More and more pharmacists are practicing telepharmacy--that is, using technology to provide pharmacy services to patients from a distance.
"There is a larger vision, called telemedicine or telehealth, that ties technology to the delivery of health services," said pharmacist Christopher Keeys, president of MedNovations in Laurel Md. "There is a huge need out there and just not enough providers," he continued. "Telehealth is a global trend. It lets us close gaps in care. Used appropriately, telehealth and telepharmacy can enhance access to care."
The concept is simple, said Michael Coughlin, president of ScriptPro, a telepharmacy provider in Kansas City. A pharmacist at one location receives a prescription written in another location, reviews the script and the appropriate patient data, and approves dispensing.
A technician or a dispensing machine at the other end prepares the drug, which is visually checked by the pharmacist and released to the patient. If appropriate, the pharmacist counsels the patient or discusses the script with a provider at the remote site.
"Well-structured telepharmacy allows interactions among pharmacist, patient, and other healthcare professionals similar to those you would get in person," said Susan Winckler, VP for policy and communications for the American Pharmacists Association. "Telepharmacy allows more patients to access pharmacy and pharmacy services."
The only difference between traditional practice and telepharmacy is that the pharmacist and patient are far apart--sometimes thousands of miles apart. Texas may hold the distance record: A telepharmacist currently living in Italy is reviewing drug orders in Texas.
"I see an almost explosive interest in telepharmacy," Coughlin said. ScriptPro has provided remote dispensing systems for the U.S. military and other government agencies. "A couple of years ago, telepharmacy was intriguing. Now we see an outpouring of ideas."
The idea of using technology to extend health services is hardly new. As technology improves, so does telehealth. In the early 20th century, physicians in Australia used the highest technology of the time, radio, to provide advice and consultation to remote ranches and communities. By the early 1990s, radiologists were using digital imaging to read X-rays taken down the block or halfway around the world.
Today, hospitals across Massachusetts use video and computer links to give hospital emergency rooms immediate access to stroke neurologists, noted Joseph Kvedar, M.D., past president of the American Telemedicine Association and president of Partners TeleMedicine in Boston. The company helps physicians and patients worldwide connect electronically with Harvard Medical School specialists. State law requires ERs to provide stroke neurology services, he explained. There are not enough specialists for 24-hour coverage at every ER, so telemedicine fills the gap.
A survey by Spyglass Consulting Group in Menlo Park, Calif., earlier this year found that 65% of healthcare organizations have a strong interest in a piece of telemedicine called remote patient monitoring. Successful programs include virtual intensive care units, where a central intensivist monitors ICU patients across multiple hospitals, and remotely monitors patients with congestive heart failure, pediatric asthma, diabetes, obesity, and a variety of other conditions.
"Caregivers at the other end are the arms and legs for the knowledge person," Kvedar said. "The judgment piece of care doesn't necessarily require a personal presence."
Remote hospitals
In Spokane, Wash., Sacred Heart Medical Center pharmacy director Larry Bettesworth, Pharm.D., came to a similar conclusion. His 623-bed institution had enough pharmacists to provide 24-hour order entry and drug utilization review, but smaller institutions in the state needed help to cover night and weekend shifts. Some hospitals relied on a community pharmacist. Others had no R.Ph. services at all.
Bettesworth convinced Sacred Heart and the state pharmacy board to pilot a program using Internet technology to link his pharmacists with a remote hospital. The part-time experiment has grown into a self-supporting program with nine remote hospitals and seven full-time equivalent R.Ph.s who review 15,000 to 16,000 drug orders every month.
The remote hospitals pay for pharmacy services based on drug order volume. Most are designated as critical access institutions, Bettesworth said, which entitles them to additional payments from the Centers for Medicare & Medicaid Services. The additional federal funding helps cover telepharmacy and other services. "It is more economical to contract with us than to hire multiple pharmacists for after-hours service," he said. "Telepharmacy has been very effective in encouraging and assisting these smaller hospitals. There is a real push to ensure patient safety, and hospitals are looking for these kinds of alternatives."
Some of Bettesworth's telepharmacists work in a typical hospital setting and some work out of their homes. Either way, he said, Sacred Heart helps the remote hospital design a complete medication management system that includes 24-hour order entry review, drug utilization review, and automated dispensing.
Pharmacists in Spokane or in neighboring Montana use computer links to review and approve drug orders before dispensing. Real-time video links also allow telepharmacists to supervise tasks such as refilling dispensing devices or talking with pharmacy technicians, nurses, physicians, and patients.
"If the hospital can recruit pharmacists to work on site, that is obviously better than remote services," Bettesworth said. "But it is impossible to recruit and keep pharmacists in some of these communities. That's where telepharmacy comes in."
Into the community
Telepharmacy, like other forms of telehealth, offers three distinct benefits, according to Kvedar. Programs can provide improved quality of care, improved access to care, or improved efficiency of care.
Programs are most effective in physical locations or types of care that have a shortage of providers. That makes pharmacy a prime candidate. "We see a lot of interest in telepharmacy as a way to improve access to pharmacists," said Douglas Scheckelhoff, director of pharmacy practice sections for ASHP. "The data are pretty compelling that these arrangements can be effective." About 12.2% of hospitals nationwide are using telepharmacy, according to ASHP data. Among smaller hospitals, that percentage rises to 17%.
Large institutions also use remote pharmacists. Most use telepharmacy to cover night and weekend shifts. Some use it to speed order review during peak hours.
One of the fastest growing models is shared pharmacist services, Scheckelhoff said. A group of small hospitals that can't afford 24-hour pharmacy services join forces to create a central approval and review center with 24-hour service.
There are similar moves on the community side. Thrifty White Pharmacy, a regional chain concentrated in Minnesota and North Dakota, is reportedly considering a central telepharmacist who would oversee multiple satellite pharmacies staffed by technicians.
Independent R.Ph.s are already using telepharmacy to cover for one another during lunch, breaks, weekends, and vacations. "These pharmacists can actually have a life now, thanks to telepharmacy," said Ann Rathke, telepharmacy coordinator at the North Dakota State University College of Pharmacy. "That's a positive change from what has generally been a downward trend in pharmacies here."
Eight to 10 states have recently revised regulations or are in the process of revising them to ease the way for telepharmacy. Many states already mention telepharmacy in their regulations, said Carmen Carlzone, executive director of the National Association of Boards of Pharmacy, though not all have active programs. "We are supportive of progressive changes," he said. "But we also want to be sure the safety and security aspects are there. We are working with telepharmacy, not trying to slow things down."
Most state boards want to prevent telepharmacy competition with existing pharmacies. Texas, for example, requires telepharmacies to be at least 10 miles from the nearest brick-and-mortar pharmacy.
"We are aware that you don't want to drive pharmacists out," said Marilyn Kelly-Clark, program manager for the Montana state pharmacy board. "There aren't enough of them as it is."
The Montana Pharmacy Association is trying a different tack. At its recent annual meeting, the group solidly supported policy calling for telepharmacy as part of a larger solution to meet the medication needs of the community.
In addition to prescription drug access, said Minnesota Pharmacists Association president Todd Sorensen, pharmacy providers and the state pharmacy board should ensure access to nonprescription medications, consultation, medication therapy management, and collaboration with other community providers and leaders. "Telepharmacy always comes up as a potential solution in communities at risk of losing their local pharmacy," he said. "A pharmacist is more than a point for dispensing drugs and healthcare information. There is more to medication therapy and management than just filling scripts."
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