Fred Gebhart

COVID-19 has flooded media headlines and health care practices for the past year, but diabetes has not taken a pandemic holiday. Professional groups continue to publish and update practice guidelines and the FDA continues to work on new diabetes drug applications. During a virtual session titled 

New and Approved: Your Annual Diabetes Update

 at the American Pharmacists Association Annual Meeting and Exposition, which was held March 12-15, Jennifer D. Smith, PharmD, BCACP, BC-ADM, CDCES, a clinical pharmacy specialist for the US Department of Veterans Affairs, provided an update on treatment advances in the type 2 diabetes (T2D) space.

The FDA has approved continuous glucose monitoring (CGM) for ambulatory care, but pandemic pressures are spurring the use of CGM in all practice settings, especially inpatient.

“You are going to see more CGM in the hospital setting,” said Smith during her presentation.

The FDA has not approved CGM for inpatient use, Smith noted. But a growing number of institutions are using CGM to reduce patient contact and consumption of personal protective equipment during the pandemic. As health system practices and procedures increasingly promote CGM, pharmacists should remember that CGM is not appropriate for intensive care or other critically ill patients, Smith said. All CGM use should be supervised to ensure that appropriate adjustments to insulin doses can be made in a timely manner.

 The American Diabetes Association (ADA) guideline goal for CGM is to maintain patients within their target glucose range at least 70% of the time, she noted.

 It is also important to individualize glucose targets, according to Smith. The ADA’s global glycated hemoglobin (A1C) target is less than 7%. New 2021 guidelines target from less than 7% to less than 7.5% for healthy adults aged 55 years or older. Patients with complex cases might do better with an A1C target of less than 8%. However, in very complex cases, targeting A1C goals may not be helpful. 

“Instead, let’s keep our patients comfortable and avoid glycemic extremes,” Smith said. “The goal is to avoid all hypoglycemia and any symptomatic hyperglycemia.”

The Kidney Disease: Improving Global Outcomes Diabetes Work Group issued its first-ever practice guidelines for diabetes management in chronic kidney disease (CKD) in late 2020.

Angiotensin-converting enzyme inhibitor (ACEi) or angiotensin II receptor blockade treatment should be initiated for patients with diabetes, hypertension, and albuminuria. Titrate medications to the highest tolerated dose.

A1C is the appropriate measure of glycemic control, but A1C accuracy and precision declines with advanced CKD, in dialysis, or when using erythropoietin-stimulating agents. Individualize A1C targets from less 6.5% to less 8.0% based on comorbidities. A glucose management indicator derived from CGM may be useful for glycemic assessment, especially in patients for whom A1C is not accurate because of declining kidney function, dialysis, or other treatment factors.

Metformin plus a sodium-glucose cotransporter 2 inhibitor (SGLT2i) can be used as a first-line treatment for T2D in CKD. Avoid SGLT2i treatment if the patient has an estimated glomerular filtration rate (eGFR) below 30 mL/min/1.73m2 and stop SGLT2i in dialysis. The preferred agents for patients with a low eGFR are a dipeptidyl peptidase 4 inhibitor, insulin, or a thiazolidinedione. The preferred add-on agent for all patients is a long acting glucagon-like peptide-1 (GLP-1) receptor agonist.

The ADA takes a different approach. For patients with CKD and no albuminuria, the ADA recommends a GLP-1 receptor agonist or SGLT2i with proven cardiovascular disease benefit. For patients with CKD and albuminuria, use a SGLT2i with a documented reduction in CKD progression. For patients who cannot use a SGLT2i, a GLP-1 receptor agonist is acceptable.

 The American Association of Endocrinology (AACE) and the American College of Endocrinology (ACE) published a new algorithm for the comprehensive management of dyslipidemia and prevention of cardiovascular disease in late 2020. Lifestyle changes remain the primary management tool, but treatment recommendations have been updated since AACE/ACE last addressed dyslipidemia in 2017.

The low-density lipoprotein cholesterol (LDL-C) goal for high-risk patients with diabetes and no other risk factors is 100 mg/dL. The triglycerides (TG) goal is less than 150 mg/dL. Recommended treatment is a moderate- to high-intensity statin as needed. Major risk factors include advancing age, elevated nonhigh-density lipoprotein cholesterol (HDL-C), elevated LDL-C, reduced HDL-C, diabetes, hypertension, CKD, cigarette use, or family history of atherosclerotic cardiovascular disease (ASCVD).

For very high-risk patients who have diabetes with 1 or more risk factors, the LDL-C goal is less than 70 mg/dL and the TG goal is less than 150 mg/dL. Add ezetimibe, a PCKS9 inhibitor, colesevelam, or bempedoic acid, depending on LDL needs.

For extreme risk patients with established clinical ASCVD and diabetes, the LDL-C goal is less than 55 mg/dL and the TG goal is less than 150 mg/dL. Add a PCKS9 inhibitor, ezetimibe, colesevelam, or bempedoic acid, depending on LDL needs. For patients with diabetes, 2 or more risk factors and TG 135-499 mg/dL, add icosapent ethyl.

 For patients with heart failure with reduced ejection fraction (HFrEF), left ventricle ejection fraction less than 45%, the ADA recommends a SGLT2i with proven heart failure benefits. Prescribers have multiple choices, according to Smith.

 Two agents, dapagliflozin and empagliflozin, have primary heart failure outcome data.

 Three agents––empagliflozin, canagliflozin, and dapagliflozin––have shown reduction in heart failure and reduction of 

CKD progression in cardiovascular outcome trials.

 The 2021 ADA guidelines introduced a new concept: overbasalization, which is characterized as an excessive basal dose of insulin. Too much basal insulin can overcorrect fasting glucose levels, which then rebound to excessive levels, Smith explained. Typical examples of overbasalization are an elevated bedtime-morning glucose differential, greater than 50 mg/dL, an elevated post-preprandial differential, hypoglycemia, and high glucose variability.

Guidelines noted overbasalization is a potential concern anytime the basal dose exceeds 0.5 units/kg/d, Smith said. Any indication of overbasalization should prompt reevaluation of insulin dosing to reduce glucose variability.

 High-dose glucocorticoids can increase the need for insulin. Patients with diabetes who start high-dose prednisone for an asthma flare, for example, need a corresponding increase in insulin. Neutral protamine Hagedorn insulin protocol is the standard approach for once daily or twice daily steroids, Smith said.

 Insulin formulation and dose should match the steroid. A long-acting steroid needs a long-acting insulin and increasing doses of steroids need increasing doses of basal, prandial, and correctional insulin. The ADA recommends an increase of 0.1 IU/kg of insulin for each 10 mg/d of prednisone to a maximum of 0.4 IU/kg for 40 mg or more of prednisone.

Jennifer D. Smith, PharmD, BCACP, BC-ADM, CDCES, a clinical pharmacy specialist for the US Department of Veterans Affairs, highlighted recent safety changes for diabetes treatments that pharmacists should know:

Canagliflozin has lost its black box warning for lower-limb amputation. However, an increased risk of lower-limb amputation remains in the label warning and precautions section.

An FDA safety communication recommends stopping canagliflozin, dapagliflozin, and empagliflozin at least 3 days prior to scheduled therapy. Ertugliflozin should be stopped at least 4 days before surgery. All 4 agents can be restarted after surgery.

New data also suggest stopping sodium-glucose cotransporter 2 inhibitor therapy before scheduled surgery to lessen the risk for ketoacidosis.

At least 4 new agents are in the pipeline, Smith reported.

, a once-weekly “twincretin” combination of a GLP-1 receptor agonist and a glucose-dependent insulinotropic polypeptide, showed solid phase 3 data in T2D. A cardiovascular outcomes trial is ongoing.

 a nonsteroidal selective mineralocorticoid receptor antagonist, reduced the risk of composite cardiovascular outcomes in patients with CKD and T2D in the FIDELIO-DKD trial (NCT02540993). The agent’s application has been submitted to the FDA, she said, and a decision is expected sometime this summer.

, a prefilled rescue pen for severe hypoglycemia, is under review by the FDA.

, a once-weekly basal insulin, showed efficacy and safety profiles similar to once-daily insulin glargine U100 in T2D.

“Even with all these changes, we cannot underscore more the benefits of lifestyle and nutrition management,” Smith said. “Whole-food, plant-based, Mediterranean, and DASH [dietary approaches to stop hypertension] diets remain the bedrock of therapy for diabetes and ASCVD risk reduction. Physical activity is key, and treatment must be tailored to the patient.”

Smith JD. New and approved: your annual diabetes update. Presented at: American Pharmacists Association 2021 Annual Meeting and Exposition; March 12-15, 2021; virtual. Accessed March 12, 2021. 

Articles

A session held during the American Pharmacists Association 2021 Annual Meeting and Exposition provided an update on diabetes practice changes and new treatments. 

Diabetes Treatment Guidelines, Practices Advance Despite COVID-19 Focus in Health Care

Telepharmacy turns 20 this year. Two decades after it emerged as a way of preserving and expanding pharmacy access across rural North Dakota, telepharmacy innovators are moving into sterile compounding, secure medication storage, primary care consults, and more.

 Telepharmacy has gone from a pilot project to accepted practice in 25 states, according to Jessica Adams, PharmD, director of regulatory affairs for Telepharm, an early telepharmacy provider acquired by Cardinal Health in 2016

. Many states who do not have telepharmacy rules in place today, are in some stage of approving telepharmacy as pharmacists and patients continue to push the need for access to pharmacy care. As pharmacists, providers, patients, payers, and regulators recognize the benefits that telehealth can bring to pharmacy, technology-based services will continue to expand.

At its simplest, telepharmacy allows a pharmacist to supervise a remote dispensing site via HIPAA-compliant, 2-way audio-visual technology. The pharmacist remotely supervises the telepharmacy technicians, verifies prescriptions, and counsels patients from their host pharmacy location. Newer iterations are combining remote oversight with other familiar technologies to expand the reach of pharmacy care.

 One of the newest expansions is using remote verification for sterile IV compounding at the University of North Carolina (UNC). Pharmacists saw the potential to balance workload across multiple pharmacies that were using BD Pyxis IV Prep to prepare sterile IV solutions, explained Lindsey B. Amerine, PharmD, MS, BCPS, director of pharmacy and associate professor of clinical education at the UNC Eshelman School of Pharmacy in Chapel Hill, North Carolina. She proposed a double arm, prospective study of remote versus onsite verification at 4 UNC pharmacies.

 The Pyxis system uses gravimetric-based technology to weigh and verify compounded products, Amerine explained. The system images the compounding process, which is typically managed by a technician and reviewed by a local pharmacist. Because the onsite pharmacist was using images generated by the system, there was no obvious difference between reviewing images in the next room or 25 miles away.

 Results of the 90-day trial demonstrated no difference in accuracy or safety for remote versus local oversight, and resulted in an annualized cost savings of nearly $24,800, according to Amerine. “When we did the study, the state had no rules around this kind of telepharmacy,” Amerine said, “so we designed the trial with remote plus onsite review of all compounded sterile products.” When the COVID-19 pandemic started, “we received a waiver from the [State] Board of Pharmacy 

to be able to do this remote sterile product check as long as the health emergency lasts,” she said.

“Our next initiative is to be able to use telepharmacy routinely in the long term to do more workload sharing across sites. There is also the advantage of having a pharmacist able to check product from anywhere in the hospital. Not being tied to the pharmacy frees you up to spend more time with patients.”

 Roger Rose, RPh, director of pharmacy services for Wickenburg Community Hospital, opened the first telepharmacy in Arizona in 2019. Wickenburg has long had a satellite clinic in the town of Congress, which is about 16 miles away

. With a population of 3500, Congress is too small to support an onsite pharmacist, Rose said. The drive to Wickenburg to fill prescriptions is not always practical for patients.

 “We were doing deliveries to the Congress clinic twice a day, but that didn’t always work, either,” Rose said. “Patients still had to go home after their clinic visit, then come back later, or maybe the next day. Too many prescriptions never got picked up.”

 When Arizona approved telepharmacy in 2018, Rose had a solution and 2 more problems. One was security. Most telepharmacy operations he visited had a single technician handling the entire operation.

 “You’ve got your front end, you’ve got prescriptions at the back, and just 1 person,” Rose said. “For any pharmacist who has been around for a while, that’s a stress.”

 The second problem was space. State telepharmacy regulations required at least 300 square feet. The only available space at the Congress clinic was 125 square feet.

 His solution was RxSafe, a secure medication storage unit that can hold about 1300 medication vials. The unit weighs every container coming out and going back into storage to verify the medication removed for each prescription.

 “Combining telepharmacy and RxSafe answered our questions,” Rose said. “We can stock just about everything our providers write in the limited space, and I know the location is safe for our tech. The technologies work well together.”

 Adam Chesler, PharmD, MBA, senior vice president for pharmacy integration at VillageMD, a network of primary care clinics, envisions a day when every patient in nearly 2000 primary care clinics can have a pharmacist consult. Some consults will likely come through an in-person Walgreens pharmacist. Walgreens is investing $1 billion to support up to 700 new Village Medical primary care clinics at its locations by 2025. Other consults will likely come via telepharmacy.

 “Having a pharmacist directly involved in care improves patient outcomes,” said Chesler. “By integrating a pharmacist into primary care, we have shown significant, sustained increases in medication adherence to treat cholesterol, diabetes, and hypertension. We can utilize telepharmacy and telehealth technology by taking an iPad or tablet into any exam room and having a conversation between the pharmacist, physician, and patient anywhere, anytime.”

 The telepharmacy technology already exists and VillageMD already has a focus on pharmacy integration. Patients with multiple chronic disease states or those who use multiple pharmacies have an elevated risk of therapy failure. These patients already receive in-person or telephonic pharmacy consults, as do discharged and homebound patients. Telepharmacy can further expand this reach. Pharmacists in these settings have full access to patient electronic medical records, a common communication platform with clinicians, and collaborative practice agreements with delegated prescribing authority.

 “We are taking full financial risk for many Medicare patients,” Chesler explained. “The physicians here understand that the best way, the only way, to successfully improve outcomes and reduce costs is by having pharmacists directly integrated into the care team. Having a pharmacist on the care team is integral to our success and telepharmacy can help make that integration happen.”

As telepharmacy evolves, regulators are playing catch-up. On a federal level, the COVID-19 pandemic called for loosened telehealth restrictions overall during the public health emergency. The Centers for Medicare and Medicaid Services (CMS) expanded the number of covered services that can be provided via telehealth. Many of these changes are noted as temporary during the COVID-19 emergency period. However, as telehealth benefits prove valuable, it is the hope that these changes will carry over post pandemic, enabling telepharmacy expansion. 

Many states already had telepharmacy laws in place prior to the pandemic. California’s Legislature authorized telepharmacy in 2018. It took 2 years to work out the regulatory details and open the state’s first telepharmacy. Arizona’s first telepharmacy was 6 years in the making.

 “When we first asked, the state pharmacy board told us they had no regulations and nothing in the practice act that would let them authorize telepharmacy for the hospital’s remote clinic,” said Rose. “Five years later, they had changes to the practice act, called us back for a hearing in July, and we were licensed the next April.”

 Outreach to the state board, showing up at board meetings, and providing public comments make the difference, said Adams. “ Each state is unique and has its own challenges, but access is an issue everywhere. Telepharmacy has been proven to work for 20 years, and is now permitted in 25 states. If pharmacists attend board of pharmacy meetings and explain how telepharmacy can reduce gaps in pharmacy care that their patients are experiencing, it can make a positive difference in getting telepharmacy moving,” she explained.

 Changing pharmacy regulation and legislation is a team sport, Adams continued. Arizona was slow to adopt telepharmacy in part because chain pharmacists feared remote oversight could lead to job losses. The Arizona Pharmacy Association demanded language in the practice act to safeguard pharmacist employment.

 Rural health associations can be solid partners, particularly for pharmacists seeking to bring telepharmacy to underserved rural areas. Federally qualified health centers, health systems, and physician practices that recognize the advantages of bringing pharmacy to the care team can help build support.

 “The basic message is telepharmacy safely provides greater access to pharmacist care,” Adams said. “Why are we not using a proven technology to help ensure that our patients are getting the best pharmacy care possible? The more stakeholders you bring to support your message, the more likely you are to get a positive response.”


Scaling Up Telepharmacy for the Future 

Immunization is one of the most familiar pharmacy clinical services; approximately 77% of community pharmacies offer flu vaccines and 73% provide other immunizations, according to the National Community Pharmacists Association (NCPA).

 All 50 states have had authorized pharmacists to immunize patients in some form since 2010, but promoting such services also is necessary to achieve results.

“People don’t often come in out of nowhere asking for flu vaccine or a shingles shot,” said Beverly Schaefer, RPh. “You need to start the conversation.”

Schaefer has been starting immunization conversations at Katterman’s Sand Point Pharmacy in Seattle, Washington, for more than a decade. She is co-owner and evangelist-in-chief for a program that delivered over 4000 influenza immunizations from September 1 to October 10, 2020, even amid store closures for Sundays and Labor Day weekend.

Promoting immunization services is more about generating questions and providing information than about selling, she said. Something as simple as a countertop card asking “Have you had your shingles vaccine yet?” can be highly effective. Patients see the sign while they’re doing something else, such as having a prescription filled, asking a question, or looking for an OTC product, Schaefer explained.

“If they know about shingles vaccine, they think, ‘Oops, I need to get that done,’ ” she said. “If they don’t know about it, they ask what it is. Either way, you started that first conversation that leads to immunization. And because they asked the question, you’re providing information they can use, not trying to sell them some product they may or may not want.”

The scenario is different for severe acute respiratory syndrome coronavirus 2 vaccines. The coronavirus disease 2019 (COVID-19) pandemic itself is starting vaccine conversations around the world.

“Vaccine demand greatly exceeds supply right now,” said John Vinson, PharmD, CEO of the Arkansas Pharmacy Association. Community pharmacies have been the primary distribution point for COVID-19 immunizations in Arkansas since the first doses were delivered in late December 2020.

“Anytime demand greatly exceeds supply, you don’t have to do a lot of marketing,” Vinson said. “But you do have to do a lot of planning to get that vaccine into as many people as possible, as fast as you can.”

Planning is part of any successful immunization program. Under normal circumstances, state laws and regulations govern pharmacy immunization programs.

“Some states have [been] pretty liberal with vaccine authority,” noted John Beckner, RPh, NCPA senior director of strategic initiatives. “Others are still pretty restrictive, whether it’s limited pharmacists to certain vaccines or certain age groups.”

Pharmacists must tailor their immunization programs to meet state requirements. That could mean not providing pediatric immunizations or only providing select vaccines such as influenza, shingles, or measles-mumps-rubella.

In Wisconsin, however, changes to the state pharmacy act that took effect in early 2020 allow pharmacists to prescribe and administer any vaccine approved by the FDA as recommended by the CDC. Pediatric vaccines must be reported within 7 days.

Wisconsin’s broad immunization authority was no accident. The Pharmacy Society of Wisconsin (PSW) actively promoted pharmacy-based immunization—first with other providers, then with state legislators and regulators—to expand vaccine access.

“We worked with other health care providers to expand immunization authority for pharmacists and to get more patients into pharmacies to get vaccines,” said Sarah Sorum, PharmD, PSW executive vice president and chief executive officer. “It started with a formal survey that documented what we knew, that other providers recognize pharmacists as fully competent to provide vaccines, and that pharmacists are more accessible than any other providers. We went to the state as a group saying that better vaccine uptake is better health care regardless of who administers it. Easy access makes pharmacy an easy immunization choice for patients everywhere.”

COVID-19 gives pharmacies nationwide similar authority. The US Department of Health & Human Services (HHS) promulgated rules under the Public Health Emergency (PHE) Declaration allowing pharmacists to administer any FDA-approved vaccine. While the PHE continues, HHS rules override state regulation to give pharmacists broad immunization authority.

“Pharmacy is taking on a much more active role making sure that children as well as adults aren’t falling behind in their immunizations,” said Michael Hogue, PharmD, FAPhA, FNAP, president of the American Pharmacists Association and dean and professor at Loma Linda University School of Pharmacy in California. “And with kids, pharmacists are strengthening their connections to pediatricians to refer for developmental checks and well-child visits that are usually tied to childhood immunizations. That’s the kind of thing too many people don’t realize pharmacists are doing.”

 Many pharmacists have been too busy providing immunization services to talk about it.

 “Pharmacists get into this business to help people, to serve our patients,” said Hannah Fish, PharmD, NCPA associate director of strategic initiatives

. “We don’t always remember that we have to promote ourselves and our services to better care for patients.”

 That’s where sparking that initial conversation about immunization matters. Countertop signs can start the conversation for patients who are already in the pharmacy. Sidewalk signs are just as effective at bringing in drive-by traffic.

“They don’t suddenly swerve into the parking lot asking for a shingles shot or FluMist,” Schaeffer said. “But when you see that sign every day when you drive by, it has a cumulative effect. One day people stop in and the conversation starts.”

Word of mouth and social media can be more effective over a broader area. Schaeffer used Twitter to spread the word about appointment-only flu vaccinations. The problem wasn’t publicity, but staff time.

It takes at least 10 minutes to enter new patient information for an influenza vaccine. That’s no problem for the occasional walk-in patient, but for 4000 new flu vaccine immunizations, 10-minute periods add up. Schaeffer expects to administer 7000 to 10,000 COVID-19 immunizations during the next few months.

“That kind of time takes some modification to workflow,” she said. “When you start promoting immunizations and ramping up your program, you have to take staff time into consideration.”

 Pharmacies nationwide should be preparing to modify their workflow for COVID-19 immunizations, talking with patients about vaccines in general and COVID-19 in particular.

 “Community pharmacies are the key distribution point for COVID-19 vaccines for the CDC,” Hogue said. “They are expecting that community-based pharmacies will pick up the yeoman’s work in administering vaccines in local communities. Having adequate staffing is going to be key to success in this.”

Trust and information are also key. Vaccine misinformation has been growing for years, noted Anna Dopp, PharmD, senior director of clinical guidelines and quality improvement  for the American Society of Health-System Pharmacists.

“Pharmacists are already the most trusted voice with patients,” Dopp said. “Vaccine choices often come down to a one-on-one interaction between the patient and the pharmacist. That relationship, that trust, will likely be the driver for someone to access care and get a vaccine from there. And pharmacists are available. We have the flexibility to meet people wherever they are.”

Arkansas pharmacies are adapting familiar onsite clinic models to promote and deliver COVID-19 vaccines. In the initial rollout to long-term care facilities, community pharmacies vaccinated 100% of residents and staff within 72 hours, Vinson reported. Similar on-site delivery by chain providers in the state took about 30 days.

Immunizing about 300 million individuals against COVID-19 could be the beginning of greater pharmacy involvement. State and national pharmacy groups built on the success of pharmacy-based novel influenza A (H1N1) vaccines to expand immunization authority for pharmacy. COVID-19 could provide a similar boost.

“COVID-19 is absolutely transformational for the profession,” Vinson said. “Pharmacists are not only the prescribers of the vaccine, they’re also the educators, counselors, and providers. Protection from this deadly virus will elevate the status of our profession.”

NCPA releases 2020 digest report. News release. NCPA. October 19, 2020. Accessed January 8, 2021. 

https://ncpa.org/newsroom/news-releases/2020/10/19/ncpa-releases-2020-digest-report

Pharmacists can employ several strategies to enhance these programs. 

Promote Immunization Services More Effectively

Telepharmacy began as a pilot project to bring pharmacy services to rural North Dakota communities too small to support a fulltime pharmacist. Two decades later, telepharmacy is an everyday reality across the country. The concept remains the same: a pharmacist in one location provides services electronically to patients in another location. But pharmacists, providers, patients, prescribers, payers, and regulators are all recognizing the benefi ts that virtual services can bring to pharmacy

There is a wide spectrum of needs that telepharmacy can meet, according to Adam Chesler, PharmD, MBA, the director of regulatory and legislative a­ airs for Cardinal Health and former vice president of operations at TelePharm, an early telepharmacy technology provider. Cardinal acquired TelePharm in 2016 and is now among the largest telepharmacy technology providers in the United States.

Do you have a deaf patient who needs an American Sign Language consultation? How about freeing up pharmacists for clinical activities or to spend more time on immunizations? Telepharmacy does all that and more, and can be further used to:

• Balance work load across multiple pharmacy locations 

• Open an urban location that seems unlikely to support a pharmacist 

• Take over an independent pharmacy whose owner is ready to retire 

• Provide pharmacy services inside a physician practice or clinic 

• Consult with patients who can’t leave home 

• Bring pharmacy services to disaster relief and homeless shelters

“We have seen a surge in remote consultation, especially during COVID-19 [coronavirus disease 2019],” Chesler said. “Patients needed telepharmacy more than ever when physician offices were closed and pharmacy was the only place to get any kind of access to care. The reality is that we can have a pharmacist just about anywhere to get questions answered on prescription or OTC medications, get an interactions check, adjust therapies for patients, [or] verify a product before dispensing. Telepharmacy puts pharmacists in the cloud. That means they can be anywhere that you ever wanted a pharmacist to be.”

Devin Trone, PharmD, took a familiar route into telepharmacy. He used telepharmacy out of one of his Medicap Pharmacies in Meridian, Idaho, to provide remote services for a new store in Garden Valley, a rural mountain town about 50 miles away. Pharmacy technicians in the new store took care of customers, while a touchscreen video link brought in a pharmacist as needed to check prescriptions before dispensing, provide consults, and answer patient questions. 

“It didn’t take us long to realize we could use the same telepharmacy system as part of our quality control workfl ow for all our prescriptions,” Trone said. “We have 4 locations, so you know that some aren’t as busy as the others. Instead of having scripts back up on the busier location, why not use telepharmacy to distribute the workfl ow? Putting all of our pharmacists in the cloud helps keep any one pharmacist from getting overloaded. Telepharmacy gives pharmacists more time with patients and cuts wait times at all of our locations.”

With 4 stores, Trone has at least 3 pharmacists in the cloud during all open hours. But even the smallest location doesn’t depend entirely on telepharmacy. All 4 locations have a pharmacist physically on site at scheduled times. It helps remind patients that there really is a pharmacist available, he explained. And there are some services, such as immunizations, that can only be provided in person.

What can be done virtually and what must be done in person depends on the state, Trone said. In Idaho, technicians who have completed a certification program may provide immunizations under the supervision of a pharmacist, which can be done virtually. But in Oregon, for example, where Trone also has a pharmacy, immunizations can only be administered by pharmacists.

Telepharmacy is also an easy route to growth. Taking the pharmacists out of the local workflow and putting them in the cloud removed them from the physical dispensing flow. What no one had recognized is that they had been doing part of the technicians’ jobs as well as their own.

“When we put our pharmacists in the cloud, we discovered that 40% to 50% of their time had been spent on mundane things like stuffing bags, stickering, applying labels,” Trone said. “Working in the cloud helps them focus on pharmacist-only activities. We could easily add another 500 prescriptions a day without making our pharmacists work harder. We will be able to continue growth without over taxing or adding pharmacist labor.”

NuCara focuses on rural, small-town health care with pharmacies in Illinois, Iowa, Minnesota, North Dakota, and Texas. The company looks at telepharmacy as a tool to improve patient care and extend the reach of pharmacists. But instead of relying entirely on virtual services, NuCara is developing a hybrid model that combines telepharmacy with in-person pharmacist services to provide the best of both.

“We had the second pilot telepharmacy in Iowa, a little town called Zearing, population 500,” said Brett Barker, PharmD, vice president of pharmacy at NuCara Management Group. “When we got into telepharmacy, we were looking at the majority of rural independent pharmacies in the Midwest being owned by pharmacists in the later stages of their career. They wanted an exit strategy, but they didn’t want to abandon their communities. Telepharmacy can meet both those goals.”

The obvious approach is to take over an existing pharmacy from the retiring owner and convert directly to telepharmacy operations, Barker continued. But telepharmacy also offers more options and more flexibility. Some rural pharmacists had cut their operations to half-days, whereas others split their time between retail operations and the local hospital.

A town of 500 may not be able to support a full-time pharmacist, Barker said, but there is no lack of demand for pharmacy services. A small medical clinic in Zearing had a call list of 3 dozen pharmacies that patients used that were within a 60-minute driving radius.

Few patients were using any one pharmacy consistently, Barker said. Which pharmacy they used for which prescription depended on where they had to go that day or week. And if they didn’t have to go to a larger town, they may not have filled a prescription at all.

“What we were seeing was patients using a combination of mail order, whatever happened to be in prescribers’ sample closets, multiple pharmacies, and maybe not getting to a pharmacy at all,” he explained. “And that’s definitely not better. Telepharmacy can bring all those prescriptions to 1 place, with 1 pharmacist or 1 group of pharmacists looking at them all. And even if you don’t have a pharmacist in town every day, you have technicians who know the patients who can oftentimes identify problems they can refer to the pharmacist.”

However, the flexibility that telepharmacy can provide is not a panacea, he continued. A live pharmacist in the pharmacy is still the gold standard for pharmacy practice, but that isn’t always economically viable. Telepharmacy gives patients and providers options they might not have had before.

“Obviously, there’s a learning curve for patients and prescribers,” Barker said. “But people grasp the concept immediately, especially with the broad push for telehealth services during COVID-19. We also train our technicians to walk patients through the process because there are people out there who have never used a touchscreen device before. Patients get so used to remote counseling that they walk right up to the station expecting to use it. It’s a surprise on days when we have a pharmacist on site and they can talk to the pharmacist in person.”

“The hybrid telepharmacy model maintains a pharmacist in those locations at least part of the time and pharmacy services all the time,” he continued. “Too many people think ‘all or nothing’ when it comes to telepharmacy. Just like there’s a spectrum of pharmacy services, there’s a spectrum of telepharmacy. If there’s an unfilled need for pharmacy services, there’s a good chance telepharmacy can help fill that gap.”

Telepharmacy brings patient services anywhere. 