Innovate and Stretch Your Footprint in the Community: Telepharmacy

Home , Chronic care, Electronic health record, Pharmacotherapy, Telepharmacy

6/29/2018

#FSHP2018 Disclosure

Innovate and stretch your • I have no conflicts of interest related to this presentation footprint in the community: Telepharmacy

Leah Loeffler Pharm D, BCPS Clinical Hospital Pharmacist: Transitions of Care Jackson Memorial Hospital

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Objectives

• Define the definition of telehealth and telepharmacy Who is currently using telehealth in their • List the barriers and benefits of telepharmacy practice today? • Identify opportunities for expansion of the pharmacist role through telepharmacy • Describe the integration of telepharmacy into pharmacy practice • Review Federal and State pharmacy profession regulations regarding telepharmacy

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Introduction to Telehealth1,2 Key Terms1 • As many as 75 million telehealth encounters are expected in North America annually 1. Telemonitoring • Health Resources and Services Administration (HRSA) has projected a need for 3,060 additional primary care physicians (PCPs) in Florida 2. Store-and-forward (asynchronous) by 2025 3. Video conferencing (synchronous) • The vast majority of the United States population has a cellphone, 4. Distance (hub) site including 92% of adults with an income of < $30,000 a year • Over 97% of Floridians have access to wireline services and 100% have access 5. Originating site to high-speed mobile service 6. Interoperability • Telehealth is a reimbursable service in Medicaid programs in all but two states  Connecticut  Rhode Island #FSHP2018 #FSHP2018

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Technology Timeline3 What is Telehealth?1

1876 1928 • Definition: Alexander Television is 1972 1991 Graham Bell introduced in Ray World Wide  invents the the United Tomlinson Web Opens Telehealth is the use of electronic information and "telephone“ States Invents Email to Public telecommunication technologies to provide long-distance health care and education to patients • What:  Eligible technologies include: videoconferencing, store-and-

1879 1958 1974 1996 forward, remote patient monitoring, and telephone calls Thomas Bell Labs Vint Cerf, Email Edison Invents Robert Kahn Surpasses demonstrates Modem Coin Postal Mail • Why: the carbon 'Internet‘ filament light  Telehealth strategies are used to provide patient care services bulb and optimize outcomes #FSHP2018 #FSHP2018

What is telepharmacy?4 telepharmacy Services4 • Drug review and monitoring “The provision of pharmacist care by registered pharmacies and pharmacists located within U.S. jurisdictions through the • Dispensing use of telecommunications or other technologies to patients • Sterile and nonsterile compounding verification or their agents at distances that are located within U.S. • Medication therapy management (MTM) jurisdictions.” • Patient assessment • Patient counseling -Model State Pharmacy Act and Model Rules of the National Association of Boards of Pharmacy • Clinical consultation • Outcomes assessment • Drug information #FSHP2018 #FSHP2018

Patient : Barriers to Barriers to telepharmacy Patient telepharmacy1

Patient • Motivation to adhere to monitoring and telehealth visits • Ability to maintain and operate devices • Telephone and Internet access preferred • Insurance coverage or other means for Clinical Tele- reimbursement Pharma- health cist Team

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Telehealth Team: Barriers to Telehealth Clinical Pharmacist: Barriers to Clinical telepharmacy1,5 Team telepharmacy1,5 Pharmacist • Infrastructure to support telehealth services • Knowledge of the availability, features, and limitations of • Knowledge of the features and limitations of remote remote monitoring devices monitoring devices • An electronic health record (EHR) to transfer data and care • Ability to access monitoring data, manage alerts, and responsibilities among team members input plans into the EHR • Data sharing and trust agreements in place • Adherence to HIPAA regulations to ensure confidentiality of patient information • Adherence to HIPAA regulations to ensure confidentiality of patient information • Data sharing and trust agreements in place • Government restrictions on the use of telehealth in managed • Cost of equipment care #FSHP2018 #FSHP2018

1 Integration of telepharmacy Benefits of telepharmacy into Pharmacy Practice6

HCP Time

Decrease HCP Hospitaliza Resources Retail Ambulatory Inpatient -tions

Reduce Assist in Transporta ToC -tion Cost #FSHP2018

Opportunities in telepharmacy Integration of telepharmacy Programs1 into Pharmacy Practice1

• Anticoagulation • Comprehensive Medication Management • Diabetes • Medication Therapy Management • Hepatitis C • Transitions of Care • Hypertension • Physician-pharmacist collaborative practice

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Comprehensive Medication Comprehensive Medication Management1 Management1 Qualifications for practice do not change 1. Assessing the patient and evaluating medication therapy •Maintaining patient safety and privacy 2. Technology requirements for assessing the patient and  Private and secure area evaluating medication therapy  Patient must be made aware of technologists or assistants 3. Developing and implementing a plan of care  Lighting and camera placement 4. Technology requirements for developing and implementing a •Protecting the patient–pharmacist relationship plan of care •Enhancing communication and coordination of care 5. Follow-up Evaluation and Medication Monitoring  EHR and Health information exchange (HIE) 6. Technology requirements for follow-up evaluation  Secure e-mail, facsimile, instant messaging or text message 7. Documentation #FSHP2018 #FSHP2018

Medication Therapy 8 Management (MTM)7 Transitions of Care 1. An Interactive Contact (within 24-48 hours) MTM must be documented in consistently for • Telephone patients and billing purposes • Email • Face-to-face 1. Annual comprehensive medication review (CMR) 2. Certain Non-face-to-face Services • Provide education to the patient/caretaker to support self- • Interactive person-to-person visit management, independent living, and activities of daily living • Telehealth consultation • Assess and support treatment regimen adherence and medication 2. Quarterly targeted medication reviews (TMRs) management • Person-to-person (by phone) is acceptable • Identify available community and health resources • Assist the patient and/or family in accessing needed care and services

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Transitions of Care8

3. A face-to-face Visit • As of January 1, 2014; you may use CPT codes 99495 and 99496 for a telehealth service Objective To assess the effect of a telephone-based care-management strategy on medical costs and resource utilization Primary Outcome Cost of care and the use of hospital, emergency room, and outpatient services, as well as selected surgical procedures

Intervention The enhanced-support group received up to five outreach attempts versus three in the usual-support group • Supplemented with web links, video and print materials Results - Monthly pharmacy costs per person ($213.82 vs. $221.78, P = 0.05)10.1% - Reduction in annual hospital admissions (P<0.001) #FSHP2018 #FSHP2018

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Technology Infrastructure

Objective To evaluate an online disease management system supporting patients with uncontrolled type 2 diabetes Primary Outcome A1C was the primary outcome variable Intervention (1) wirelessly uploaded home glucometer readings with graphical feedback (2) comprehensive patient-specific diabetes summary status report (3) nutrition and exercise logs (4) insulin record (5) online messaging with the patient’s health team (6) nurse care manager and dietitian providing advice and medication management (7) personalized text and educational videos dispensed electronically by the care team Results - A1C at 6 months (−1.32% INT vs −0.66% UC; p<0.001) - A1C at 12 months (−1.14% INT vs −0.95% UC; p=0.133) #FSHP2018 #FSHP2018

Telehealth Services1,2 Costs and Compensation1,5

• Programs between health plan payers and • Reimbursable telehealth services medical/pharmacy services  Consultations  Kaiser Permanente  Office visits  Cigna  Pharmacologic management  Aetna • Asynchronous “store-and-forward visits” are not covered if • Systems that document interactions there is no direct patient contact  Teladoc • Medicaid less restrictive compared to Medicare  McKesson’s RelayHealth  State and site of service • Data exchange systems  Technology used  eHealthExchange  Distance between the patient’s home and provider’s location  Carequality #FSHP2018 #FSHP2018

Federal Regulation2,4,5 State Regulation2,4,5,12 • Centers for Medicare and Medicaid Services (CMS) Standards Florida composite grade for telehealth is a B for telepharmacy  Medicare has strict requirements: geographic location, care setting, • Florida Medicaid fee-for-service updated to a broader array and specific technological modalities of licensed health care practitioners and settings  Medicare Telehealth Parity Act • All health care practitioners providing care to Florida • Medicare Prescription Drug, Improvement, and Modernization residents using telehealth have to be licensed in Florida Act of 2003 • Mental/behavioral health and medication management are • Health Information Technology for Economic and Clinical the most covered services via telemedicine Health (HITECH) Act and the Health Information Exchange • The Agency provides governance for the statewide Heath (HIE) Information Exchange (HIE) program • FDA Standards #FSHP2018 #FSHP2018

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American Telemedicine Association (ATA)5,12 • The voice and primary authority about telehealth that actively works with Congress • State Telemedicine Gaps Analysis  Parity  Medicaid Service Coverage and Conditions of Payment  Innovative Payment or Service Delivery Models  Gaps

Thomas L, et al. American Telemedicine Association. 2017 #FSHP2018 #FSHP2018

Future of telepharmacy1,4,5 Telehealth Resources • Standardize telepharmacy practices • Education and training of participating pharmacists • Telehealth Resource Center • Professional degree and postgraduate training programs are • https://www.telehealthresourcecenter.org expected to incorporate telehealth into the curriculum • American Telemedicine Association • Adjust Medicare payment methods for federally-qualified • http://www.americantelemed.org health centers to facilitate the provision of chronic care • Requires membership coordination and remote monitoring • American Telemedicine Association (ATA) encourages state • HealthIT.gov lawmakers to accommodate interstate care • https://www.healthit.gov • Extend the availability, capacity, and quality of broadband infrastructure #FSHP2018 #FSHP2018

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References #FSHP2018 1. Badowaski ME, Walker S, Bacchus S, et al. Providing comprehensive medication management in telehealth. Pharmacotherapy. 2018 Feb;38(2):e7- e16 2. Senior JM, Phillip C, Bertha E et al. Expanding florida’s use and accessibility of telehealth. Telehealth Advisory Council.. 2017 Oct. https://ahca.myflorida.com/SCHS/telehealth/docs/TAC_Report.pdf. Accessed May 20, 2018 Innovate and stretch your 3. Internet Hall of Fame. Timeline. 2018 Available from https://www.internethalloffame.org/internet-history/timeline. Accessed April 22, 2018. 4. Alexander E, Butler CD, Darr A, et al. ASHP statement on telepharmacy. Am J of Health-Sys Pharm. 2017 May; , 74 (9): e236-e241 5. American Telemedicine Association. Federal Policy. 2018. Available from http://www.americantelemed.org/policy-page/federal-policy. Accessed May15, 2018. footprint in the community: 6. Kosowsky J. The potential for telehealth within the pharmacy space. Pharmacy Times. 2015 Aug. https://www.pharmacytimes.com/publications/directions-in-pharmacy/2015/august2015/the-potential-for-telehealth-within-the-pharmacy-space. Accessed March 12, 2018. telepharmacy 7. American Pharmacists Association (APhA). Medication therapy management digest: Perspectives on 2009: A Year of Changing Opportunities. Available at www.pharmacist.com/ sites/default/files/files/mtm_2010_digest_2.pdf. Accessed October 12, 2016. 8. Deoartment of Health and Human Services Centers for Medicare & Medicaid Services. Transitional management care services. 2016 Dec. Available fromhttps://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Transitional-Care-Management- Services-Fact-Sheet-ICN908628.pdf. Accessed April 22, 2018. Leah Loeffler Pharm D, BCPS 9. Wennberg DE, Marr A, Lang L, et al. A Randomized Trial of a Telephone Care-Management Strategy. N Engl J Med 2010;363:1245-55. 10. Tang PC, Overhage JM, Chan AS, et al. Online disease management of diabetes: Engaging and Motivating Patients Online With Enhanced Clinical Hospital Pharmacist: Transitions of Care Resources-Diabetes (EMPOWER-D), a randomized controlled trial. J Am Med Inform Assoc. 2013; 20(3):526-534. Jackson Memorial Hospital 11. Centers for Disease Control and Prevention (CDC). State law fact sheet. Select features of state pharmacist collaborative practice laws. 2013 Dec. Available from www.cdc.gov/ dhdsp/pubs/docs/Pharmacist_State_Law.PDF. Accessed May 20, 2018. 12. Thomas L, Capistrant G. State telemedicine gaps analysis coverage & reimbursement. 2017 Feb. Available from www.americantele med.org/policy- page/state-policy-resource-center. Accessed May 20, 2018. 13. Tang PC, Overhage JM, Chan AS, et al. Online disease management of diabetes: Engaging and Motivating Patients Online With Enhanced Resources-Diabetes (EMPOWER-D), a randomized controlled trial . J Am Med Inform Assoc. 2013;20:526–534