfaction in rural community telepharmacies" that attempted to assess patient satisfaction with outpatient telepharmacies in rural communities. The study concluded:

A previous application of this instrument in a traditional community pharmacy setting yielded two interrelated latent constructs ("friendly explanation" and "managing therapy"). Our analysis suggests that the formation of patient satisfaction in rural community telepharmacies is much simpler in that patients form a single construct exhibiting high mean and median values. Anecdotal evidence from the literature suggests that the formation of a single construct reflects patients' desire to retain a point of access to health care in their communities.

Jayashri's analysis of the study is a little more straightforward:

Low response rate (24%) may have biased the study findings because highly satisfied patients may have responded to the survey and dissatisfied patients may not have responded. Study results are limited to telepharmacies in the Midwest. Because some patients may want to keep a point of access to healthcare in their communities as opposed to driving outside of the community to receive it, they may have reported high satisfaction with telepharmacies.

This is one of the first studies to evaluate patient satisfaction with telepharmacy. If patient behaviors are consistent with patient values, telepharmacy may complement the rural community pharmacy and have the potential to remain profitable while improving quality of care.

Sounds like in any case, patients were able to get the drugs they needed, which might not have been possible locally, without a telepharmacy.

Upon realizing I missed this study back Fall 2009, I looked back through PubMed for more interesting stuff I might have missed and found a couple more.

Implementing after-hours pharmacy coverage for critical access hospitals in northeast Minnesota (Sept. 2008)

CONCLUSION: Using Internet-based health IT, pharmacists from a metropolitan (hub) hospital with round-the-clock pharmacist coverage participated in the care of patients at a number of small, rural hospitals and helped ensure that those patients received safe and effective medication therapy. The coverage provided by pharmacists at the hub hospital improved nursing satisfaction with the overall quality of pharmacy services provided by both the hub hospital and the local onsite pharmacists.

Implementation of home-based medication order entry at a community hospital (Nov. 2009)

CONCLUSION: A community-based hospital successfully implemented a home-based medication order-entry program. The program alleviated the shortage of pharmacists during spontaneous surges of medication orders.

NDSU Telepharmacy Update at the North Dakota Pharmacists Association Convention

The North Dakota Pharmacists Association (NDPhA) is hosting several talks at their 125th Annual Convention in April. One is an update on the North Dakota Telepharmacy Project from Shelley Johnsen and Ann Rathke, the director of the Hospital Telepharmacy Project, and Telepharmacy Coordinator at NDSU, respectively. According to the convention schedule, it's from 2 to 3 PM on Friday, April 23, 2010. Students get in free and the lectures are worth CE credits.

New Nationwide Grants Provide for Telepharmacy Service in Rural Hospitals

First up, the FCC gave out $145 million in grant money to rural health consortiums in support of upgrading their networks for things like telehealth and just general day-to-day operations. All in all, the grants affect more than 2000 rural hospitals around the US. The press release, Rural Telemedicine Program Funds 16 More Broadband Telehealth Networks, states at least one health network will use the cash explicitly for a telepharmacy system between 12 hospitals:

Pennsylvania Mountains Healthcare Alliance ($4.49 M) – A new broadband network of approximately 12 hospitals in rural western Pennsylvania will provide a variety of telehealth services, specialty care, and telepharmacy in 18 counties. The network will provide a minimum of 10 Mbps service and connect with Internet2. The project previously merged with the Juniata Valley Network project, a network in the rural region of the Appalachian Mountains that will connect approximately 79 health care facilities to enable telemedicine and school wellness programs, and will connect to Internet2 at speeds ranging from 7 to 100 Mbps.

Additionally, this "Flex Update" from the University of North Dakota's Center for Rural Health has a section called Impacts of the 2009-2010 SHIP Grant Awards where they detail how Small Rural Hospital Improvement Program grants from the federal Office of Rural Health Policy were spent at Critical Access Hospitals around the state. North Dakota CAHs received a total of $271,250, of which, 69% were purchases for computers, software, servers and the like. Last years grants allowed CAHs to implement Electronic Medical Records. Some of this money will undoubtedly go to telepharmacy projects.

New Study: Telepharmacy an Effective Method of Providing Pharmaceutical Reviews

The Journal of Telemedicine and Telecare has released a new study out of Australia evaluating the effectiveness of remote pharmacist reviews of dispensed medications in rural hospitals without on-site pharmacists. Pharmaceutical review using telemedicine - a before and after feasibility study:

Only 42 of the 116 public hospitals in Queensland employ qualified pharmacists to staff their pharmacies. We undertook a feasibility study to determine if pharmaceutical reviews, undertaken face-to-face by a visiting pharmacist, could be replicated using telemedicine. The study was conducted in two phases, with the same pharmacist coordinating the project from the main hospital to two rural hospitals, which relied on supply nurses for all their pharmaceutical services. All inpatients admitted between October 2006 and May 2007 were included in the study. In Phase I the pharmacist made weekly visits to both facilities, to perform face-to-face pharmaceutical reviews of the current inpatients. In Phase 2, all pharmaceutical reviews were performed remotely by the pharmacist by telephone or videoconference. In Phase 1, 186 pharmaceutical activities were performed (mean 3.9 per patient). Of these, 78 pharmacist-initiated changes were recommended and 47 (60%) were implemented. In Phase 2, a total of 296 activities were performed (mean 3.1 per patient) and of the 140 recommendations made by the remote pharmacist, 74 (53%) were accepted. Of the accepted recommendations, there were 11 major interventions (those with a potential to prevent harm to the patient) in Phase 1 and 32 in Phase 2. There were no significant differences in the pharmaceutical activity rates in the two phases. Telepharmacy therefore may be an effective method of providing pharmaceutical reviews for patients in rural inpatient facilities, without an on-site pharmacist.

Thanks Louise Poulson, Lisa Nissen, and Ian Coombes!

Minnesota Board of Pharmacy Grants Telepharmacy Variances

Back in September the Minnesota Board of Pharmacy granted and renewed a host of variances for pharmacies around the state:

New variances:
Abbot Northwestern Hospital in Minneapolis was permitted to have a pharmacist provide remote verification of pre-op and post-op orders for the Edina Surgery Center so long as the pharmacist-in-charge remains the same person.

Extension to current variances:
West Duluth Clinic Pharmacy in Duluth was allowed to provide telepharmacy services to the Duluth Clinic in Remer, MN for the duration of two years so long as they continue to make visits and monitor usage.

Re-approved variances:
Cub Pharmacy in Cottage Grove and Cub Pharmacy in Shorewood were permanently allowed pharmacist certification of the prescription medication with use of the digital image of the medication so long as the pharmacist-in-charge remains the same.

Finally, Mercy Hospital Pharmacy in Moose Lake was allowed remote "After Hours Order Entry" of the hospital's physician medication orders when pharmacy is closed from normal business hours of operation from St. Luke's Hospital in Duluth, until 4/1/2011.

Missouri Hospital District receives USDA telepharmacy grant

The Scotland County Memorial Hospital District, serving Scotland and Schuyler Counties (Memphis area) in northeast Missouri received a $62,622 grant from the US Department of Agriculture, as 1 of 4 Missouri grant recipients from this year's USDA Distance Learning and Telemedicine Program:

This project will connect a hospital, two clinic and a phamacy. The primary purpose is telepharmacy. There will also be upgrades to the existing video-conferencing system which supports remote consultation.

Read the full report here (or Original PDF).

South Dakota Hospital gets Huge Telepharmacy Equipment Grant

From the Rapid City Journal out of Rapid City, SD, comes this news:

Regional Health of Rapid City will receive a $386,549 federal grant to buy videoconferencing devices to link 15 sites, including rural hospitals as well as clinics, with regional medical resources at three sites in Rapid City. The grant was one of three Distance Learning and Telemedicine grants awarded in South Dakota last week by U.S. Department of Agriculture Rural Development.

Among the goals of the Regional Health project are specialty consultation, tele-dialysis and tele-pharmacy, as well as continuing medical education for providers, according to a Rural Development news release.

Telepharmacy keeps rural pharmacies open, more than half of CAHs do not have a dedicated pharmacist

The Fall issue of the Rural Monitor Newsletter examines rural pharmacies' challenges as they attempt to compete with internet sales, large pharmacy chains, and the national shortage of pharmacists. Writer Candi Helseth gives the obligatory nod to the North Dakota Telepharmacy Project, and also highlights the use of remote pharmacist services by hospitals for filling the pharmacy services void in rural hospitals:

63 percent of CAHs nationwide ... do not have full-time pharmacists on-site.
...
“It’s pretty obvious that these rural providers aren’t going to be able to find full-time pharmacists even if they can afford them,” Moore said. ”With remote pharmacy, where you can leverage a pharmacist taking care of three to five hospitals, it becomes cost effective for these small hospitals. I hope it’s an idea that takes off in more states because it offers answers for small areas where the retail pharmacist is no longer available as a back-up.”

Read the full article here.

Establishment of Health Information Exchange Facilitates Telepharmacy Service

InformationWeek published an interesting article today about Health Information Exchanges (networks for sharing patient information between health-systems) in the United States. Marianne Kolbasuk McGee highlights a specific network, the Western Washington Rural Health Care Collaborative where by virtue of the fact that they use an Information Exchange, the hospitals are able to provide telepharmacy services to each other:

The exchange will initially provide the smaller hospitals, some of which have fewer than 25 beds and are located 35 or more miles from other healthcare providers, with telepharmacy services. Patient data, such as allergies, medications, lab results, and demographic information, is collected in a central repository, and pharmacists at one of the facilities can remotely provide assistance to other hospitals.

The article also mentions how 20 billion federal "stimulus" dollars have made it to or are destined for Healthcare IT needs of various health-systems around the US. Health Information Exchanges are one major result, and apparently provide a ready infrastructure for telepharmacy services.