Pharmacy Students Working Toward “Closing the Gap”

Excerpt:

Finally, the event ended after a “Call to Action” panel moderated by Roshini Epasinghe, consisting of three student pharmacists from the UCSF School of Pharmacy: Serena Huntington, Megan McCurdy and Martha Prieto. Advocates for the cause, these three student pharmacists spoke to their experiences and involvements with serving the underserved. Huntington focused on her current Schweitzer Fellowship, which is aimed at improving health outcomes through preventative medicine.

McCurdy shared her experiences in serving the underserved internationally in Mexico this past summer, where she was able to shadow physicians and learn Spanish for a period of one month. Prieto spoke about her current involvement with telepharmacy and how her fluency in Spanish has helped her to serve the underserved Spanish-speaking populations of San Francisco.

The event concluded with a brief speech given by Epasinghe, advising fellow student pharmacists on career development and matters related to networking. The sponsoring organizations hope to make “Closing the Gap” an annual event, so be sure to support them in advocating for the underserved at next year’s event.

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Telepharmacy and ePharmacy: Siamese or discrete?

There's a new paper out in the International Journal of Healthcare Technology and Management addressing Telepharmacy and e-pharmacies.

State pharmacy board meeting Wednesday in Rothschild

The Wisconsin Department of Regulation & Licensing will hold its professional pharmacy examining board meeting starting at 9 a.m. Wednesday at the Cedar Creek Lodge, 805 Creske Ave., Rothschild.

The board is part of the state’s Department of Regulation & Licensing, which licenses and regulates 128 different types of credentials in 57 professional fields, including pharmacists’ licenses. It issues nearly 50,000 new credentials and it renews approximately 350,000 credentials every two years.

“This is a great opportunity for pharmacists in central Wisconsin, other health professionals and the general public to see the work of the Pharmacy Board first hand,” said Celia Jackson, the department’s secretary. “Holding this type of meeting outside Madison is part of a broader effort to make the work of licensing and regulatory boards more visible and accessible to the people of the state.”

Agenda items include discussing various issues related to filling prescriptions as well as a closed session to deliberate on possible disciplinary actions.

Following the meeting, participants are invited to travel a short distance to Marshfield Clinic Weston Center to observe a demonstration of a remote dispensing and telepharmacy operation.

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Houston Cronicle / AP Story comments

There were a number of comments around the web on the widely mirrored Associated Press story on the North Dakota Telepharmacy Project as well as the Telemedicine project at Texas Tech University. See the previous post for that story.
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Telepharmacy project expands across country

ARTHUR, N.D. — The days of walking down to the general store for prescription drugs are returning to rural America, thanks to a virtual pharmacy system that has been tested on the frozen prairie.

As recently as three years ago, many elderly residents in this area of southeastern North Dakota were forced to order their medications by mail. Now, customers have a real drug store and can talk to a real person who's connected to a pharmacist by the Internet.

"It's perfect," said Jim Williams, a longtime Arthur resident. "You can walk down there and it's done in a few minutes."

North Dakota lawmakers opened the door for the telepharmacy project by passing legislation in 2001, after dozens of rural pharmacies went out of business. The project began with 10 volunteer sites in 2002 and has grown to 67 locations.

The idea may be catching on in other places.

States that have changed laws to allow for remote pharmacies include Alaska, Idaho, Illinois, Montana, South Dakota, Texas, Utah, Vermont and Wyoming, along with the District of Columbia. More are on the way, the head of North Dakota's project said.

"We get calls every day from other states," said Ann Rathke, director of telepharmacy at North Dakota State University in Fargo. "A lot of states have used or have adopted in some way our rules, because they were out there."

Charles Peterson, dean of pharmacy at NDSU, said the rest of the country has been "watching and waiting" to see how the North Dakota project worked.

"Every state is struggling with, the most part, the same issues," he said. "Access to health care in a rural setting is a problem for everyone. We have shown that this is a solution."

Most telepharmacies are staffed with registered pharmacy technicians, who usually need about two years of schooling and earn about $15 an hour in North Dakota. Some registered nurses also have been trained for the job.

"You don't have the expense of a regular pharmacist," said Katie E. Thompson, a registered pharmacist who lives near Page. "That's the point of a telepharmacy."

The pharmacy technicians use remote cameras to show pharmacists the original signed prescription, computer-generated label, stock bottle where the pills are stored and the bottle the patient will take home. Once the prescription is approved, patients have a mandatory private consultation with pharmacists through real-time video and audio.

"We can do most of the things the pharmacists do except give professional advice," said Jennifer Joyce, the pharmacy technician in Arthur.

She can offer guidance on other matters, such as the weather, crop conditions, family events and high school basketball. Joyce knows all of her patients on a first-name basis. Many of them are there for more than just a bottle of pills.

"When they're sick, sometimes they just want people to listen to them," she said.

Rathke said it costs about $18,000 to set up a site in North Dakota, including equipment, installation and one year of Internet service. Telepharmacies pay an annual licensing fee of $175.

"It's not rocket science, and it doesn't cost a tremendous amount of money," Rathke said.

It does take some political will, Peterson said. In most cases pharmacy has more laws and rules than any other area of health care and many states are unwilling to make modifications or adjustments, he said.

"Finally, those other states that haven't in some cases been willing to talk about it, willing to even look at it, are being forced to look at it because North Dakota has proven this thing," Peterson said.

It hasn't been proven in every state.

The first telepharmacy in Texas opened in 2002 in the town of Turkey and has gained in popularity. But only a few more sites in Texas have popped up since then, said Debbie Voyles, director of telemedicine at Texas Tech University.

"Where there are no pharmacies, there are no doctors," she said. "Patients have to travel to see the doctors, so it's no big deal to them to have to pick up the prescriptions."

The Texas Tech pharmacy school is looking at ways to increase interest and is hoping to learn from North Dakota's success, Voyles said.

Don Turner, who runs the pharmacy in Turkey, said his clients are mostly elderly people who don't have access to transportation. The nearest pharmacist to the town of 400 people is about 50 miles away.

"It's a great thing for Turkey," Turner said. "I think it's just a matter of time for other small towns."

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Automated drug dispensers become more popular in Fargo-Moorhead

FARGO – A screaming child with a late-night earache will make any parent’s skin crawl.

Not only may the pain trigger a trip to the emergency room, but the chances of getting needed medications before morning are often nil.

The InstyMeds machine at Innovis Health in Fargo dispenses prescription medicine much like a vending machine. (David Samson/The Forum)

Hospitals can’t stop ear infections, but several are addressing the prescription problem by installing ATM-style machines that dispense drugs.

These InstyMeds systems hold dozens of commonly prescribed medications, giving patients access to drugs after retail pharmacies close or saving them another trip when they’re not feeling well.

“For us, it was really about offering our patients the convenience factor,” says Todd Forktel, an administrator at Innovis Health. The Fargo hospital installed its system in April.

InstyMeds works much like an ATM machine, automatic car wash or any other type of automated kiosk.

A physician sends the prescription to InstyMeds via a computer. The patient receives a code that he or she punches into the machine to retrieve the medication, which is labeled and comes with instructions.

The system bills the patient’s insurance. Co-pays are accepted via credit card, debit card or cash. If problems or questions arise, patients can use an attached phone to reach an InstyMeds pharmacist.

“They’re so easy to use,” says Natalie Rund, emergency department nurse manager at Lake Region Healthcare in Fergus Falls, Minn. “I tell patients, if they can use an ATM machine, they can use this.”

Each hospital determines which drugs the machine will dispense. Limited supplies of antibiotics, anti-nausea drugs and pain relievers are among the most common.

InstyMeds doesn’t allow refills and most hospitals avoid filling it with medications designed for chronic conditions like high blood pressure.

“We’re not trying to compete with the pharmacists,” says Chris Harff, CEO at MeritCare Thief River Falls, Minn. “We just want to help patients who like the convenience.”

The technology fills a gap in communities that don’t have pharmacists ready to fill prescriptions 24 hours a day, seven days a week. For example, there’s no retail pharmacy open in the Fargo-Moorhead area after 10 p.m., Forktel says.

MeritCare in Fargo has a pharmacy open all the time for its emergency room patients, but not for the general public, says spokeswoman Carrie Haug.

MeritCare Thief River Falls installed its InstyMeds machine several years ago, Harff says.

“Patients love it,” she says. “If you’re sick enough to go to the emergency room, you don’t want to hang out at the pharmacy. They’re done when they leave here.”

Not everybody is fond of the technology. The North Dakota Board of Pharmacy discourages the use of dispensing machines like InstyMeds, says Howard Anderson, its executive director.

“Research has shown that the best scenario is for a patient to get information and counseling from a pharmacist,” he says. “We recommend physicians give the patient a starter supply of drugs and a prescription so a pharmacist reviews it as soon as possible.”

North Dakota has a telepharmacy program that allows patients to consult with a pharmacist even if one isn’t in the community, Anderson says.

“We’re not telling physicians they can’t dispense medications, but we’d prefer they look at this (telepharmacy) model,” he says.

Emergency rooms and urgent cares with automated dispensers still allow patients to get their prescriptions filled at a pharmacy. But patients who are comfortable getting cash from ATMs and checking in on airline flights via computer terminals have few qualms about doing the same for their prescriptions.

“In the evenings, everyone’s wondering how they’ll get medications,” says Dr. John Baugh, who works in the emergency room at Innovis Health.

Physicians, too, wonder if they’re giving patients enough drugs to last until they can get to a pharmacy, he says.

The popularity of InstyMeds has increased since Innovis installed its system in April. The first month, it dispensed 249 prescriptions. During three weeks in July, it dispensed 418 before running out of medications.

Baugh say, “Most patients seem to want to use it so they can get their medications and go home.”

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Dialing Up Medication Safety

When Lewistown (Pa.) Hospital decided to implement an electronic medication administration record, hospital executives decided patient safety was also going to get an upgrade.

The 139-bed hospital's in-house pharmacy was only open 14 hours a day. During that time an on-staff pharmacist would review all new prescription orders. Drug orders placed during off hours, however, would be reviewed and filled by nurses, who are well-versed in potential adverse drug interactions but lack the in-depth knowledge of pharmacists, says Richard Stomackin, director of the inpatient pharmacy at Lewistown.

So when the hospital deployed the electronic medication record, Stomackin also wanted to have 24-hour pharmacist review of drug orders. His first inclination was to hire two new pharmacists, but considering each position would require a six-figure salary plus benefits, finding two new staff members wasn't an attractive financial option. He also thought it would be difficult to attract qualified candidates to Lewistown's central Pennsylvania location.

Stomackin found another option in Rxe-source, a telepharmacy service from Cardinal Health, Dublin, Ohio. The telepharmacy enables a hospital to supplement its onsite pharmacy services by connecting to telepharmacists working at remote locations.

The telepharmacists receive faxed or phone drug orders, then evaluate a patient's medication profile, review necessary lab values, enter the medication into the patient profile, check for possible interactions and authorize orders for administration.

Lewistown began using Rxe-source in September 2005. The hospital's on-site pharmacy is staffed from 7 a.m. to 9 p.m. weekdays and 8 a.m. to 6 p.m. on weekends. When the on-site pharmacists leave, all calls and faxes are routed to the telepharmacy in Ohio.

Lewistown nurses typically fax the orders to the telepharmacy. The telepharmacists then connect via a secure Internet connection to Lewistown's medication administration record to check the patient's previous medications and medical conditions. The telepharmacist reviews the current order and calls a nurse or physician at Lewistown if any revisions are necessary.

After the telepharmacist approves the order, either via fax or phone, the nurse then retrieves the medication from cabinets that are stocked during the day with drugs the caregivers will need during the night shifts. If the medication is not available in a cart and needs to be administered immediately, a staff pharmacist is asked to come to the facility and fill the order.

Cardinal Health charges Lewistown a monthly fee based on the medication order volume during Rxe-source's hours of coverage. Lewistown declined to provide details about costs.

Initial setup of the telepharmacy was challenging, Stomackin says. Staff pharmacists had to fill out a 26-page survey that asked questions about the hospitals policies and procedures, as well as what drug substitutions the hospital allows and the facility's potential order volume. Lewistown also had to standardize order sets so the telepharmacist could follow standard protocols.

In addition, Lewistown nurses have had some run-ins with the telepharmacists, Stomackin says. "Nurses complain that the telepharmacy guys are stricter than we are," he says. "If you tell the telepharmacy this is hospital policy they adhere to it. This is different when we're here during the day when we have some flexibility to work things out."

Stomackin adds that because the pharmacists know the physicians and the personalities involved it's easier for them to make exceptions to hospital policy, whereas telepharmacists will stick to the rules.

But Stomackin believes the telepharmacy service has helped increase patient safety at Lewistown. "Any time you have an additional check you improve patient safety," he says. "It's one more safeguard to make sure that the patient is getting the right drug."

Another benefit of the service: by enabling the hospital to have 24-hour pharmacy coverage, it helped Lewistown improve its score during a recent review by the Joint Commission on Accreditation of Healthcare Organizations, Stomackin adds.

Pharmacists increasingly are in demand, and it's likely the need for telepharmacy services will increase, says Paul Johnston, senior consultant at Healthia Consulting, a Minneapolis-based health care I.T. consulting firm. The U.S. Department of Labor is predicting a shortfall of 157,000 pharmacists by 2020.

Rural areas that have chronic problems hiring full-time pharmacists are turning to telepharmacies to improve safety around the medication administration process, Johnston says.

"In an inpatient setting it's critical to have a pharmacist involved," he says. "The telepharmacist can check for harmful interaction, review current medications and perform dosage correction."

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Broadband Innovations, Part 4: The Doctor Isn't In but Can Still See You

How telehealth is changing the way America gets well.

"Broadband Innovations" is a four-part series that highlights groundbreaking broadband uses, and the people who employ the technology to preserve the past, reshape the future, and fulfill their dreams. This final story in the series focuses on residents of Washington State who receive medical and psychiatric care via video over the Internet.

Timothy Moon's 48 years have been colored by violence. At 16, he was shot. In 1989 he received his first prison sentence. Diagnosed as a manic depressive, Moon finally made a decision about a year ago to get help in dealing with all the anger inside him.

Typically, obtaining medical care would mean transporting Moon, accompanied by two guards, from his cell at Coyote Ridge Corrections Center in Connell, Washington, to a caregiver in Spokane, 100 miles away. A second option would be to have a psychiatrist drive all the way from Spokane to the penitentiary for every consultation.

However, thanks to the Northwest Telehealth network, which uses broadband to provide health care to remote locations, Moon undergoes videoconferencing sessions with his psychiatrist without ever leaving the penitentiary. And he likes it better than meeting in person.

"When I'm in a room by myself, there is less pressure. It's like talking to the camera, which works for me since I find it more difficult to talk about my problems in person," he says.

Moon initially tried confiding in his fellow inmates, but found that it did more harm than good. "You can't just express yourself to anyone. They'll interpret it as weakness and take advantage of it." Having been in a couple of fights, he now tries to stick to himself.

"But it's important to have someone to talk to," he says.

The Benefits of Telehealth

About 50 of the 620 inmates at Coyote Ridge use the network for their health-care needs. Aside from saving tax dollars and improving safety by minimizing the transport of prisoners, the system also discourages prisoners from feigning symptoms to break the monotony of prison's daily routine.

Telehealth executives Brian G. Hoot (left) and Gram McGregor, in front of a monitor showing an emergency room in one of the rural clinics they serve.

"In my experience, 50 percent of the inmates that come to the ER don't need to be here," says Gram McGregor, emergency department manager at Deaconess Medical Center in Spokane.

His ER department is another one of 65 sites throughout eastern Washington and northern Idaho that are connected to the Northwest Telehealth network by broadband speeds of up to 100 megabits per second. Besides penitentiaries, his ER provides rural hospitals and other sites with remote consultations.

McGregor maintains that the remote service is not just about saving money--it's also about improving the quality of care. "Many rural clinics are understaffed. Whether they need an expert consult, a second opinion, or emergency advice, they need to be able to access it remotely," he says.

Prison Saved My Life

Jorge Martinez had lost 145 pounds for no reason that he could pinpoint. He was always tired, but didn't suspect that something was seriously wrong. It was not until Martinez was incarcerated at Coyote Ridge for a narcotics crime that he found out that he was a diabetic.

"Prison saved my life. The way I was eating and drinking, I wouldn't have lasted long," says Martinez, who also says he has been able to turn his health around through hard work and guidance from regular consultations via the telehealth network.

By exercising, Martinez has been able to decrease his insulin dependency by more than half. Through diabetes education in a group over the network, he has also learned how to care for his body and skin. Next he hopes to have a teleconsult with a dietician to work out a meal plan.

Diane Benfield, the dietician at the Washington State Penitentiary in Walla Walla, saves 3 hours of travel per visit due to remote consultations with the inmates at Coyote Ridge. She says this setup allows her to schedule many more appointments with prisoners.

"The inmates are positive and don't seem to mind not meeting in person," she says. "I'd love to see the whole statewide system connected."

How Telehealth Works

In 2003, the TelePharmacy service also became available on the network. It enables nurses in 12 remote hospital sites to access approved prescription medicine through a secure vending machine.

Medication orders transmit via the network from rural hospitals to a pharmacist at Sacred Heart Medical Center in Spokane. The pharmacist reviews the prescription and confirms it on the computer. After swiping an identification card and typing in a password, the nurse at the remote site can take out the drug from the dispenser.

"Many rural communities may have a pharmacist who comes by twice a week, but they can't afford or aren't able to recruit someone full-time," says Fred W. Hoefler, manager of the TelePharmacy program at Sacred Heart.

Ronda Golladay has worked as a nurse for 30 years. Her current employer, the Othello Community Hospital, participates in the TelePharmacy program to provide pharmacy service 24/7. Under its guidelines, nursing staff must be monitored via videoconferencing when performing activities such as restocking the medicine dispenser.

"People are always apprehensive about letting other people watch them in a Big Brother way. We've tried to overcome that by educating them well in how to use the equipment," says Brian G. Hoots, telehealth analyst at Northwest TeleHealth.

In 2007, nearly 300,000 prescription orders went through the system, a number expected to increase as the TelePharmacy program adds two more sites.

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Via Christi to offer electronic pharmacy services

Via Christi Health System announced this week it is planning this fall to launch an electronic pharmacy program that is aimed at giving rural counties better access to medications.

Via Christi, the state's largest health care provider, says its e-Pharmacy incentive will address a statewide pharmacist shortage and bolster patient safety.

"Some Kansas counties do not have a pharmacy or pharmacists and many counties only have one pharmacist," said Jim Garrelts, director of pharmacy at the Via Christi Wichita Health Network in a statement. "This shortage of pharmacists likely contributes to a higher risk of adverse medication events, medication errors and substantial inconvenience."

Six Kansas counties presently have no pharmacist and 31 have only one pharmacist or pharmacy. According to the Pharmacy Manpower Project, by 2020, the national supply of pharmacists is likely to fall short of demand by 157,000 nationwide.

The Kansas Legislature recently earmarked money to increase enrollment in the University of Kansas School of Pharmacy, but the first graduates will not complete their schooling until 2014.

The e-Pharmacy program will utilize a remote order entry system under which licensed pharmacists, working outside of regular hours, such as evenings and overnight, will review scanned or faxed medication orders and patient records. The pharmacists then review and profile the accuracy of the order and authorize the hospital pharmacy system to dispense the drug. The licensed pharmacist also checks for allergies, drug interactions, correct dosage and the patient's pharmaceutical history before authorizing the dispensing of a medication.

The U.S. Department of Health and Human Services wants to reward doctors for successfully adopting electronic prescribing practices. It says e-Pharmacies improves the quality of care, lowers administrative costs and has the potential to eliminate thousands of medication errors every year.

The e-Pharmacy services are being developed in conjunction with hospital pharmacy leaders at Via Christi Health System medical centers and Salina Regional Health Center, which is affiliated with Via Christi. The program is set to begin October among Via Christi's network hospitals, Mercy Regional Health Center in Manhattan and in Mt. Carmel Regional Medical Center in Pittsburg and also will be offered to hospitals outside of the health system.

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Searsport prescribes to telepharmacy technology

SEARSPORT (July 24): The Board of Selectmen voted Tuesday, July 22 to proceed with a grant application that would make Searsport the first town in Maine to explore a new approach to the way pharmacies operate.

At a public hearing, selectmen discussed applying for grant money through the state Community Development Block Grant program to explore the feasibility of bringing a pharmacy into town.

Last year, Waltz Pharmacy closed its Main Street store.

Selectman Dick Desmarais said for several months he has worked on getting a drug store to Searsport, but that he was having difficulty finding a company or individual willing to make a move.

After contacting several in-state pharmacy chains and schools of pharmacy in Massachusetts and Connecticut, Desmarais said he contacted Chris Shrum with Eastern Maine Development Corporation in Bangor.

Two weeks later, Shrum pitched an idea that would bring a pharmacy into Searsport and provide technology to serve health centers in surrounding towns through a networking system of Massachusetts-based company, CBSRx.

Shrum said the firm takes on a variety of roles with regard to prescriptions. CBSRx has been instrumental in getting a profitable pharmacy into the Deer Isle-Stonington community, and has worked with a hospital in Sanford on fine-tuning its existing pharmacy.

“They make sure the hospital takes advantage of all the programs it can, and that they get as much reimbursement as possible from the insurance companies,” said Shrum.

Desmarais, Town Manager James Gillway, Economic Development Committee chairperson Dianne Smith and Shrum met with Jack Hellmann, CEO and president of CBSRx.

“The response was very, very good with them,” said Desmarais, adding it could lead to Searsport residents having a drug store “for many years to come.”

Hellmann, said Shrum, was vice president of operations for Rite Aid when it had 17 stores. Hellmann left Rite Aid 15 years ago after Rite Aid had opened about 2,500 stores.

Then he launched CBSRx.

And, said Shrum, Hellmann has been successful launching pharmacies. Part of Hellmann’s strategy is to conduct a market feasibility study in communities looking to partner with his company to ensure the store is needed.

“He’s figured out how to make it work in rural communities,” said Shrum. “… He’s never closed a pharmacy that he’s opened.”

EMDC, said Shrum, assists the town with the cost of the feasibility study in the form of the CDBG grant. Those grants, said Shrum, are part of a block of money - $12 million to $13 million - that the federal government annually sets aside for the state.

The funding is used for downtown planning, housing rehabilitation and municipal building restoration. for example, a CDBG grant was awarded to Searsport about nine years ago to assist with the cost of restoring Union Hall.

Once the board gives the go-ahead to apply for the CDBG funds, the town submits its grant application for the pharmacy feasibility study. Shrum said it takes four to six weeks to score the application, and if EMDC awards the grant, Searsport must hold another public hearing, followed by a townwide vote to accept the money.

Along with paying for the feasibility study, the funds will help plan ways of building a network of so-called satellite pharmacies.

The plan with CBSRx, said Shrum, would involve the establishment of a hub pharmacy, likely located at the former Waltz Pharmacy site, said Desmarais. That site is equipped with security systems that the state requires for businesses dealing with pharmaceuticals.

Once the hub pharmacy is established, CBSRx would assist in securing sites that could work as satellite pharmacies. The satellite sites, said Shrum, could include health-care facilities in Brooks, Lincolnville, and others under Waldo County Healthcare, Inc. umbrella.

Through that network, technology known in the industry as a "telepharmacy" would dispense medications through what Shrum likened to “candy machines” at satellite locations.

A doctor would prescribe medicine to a patient with a hand-held electronic device. That prescription would arrive at the hub in Searsport. A pharmacist at the hub would program the information for that particular prescription into the medication dispenser at a satellite location.

A physician, qualified nurse or pharmacist at the satellite location would check the prescription before giving it to the patient.

The medicine dispenser has a booth where patients can video conference with the pharmacist at the hub if they have questions about their medications.

Shrum said the nature of Searsport’s CDBG grant application would be the first of its kind in Maine in regard to its approach to how pharmacies operate.

Selectman Doug Norman asked if satellite locations could be susceptible to crime. Gillway said all sites are required to have security systems in place.

Desmarais said the upside is the town would not own the pharmacy; the board had established it did not want ownership.

Instead, Shrum said, an entity such as WCGH could serve as the owner of the pharmacy, and would contract with CBSRx. Shrum plans to meet soon with officials at Waldo County General Hospital to discuss the possibility of including the WCHI sites in the pharmacy network, and of the hospital taking ownership of the hub pharmacy.

Because of all the steps that must be taken to meet state and federal requirements, a hub pharmacy would not likely come to fruition before April, 2009.

Satellite locations would likely be online six to eight months later. The cost of one medication dispensing machine is $50,000 to $75,000, though Shrum said there was funding available to assist with those costs.

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