30 Technology Pharmacy Practice News • March 2009 Remote Pharmacy Telepharmacy Continues To Take Hold

hen administrators at Saint Luke’s patient safety, explained Doug DeJong, the e-pharmacists handling an WHealth System, based in Kansas RPh, senior director of pharmacy at the average of more than 333 City, Mo., launched a telepharmacy pro- health system. medication orders gram this winter to provide overnight Before the launch of ePharmacy, over- and more than 20 pharmacy coverage to six of its medical night pharmacy coverage was provided phone calls per centers, they joined a growing num- by pharmacists at one of the Saint Luke’s shift. Feedback so ber of institutions across the country hospitals. “As patient volumes and far has been “very, using remote pharmacy systems in some patient acuity levels grew, the workload very positive,” Mr. capacity to provide continuous care. warranted dedicated resources for that DeJong said. Fueled in part by a mandate from facility, and we began to look at options “Within the the Joint Commission that pharmacists for the other campuses,” he said. “We metro area hos- prospectively review all medication also wanted to be able to start expand- pitals, the medi- orders and in part by an ever-increasing ing services to our facilities outside the cal staff has come shortage of pharmacists, telepharmacy metro area.” to expect 24/7 is “a trend that is becoming more and The health system already had a cen- coverage, and so it’s more of a practice,” said Anthea Francis, trally located remote intensive care unit seamless,” he added. “For RPh, director of the American Society (ICU), so Mr. DeJong hired a team of smaller hospitals in rural areas, they of Health-System Pharmacists (ASHP) pharmacists specifically for overnight really appreciate having someone to fill Section of Inpatient Care Practitioners. coverage and based them within the orders, check over prescriptions, etc. “I can’t imagine this is going away.” eICU, to piggyback on existing technol- Remote pharmacy services have been ogy and to provide neutrality so that crucial in maintaining or restoring phar- all six sites would be seen as equal- ‘For smaller hospitals in rural areas, they really appreciate macy services to rural areas, where health priority customers. care institutions may not be open 24 Within their system, physician orders having someone to fill orders, check over prescriptions, etc. hours or may have particular difficulties are scanned to the pharmacist on duty at They have a resource who’s really their resource.’ recruiting pharmacists, Ms. Francis said. the ePharmacy. That person reviews the Although ASHP does not maintain a orders and enters them into the com- —Doug DeJong, RPh list of all telepharmacy programs, the puter system, screening for potential boards of pharmacy in about 16 states, drug interactions and performing other including North Dakota, Alaska, Idaho, clinical activities as an on-site phar- They have a resource who’s really their Of those, 51 were retail pharmacies and Illinois, Montana, South Dakota, Texas, macist would. Entering the order into resource.” 21 were hospital pharmacies. Through Utah, Vermont and Wyoming, all have the computer system allows nurses to Mr. DeJong said the ePharmacy has the project, approximately 40,000 rural amended their laws within the past remove the medication from automated additional benefits. For one, it is cost- citizens saw pharmacy services restored, few years to allow remote pharmacy dispensing cabinets located at the indi- efficient. Outside labor, the expenses retained or established. For example, the services. vidual hospitals. The facilities also have were minimal—less than $3,500 per site town of Enderlin, located 90 minutes For Saint Luke’s, the decision to start an on-call pharmacist available should to put in a computer workstation, scan- outside Fargo, had no pharmacy services the “ePharmacy” was multifactorial, the need arise. ner and fax machine. In addition, the for about 18 years before telepharmacy, addressing staff needs, budgeting and- The service has been popular, with service adds a layer of safety by reducing Ms. Rathke said, so that patients had to potential medication errors. drive a minimum of 30 minutes each “If we tried to put a 24-hour pharma- way to get their medications. An ePharmacy Checklist cist in each location, it would be pro- “Communities like that are thrilled when they can have their services hink telepharmacy may be right for you? Ann Rathke, telepharmacy coor- hibitively expensive,” he said, but with Tdinator at North Dakota State University College of Pharmacy, Nursing and the members of a central team applying restored or maintained,” she noted. Allied Sciences, and Doug DeJong, RPh, senior director of pharmacy at Saint their skills to multiple locations, the In this network, patients take prescrip- Luke’s Health System in Kansas City, Mo., offer the following tips: overhead costs are spread across several tions to their local telepharmacy site and  Contact your local board of pharmacy to facilities. give it to a registered pharmacy tech- determine the rules regarding telepharmacy nician, who prepares the prescription in your state. The North Dakota Experience for dispensing by a licensed pharmacist  As early as possible, cooperate with state Another relatively low-cost telephar- at a distance. The pharmacist reviews agencies or partner with other organizations macy system—one deployed in North the patient’s medication profile for drug that also have an investment in increasing Dakota—has helped provide pharmacy interactions and other potential prob- pharmacy services in your area. services to thousands of rural citizens lems before examining digital pictures of  Try to standardize computer equipment and since 2002. The North Dakota Tele­ the completed prescription for accuracy software for all of your planned sites to ensure a smoother process or faster connectivity. It also helps to have a standard formulary. pharmacy Project, which is a collabo- via videoconferencing equipment. Once ration of the North Dakota State Uni- the pharmacist has approved the pre-  If you are planning to use telepharmacy for overnight or holiday coverage, set up a good communication system between your after-hours and regular phar- versity College of Pharmacy, Nursing pared prescription, the pharmacy tech- macists. At Saint Luke’s, the overnight pharmacists have created a communica- and Allied Sciences, the North Dako- nician brings the patient to a private tion tool to record any issues occurring during the night that require follow-up, ta Board of Pharmacy and the North consultation room for video counseling so regular pharmacists reporting for duty in the morning can take over. Dakota Pharmacists Association, came by the pharmacist on proper use of the Resources about when the state board of phar- medication. macy determined that 26 community “There is that real-time, face-to-face  North Dakota State University has a “how-to” guide for telepharmacy on its Web site: http://www.ndsu.edu/telepharmacy. pharmacies had closed in the 1990s and interaction between the pharmacist and 12 more were threatening to close, said the tech, and the pharmacist and the  Vendors that provide telepharmacy computer systems include ScriptPro (http://www.scriptpro.com), AmerisourceBergen (http://www.telepharmacys- Ann Rathke, telepharmacy coordinator patient,” Ms. Rathke said. olutions.com), CardinalHealth (www.cardinal.com), E-PharmPro Inc. (www. at the college. Most telepharmacies in the system epharmpro-inc.com), Envision Telepharmacy (www.envision-rx.com) and As of September 2008, 72 pharmacies are full-service sites with a complete Metabolyst Healthcare Solutions (www.metabolyst.com). were involved in the project, including inventory of prescription and nonpre- 24 at central sites and 48 at remote sites. scription drugs, although some, called Pharmacy Practice News • March 2009 Technology 31 Remote Pharmacy consultation sites, link with a nearby “There are so many different ways it Pro’s Central Workflow System pro- under the control of a pharmacist.” pharmacy and receive medication deliv- has proved useful.” grams in place can add telepharmacy eries. In the hospital models, registered For example, when the town of Adrian, sites for about $15,000 to $20,000, Mr. —Karen Blum pharmacy technicians prepare medica- Minn., where 40% of the citizens are Coughlin said, whereas new customers References tions, which are checked by a remote seniors, was faced with the loss of its may pay $50,000 to $75,000 to get the 1. Clifton GD, Byer H, Heaton K, Haberman pharmacist via audio and video com- only pharmacists, it found a technician basic servers in place. He added that DJ, Gill H. Provision of pharmacy services to underserved populations via remote dispens- puter links before being dispensed to a for a local pharmacy, signed up for the the prices include full technologic sup- ing and two-way videoconferencing. Am J patient. Some hospitals have the video company’s telepharmacy products and port, including planning, training and Health Syst Pharm. 2003;60:2577-2582. equipment on mobile carts, which can contracted with a regional drug chain setup and maintenance of the prod- 2. Meidl TM, Woller TW, Iglar AM, Brierton DG. be wheeled to the nurses’ stations or to provide pharmacist oversight. And ucts, which free pharmacists to focus Implementation of pharmacy services in a into patients’ rooms if necessary. at the University of Kansas, its systems on their specialty. telemedicine intensive care unit. Am J Health Syst Pharm. 2008;65:1464-1469. Costs for the participating pharma- are being used to allow pharmacists to “Telepharmacy is a lot more than a 3. Khan S, Snyder HW, Rathke AM, Scott DM, cies are relatively small, Ms. Rathke supervise technicians in the preparation videophone or a vending machine,” Mr. Peterson CD. Is there a successful business noted: a computer system and moni- of sterile compounded medications. Coughlin said. “It’s a systematic way of case for telepharmacy? Telemed J E Health. tor for about $2,000; a high-definition Pharmacies that already have Script- operating the remote dispensing process 2008;14:235-244. document imaging camera for about $1,200; a video conferencing system (they use Polycom), at about $11,000 per unit; and DSL or T-1 line charges of about $250 to $800 per month. Ms. Rathke said they also have firewalls to protect patient privacy and fulfill HIPAA regulations. Evidence That ePharmacy Works Published studies indicate that tele­ pharmacy programs are effective. A sur- vey of patients treated through a small telepharmacy program run by the Com- munity Health Association of Spokane, Wash., showed that more than 75% of patients seen at the remote sites were sat- isfied with their videoconference inter- actions with the pharmacist, and a high percentage of patients at both the base site (94%) and remote sites (63%) agreed that they would have difficulty affording their medications without this program.1 And a 2008 study from Aurora Health Care in Milwaukee demonstrated that implementing a remote ICU pharmacy service for its 13-hospital health system provided consistent pharmaceutical care for patients while minimizing costs.2 Telepharmacy also can be profitable. Ms. Rathke and colleagues assessed the financial operation of a single business unit, consisting of one central retail pharmacy and two remote retail tele­ pharmacies, by analyzing income state- ments and balance sheets for three con- secutive years (2002-2004). They found that despite some concern about the low rate of inventory turnover, the gross profit increased from $260,093 in 2002 to $502,262 in 2004.3 Pharmacists who do not want to build their own remote pharmacy system can turn to vendors such as Script- Pro or AmerisourceBergen (sidebar) and/or hire staffing agencies that pro- vide remote pharmacist oversight. According to Mike Coughlin, president and CEO of ScriptPro, the company now has some 5,000 customers world- wide, including the U.S. Navy and Vet- erans Administration. “Our concept is that the system should be part of the overall phar- macy work flow,” Mr. Coughlin said.