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Implementation of a telepharmacy service to provide round-the-clock order review by Douglas S. Wakefield, Marcia M. Ward, Jean L. Loes, John O’Brien, and Leevon Sperry ffective execution of all aspects of the medication-use process, Purpose. The implementation of a tele­ the selects the appropriate Eincluding prescribing, dispens- service to provide round-the- medication to dispense from the CAH’s ing, and administration, is necessary clock medication order review by pharma­ . If the medication order is not to ensure high-quality, safe medica- cists is described. made using the CPOE system, the order tion practices. Many regulatory, ad- Summary. Seven critical access is scanned into a document and sent via (CAHs) worked collaboratively as part e-mail to remote pharmacists. The pharma­ visory, and purchasing groups have of a network of hospitals implementing cist enters the necessary information into established numerous requirements the same electronic record (EHR), the EHR and pharmacy . and recommendations for improving computerized prescriber-order-entry The medication order review process from medication safety.1-3 Chief among (CPOE) system, and pharmacy information this point forward is identical to that used these is the need for pharmacist system to serve as the health information for ordered via CPOE. The new review of medication orders before technology (HIT) backbone supporting medication order is then entered into the medications are dispensed and ad- round-the-clock medication order review EHR, and the CAH nurse can proceed with by pharmacists. Collaboration permitted the order. ministered to . standardization of workflow policies and Conclusion. The implementation of a Approximately half of all medica- procedures. Through the HIT backbone, telepharmacy model in a multihospital tion errors occur in the prescribing both onsite and remote pharmacists were increased access to pharma­ stage of the medication-use process given access to the medication orders, the cy services, allowing for round-the-clock and may be attributed to the pre- pharmacy information system, and other medication order review by pharmacists. scriber’s lack of knowledge of a drug, -specific clinical data in patients’ the prescriber’s failure to adhere to EHRs. Orders are typically reviewed within Index terms: Computers; Hours; Medica­ 60 minutes of when they are entered into tion orders; Pharmaceutical services; Phar­ accepted practices and procedures, or the system. The reviewing pharmacists macists, ; Pharmacy, institutional, general slips and memory lapses dur- have remote access to the EHRs in each hospital; Telepharmacy ing the ordering process.4 Pharmacist CAH. After completing the clinical review, Am J Health-Syst Pharm. 2010; 67:2052-7 review of medication orders reduces

Douglas S. Wakefield, Ph.D., is Professor, Depart- Address correspondence to Dr. Wakefield at the Center for Health ment of Health Management and Informatics, the Care Quality, University of Missouri, CE548, Clinical Support and University of Missouri Informatics Institute, and Building, DC375.00, One Hospital Drive, Columbia, MO Director, Center for Quality, University of Missouri, 65212 ([email protected]). Columbia. Marcia M. Ward, M.A., Ph.D., is Professor and Associ- Supported in part by Agency for Healthcare and Quality ate Head, Department of Health Management and Policy, College grant UC1HS016156, the University of Center for of , University of Iowa, Iowa City. Jean L. Loes, M.S., and Research, and the University of Missouri Center for Health Care RN, is Network Clinical Information Analyst, Clinical Practice and Quality. Informatics, Mercy Medical Center—North Iowa, Mason City. John The authors have declared no potential conflicts of interest. O’Brien, M.B.A.; at the time of writing he was Chief Executive Of- ficer, Ellsworth Municipal Hospital, Iowa Falls, IA. Leevon Sperry, Copyright © 2010, American Society of Health-System Pharma- B.S., is Graduate Research Assistant, Center for , cists, Inc. All rights reserved. 1079-2082/10/1201-2052$06.00. University of Missouri. DOI 10.2146/ajhp090643

2052 Am J Health-Syst Pharm—Vol 67 Dec 1, 2010 case study Telepharmacy service prescribing errors, as the pharmacist attention directed toward the use of and implementation. This article screens the orders for incorrectly health information technology (HIT) describes the creation of a HIT-based prescribed medications (e.g., wrong to review medication orders when no process for obtaining round-the- drug, wrong dose, wrong frequen- onsite pharmacists are available. clock pharmacist review of medica- cy), interactions, and contraindica- A number of telepharmacy mod- tion orders in seven CAHs and a large tions.5-7 The potential advantages els have been implemented by rural hospital. These hospitals col- of medication order review in acute rural hospitals, the most common laborated in implementing the same care facilities have been previously of which is a “hub and spoke” EHR, computerized prescriber-order- discussed in-depth.2,3,8-12 system.11-27 The hub is the entity entry (CPOE) system, and pharmacy responsible for supplying the rural information system to serve as the Problem hospital with round-the-clock phar- HIT backbone supporting round- Despite the recommendations macist medication review. A hub is the-clock prospective medication and evidence of the benefits, very few usually a larger hospital that either order review by pharmacists. rural hospitals have sufficient phar- has contracted with the rural hos- macist coverage to ensure adequate pital or is a part of the same health Analysis and resolution prospective pharmacist review of system, though the use of outsourc- Mercy Health Network—North medication orders. A 2008 study ing to a telepharmacy organization Iowa serves 14 counties in north found that almost half (48%) of 410 has also been documented. The rural central Iowa with a combined popu- small rural hospitals had pharmacists hospital, through the use of informa- lation of over 200,000. This network onsite fewer than five hours per week, tion technology, sends orders to the comprises Mercy Medical Center— and the lack of pharmacist coverage hub pharmacy for review when its North Iowa (MMC-NI), eight CAHs was magnified on nights and week- own pharmacist is unavailable. The contract-managed by MMC-NI, ends, where approximately 90% of level of technology associated with and one CAH owned by MMC-NI. hospitals reported that nurses were a telepharmacy model may vary, MMC-NI’s contract management responsible for dispensing and ad- ranging from communication via activities principally include recruit- ministering the medications.13 With fax to two-way video conferenc- ing and hiring for key leadership such limited pharmacist availability, ing. Evidence of the effectiveness of positions in the CAHs and providing most rural hospitals do not use pro- telepharmacy systems in decreasing selected management services. Each spective medication order review. the rate of medication errors at rural CAH is its own legal entity with an Only 20% of rural hospitals review hospitals is sparse, but initial research independent governing board and orders before the medication is dis- suggests that telepharmacy systems separate medical staff bylaws and is pensed, and only about half review have been generally well received by organized as an independent hospi- orders within 24 hours after medica- patients and staff.12,18,24,25,27 tal with its own clinical services and tion administration.5,13 Other barri- There is also growing interest by support departments (e.g., , ers to pharmacist review of medica- rural and critical access hospitals pharmacy, , billing). The tion orders in rural hospitals include (CAHs) to implement HIT-based majority of cost and lack of patient volume to solutions that allow the reviewing practicing in the seven CAHs studied support a full-time pharmacist.6 pharmacist, regardless of location, to are also affiliated with the primary have real-time access to the patients’ care practice network managed by Background electronic health records (EHRs) and MMC-NI. The dominant referral Small rural hospitals have devel- the hospital’s pharmacy information pattern is between primary care oped a number of ways to increase and ordering systems. However, high providers practicing in the network pharmacist availability through loan purchase and implementation costs, CAHs and medical and surgical spe- forgiveness and rural training pro- limited local expertise in imple- cialists working at MMC-NI. grams, as well as through contracting menting HIT, a need for significant At the time of initiating this proj- with community pharmacists or shar- process redesign to take advantage ect (2007), all CAHs had 25 or fewer ing a pharmacist with another health of potential HIT functionality, and beds; one CAH included care institution.13-15 Despite these the limited number of pharmacists a 10-bed psychiatric unit, and two and other efforts, onsite availability make this approach particularly chal- CAHs had attached nursing homes. of pharmacists to routinely provide lenging. The shortage of pharmacists Annual CAH inpatient admissions medication order reviews before med- in rural hospitals and CAHs is par- ranged between 350 and 1,795, and ication administration to patients is ticularly problematic because of the all but two offered obstetric services. usually limited to a few hours per day. reduced opportunity for pharmacist Each CAH maintained an active As a result, there has been increasing input in HIT system workflow design outpatient department, with an-

Am J Health-Syst Pharm—Vol 67 Dec 1, 2010 2053 case study Telepharmacy service nual visits averaging 16,000–60,600. The pharmacy technicians predomi- Service implementation. Ide- The number of visits to the hospi- nantly assisted the pharmacists with ally, medication order review occurs tals’ emergency departments (EDs) medication dispensing and billing before a medication is administered. ranged from 2,200 to 6,600 annually. for medications administered to To optimize both quality and safety, The total number of surgical pro- patients. As a large rural referral hos- order review should occur soon after cedures performed in these CAHs pital, MMC-NI already had round- medications are ordered. Medication ranged from 450 to 1,280 annu- the-clock inhouse pharmacist staff- orders needing review include initial ally. The total number of full-time- ing and medication-order-review medication orders, orders resulting equivalents ranged from 92 to 180. capability. in changes to existing orders, discon- In contrast, MMC-NI, as a large rural HIT implementation. MMC-NI, tinued orders, and orders resulting referral hospital, had 241 staffed beds a member of Trinity Health (Novi, from changes in patient care status, and provided approximately 13,000 MI), implemented its EHR and which are handled in a special way inpatient admissions, 450,000 out- CPOE systems in July 2005.28 Build- in CAHs and rural hospitals. In patient visits, 29,000 ED visits, and ing on a tradition of collaboration particular, CAHs and rural hospitals 7,000 surgical operations annually. centered around improving patient under the program can use Combined, the MMC-NI network care and administrative processes, the same inpatient beds to provide had over 18,000 inpatient admis- planning began in 2006 for a re- acute inpatient care and skilled nurs- sions, 53,000 ED visits, and 670,000 gional implementation of the same ing care. By using these designated outpatient visits. CAH outpatient EHR, CPOE system, and pharmacy “swing beds,” there can be a smooth- gross revenues ranged from $11.3 information system from the same er transition to skilled nursing care million to $21.6 million, accounting vendor. In addition to the benefit of without physically moving the pa- for 60–82% of total gross revenues. sharing clinical data for patients seen tients. Rural facilities benefit from CAH total net revenues ranged from in more than one network facility, greater utilization of the facility as $11 million to $21.6 million. The cost this collaborative network approach well as from an additional payment of charity care ranged from $57,000 yielded major advantages, including received for the skilled nursing care. to $153,000. In contrast, MMC-NI’s (1) sharing clinical, HIT, and admin- However, Medicare requires that total net revenue was about $300 istrative expertise of the larger rural patients be discharged from the acute million, about 26 times that of the referral hospital across the CAHs, (2) care bed and admitted to the swing smallest network CAH. Combined use of similar HIT readiness assess- bed. Even though patients remain in total network revenues exceeded ment, workflow policies and rede- the same nursing unit and bed, the $415 million. sign, planning, implementation and discharge and admission processes Pharmacist coverage. Before the postimplementation maintenance require discontinuing existing medi- system changes described herein, the processes to reduce the amount of cations associated with the acute care CAHs used a variety of approaches to trial-and-error learning, and (3) stay and initiating new orders written provide pharmacy coverage, includ- increased economies of scale from as part of the admission to the swing ing two full-time MMC-NI pharma- group purchasing opportunities. bed. cists shared among multiple CAHs, All seven CAHs implemented the Because of the limited onsite one full-time MMC-NI pharmacist, EHR, CPOE, and pharmacy informa- pharmacy coverage, implementing and three community-pharmacy tion systems during the summer of round-the-clock pharmacist review pharmacists providing part-time 2008 using a strategy similar to that of medication orders was achieved service to different CAHs. Onsite used by MMC-NI28 to bring the HIT by partnering with remotely lo- pharmacist coverage was provided components online at approximately cated pharmacists. Through the 15–40 hours per week (mean, 24 the same time. Three CAHs imple- HIT backbone, both onsite and hours), with only one CAH regularly mented the systems in July 2008, and remote pharmacists were given scheduling onsite pharmacist cover- the other four CAHs implemented access to medication orders, the age for any portion of the weekend. them in September 2008. During pharmacy information system, and Although two CAHs did not have the preimplementation, “go-live,” other patient-specific clinical data in support, the and postimplementation stages, patients’ EHRs. Pharmacists’ ability other five did, and these techni- MMC-NI provided a significant to verify orders for various medica- cians worked 24–70 hours per week. amount of leadership, consultation, tions was facilitated by the develop- Pharmacists were responsible for and planning and educational sup- ment of a standardized formulary, verifying provider orders, dispensing port. The resulting HIT-enabled accessible through the pharmacy medications, and providing general changes in medication order review information system. Development of oversight of pharmacy operations. in the CAHs are discussed below. the shared formulary by the CAHs

2054 Am J Health-Syst Pharm—Vol 67 Dec 1, 2010 case study Telepharmacy service was discussed in-depth elsewhere.29 Messages are sent without leaving the has an associated National Drug After implementation of the EHR internal network to which the CAHs Code (NDC). These NDCs, embed- and CPOE systems, the pharmacists and MMC-Dubuque belong and ded in bar codes, are used for the employed locally by the CAHs con- therefore do not require Privilege subsequent dispensing and bar-code- tinued to provide initial medication Management Infrastructure encryp- assisted medication administration order reviews during their usual tion. Security is managed through (BCMA) processes. An advantage for scheduled work hours. In order to role-based access to patient informa- the reviewing pharmacists is the use provide this service round-the-clock, tion, which ensures Health of the same EHR, CPOE system, and the CAHs issued a request for pro- Portability and Accountability Act pharmacy information system plat- posal to potential institutions who compliance. This is the same system forms and the same formulary across could offer telepharmacy services. Six used for all other health information all facilities. bidders responded, and the successful applications, in which the degree of Order volume and costs. Initially, bidder was Mercy Medical Center— access is determined by security posi- the CAHs estimated the expected an- Dubuque (MMC-Dubuque). tion as well as authorization by the nual volume of remote medication MMC-Dubuque, like MMC-NI, is administrator of the group e-mail order reviews to range from 2,834 a member of Trinity Health and has account. Users have their own unique (about 9% of all medication orders) the same EHR, CPOE system, and usernames and passwords, and sites to 10,076 (33% of all medication pharmacy information system. As have methods of system orders). Experience to date suggests of 2008, MMC-Dubuque has been usage. A dedicated computer screen that these estimates were too low. For providing remote medication order at MMC-Dubuque is used to sepa- example, the CAH that estimated a review for the seven CAHs affiliated rately process all off-site medication total of 10,076 annual order reviews with MMC-NI. Currently, all after- order reviews. Pharmacists access had 15,634 orders reviewed remotely hours, weekend, and holiday reviews their e-mail, noting the sending site’s through the first eight months of the of first medication orders for acute name and the phone number of year. The average number of orders care CAH inpatients (i.e., inpatients the nurses’ station. If the priority of reviewed monthly was 1,954, almost on the medical, surgical, , the order is stat, the e-mail subject half of all medication orders being and behavioral health units) are done begins with “stat.” Pharmacists open reviewed in that CAH. remotely. the e-mail, which contains the order Currently, the CAHs pay $4 per Medication order review. Or- as an attachment in portable digital medication order reviewed via this ders entered by the provider are format and process the order in the HIT-based system. For example, in automatically received by the remote pharmacy information system with- the case of a patient for whom there pharmacy during its hours of cover- out the need to print the order. Each is just 1 order for 1 new medication, age through the integrated pharmacy order is then stored in site-specific the charge is $4. Alternatively, for a information system (PharmNet, folders where network pharmacists patient with 10 different medication Corporation). The process may review the orders when they orders who is discharged from acute for written medication orders is to return to work. The scanned orders care status and admitted to skilled have only pharmacists enter those remain in electronic storage and are nursing care status, every order to orders into the system. This has been deleted after seven days. discontinue and every order to start accomplished by an innovative, elec- Orders are typically reviewed a medication is reviewed, generating tronic method that eliminates the within 60 minutes of their entry into a total charge of $80 (10 discontinu- need to generate a paper copy for the the system. The reviewing pharma- ation orders × $4 and 10 admission pharmacist. In the e-mail program cists have remote access to the EHRs orders as a swing bed patient × $4). used by Trinity Health, a group e- in each CAH in order to review the While it is in the CAHs’ financial in- mail account was created and is ac- patients’ laboratory test results and terest to have changes in care level oc- cessible to all regional pharmacists other clinical data. If additional in- cur during weekdays when their local and pharmacists employed by the formation is needed, they can call pharmacists are available to review contracted pharmacy. Each network the prescribing or CAH the orders, such transfers frequently site has at least one scanner that can nurses. After completing the clinical happen outside these hours, on scan either stat or regular orders to review, the pharmacist selects the weekends, and holidays. As expected, the group e-mail account. Nurses appropriate medication to dispense the volume of and costs for medica- scan written and signed orders, select from the CAH’s formulary.29 Each tion orders reviewed remotely varies the priority of the order, and send formulary item is represented by widely among the seven CAHs, from the order as an e-mail message to the a unique stock-keeping unit (i.e., approximately 700 orders ($2,800) to remote pharmacy e-mail account. specific drug, dose route, dose) and over 2300 orders ($9,200) per month.

Am J Health-Syst Pharm—Vol 67 Dec 1, 2010 2055 case study Telepharmacy service

Because the CAHs are reimbursed across all hospitals, development of about having the same charge ap- by Medicare on a cost-plus basis, the policies and procedures requiring plied to all orders, particularly for additional costs for the pharmacists’ pharmacist review of first medica- transitions in level of care, for which reviews for Medicare patients are tion orders (except in emergencies), there may be no changes made to the directly reimbursable. The CAHs’ and use of the same equipment actual orders. However, even when cost-plus reimbursement model al- and software to support automated orders are rewritten without any lowed them to receive significant dispensing and BCMA devices. changes, pharmacist review plays a funding to cover portions of the costs Further, before implementation of key role in supporting medication associated with purchasing computer round-the-clock order review, most reconciliation requirements, as well hardware and software. This financial pharmacists working in the local as providing an important check for advantage available to CAHs is not hospitals had not previously met or potential transcribing errors. available to larger hospitals receiving worked with each other. In order to One final concern is that because diagnosis-related group case-based have a seamless review process, it was different remotely located pharma- reimbursements. essential that these pharmacists work cists review the orders, the opportu- To gain a better idea of the value together not only to standardize the nity for these pharmacists to develop added by the pharmacists’ reviews, formulary but to help develop the close working relationships with the the types of actions taken as a result review process to ensure consistency physicians located in the CAHs is re- of these reviews were evaluated be- between local and remote pharma- duced. This potential negative effect tween February–April, 2009. These cists’ reviews. is easily outweighed by the advan- included a total of 9163 orders that With few exceptions, remote tages associated with having round- were approved, 2226 new orders, pharmacist review of medication the-clock pharmacist order review. 1294 modified orders, 972 discon- orders has been well received and One option to address this concern is tinued orders, and 179 orders void- is perceived to improve the quality to have the remote pharmacists visit ed by the reviewing pharmacists. and safety of patient care. Interviews the CAHs and meet the medical staff Overall, about 58% of the total re- with all of the CAHs’ chief nurses and nurses with whom they will be views were conducted by the remote and pharmacy directors revealed that communicating. pharmacists. physician response to the process has The successful implementation been positive. The potential to talk of a HIT-enabled process that sup- Discussion with a pharmacist, regardless of the ports round-the-clock pharmacist The CAHs affiliated with MMC-NI time of day or day of the week, was medication order review is a major have gone from very limited to also viewed as very positive. step forward in the CAHs’ efforts to round-the-clock pharmacist order One concern raised in one CAH create safer and more-reliable medi- review coverage in all but one hos- was the occasional delay in obtain- cation processes. Combined with the pital, with that one lacking coverage ing the remote pharmacists’ reviews. introduction of automatic dispens- for only one hour per week. This has Such delays may be a result of how ing units and BCMA, the CAHs suc- been accomplished by the direct use a medication order is sent from a cessfully implemented a closed-loop of HIT to connect remotely located particular CAH or a specific prob- medication process. Critical to this pharmacists in near real time, gen- lem with receiving orders from that success was the shared vision for erally within 60 minutes, to when a CAH. If there is a delay or an imme- improving patient care quality and medication order is entered. diate need to dispense medication, safety, combined with the collab- Critical to the success in estab- the CAH staff still has the ability to orative approach used to incorporate lishing round-the-clock pharma- dispense and administer the medi- knowledge and skills from the larger cist review of medication orders cations without the pharmacist’s rural referral hospital into their own were several key decisions made by review. Another concern was that facilities and patient care processes. each hospital’s executive leadership some nurses who previously acted This partnership approach allowed toward standardizing medication- immediately on a physician’s medica- for the sharing of expertise and de- related policies and practices. The tion order were frustrated that they velopment costs, making this impor- results of these decisions included now had to wait for the pharmacist’s tant transition less expensive, both in standardization of the formulary review before giving the patient the direct dollar costs and staff time. The system across all hospitals involved, prescribed medication. shared bid process covering several creation of a regional pharmacy and Although CAHs can pass the CAHs and using the same informa- therapeutics committee to oversee incremental costs of remote pharma- tion technology infrastructure to link future formulary changes,29 use of cist review on to third-party payers, remote pharmacists to the hospitals the same clinical software systems concern was raised by the CAHs resulted in multiple bidders. While it

2056 Am J Health-Syst Pharm—Vol 67 Dec 1, 2010 case study Telepharmacy service is not possible to estimate a specific 2. National Quality Forum. Safe practices 16. Gulliford SM, Schneider JK, Jorgenson for better healthcare: a consensus report. JA. Using telemedicine technology for economy-of-scale effect, this may Summary. www.ahrq.gov/qual/nqfpract. pharmaceutical services to ambulatory have had a positive effect on both the htm (accessed 2009 Mar 28). care patients. Am J Health-Syst Pharm. number of bidders and bid prices. 3. Leapfrog Group. The Leapfrog safe- 1998; 55:1512-5. ty practices. www.leapfroggroup.org/ 17. Bynum A, Hopkins D, Thomas A et al. The study hospitals clearly demon- for_hospitals/leapfrog_hospital_survey_ The effect of telepharmacy counsel- strated the potential for HIT solu- copy/leapfrog_safety_practices (accessed ing on metered-dose inhaler technique tions to address both work force and 2009 Mar 28). among adolescents with asthma in rural 4. Leape LL, Bates DW, Cullen DJ et al. Arkansas. Telemed J E Health. 2001; 7: distance challenges faced by rural Systems analysis of adverse drug events. 207-17. hospitals. JAMA. 1995; 274:35-43. 18. Lordan D, Vorhees N, Richards C. Tele­ In the case of the CAHs affili- 5. Coburn AF, Wakefield M, Casey M et pharmacy offers hope for rural hospitals. al. Assuring rural hospital patient safe- National pharmacist shortage prompts ated with MMC-NI, local and remote ty: what should be the priorities? J Rural innovative approach to hospital-based pharmacist order review resulted in Health. 2004; 20:314-26. services in Washington state. Telemed pharmacists taking actions beyond 6. Casey MM, Moscovice IS, Davidson Today. 2002; 9:13-5. G. Pharmacist staffing, technology use, 19. Pickette S, Sodorff M, Lordan D. In- order review and approval (e.g., and implementation of medication tegrated telepharmacy network offers order modification or discontinua- safety practices in rural hospitals. J Rural hope to rural hospitals dealing with tion) for approximately one third of Health. 2006; 22:321-30. critical pharmacist shortage. Adv Pharm. 7. Casey MM, Moscovice I, Davidson 2002; 1:15-27. the medication orders. However, this G. Pharmacist staffing and the use 20. Clifton GD, Byer H, Heaton K et al. Pro- information does not allow for the of technology in small rural hospi- vision of pharmacy services to under- exact measurement of the number tals: implications for medication safety. served populations via remote dispens- www.uppermidwestrhrc.org/pdf/ ing and two-way videoconferencing. Am of prescribing errors prevented or medication_safety.pdf (accessed 2008 J Health-Syst Pharm. 2003; 60:2577-82. near misses identified as a result of Nov 30). 21. Peterson CD, Anderson HC. The North the pharmacist order reviews. In ad- 8. Brown JN, Barnes CL, Beasley B et al. Dakota telepharmacy project: restoring Effect of pharmacists on medication er- and retaining pharmacy services in rural dition, we could not document how rors in an . Am J communities. J Pharm Tech. 2004; 20:28- the pharmacists’ reviews may have Health-Syst Pharm. 2008; 65:330-3. 39. improved the quality of the prescrib- 9. American Society of Health-System 22. Woodall SC. Remote order entry and Pharmacists. ASHP guidelines on pre- video verification: reducing after-hours ing physicians’ decisions related to venting medication errors in hospitals. medication errors in a rural hospital. Jt medication type, dosage, frequency, Am J Health-Syst Pharm. 1993; 50:305-14. Comm J Qual Patient Saf. 2004; 30:442-7. or route of administration. However, 10. Joint Commission. Accredita- 23. Bingham FG, Quigley CJ, Collinc LA. An tion program: critical access hospital. off-site distribution system designed to the number of medication orders www.jointcommission.org/NR/ expand service into underserved areas: a being reviewed and the frequency rdonlyres/E6FF3F84-280A-48DB-AA67- case study. Bus Rev. 2005; 4:129-35. with which pharmacists took actions B9CE7CA693FE/0/July2010NPSGs_ 24. Kimber MB, Peterson GM. Telephar- Scoring_CAH2.pdf (accessed 2010 Aug 26). macy—enabling technology to provide beyond just reviewing the orders in 11. Keys CA, Dandurand K, Harris J et al. quality pharmacy services in rural and this case study suggest that pharma- Providing nighttime pharmaceutical ser- remote communities. J Pharm Pract Res. cist review of medication orders is an vices through telepharmacy. Am J Health- 2006; 36:128-33. Syst Pharm. 2002; 59:716-21. 25. Winterstein AG, Hartzema AG, Johns TE important value-added service. 12. Stratton TP, Worley MM, Schmidt M et et al. Medication safety infrastructure in al. Implementing after-hours pharmacy critical-access hospitals in Florida. Am J Conclusion coverage for critical access hospitals in Health-Syst Pharm. 2006; 63:442-50. northeast Minnesota. Am J Health-Syst 26. Rose JL. Improved and expanded The implementation of a teleph- Pharm. 2008; 65:1727-34. pharmacy care in rural through armacy model in a multihospital 13. Cochran G, Jones K, Xu L et al. Preva- telepharmacy and alternative methods health system increased access to lence of evidence-based safe medica- demonstration project. Int J Circumpolar tion practices in small rural hospi- Health. 2007; 66(suppl 1):14-22. pharmacy services, allowing for tals. www.unmc.edu/ruprihealth/Pubs/ 27. Lam AY, Rose D. Telepharmacy services round-the-clock medication order IssueBrief2008-1.pdf (accessed 2008 Dec 9). in an urban community health sys- review by pharmacists. 14. Daniels ZM, Vanleit BJ, Skipper BJ et al. tem. J Am Pharm Assoc. 2009; 49:652-9. Factors in recruiting and retaining health 28. Crandall D, Brokel J, Schwichtenberg T professionals for rural practice. J Rural et al. Redesigning care delivery through References Health. 2007; 23:62-71. health IT implementation: exploring 1. Joint Commission. Accreditation pro- 15. Casey M, Elias W, Knudson A et al. Imple- Trinity Health’s IT model. J Healthc Inf gram: hospital. National mentation of telepharmacy in rural hos- Manag. 2007; 21:41-8. goals. www.jointcommission.org/NR/ pitals: potential for improving medica- 29. Wakefield DS, Ward MM, Loes JL et al. rdonlyres/31666E86-E7F4-423E-9BE8- tion safety. www.uppermidwestrhrc.org/ Creating a shared formulary in 7 critical F05BD1CB0AA8/0/HAP_NPSG.pdf pdf/report_telepharmacy.pdf (accessed access hospitals. J . 2010; (accessed 2009 Mar 28). 2009 Oct 12). 26:283-93.

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