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8/6/18

Disclosures Empowering the Telepharm, a Cardinal Company, has a commercial interest in with telepharmacy, but does not reference any commercial products in this Jessica Adams, PharmD presentation.

August 2018 The opinions and recommendations expressed by the presenter are their own, and are to be used for educational purposes only.

Learning objectives

1. Explain why telepharmacy started and how it has evolved Why telepharmacy? with technology.

2. List the different types of telepharmacy and how its use is improving care. 1. Utilize technology to improve patient 2. Enable access to a pharmacist in rural communities 3. Describe the telepharmacy regulatory environment around the and what states are doing with rules. 3. Increase pharmacist outreach in urban areas

The four types of telepharmacy Need for alternative delivery

INPATIENT OUTPATIENT Independent Rural 2003-2013

7,624 Remote order Retail 924 independent rural entry review telepharmacy pharmacies closed 12.1% decrease 490 Remote 2007-2009 rural communities IV admixture lost their only counseling 7.2% 6,700 decrease

Source: Update: Independently Owned Pharmacy Closures in Rural America, 2003-2013; RUPRI Center for Rural Analysis, Rural Policy Brief June 2014; Fred Ullrich, BA; Keith J. Mueller, PhD

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Telepharmacy historical timeline North Dakota telepharmacy case study

Study conducted from 2002 - 2008 dispensing

1942 Australia’s Royal Flying Service error rate for Information of the North telepharmacies Dakota Telepharmacy 2001 North Dakota first state to allow Program provided by North Dakota State 2001 Association in University School of Pharmacy Spokane, WA launches program 81 telepharmacies <1% 2002 NDSU study begins Compared to a national 2003 Alaska Native Medical Center program average of: ~1.7% 2006 U.S. Navy begins telepharmacy Result: Positive outcomes, mechanisms could be improved

Source: The North Dakota Experience: Achieving High-Performance Through Rural Innovation And Cooperation. May 2008

North Dakota telepharmacy case study Telepharmacy regulations, 2008

Information of the North Dakota Telepharmacy Program provided by North Dakota State University School of Pharmacy

Source: The North Dakota Experience: Achieving High-Performance Health Care Through Rural Innovation And Cooperation. May 2008 Source: Telepharmacy project expands across country; 9/12/2008; Dave Kolpack, Associated Press

Telepharmacy regulations, 2018

WA Why telepharmacy? ME MT ND OR VT MN NH ID SD NY WI MA RI WY S MI CT

IA PA NJ NV NE IL OH MD UT IN 1. Utilize technology to improve patient adherence DE CO WV CA VA KS MO KY NC 2. Enable access to a pharmacist in rural communities TN AZ OK AR NM SC MS AL GA Permitted, but practice may be 3. Increase pharmacist outreach in urban areas restricted and/or requires Board TX LA approval

AK In progress FL HI Not permitted

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How big is the adherence problem? “The Leaky Bucket”

According to IMS Health:

% 187M 13 Americans take $290 billion 1+ prescriptions Out of every 50-70 48-66 25-30 15-20 are healthcare expenses directly 100 new arrive at a are picked up are taken refilled as related to non-adherence prescriptions pharmacy by the patient properly prescribed avoidable costs

Sources: Osterberg, L., Blaschke, T. (2005). Adherence to medication. N Engl J Med, 353(5), 487-497; Thinking Outside the Pillbox, A System-wide Approach to Improving Patient Medication Adherence for Chronic ; A NEHI Research Brief – August 2009 Source: IMS Health Data, March 2011

Frequent interactions with Patients desire convenience

Patients visit their pharmacist more than any other healthcare provider

Provider # visits 95% 4 patients filled initial prescriptions when offered at doctor’s office Other healthcare providers 9

Pharmacist 35

Source: New Prescription Medication Gaps: A Comprehensive Measure of Adherence to New Prescriptions; Harvard Source: as Influencers of Patient Adherence, August 21, 2014, Joseph Moose, PharmD, and Ashley Branham, PharmD, BCACP Business Review Vol 44 | Num 5 | Oct 2009.

Definition of rural

Why telepharmacy? According to HRSA:

1. Utilize technology to improve patient adherence “Rural” encompasses all population, housing, and territory not included within an urban area. 2. Enable access to a pharmacist in rural communities 3. Increase pharmacist outreach in urban areas

Source: https://www.hrsa.gov/ruralhealth/aboutus/definition.html

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Rural is becoming more rural Creating patient relationships

“Telepharmacy helps create a new patient-pharmacist relationship that 64+ wasn’t possible before.” 77% rural counties considered - Angela Falk, Pharm.D.

Million shortage areas People in the US live in rural areas

Source: The Crisis in Rural Primary Care; WWAMI Rural Health Research Center, Policy Brief April 2009 2010 Census Urban and Rural Classification and Urban Area Criteria, https://www.census.gov/geo/reference/ua/urban-rural-2010.html

Rural telepharmacy next to a health Interior of a rural telepharmacy

Rural community pharmacy grand opening Rural telepharmacy revives Main Street

BEFORE

AFTER

Shoshone Telepharmacy, December 2016

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Economics of telepharmacy

NORTH DAKOTA ILLINOIS Why telepharmacy? Results of the 6-year study with Estimate for one pharmacy based 81 locations: on financial data:

1. Utilize technology to improve patient adherence $26.5 million $640,000 2. Enable access to a pharmacist in rural communities in economic development annual economic impact 3. Increase pharmacist outreach in urban areas 80-100 new jobs created

Source: North Dakota Telepharmacy Project https://www.ndsu.edu/telepharmacy/; Rural Economic Technical Assistance Center (RETAC) in Macomb, IL; Economic impacts of a pharmacy for Deiterich, Illinois, June 2015

Access challenges in urban areas Readmission rates are high

University of Illinois Chicago did a study looking at “pharmacy A study in Oregon found that readmission rates were higher deserts” in Chicago: in rural areas than urban, but both are still high:

Over one million residents live in 1+ miles these areas in Chicago 15.3% 14.7% to nearest pharmacy Rural Urban

Source: Source: ‘Pharmacy Deserts’ Are Prevalent In Chicago’s Predominantly Minority Communities, Raising Medication Access Concerns, Dima M. Source: Lack of pharmacy access sends some patients back to the ; Oregon State University and Qato, Martha L. Daviglus, Jocelyn Wilder, Todd Lee, Danya Qato and Bruce Lambert. Oregon Health & Science University, August 2016

Telepharmacy in a community health center

Better Education

+ Better Access

Better Outcomes

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In-clinic pharmacy providing 340B Telepharmacy in a FQHC

Software solutions

Common Questions Advantages • Live pharmacist interaction • Constant updates • Low initial costs • Better education

Disadvantages

• Can be limited hours • Live internet connection

Hardware or AMDS solutions Telepharmacy workflow

Advantages New prescription arrives at 1 Pharmacy A • Can be available 24 hours • No on-site staff needed A B Technician A fills, taking 2 images of the process Disadvantages

• Cost-prohibitive Pharmacist B reviews images • Limited formulary 3 to verify fill is accurate • Mechanical failure • Complicated Rx Tec RPh Tec Patient picks up Rx at h h Pharmacy A and 4 Pharmacist B counsels

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Endless opportunities FAQ

Workload Safety balancing Fill Accuracy (staff & location)

Internet Pharmacy Accessible Diversion deserts specialists outage

Telepharmacy regulations, 2018

Regulatory Considerations WA ME MT ND OR VT MN NH ID SD NY WI MA RI WY S MI CT

IA PA NJ NV NE IL OH MD UT IN DE CO WV CA VA KS MO KY

NC TN AZ OK AR NM SC

MS AL GA Permitted, but practice may be restricted and/or requires Board TX LA approval

AK In progress FL HI Not permitted

Regulations are fragmented Utah Statistics

• Different for each type of telepharmacy ● Over 25,799 residents in pharmacy deserts • Vary widely by state ● 27 rural pharmacy • Practice setting deserts • Verification site location ● 26 at-risk communities • Urban allowances ● 62 primary care HPSA’s States that have telepharmacy language can benefit from aligning their rules NABP currently has a task force to create model language

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Typical regulations Telepharmacy regulation considerations

Need is increasing every year certification

Limits on number of remote sites or technicians Successful programs already in place Special rules around Controls

Mileage restrictions Consider the present as well as the future Security requirements

Technology requirements Get ahead of the technology and legislators

Signage in the telepharmacy location

Steps to implementing regulations Tips to drafting regulations

Look for statutory authority 1 Look into what other states

have for regulation Have Board Rules Committee draft rules 2 Visit a retail telepharmacy Board notices rules to the public location which is in operation 3

Public comment period Understand the landscape in 4 your state

Administrative rules review process & approval 5 Ensure statutes leave room for administrative rules Implementation 6

CE Question #1

Why telepharmacy? Which of these is not a type A. ) Remote Order Entry of “telepharmacy”? B. ) Remote Dispensing

1. Utilize technology to improve patient adherence C. ) Remote Consultation 2. Enable access to a pharmacist in rural communities D. ) Internet Pharmacy 3. Increase pharmacist outreach in urban areas

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CE Question #2 CE Question #3

Telepharmacy is becoming A. ) True Which of the following A. ) Pharmacist less prevalent in America. healthcare providers has B. ) False B. ) Primary Care the most patient contact? Physician C. ) Answering this question is a slippery C. ) Dentist slope D. ) Veterinarian D. ) I can neither confirm or deny this

CE Question #4 CE Question #5

Available data from the A. ) Yes, it created over Which group would be A. ) Seniors implementation of 80 new jobs considered to have access B. ) Low vehicle telepharmacy in North issues? B. ) Yes, but all the jobs ownership Dakota showed the creation went to China of new jobs. C. ) Both C. ) No, no new jobs were D. ) Neither created

D. ) No, it actually took away jobs

CE Question #6

Which of the following are A. ) Telepharmacy in ways to increase warfarin pharmacist presence? B. ) Telepharmacy to allow HIV Questions? at discharge Jessica Adams, Pharm.D. C. ) Telepharmacy to allow overnight [email protected] coverage at rural (512) 426-6868 hospitals/clinics D. ) All of the above

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