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.

MedCenters: Pharmacies in a box

Here's a video from CNN's coverage of PharmaTrust's MedCentre at work in the UK and coming soon to the US: http://www.cnn.com/video/#/video/health/2010/08/22/pharmacies.in.a.box.cnn

Sorry about the lack of an embedded video post, CNN isn't allowing it.

Illinois Added to the 9+ States which Provide for Outpatient Telepharmacies, Fills Rural Pharmacy Gap

Tim Landis of Illinois' State Journal-Register writes about a new outpatient pharmacy that opened in Illinois where the owner might convert it to a telepharmacy soon thanks to new legislation in the state. Some other good tidbits result from Landis speaking to Illinois Pharmacists Association executive director Michael Patton:

Patton said telepharmacy regulations were included in a rewrite of the state’s pharmacy laws that is done every decade. Two have opened in the state since the regulations were approved in April, he said.

“It allows us to reach underserved areas, and still have it under the supervision of a licensed pharmacist,” said Patton.

...

“It’s really taking pharmacies to a new dimension,” said Patton.

The first two remote locations are in Earlville, southwest of Aurora, and Chillicothe, north of Peoria. The same “home” pharmacy operates both.

According to the U.S. Department of Health and Human Services, telepharmacies also have been authorized in Alaska, Idaho, Montana, South Dakota, Texas, Utah, Vermont, Wyoming and the District of Columbia.

Patton said most of the early remote pharmacies are in rural areas.

“It would be a remote dispensing pharmacy with a certified technician. They have high-tech communications through cameras, computers and telephones,” said Patton.

Here's the regulation as defined by Illinois:
http://law.onecle.com/illinois/225ilcs85/25.15.html
Congratulations to the two Illinois towns restoring their pharmacy services!

Landis' article doesn't list Illinois because it's about Illinois, and for some reason they don't mention North Dakota either, even though ND has established most of the standards for outpatient telepharmacy operation in the United States. I'm going to attribute this to Landis' HHS figures coming from this article on the HHS website, which mentions North Dakota as the preamble to the list, which, after being ported, leaves North Dakota out. Though there's no date on their article (Bad HHS!), it seems to be from 2008 and the origin of this list of 10 states that allow for outpatient telepharmacy programs in their laws/regulations, which many media articles use.

Telepharmacy Results in Better Care!

... when a local pharmacist is not available, of course.

Pharmacy Practice News published an article in its July 2010 issue called Does Telepharmacy Result in Better Care? (free login required, or use bugmenot). As evidence that it does, they offered up an article by Judy L. Rose, PharmD, U.S. Public Health Service captain and clinical pharmacy director for Alaska Native Medical Center. She reports that pharmacists consult with clinical patients via video teleconferencing equipment, and:

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.)
...
Our results are clear: Telepharmacy can help remote hospitals deliver high-quality pharmaceutical care, despite staffing and resource challenges.

Here's an article published in Pharmacy Today from way back in 2005 about their program's success in improving care and reducing costs while providing comprehensive pharmacy services called Telepharmacy delivers comprehensive services in rural Alaska (PDF).

Additionally, Judy put out a study in 2007, Improved and Expanded Pharmacy Care in Rural Alaska Through Telepharmacy and Alternative Methods Demonstration Project (Original PDF) and this informative presentation for the 2008 USPHS Scientific & Training Symposium in San Diego, California (PDF):


What's blocking outpatient telepharmacies from serving the medically underserved in Ohio?

Ironically enough, it seems it is the Ohio State Board of Pharmacy.

Back on the subject of the original article mentioned in this blog post, Does Telepharmacy Result in Better Care?, Pharmacy Practice News also offers a second opinion, this one from Tim Benedict, Assistant executive director of the Ohio State Board of Pharmacy. Tim says, "Compared with Ohio, the states that allow telepharmacy are larger and more sparsely populated. The board feels telepharmacy isn’t relevant for our geography and populace."

I wonder if the populace which he acknowledges live 30 minute+ drives from pharmacies in Ohio would concur. He mentions a Pharmacist in Charge is required at every pharmacy as an obstacle, although plenty of other states still manage to have outpatient telepharmacy programs while satisfying the rule. Unless I'm reading his text incorrectly, he also implies that physicians can serve the medication needs of patients as well as pharmacists can and that pharmacy technicians are more likely to divert controlled substances than doctors. Does anyone know where to find numbers as to whether this is true?

Thankfully, he does mention:

The board has approved several off-site pharmacies to receive the new orders from the hospital and then enter into the hospital computer system to perform utilization review and either approve or reject the order. Furthermore, the board recently approved the use of a dispensing machine placed in an emergency room for use in after-hours situations. The physician creates the prescription in the hospital computer and then provides the prescription to the patient. The prescription contains a bar code. The patient takes the prescription to the machine and the machine reads the bar code and provides the drug to the patient. There is a telephone connected to the machine for patient counseling with a pharmacist. The pharmacist is located in another state.

Good news that they at least allow applications of clinical telepharmacy!

Nebraska State Board of Pharmacy to Write Telepharmacy Legislation

According to their May minutes (PDF), the Nebraska State Board of Pharmacy is about to begin drafting telepharmacy legislation:

Borcher requested help from the Department in writing proposed legislation for tele-pharmacy and also requested the Department's support of the tele-pharmacy legislation
...
Borcher mentioned that he would help with the concept papers for the proposed legislation on tele-pharmacy.

Last year, the Nebraska legislature defined Telepharmacy and Remote Order Entry officially.

ASHP finds 80% of Hospitals without 24/7 Pharmacist Coverage, Publishes RMOP Guidelines, Trumpets RMOP Providers

In the upcoming issue, Drug Topics reports on ASHP's Remote Medication Order Processing guidelines published earlier this year. From the aritlce:

I had all of 2 weeks to fill those slots. It was less expensive and faster to utilize a night pharmacy service."

Stomackin signed with Cardinal Health's Rxe-source, then one of the few national RMOP providers. He still uses the service as coverage for third shift and as a resource while Lewistown builds a computerized physician order-entry system that also requires 24-hour pharmacy support 7 days a week.

Lewistown Hospital is not unusual. The latest ASHP survey found that nearly 80% of hospitals nationwide lack pharmacy coverage at some point during a typical week. The widespread lack of 24/7 coverage combined with mandates to enhance hospital technology are fueling a surge of interest in remote pharmacy management. Community pharmacy is grappling with similar issues as telepharmacy replaces pharmacists in small-town and rural healthcare settings.

ASHP's RMOP Guidelines can be found here (PDF).

MedCentre Remote Dispensing Machine to expand further in Canada, UK, and soon, USA?

PharmaTrust issued a press release today, announcing they were enabling all Ontario Telemedicine Network members to easily install and use their MedCentre dispensing machine. As a result, they got some good press on CBC News which relayed this tidbit:

[d]iscussions are continuing with about 30 health facilities, with six to 10 showing strong interest in adopting the new technology.

In an article late last month, CBCNews asked the Canadian public, "Drug vending machines: Would you use one?" in a(n unscientific) poll, to which they for the most part, surprisingly, answered NO:

Yes: 31% (410 Votes)
No: 69% (924 Votes)

See comments for their reasoning. The article also mentions:

PharmaTrust introduced the machines in Britain this week, already has three operating in Ontario and expects to have them in five U.S. states within a few months.
...
Three of the machines are currently being tested in Ontario, two at Toronto's Sunnybrook Health Sciences Centre and one in the emergency room at Cambridge Memorial Hospital.

US Navy's Worldwide Outpatient Telepharmacy Program to be Extended to Inpatients, Army, Air Force?

An article by Kate Traynor from next month's ASHP News interviews the the Navy's telepharmacy program project manager, Lieutenant Commander Marc Young (Lt. Justin Eubanks pictured above). From the article:

"We have a lot of sites, more than the other two services, that have technicians only," Young said of the Navy. "Some of these branch clinics with these technicians are literally almost like closets. They’re very small pharmacies; they’re doing 80 prescriptions a day, in some cases, with one technician."

"It’s difficult to hire folks in those places as well to get people to move to some of our remote locations," Young said.

Through telepharmacy, the technician-run pharmacy at the remote Mountain Warfare Training Center in Bridgeport, California, has access to pharmacists at the Robert E. Bush Naval Hospital in Twentynine Palms, California, Young said.

The article also mentions the Navy is waiting on funds to determine whether they'll expand the program to their inpatient pharmacies around the world and that they're talking to the Army and Air Force as well. There are also some interesting numbers on Navy pharmacists and technicians. Great, insightful article.

New Study: Many US States Neglect Setting Any Telepharmacy Policy

In a new study in the American Journal of Health-System Pharmacy (AJHP), the "Current practices and state regulations regarding telepharmacy in rural hospitals" were examined for a good number of US states. Through a series of interviews with board of pharmacy directors, a team out of the University of Minnesota including Michelle Casey, Todd Sorensen, Walter Elias, Alana Knudson, and Walter Gregg found:

Results. Although telepharmacy is addressed in NABP’s model pharmacy practice act, many state boards are just beginning to address it. The model act addresses the practice of pharmacy across state lines, and the state board directors interviewed generally agreed that pharmacists should be licensed in the state where they are providing the service. States differed on whether a pharmacist should be required to be physically located in a licensed pharmacy and how much time the pharmacist should have to spend onsite. Telepharmacy models being implemented in hospitals in several states incorporate long-distance supervision of pharmacy technicians by pharmacists. The models being implemented vary according to area, state regulations, hospital ownership, and hospital size and medication order volume. Most hospitals reported that they track medication error rates, and some said error rates have improved since telepharmacy implementation.

Conclusion. 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.

Arkansas: Medical Center Provides Telepharmacy for Disaster Relief, Reduces Errors

In an article in online magazine "Lifestyle" called White River Medical Center Uses Meta Pharmacy System to Support Distance Medication Dispensing, Holly Meyer of tells a tale of two medical centers in North Central Arkansas, one providing remote order entry to the other in the absence of an on-site pharmacist:

This remote link allows WRMC pharmacists to provide remote medication order entry and real time review of medication orders for appropriateness of doses, as well as screening for medication allergies and drug-drug interactions. Although 35 miles away, SCMC functions as a virtual nursing unit of WRMC, allowing nurses at SCMC immediate access to medications in their dispensing machines. Two goals are achieved with this arrangement - orders for every patient are reviewed and verified by a pharmacist and nurses have access to medications without using an antiquated medication cart fill each day.

"Implementation of this unique technology has had a significant impact on patient care through the reduction of medication errors, adverse drug reactions and drug-drug interactions," explained Jody Smotherman, PharmD, Co-director of Pharmacy Services at White River Medical Center. "It has also produced improvements in employee and nursing job satisfaction as well as improved drug charge capture. A major unexpected benefit was realized in February of 2008 when an F-3 tornado struck Mountain View, destroyed part of SCMC and forced the closing of the pharmacy area. Without our remote order entry and automated dispensing machines, there would have been no access to medications after the storm."

Another advantage of telepharmacy: disaster relief!