Patients in rural settings can still receive personalized care from pharmacists. With tele consults, all they need is an internet connection and a laptop.

Whether they are visiting their local community pharmacies or being hospitalized at the nearest facility, patients in rural settings, such as those in North Dakota, Minnesota, and Iowa, can still receive personalized, specialized care from pharmacists. Telepharmacy makes this possible.

Thrifty White Pharmacy, a chain of 91 drugstores serving the Midwest, offers medication therapy management (MTM) and comprehensive medication review (CMR) through Webcam consultation with a pharmacist located at its patient-care center in Fargo, North Dakota. In addition to its 91 drugstores, Thrifty White operates seven telepharmacies in locations with small populations of 1,000 or less. In these communities, a technician working with the remotely located pharmacist will be able to fill and dispense prescriptions and also offer MTM provided by the telepharmacist.

“Telepharmacy has given us a chance to gain access to patients that we didn’t have and also helped us to strengthen our reach to our patients. Telepharmacy fills the void for us at Thrifty White. We continue to make it a bigger part of our business,” said Aaron Jennissen, vice president of pharmacy operations, Thrifty White Pharmacy, during a telehealth presentation at the recent NACDS Total Store Expo meeting in Las Vegas.           

How telepharmacy works

Telepharmacy at Thrifty White is accomplished through Web-based conferencing, during which the remote pharmacist dials into the telepharmacy, reviews and verifies prescriptions, and counsels patients via Webcam. To prevent prescription diversion, the telepharmacies are set up for additional monitoring, so that the remote pharmacist can have access to the entire store.

At the Thrifty White patient-care center, two pharmacists who are dedicated to its seven telepharmacies work using a secure VPN connection. The patient-care center also has a bank of pharmacists who offer MTM to patients at its local stores, which all have counseling rooms fitted with Webcam.

“To make remote MTM work, you need to be able to schedule the appointment, ensure that patients show up for the appointment, and execute on both the remote and local sides. It is very important to have that relationship with the patient. We are able to do that by allowing the local store to be involved in MTM,” Jennissen said.

Patients are scheduled for MTM at the time that they pick up their synchronized monthly medications. At the beginning of each MTM session, the local pharmacist will introduce the patient to the remote pharmacist. The remote pharmacist will review prescriptions and over-the-counter medications with the patient and complete the CMR. At the end of the session, the local pharmacist will join the patient and the remote pharmacist to wrap up the meeting.

“We still do onsite MTM, but to offer on a large scale, we have found that telehealth has been the answer. We have consultation rooms in almost all of our pharmacies,” he said.

Thrifty White also uses telepharmacy in two pilot programs to offer hospital discharge counseling. Through its patient-care center, the remote pharmacist reviews the patient’s medications before discharge and on the day of discharge. Using an iPad, the patient and any family members can speak with the remote pharmacist, who reviews a list of medications, provides direction for the patient’s next steps, and makes sure the patient understands what has been discussed. In 72 hours, the remote pharmacist follows up with a phone call to see how the patient is faring.

“Recently, through this process, we were able to speak with a patient who received a hip replacement and found out that she hadn’t taken any of her medications because she wasn’t feeling well,” Jennissen said. “Had we not called, she would not have taken her Coumadin and other medications. So we certainly were able to reduce the cost of care downstream and improve the outcome.”      

Serving rural hospitals

Also located in Fargo, North Dakota, is ePharmacist Direct, a telepharmacy operation staffed by certified clinical pharmacists serving 23 rural hospital facilities in five Midwestern states as of mid-October 2013. ePharmacist Direct is an extension of the North Dakota Telepharmacy Project, which started in 2002 after lawmakers passed legislation that allowed remote pharmacists to work with local pharmacy technicians and nurses to fill prescriptions.

Currently, ePharmacist Direct offers 24-hour pharmacy coverage to eight hospitals from the North Dakota Pharmacy Project. Seven of these belong to Catholic Health Initiatives, owner of ePharmacist Direct. The participation of the seven facilities commenced with the original grant funding.

ePharmacist Direct is a fully dedicated service that employees 16 pharmacists, 12 of them FTEs, with four working part-time, explained its director, Shelley Doherty-Johnsen, PharmD.

“For a small facility in a small town to find a pharmacist who will want to come and stay there, and staff it for 24 hours - it is virtually impossible and financially impossible,” Doherty-Johnsen said.

“The nursing staff and providers can access us at any time that their onsite pharmacist is not available. For nursing, it is a relatively seamless process, if the facility has automation. If we are processing the order or the onsite pharmacist is processing the order, the process is seamless. The nurses just know the order is there on their EMRs,” she continued.

ePharmacist Direct evaluates prospective sites with its site assessment form to determine whether they are candidates for its service. Hospitals indicate the number of onsite hours, the health information system, use of automated dispensing cabinets, and anticipated volume. Once a business service agreement is drawn up and signed, it automatically renews annually.

Typical services covered by ePharmacist Direct include order entry and verification, dosing adjustments, and pharmacist interventions to prevent adverse drug events.

“Talking face-to-face with patients for medication reconciliation and MTM will come along later, but it is not happening yet,” Doherty-Johnsen said. “However, we do have providers talk directly to us face-to-face.”

ePharmacist Direct has worked hard to expand. Last year, the program served 16 hospital facilities in three states; by the end of November, it will be serving 26 facilities in five states. This is a challenge, as the remote pharmacist must be licensed in each state that he or she serves. ePharmacist Direct helps out with the licensing fees for its clinical pharmacists, Doherty-Johnsen said.

Specialty medications/MTM

Telepharmacy is branching out beyond the retail and hospital settings. Catamaran, the fourth leading pharmacy benefit manager in the United States, started a pilot program in April for patients receiving specialty medications and patients needing MTM.

Although the numbers are small so far, with 25 specialty patients and two patients consulting with a telepharmacist for MTM, the response has been positive, said Sumit Dutta, chief medical officer for Catamaran. Most patients were more confident in their ability to use their medicines after the consultation. All patients said they viewed the video consult as an improvement over the traditional telephone conversation, and all said they would recommend the service to family members and friends.

“If you think about the patient who receives a diagnosis of multiple sclerosis, for example, he has a lot going through his mind,” said Dutta, who has experience with the specialty pharmacy-care delivery model. “In the case of MS, maybe the patient has to inject himself for the first time. Under the old-world scenario, the patient was trained through a phone conversation. Now, patients have the ability to have a video engagement that is recorded. They can pull it up when they need to.”

Through Catamaran’s specialty pharmacy Briova Rx, pharmacists can guide patients and family caregivers through the treatment process by means of a video consult in their homes. They receive their medications by mail order and schedule a time to speak to the pharmacist, who will help them better understand, administer, and manage their complex medication regimens.  “It really is about convenience and personalization,” Dutta said.

Patients can also share all their prescriptions with the pharmacist via video and receive MTM counseling. Technical requirements are simple: Patients need only an internet connection and a laptop, desktop computer, or tablet to engage with the pharmacists.

Benefits of engagement

Catamaran lists a number of benefits conferred by the video consults, including increased medication compliance, better health outcomes for patients taking medications properly, prevention of harmful drug-drug interactions, reduction of healthcare costs through avoidance of more costly services such as hospitalization, and improved quality of life.

“Our newest specialty pharmacy will have dedicated consult rooms, in order to create the right kind of environment for this kind of interaction,” said Dutta. “So wherever we engage patients with video consult, we are creating the physical infrastructure to have spaces for this. This is very different than a regular call center.”

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