Telepharmacy helps move error rates 'close to zero'?

Helen Figge of the Pharmacy Informatics Section of ASHP writes in US Pharm:

A telepharmacy system has been described at the University of Kansas Hospital in which the chemotherapy preparation process in the pharmacy's sterile room is monitored by bar coding and a camera that documents key steps. The technician scans the bar code on the chemotherapy drug vial to establish a match in the patient's computerized record. Then, in the sterile prep room, the technician captures an electronic image of the vial label and filled syringe prior to injecting the dose into an IV bag. A clinical pharmacist at a remote location then verifies the identity of the drug, the dose on the pulled-back syringe, the label on the IV bag, and the patient's medication order. This telepharmacy process, an alternative to using a robot, features quality assurance steps that are expected to greatly reduce errors.
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Given the magnitude of morbidity caused by adverse drug events, including medication errors, it is imperative that systematic approaches be taken to redesign the medication dispensing process to eliminate the potential for error. It is conceivable that the combined application of powerful computer software and pharmacy system automation, including robotics, can bring dispensing error rates down close to zero. With the introduction of monitoring methods such as telepharmacy and SORS, the potential exists to continuously monitor dispensed products for correct product and dose, which could further detect and eliminate errors.

University research group compiles rural Telepharmacy policy brief for Federal Government

The Upper Midwest Rural Health Research Center, a group from the University of Minnesota Rural Health Research Center and the University of North Dakota Center for Rural Health who focus on the quality of rural health care, prepared a policy brief for the US federal government (available here), who will likely use it to set national policy regarding telepharmacy.

The full report's summary:

Implementation of Telepharmacy in Rural Hospitals: Potential for Improving Medication Safety - Findings from this new report and policy brief describe successful telepharmacy activities being implemented in rural hospitals and analyze policy issues related to the implementation of telepharmacy projects in rural hospitals.

The following pharmacies participated in the data collection:

Arkansas State Board of Pharmacy
Cross Ridge Community Hospital, Wynne, Arkansas
St. Bernard’s Medical Center, Jonesboro, Arkansas
Idaho State Board of Pharmacy
St. Luke’s Wood River Medical Center, Ketchum, Idaho
St. Luke’s Meridian Medical Center, Meridian, Idaho
Minnesota State Board of Pharmacy
Ely-Bloomenson Hospital, Ely, Minnesota
St. Luke’s Hospital, Duluth, Minnesota
Wheatland Memorial Hospital, Harlowton, Montana
St. Vincent’s Hospital, Billings, Montana
North Dakota State Board of Pharmacy
North Dakota State University College of Pharmacy
Heart of America Medical Center, Rugby, North Dakota
Lisbon Area Health Services, Lisbon, North Dakota
Oklahoma State Board of Pharmacy
Atoka Memorial Hospital, Atoka, Oklahoma
South Dakota State Board of Pharmacy
Lead-Deadwood Regional Hospital, Deadwood, South Dakota
Texas State Board of Pharmacy
Envision Telepharmacy, Alpine, Texas
Utah Division of Occupational and Professional Licensing
Allen Memorial Hospital, Moab, Utah
San Juan Hospital, Monticello, Utah
University of Utah
Washington State Board of Pharmacy
Sacred Heart Medical Center, Spokane, Washington
Coulee Community Hospital, Grand Coulee, Washington

Support for this report was provided by the Office of Rural Health Policy, Health Resources and Services Administration, PHS Grant No. 5U1CRH03717-02-00.

Rural Washington gets new telepharmacy service, allows for 24/7 pharmacist review

The rural Lake Chelan Community Hospital in the US state of Washington finds new telepharmacy service in Envision Telepharmacy, after their pharmacy director was involved in Sacred Heart Medical Center's 2006 telepharmacy program in Spokane, WA. From the article:

Nielson’s experience at LCCH began three years ago, when she worked with the TelePharmacy program at SHMC. TelePharmacy is a system that, with innovative technology, pairs larger medical institutions or specialty healthcare organizations with rural hospitals that may not have 24/7 pharmacy services. Nielson helped pilot SHMC’s program at LCCH in 2006.

At the time, LCCH purchased two automatic drug-dispensing devices. Those units, each about the size of a packing box for a washer or dryer, were connected to a fiber-optic system of technology, local healthcare workers and outside pharmacists, including Nielson, who communicated with Lake Chelan healthcare workers through video conferencing.

It was the same technology that was used at SHMC, explained Nielson, except that the patient was 165 miles away instead of nine floors up.

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As SHMC’s program evolved and put less emphasis on its TelePharmacy program, it impacted its service to smaller hospitals like LCCH. Nielson, however, still felt drawn to continue working with rural hospitals. That desire brought her to Lake Chelan on a permanent basis.
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Although Nielson works full-time at LCCH, she cannot be there 24/7, so she searched for a new TelePharmacy program. She found Envision-Rx, an experienced Texas-based company and developed a partnership with them. Eight pharmacists in the company now provide long-distance pharmacy services to Chelan using the technology LCCH already had in place.

“TelePharmacy bridges the gap so we have 24/7 coverage at our hospital,” explained Nielson. “Pharmacists are available at all times to works with our healthcare providers and answer clinical questions. It’s a cost-effective way to have 24-hour pharmacy services.”

Nielson’s TelePharmacy partners are located in Texas, Bellingham, Wenatchee, Blaine, Indiana and Okinawa, Japan.

In LCCH’s pharmacy department, a physician’s written prescription is scanned by nurses and entered into the computer system to access the patient’s laboratory results and other information. Nielson or one of the TelePharmacy pharmacists reviews the dosage and drug interactions and completes the order entry in the computer. After that, a nurse accesses the approved prescription in the automatic dispensing device.

Throughout the process, the pharmacist monitors the verification process and has complete auditing capabilities and access to the medical records. The pharmacist checks for allergies or adverse reactions and can advise the physician if there is a more appropriate drug currently on the market. He or she may also alert the physician that a lab test is needed to monitor the effects of the medication on the patient.

Hospital Telepharmacy Program Helps Canadian Towns Recover from the Pharmacist Shortage

This is the first mention of hospital telepharmacy in Canada! From the article:

“A small hospital can safely operate a medication storage and distribution system for their patients under the management of a registered nurse,” says Joan Kuiack, Director of Patient Care Services. “However, the addition of a pharmacist offers an enhanced quality of care to our patients.”

The hospital first contacted Kevin McDonald, manager of the hospital pharmacy telepharmacy program at Northern Pharmacy, about a year ago, but decided to try to organize a partnership with Renfrew Victoria Hospital for services of a pharmacist.

“We advertised nation-wide, but couldn’t find a pharmacist and so we went back to Kevin,” says Kuiack.

The North West Company is based out of Winnipeg; the Northern Pharmacy provides similar services to hospitals in areas such as Deep River, Cornwall and Moose Factory. McDonald, who hails from Deep River, initiated the telepharmacy project in 2004.

“A hospital pharmacist is very different from a retail pharmacist,” he says. “In smaller hospitals, there is not enough work to employ a pharmacist full-time, so it’s hard to attract them. We fill that need.”

Monique Yurkiw, a pharmacist with the company since July, will look after St. Francis Memorial. She and McDonald were at the hospital last week to test the system.

“It’s good,” she says. “We’re set to go.”

Older Report: Washington, DC hospital benefits from Telepharmacy service

From the paper, published in AJHP in 2002, Sibley Memorial Hospital, a 340-bed acute care facility in Washington, DC acquires telepharmacy service from MedNovations:

An alternative to the traditional 24-hour pharmacy service was discussed in September 2000 by SMH's pharmacy director and officers of the telepharmacy service firm MedNovations, Inc. The pharmacists in the department determined that the current on-call pharmacists could not prospectively review all new medication orders and handle existing duties during the day and evening shifts. Support for using the telepharmacy service was obtained from the hospital's senior administrators and the patient care services, medical staff, risk management, legal, and operations departments. Issues pertaining to patient confidentiality and pharmacy licensure were addressed in provisions of the contract between the hospital and the telepharmacy firm. The new service was approved in March 2001 by the pharmacy and therapeutics (P&T) committee.
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The telepharmacy service emphasized avoidance of medication errors, timely resolution of gaps in clinical data necessary for proper review of new orders and of missing doses, and enforcement of hospital policies and protocols (e.g., therapeutic interchanges and drug-use restrictions). A physician-pharmacist communication form enabled the telepharmacy service to clarify problematic orders on the morning shift more efficiently. (Occasionally, such orders were not verified or approved by the telepharmacy service, and resolution was not accomplished until the morning shift.)
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It is likely that cognitive telepharmacy services and remote order entry services will grow. Expanded use of computerization and automation will further fuel the use of telepharmacy as a supplement to onsite pharmaceutical services, especially after hours. As with other pharmacy practice innovations, issues such as pharmacoeconomics and compliance with professional standards, laws, and regulations will need to be further examined as the telepharmacy model attempts to deliver high-quality care and safety in hospitals when pharmacy departments are closed.

Grants, loans for Minnesota city telepharmacy set to bring pharmacy service back to the area

Nobles County Comissioners in Worthington, MN approved of plan to loan $25,000 to the City of Adrian, MN for installation of a telepharmacy in communication with a private pharmacy in Worthington after Adrian was awarded a $50,000 grant for broadband internet from the Blandin Foundation, and the municipality was approved for a $25,000 loan from the Worthington Regional Economic Development Corp.

Julie Buntjer of Minnesota's Worthington Daily Globe writes:

In other action, the board:

Received a request from the City of Adrian for financial assistance to help establish a telepharmacy in the Adrian Government Center.

Bruce Heitkamp, Adrian City Administrator, said the community is working with Sterling Drug of Worthington to establish a pharmacy that would allow a pharmacist to provide adequate consultation to clientele via video and teleconferencing equipment. Plans are to have a pharmacy technician on staff at the Adrian location.

“In the last year, our city council has really taken a look at health care,” said Heitkamp. When the town’s only pharmacy closed a year ago, he said it left residents scrambling for services.

“The clinic in Adrian was concerned about the ability to provide prescriptions to their clientele,” Heitkamp said.

Already the City of Adrian has been approved for a $50,000 Light Speed grant from the Blandin Foundation, and it was approved for a $25,000 loan from the Worthington Regional Economic Development Corp. Heitkamp said the city was looking to the county for another piece of financing for the project. The money would cover the estimated $100,000 cost for the telepharmacy equipment. The cost represents roughly one-fourth of the total project cost.

Commissioners voiced support for the telepharmacy and directed the county administrator to work with the WREDC and the City of Adrian to finalize the funding plan.

South Dakota gets new Telepharmacy, helps alleviate pharmacist shortage

From the article:

Just this week, the Eagle Butte location has been officially authorized as a pilot site for telepharmacy. Stephens said. That means a pharmacy technician in Eagle Butte will be able to fill prescriptions under the supervision of a pharmacist who watches the technician work via television, he said.

Stephens said he has noticed a resurgence of young people living in many of the towns Vilas serves. The courier system works well in part because of the nationwide shortage of pharmacists, he said. There are 5,000 unfilled pharmacist openings in the U.S., Stephens said.

VA implements telepharmacy, "Safety, efficiency, and patient satisfaction improved"

In their OIG report, they claim "Safety, efficiency, and patient satisfaction improved with the implementation of the telepharmacy program".

In his post New Reports From the VAOIG, Mike Fielder says "We identified the telepharmacy program and QM program redesign as organizational strengths."

Tele-pharmacy plan earns legislative OK

Can start in South Dakota, despite lawsuit potential

PIERRE - South Dakota pharmacists received final legislative clearance Monday to use pharmacy technicians to fill drug prescriptions at remote locations.

But members of the Legislature's rules-review committee raised questions about the lack of clear standards for “limited access” areas where tele-pharmacy would be allowed.

Several committee members warned that lawsuits could result if more definite criteria aren't developed.

The Legislature passed the law authorizing tele-pharmacy in 2007. The Board of Pharmacy has used the past year to develop rules for the new system.

The concept calls for pharmacists to communicate with pharmacy technicians and patients at the remote sites using audio-visual networks. Technicians would perform the physical act of filling the prescriptions.

Ron Huether, executive secretary for the Board of Pharmacy, said the rules will allow prescription services to communities where a pharmacist isn't present.

As an example, he said the Pamida pharmacy in Winner plans to operate a remote pharmacy at a medical clinic in Mission. The room will have restricted access.

Sen. Jean Hunhoff, R-Yankton, focused on what standards will be used to determine which communities have “limited” access to retail pharmacy services.

“It would be subject I guess to board member discretion,” Huether replied.

Hunhoff also noted that the rules don't specifically require service to be suspended while the audio-visual link isn't available.

Rep. Roger Hunt, R-Brandon, said he shared her concern about the ambiguity in the phrase “limited access.” He said there could be legal challenges about distance and types of drugs. He encouraged the Board of Pharmacy to develop better-defined standards.

Huether responded: “This is something we wrestled with a long time in developing rules.”

He said the board doesn't want tele-pharmacy to be used to compete with existing pharmacies in a community.

Asked by Rep. David Lust, R-Rapid City, what would happen if multiple providers sought to provide tele-pharmacy services in the same community, Huether said his opinion was the board probably would allow it.

Lust said this could become a matter of dispute under the “limited access” standard.

No one testified against the proposed rules. The rules-review committee approved the rule 6-0.

“I would certainly hope this would be taken back with the questions asked,” Sen. Jim Hundstad, D-Bath, said. “This is a really new thing. This is something that isn't really defined in many places.”

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Telepharmacy reaches out to the underserved

Not so long ago, medically underserved rural communities had only limited options, if any, when need arose for healthcare services and pharmaceutical support. That situation is finally changing, as necessity and technology converge in emerging applications of telepharmacy, the delivery of pharmaceutical care by means of telecommunications and information technologies to patients at a distance from large, usually urban tertiary healthcare centers.

Telepharmacy also provides nighttime pharmaceutical services to community hospitals. A few years ago, Sibley Memorial Hospital in Washington, DC, could not support a pharmacist to review medication orders for high-risk drugs (such as antibiotics, anticoagulants, antiplatelet agents, narrow therapeutic index drugs, and drugs with many potential interactions) during the night shift, so the hospital turned to telepharmacy. Once the service was implemented, nurses faxed new inpatient orders to clinical pharmacists and technicians, who reviewed these orders much as the hospital’s own pharmacy staff would have done during the day; the difference was that the nighttime pharmacy professionals were located at a remote site. Before administering medications, nurses waited for the pharmacists to review and confirm the orders. Pharmacy consultations and requests for drug information were also handled by telepharmacy during the night shift.

More recently, the Veterans Administration adopted telepharmacy practices in order to reduce costs and to remotely link patients as needed to centrally located pharmacies.

Another initiative, the North Dakota Telepharmacy Project, is a collaborative effort between the North Dakota Board of Pharmacy, the North Dakota Pharmacists Association, and the College of Pharmacy, Nursing, and Allied Sciences at North Dakota State University. In rural southeastern North Dakota, where initial testing of telepharmacy took place, seniors had been resorting to mail-order pharmacy. Now they have a community pharmacy, staffed by a pharmacy technician, and they use an internet connection to speak with a pharmacist located at a remote site. Under this model, a licensed pharmacist is located at a central pharmacy. Video conferencing enables the pharmacist to supervise a registered pharmacy technician at a remote pharmacy site. After preparing the prescription, the technician shows the pharmacist the original signed prescription, the computer-generated label, the stock bottle where the medication is stored, and the bottle the patient will take home. The drug is then dispensed and the patient has mandatory “face-to-face” counseling with the pharmacist by means of real-time audio and video.

To ensure the delivery of safe, high-quality pharmaceutical service and care, pharmacists provide drug utilization review, prescription verification/validation, and patient counseling. The latter 2 services are often omitted when a patient uses a mail-order or internet pharmacy. In 2001, North Dakota was the first state to pass administrative rules allowing retail pharmacies to operate remotely without requiring a pharmacist to be present. As of September 2008, North Dakota had 67 pharmacies, of which 44 were retail pharmacies and 23 were hospital pharmacies. Of these, at least 22 were central pharmacies and 36 were remote sites served by telepharmacy, according to Charles D. Peterson, PharmD, dean, professor, and principal investigator/director of the North Dakota Telepharmacy Project. The telepharmacy sites are full-service, with drug inventories that include over-the-counter drugs and other merchandise.

“Over 40,000 rural citizens have had pharmacy services restored, retained, or established through the North Dakota telepharmacy project,” said Dr. Peterson. “It has also added more than $12.5 million annually in economic development.” In addition, this project has created at least 40 to 50 new jobs.

In Anchorage, the Alaska Native Medical Center (ANMC) uses telepharmacy to improve prescription drug access and pharmacy services for rural patients whose villages are spread over 2,000 miles. The program employs an electronic medical record and prepackaged, bar-coded medication and prescription labels, as well as innovative software, videophones, and automated dispensing machines. The network began with 12 remote clinics and has since expanded. In 2006, the ANMC telepharmacy received an award for excellence in medication-use safety from the ASHP Research and Education Foundation.

As of September 2008, the states of Alaska, Idaho, Illinois, Montana, South Dakota, Texas, Utah, Vermont, and Wyoming, as well as Washington, DC, had changed their laws to permit establishment of remote pharmacies.

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