Keith Loria is a contributing writer to Medical Economics.

Keith Loria

During the COVID-19 pandemic many hospitals and health care services teams turned to telepharmacy to reduce delays in providing medications to patients while social distancing practices were in place.Hospitals quickly found that telepharmacy benefitted pharmacy services by providing patients with more efficient access to medical care and reducing costs. Thus, hospitals were able to focus more on patient care and less on logistics, which led to higher turnaround times and increased patient satisfaction.

Benjamin Kornitzer, MD, chief medical and quality officer of agilon health, noted that telepharmacy and meeting patients where they are can lead to higher-quality health care.

“During the pandemic we saw how challenging it was for a face-to-face encounter, and telepharmacy was a tremendous opportunity to continue offering these vital services to our patients, greatly increasing access to medications and medication adherence,” he said.

Randy Gerwitz, RPh, is pharmacy executive director at Vizient, a health care services company based in Irving, Texas. He notes that telepharmacy has expanded access to pharmacy services for patients, which is why hospital pharmacy teams benefit from implementing telepharmacy models into their workflows.

“There is a well-established history of operational benefits from these technologies remotely supporting common tasks such as prescriber order verification and the monitoring and verification of IV [intravenous] room production activities,” he said.

More recent efforts have focused on direct-to-patient and clinical services, including patient education, monitoring, and adherence support, as well as antimicrobial and opioid stewardship programs.

“These types of enhanced clinical offerings improve patient safety and allow [pharmacists] to reach patients that they may not have otherwise been able to care for,” Gerwitz said.

Ann Phan, PharmD, BCGP, manager of clinical programs for L.A. Care Health Plan in Los Angeles, California, said that telepharmacy in the inpatient setting allows a hospital’s pharmacy services to extend coverage, both temporarily and geographically.

“In this sense, rural and small-volume hospitals with limited resources could especially benefit from telepharmacy,” she said. “The benefits of telepharmacy can lead to expansion of service hours if [a location is] not already providing around-the-clock coverage, more available clinical pharmacy services, and improved safety and overall patient care.”

According to Seun Bammeke, managing director of PharmaServe in Winnipeg, Manitoba, telepharmacy can increase patients’ medication adherence. Additionally, these services allow an external licensed pharmacist to review and double-check the prescription to ensure it is correct, which can ease the workload of busy hospital pharmacists. He added that telepharmacy needs to be taught about from a return on investment (ROI) perspective as well, with plenty of savings available.

“Hospital pharmacies would require [fewer] pharmacists and technicians as a lot of the duties will be outsourced to the telepharmacy,” Bammeke said. “Plus, by using a JIT (Just In Time) system, the hospital can maintain less stock of medications [that] are not used on a daily basis, knowing they will arrive the next day. This prevents medications from expiring [or] being stolen, and [means] less work in process inventory, which frees up their finances to be used on things that are more needed.”

Eric Maroyka, PharmD, senior director of the Center on Pharmacy Practice Advancement at the American Society of Health System Pharmacists (ASHP), said telepharmacy has grown exponentially over the past year.

“We see it as an opportunity to improve patient outcomes, expand access to health care—whether it’s an acute or ambulatory care setting—and find that it’s also a way to enhance patient safety. It could in many ways achieve more effective delivery of care as well,” he said.

According to Maroyka, hospital pharmacy teams can benefit from implementing telepharmacy models into their workflows for medication selection order review. Dispensing the IV admixture verification can be done remotely. For instance, if you have a technician in a clean room, there could be a pharmacist who is working remotely to help with that verification process.

Then there are patient monitoring and counseling benefits. Maroyka explained that health systems that employ clinical pharmacy specialist can have them reach out to smaller facilities to provide patient counseling or consultations and real-time monitoring through telehealth services.

“It’s a solution for order review
and verification in tertiary medical centers when staffing—particularly in specialty areas [such as] oncology or pediatrics––is limited and provides a mechanism for health systems to provide enterprise-level pharmacy services throughout the system, even when those pharmacies may not operate 24-7,” he said.

It also provides a tool for virtual monitoring, assessment, detection, and decision-making for adverse drug reaction prevention and management. One major advantage, Phan noted, is the positive ROI produced by telepharmacy in decreasing pharmacy operating costs and repurposing pharmacists to other clinical services to improve patient outcomes, such as discharge medication counseling or antimicrobial stewardship.

Another advantage is increased accessibility. For instance, Gerwitz explained that telepharmacy allows the pharmacist to provide services in locations that are inefficient, impractical, or unfeasible.

“This is particularly true for services provided to at-risk populations and in rural or remote areas where distance and population density would make it impossible to pro- vide care in a way that is convenient for the patient and financially sustainable for the health care organization,” he said.

A disadvantage is patients’ dependence on technology and broad- band access.

As many learned and experienced during the pandemic, technologies and the internet ser- vices that support them are not always perfect. Gerwitz said glitchy connections, lag, and band- width challenges can at times cause frustration.

During the pandemic, the industry saw more widespread adoption of regulations that allow and even encourage the use of telemedicine and telepharmacy, but challenges still exist.

“The lack of a standardized regulatory environment and limitations on what pharmacy technicians can do under remote supervision in many states will continue to act as an obstacle to optimization of these technologies,” Gerwitz said.

There are plenty of new technologies available to help with a smoother transition and workflow.

Video conferencing has become a standard tool for telepharmacy to provide discharge medication counseling and medication therapy management.

Thankfully, systems have dramatically improved in recent years. Further maturation of technology and expanded access to broadband will continue to push the boundaries for telepharmacy, particularly in rural areas that struggle with access to health care.

“Certainly, video conferencing has existed for some time, but not always in a secure and compliant environment that was appropriate for the health care environment.,”Gerwitz said. “[Video communication] is especially beneficial when supporting patients on highly specialized therapies such as those seen in posttransplant care and oncology but can be very helpful as well in the setting of postdischarge medication reconciliation and home care.”

A graduate of the University of Miami, Keith Loria is a D.C.-based, award-winning journalist who has been writing for major publications for close to 20 years.

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Increases in service hours, programs, and locations lead to higher patient satisfaction, and lower costs.

Expanding Access Takes Telepharmacy to the Next Level

This past year, pharmacists faced unprecedented challenges with the rollout of the COVID-19 vaccines, as tens of millions of Americans fought to be among the first to get their shot. As of June 14, approximately 145 million Americans were fully vaccinated, and pharmacists, for the most part, have been able to standardize their procedures for vaccine distribution. But that wasn’t the case at the beginning of the rollout.

Kevin DeMass, RPh, owner of the Apothecary Shoppe in Salt Lake City, Utah, has more than 30 years of experience in the field. He noted that the important lesson he learned from the vaccine rollout was the need for patience.

“It seems that phase 1 took forever and we were in constant communication with our patients, providers, and even the Department of Health to find out what was going on,” he said. “And it certainly wasn’t a smooth process from the get-go.”

For instance, the state’s website crashed almost daily with patients trying to make appointments, and the vaccine supply ebbed and flowed with no predictability. Plus, he found many of his regular patients didn’t want to go into a mass immunization center and wanted his pharmacy to administer the vaccine.

“They were frustrated with the system, and we were as well,” DeMass said. “In many places in our country, patients were asked to go to a strange place to receive a strange drug that they knew nothing about. We haven’t really done anything like that before. Independent pharmacies have built a relationship and trust with their patients for years, and they relied on us, but we didn’t have anything to give them.”

Although that was frustrating to him, he knew not to let that show, as he didn’t want that frustration to spill over to his patients. He described an encounter with a longtime African American customer who refused to allow anyone but DeMass to administer the vaccine because of uncertainty and fear. DeMass worked with him to make that happen as soon as the pharmacy received doses.

“I did a lot of reading online, looked at journals, called friends in New York and California to see what they were doing…and learned from them,” DeMass said.

DeMass said he also learned not to compare what he was doing to pharmacies in different cities.

“We’re all going at different paces,” DeMass said. “You need to know what you can do with your staff to make the experience as smooth as possible. We took lessons we saw from others and improved efficiencies as we went into phase 2.”

Ghaidaa Najjar, PharmD, PhD, community pharmacist for Rite Aid in Plymouth, Michigan, added that the process was confusing and inefficient at the beginning for both patients and the pharmacy.

“I had elderly patients walking in, thinking they would be automatically signed up for the vaccine,” she said. “They did not have smartphones, they may not have children or grandchildren who can help due to the social distancing and they struggled because of isolation.”

She believes there should have been cohesive alignments in terms of eligibility among federal, state, and county entities when pharmacies had to serve the public based on certain criteria.

“People were confused, because a mile from where you live, your neighbors could be getting vaccine way ahead of you,” Najjar said. “Inequality was manifested by preferring some states to get vaccines before others. The category differences within the same state and local counties were also discriminating people and added more confusion. If we could go back, equitable distribution to all states should be the standard.”

According to Heather Ferrarese, PharmD, owner of Bartle’s Pharmacy in Oxford, New York, no one is ever really prepared for something like a global pandemic, even when they think they are. From her perspective, careful communication and planning are most important in adapting to the unpredictability a public health crisis brings. 

“To anticipate having the vaccine, then to have it delayed time and time again, was definitely something we learned from, especially about how to plan and communicate,” she explained. “Once we did get the vaccine, it was a complete learning curve to pull off vaccinations on such a large scale and figure out where to vaccinate so many people. Those were some of the key takeaways from this experience. Thankfully, most people have been very gracious. They understand this is something none of us have ever been through before.”

For many pharmacies, implementing COVID-19 vaccinations was a significant trial-and-error process that resulted in plenty of mistakes. Pharmacies had to adjust their workflows and services to fit their community’s needs. 

“The 2 biggest areas were workflow improvement in the pharmacy and improving efficiency and capacity during vaccinations,” said Mark McCurdy, RPh, an independent pharmacist from Mark’s Pharmacy in Cambridge, Nebraska.

Being in a rural area, the pharmacy works closely with the local health department. It offered vaccination events in multiple locations in 4 of the 9 counties in its service area.

“The goal was to identify the highest-risk and highest-need patients and provide them easy access to care,” McCurdy said. “So aside from the original crush of patients seeking vaccine, we also were faced with logistics of site coordination, travel, and time on making these events happen. Once supply outpaced demand, the biggest challenge has been maintaining interest in receiving the vaccine and filling available appointments. We have struggled to get information to the right places and reach the right people.”

Jasmine Chan, PharmD, chief operating officer at Central Avenue Pharmacy in Pacific Grove, California, said because her pharmacy was a little late in getting vaccines, she was able to learn from the challenges that others were facing, notably with schedules and communication with patients.

“I got to marinate on how we could do it better,” she said. “Organization was key. I like lists, I [like] Excel sheets, but very quickly we learned we can’t overorganize this. We had to be flexible and roll with it.”

She feels the biggest thing she learned was how to navigate to the need of the individual patient. For example, the pharmacy served a lot of hospice patients, and Chan needed to best figure out appointments, transportation, and all the logistics in getting the vaccine to those patients. 

“There were people with language barriers, those with no legal status in the United States, so we had to change our process for each of those barriers and break them down to make sure everyone was properly serviced,” Chan said. “Many of these people couldn’t leave during their work day, yet many clinics were only open 10 to 4.”

Chan’s pharmacy set up clinics near workplaces, such as golf courses for greenskeepers and even in homes where maids were employed, to help improve access to those patients.

Miscalculating the time needed to process paperwork, distribute vaccine cards to patients, and schedule second appointments proved to be one of the biggest mistakes, according to Ferrarese.

“We have been administering vaccines for many years, so we thought we had that down, but we weren’t prepared for all of the questions that customers had and how much more time that would take,” she said. “We also had concerns about keeping people socially distanced, and at first, we were overly aggressive trying to vaccinate too many people. We learned our staff needed to stay in close communication with each other on how things were going.”

Furthermore, the team needed to securely share patient health information, such as insurance cards, and that proved to be more difficult than originally thought.

“When we got to the point where we couldn’t handle so many people within our pharmacy, we set up a vaccination site at our local fire department,” Ferrarese said. “We used Backline from DrFirst to securely communicate with staff who were on-site at the fire department, and they were able to reach those of us who were at the pharmacy.”

One of the biggest mistakes DeMass made was underestimating the entire process from beginning to end, including time, reporting, record keeping, labor consumption, and more.

“My calculations were based on my previous immunization experience with patients in our database,” he said. “But this threw us a hard curveball. It was a little bit scary. Every day, we were adding new patients into our database. Claim after claim, patient after patient. We didn’t have any existing data so it was a very time-consuming process.”

In the beginning, DeMass was having patients fill out the intake paperwork, a qualifying questionnaire, and billing information right in the pharmacy so he could provide a good experience with hopes of getting some repeat business.

“That was a big mistake and we changed that quickly,” he said. “I pushed all of that to our website. All information, scheduling, [adverse] effect information, and everything else was available on the site, which had been underutilized for months and years, but now patients are using it daily.”

In an effort to adapt to the increasing needs of the public, pharmacists and pharmacy technicians across the country quickly set up off-site clinics and walk-up vaccination locations.

“The pharmacist’s role in health care has been greatly expanded in recent years due to our ability to adapt and seek new ventures, along with the great amount of trust that patients have in their pharmacist,” said Aaron Gilbert, PharmD, a pharmacist in Louisville, Kentucky.

Now, the Apothecary Shoppe has preloaded the vaccine into the pharmacy dispensing system and hard-coded the billing and drug utilization review codes, making the flow much easier and increasing the efficiency in processing claims.

“We also preprinted COVID-19 prescription pads and we had all of the info on there that insurance companies would require,” DeMass said.

He also contacted his landlord about extra space and was able to use 3500 square feet directly above the pharmacy to create a COVID-19 vaccination clinic.

“It took more staff than we could handle, so I begged some of my professors from the University of Utah to come and help us and they have been very gracious volunteering their time,” DeMass said. 

There is still conflicting information on whether the COVID-19 vaccination will need to be administered annually like the flu shot, with most experts believing a booster shot will be necessary, but research is still underway to know exactly when.

“As the need for additional COVID-19 vaccinations is still unknown, there is the possibility that pharmacists will play an increasing role in helping the community protect itself from the deadly virus,” Gilbert said. “But what we have seen once again is that pharmacists are stepping up to the plate and making a difference in patient care.”

DeMass said that although he’s not sure if COVID-19 vaccines will become routine, he knows the experience gained over the last 6 months has positioned pharmacists on the front line and put them in place to be a health and wellness destination.

“Now more than ever, the local pharmacy is a trusted health care provider, and the rollout in any future health crisis will happen much more quickly,” he said. “On the positive side, public awareness has been increased on the vaccine process and its importance.”

The vaccine is free to everyone, but pharmacists still need to be reimbursed for their efforts, as they are spending thousands of hours planning and executing to get the vaccine in the arms of whoever needs it.

“I’m still waiting for approval from [the Department of Health and Human Services] and waiting for a third-party check and Medicaid checks to be cut,” DeMass said. “Many pharmacists are still working for free to care for the most vulnerable, high-risk, and disadvantaged citizens of our community. The public needs to be made aware of that.”

Pharmacists reflect on their takeaways from the experience and how to move forward.

Lessons Learned from the COVID-19 Vaccine Rollout

Although pharmacists understand that all of a patient’s medical information is confidential and access to that information is protected by the Health Insurance Portability and Accountability Act (HIPPA) of 1996, some still have challenges staying 100% compliant. That is why independent pharmacy owners should establish a compliance checklist and ensure their staff does annual HIPPA training.

“Pharmacy staff need to be aware of who they are providing health information to over the phone, in person, or via mail,” said Chirag Patel, PharmD, MBA, chief operating officer and brand ambassador for Carolina Pharmacy Group in Charlotte, North Carolina “The staff also need to ensure all health information at the pharmacy—prescription vials, labels, print outs, handouts, etc—is properly disposed of. That disposal source is most often an information security company that disposes of personal health information via shred boxes.”

Arielle T. Miliambro, Esq, a partner at Pine Brook, New Jersey-based health care law firm Frier Levitt, outlined the components of HIPAA:

The HIPAA Privacy Rule protects the privacy of individually identifiable health information.

The HIPAA Security Rule sets standards for the security of electronic protected health information (PHI).

The HIPAA Breach Notification Rule requires covered entities and business associates to provide notification following a breach of unsecured PHI.

Each HIPPA rule may have different requirements and exceptions. Miliambro explained that the Privacy Rule contains certain limited exceptions for which PHI may be disclosed without authorization, such as to coordinate care among health care providers or to obtain reimbursement from a patient’s health insurer or payer.

Russell Dowdell is director of solutions engineering for 

in Austin, Texas, which provides health care organizations with a centralized solution for managing privileged access for their third-party vendors.

What independent pharmacists need to know. 

A Guide to HIPAA Compliance in the Pharmacy

Demands on pharmacists are increasing, yet all the tasks historically part of a pharmacist’s day-to-day routine are still required. Aside from COVID-19 vaccinations and responding to overall increase in volume, medication adherence is a top concern for patients and pharmacists. Using technology solutions enables pharmacists to enhance patient safety both effectively and efficiently. 

According to Gerald Finken, RPh, CEO of RxE2 Inc and a 40-year veteran pharmacist, technology-driven medication packaging is a tangible reminder for patients to take their medication as prescribed.

“Additionally, health plans, prescribers, and pharmacies are held accountable through adherence-driven quality metrics [such as proportion of days covered and medication possession ratio], and pharmacists can use packaging to improve these quality metrics,” Finken said. 

Joann Seigel, RPh, vice president of pharmacy services for Masonic Villages in Elizabethtown, Pennsylvania, noted that with automated packing technology, pharmacists can confidently handle increased volume in the pharmacy without an increase in errors.

“It allows you to service a volume you could never manage manually,” she said. “Smart technologies streamline the med packing process.”

For the pharmacist, smart technology ensures that all a patient’s medications are synced up and billed at the same time, explained Donald Brindisi, RPh, pharmacy manager of Masonic Villages.

“It saves headaches around the concern that a patient is taking their medications as they are prescribed,” he said. “Without technology, supporting a patient that could have 10-plus medications in a single blister would be nearly impossible to do efficiently. We feel much more confident because of our automation.”

Thomas E. Hanzel, PharmD, MBA, national vice president of long-term care/nutraceutical at Parata Systems in Durham, North Carolina, said pharmacies are starting to be held accountable and, to some level, rewarded for improving adherence. 

“The right technology can provide customizable adherence packaging that is flexible enough to be adopted by all customer types and, therefore, improve medication management,” he said. “Pharmacists can verify compliance, as the customer receives notice in a cyclical calendar format where the medications are automatically refilled. This can be on a weekly, monthly, or whatever cycle is best for the customer—therefore, decreasing the chance of missing a dose.”

Sapna Patel, RPh, director of clinical services at Mosaic Pharmacy Service in Sterling, Virginia, explained that previously, pharmacists had to spend a lot of time manually counting, filling, and labeling medications. With the automation of these tasks, pharmacists have additional time for patient interaction, including counseling patients on harmful drug-drug interactions, educating patients on disease states, and reiterating the importance of staying adherent to their medication.

“Pharmacy automation has also decreased medication errors made by pharmacists,” Patel said. “Many automation systems have a pill verification system that increases patient safety while decreasing human error.”

Therefore, adherence packaging services can increase a patient’s confidence in medication management and improve their overall health by helping them take their medications as prescribed.

If a pharmacy isn’t currently offering an adherence program, it usually is due to a lack of efficient technology. To start an adherence program, it can be helpful to have show-and-tells or introductory meetings with provider offices, discharge planners, short-term rehabilitation centers, and insurance companies, Seigel said.

“Getting key players involved early on to demonstrate the value of engaging with your adherence program is a great way to begin those partnerships,” she said. “Compliance packaging typically comes first and is then supported by the introduction of automation into the pharmacy.”

It will also depend on one’s customer base. For example, although smart cards are great for retail and behavioral health settings, they are not as ideal for long-term care settings.

“Knowing which patient populations you’re looking to support will dramatically change the type of adherence program and the way it is implemented,” Seigel said.

More and more seniors are staying in their own homes rather than going to a nursing home. A recent article in the 

 reported a 15% drop in nursing home occupancy since 2019—mainly due to concerns around the COVID-19 pandemic.1 Seniors who live on their own may need additional support from their care providers when it comes to medication adherence.

“Adherence packaging has allowed pharmacists to help manage patients’ medications better by spending less time filling and more time managing their overall health,” Patel said.

For example, Patel cited a recent case study on a 70-year-old man on 25 medications. The patient has an extensive medical history, which includes diabetes, hypertension, overactive bladder, hyperlipidemia, gastroesophageal reflux disease, and neuropathy. He lives alone and has a hard time remembering to take some of his medications. He became nonadherent due to cost and medication overload.

“Mosaic Pharmacy Service leverages a comprehensive care model that includes filling medications in adherence packaging to help our medically complex patients stay adherent to multiple medications,” she explained. “I switched this patient to more cost-effective medications organized by date and time of dose in adherence packaging, which helped to simplify his routine and ultimately made it easier to stay adherent.”

COVID-19 has disrupted daily processes and routines for many patients, leading to medication adherence concerns. Pharmacists have had to implement strategies to help their patients stay adherent amid a variety of logistical challenges; this includes services like curbside pickup, home delivery, and—of course—adherence packaging.

“[COVID-19] has allowed pharmacists to see the importance of adherence packaging to help manage patient’s medication regimens,” Patel said. “Having all their medication synchronized to fill once a month allows for better adherence and more time for pharmacists to focus on helping patients manage their chronic conditions.”

Adherence packaging is good for any patient managing multiple chronic conditions that require them to take medications multiple times per day. It is also good for patients who have a caregiver helping them manage their medication because adherence packaging makes it easy to see if the medications have been taken at the scheduled time.

The patients most likely to benefit from adherence packaging are those whose caregivers may be far too busy to manage family members’ medications.

“Home health agencies really value compliance packaging for their facilities,” Seigel said. “Patients who may be very far away from their loved ones or a power of attorney can rest easier knowing their medications are being managed safely—which provides peace of mind for both the patient and those responsible for their care.”

The senior population is also at high risk of nonadherence, which is why Patel believes seniors who are on 5 or more medications would benefit most from adherence packaging.

“A recent report put out by the Lown Institute indicates that seniors on 5 or more medications are 88% more likely to seek care for an adverse drug reaction versus those taking 1 or 2 medications,” she said. “More and more seniors are wanting to age in [their own] place. Adherence packaging allows them to stay independent and adherent to their medication regimens.”

There are plenty of benefits for the pharmacists as well. Automation allows them to better manage workflow, produce more cards, and service a much larger customer base.

“It significantly reduces stress for the pharmacists, which inherently reduces burnout,” Brindisi said. “Because every step along the way is barcoded, there’s confidence that processes are reliable and that patients are in good hands.”

Plus, it allows pharmacists to work with patients to reduce their overall medical spend and ensure the best-possible treatment plan.

“The shift away from simply dispensing medications toward holistic patient care allows for better clinical outcomes,” Patel said.

Adherence pouch packaging also increases prescription fills and results in less audits, less direct and indirect remuneration fees, and higher reimbursement.

“Adherence technology decreases chances of medication errors and increases efficiencies, providing a high level of confidence to the pharmacist,” Hanzel said. “Automation also frees up pharmacist time and allows them to use their unique breadth and depth as experts who can then focus primarily on the patient. As a pharmacist, any way that they can improve adherence will [improve outcomes and, ultimately, reduce] total health care cost.”

Mathews AW, McGinty T. Covid spurs families to shun nursing homes, a shift that appears long lasting. 

 Updated December 21, 2020. Accessed May 3, 2021. 

https://www.wsj.com/articles/covid-spurs-families-to-shun-nursing-homes-a-shift-that-appears-long-lasting-11608565170

Smart tech improves medication management and workflow.  