Telepharmacy?A Promising Alternative for Rural Communities

Although the scope of telemedicineencompasses many fieldsof technology, it most commonlydescribes the practice of medicineusing videoconferencing, telephones,and the Internet.¹ Telepharmacy, a morerecent concept, is analogous to telemedicine.The National Association of Boardsof Pharmacy defines telepharmacy as"the provision of pharmaceutical carethrough the use of telecommunicationsand information technologies to patientsat a distance."¹ Already, telepharmacyhas had a significant impact, and its influenceis beginning to show promise in aparticularly underserved population?rural communities.

Rural communities have been losingvital access to health care for severalyears, at least in part due to the disappearanceof local pharmacies.² In fact,some rural pharmacies have becomeincreasingly difficult to sustain. Olderpharmacists working in these communitiescannot find their replacementsbecause of the overall nationwide pharmacistshortage and because salaries fornew pharmacists have become too competitive.Why have mail-order pharmaciesand rural health clinics not filled thisever-increasing gap? They have to someextent, but both of these alternatives failto provide an essential pharmacy service:interaction with a pharmacist. Telepharmacyprovides pharmacists with ameans to counsel patients, perform drugusereview, and verify prescriptions reliablyfor patients located at a distancefrom the pharmacist.³

How Does Telepharmacy Work?

Small pharmacies or clinics in remote,isolated areas are connected to a centralpharmacy (models have included bothretail and hospital central pharmacies)through novel software, videophone systems,and automated dispensingmachines.⁴ Patients bring their prescriptionsto the remote sites, which arestaffed by either pharmacy technicians ornurses, depending on whether the ruralsite is a pharmacy or a clinic.The central pharmacistprovides oversight via teleconferencingsystems andprocesses the prescriptionfaxed from the rural site.Then, the pharmacistreleases several items atthe rural site, including theprescription label and theprepackaged medicationfrom the automated dispensingmachine. The pharmacytechnician scans thebar code matching the prescriptionwith its label,attaches the label, and dispensesit to the patient.Finally, the central pharmacist conducts a2-way video consultation with the patient.

Advantages and Disadvantages ofTelepharmacy

As suggested earlier, the primaryadvantage of telepharmacy is that pharmacistscan provide high-level pharmaceuticalcare services in rural environmentsthat have lost or are losing accessto health care services. Access to a pharmacistis essential in rural areas becausethere are risks inherent in medicationusesystems that do not include a pharmacist.These risks include increasedmedication errors and drug interactions,unresolved adverse effects, and potentialtherapeutic interchanges not used.

Furthermore, telepharmacy can savemoney. One report showed that the costof equipment and a pharmacy technicianis about 15%, compared with openinga new store and staffing with a pharmacist.⁵ Telepharmacy uses the skills ofone pharmacist for multiple sites withoutthe additional expense of hiring apharmacist for a rural site. Also, telepharmacycan eliminate an underusedinventory in a rural setting. The automateddispensing machine could dispenseonly the most used medications andcould enhance inventory control andrecord keeping.

Improved access to medications inrural areas has led to another advantagefor telepharmacy systems: patient satisfaction.An assessment of one telepharmacyprogram revealed that >75% of thepatients were satisfied with their communicationwith pharmacists throughvideoconferencing.⁶ Patients benefitedfinancially from this program too, as 63%responded that they would have difficultyaffording their medications if their telepharmacyprogram did not exist.⁶Another study showed that telepharmacycounseling via compressed video wasmore effective than using package insertinstructions to explain the metered-doseinhalertechnique.⁷

In contrast, one of the biggest disadvantagesis that laws that regulate pharmacyoperation in most states still do notaddress the growing telepharmacy industry.By 2004, only 15 states had approvedtelepharmacy regulations or pilot projects.⁵Twenty states at that time were activelyinvestigating regulations, and 15 states hadno activity centered on developing regulationsfor telepharmacy. Unfortunately, thisis not an easy fix. Complex issues must beresolved before laws can be created inmany states.⁸ For example, the act of apharmacy technician giving a medicationto a patient in a remote setting coulddescribe an illegal dispensing action.Programs have successfully petitioned,however, to their respective state boards ofpharmacy that each patient would receivepharmacist counseling through 2-wayvideoconferencing.⁶

Although telepharmacy is a great concept,it is sometimes challengingto put into practice. One pharmacistoverseeing several ruralpharmacy sites could significantlyincrease workload, andmanagement may involve timeconsumingtravel requirementsto the rural sites?especiallywhen the pharmacy law dictatesa monthly on-site visit.During the on-site visit, managersperform several dutiessuch as restocking the automateddispensing machine, trainingor retraining personnel andpatients at the site, and monitoringinventory. Finally, the startupof a telepharmacy takes considerabletime, effort, andmoney. One article suggests that a ruralpharmacy filling 30 prescriptions per daywould take approximately 3 years tobreak even.⁴

Considerations for ImplementingTelepharmacy

Would telepharmacy be a promisingalternative for providing medicationaccess to the rural population in yourarea? Before launching a campaign foryour hospital or retail pharmacy to developfledgling rural outposts, there are a fewconsiderations that will require an actionplan.³ Here are some points to consider:

?The community itself should have asufficient need for these services. Isthere already a well-established ruralpharmacy within the community, orhave these pharmacies closed withouta replacement? Do many residentsuse mail-order services? Theseneeds can be analyzed succinctlythrough questionnaires that havealready been developed.⁹

?Do laws and regulations already existfor the state in question, or do theselaws need to be developed? Statelaws usually require remote telepharmacysites to have a license andprogram in place to receive thirdpartyreimbursement and are sometimesvery specific regarding thephysical location and establishmentof such a pharmacy.

?Inventory and technology will be keyconsiderations when designing thesite. Adequate space should be availablefor the computer, video equipment,and dispensing machine, aswell as communication needs withthe central pharmacy.

?Consider the unique environment?and skills needed?when hiring thecentral pharmacist and rural-workingpharmacy technicians. Also, otherpersonnel may be needed such as acourier for transport between thepharmacies and an accessible expertin information technology.

?Do not forget the patients and localphysicians. Remember that ruralpatients and physicians will not befamiliar with such an advanced systemfor providing pharmaceuticalcare and may require additional educationand training.

Summary

Developing technology has made telepharmacya promising alternative forproviding access to pharmaceutical carein rural communities. Inherent in aunique system of providing services isthe fact that many issues will have to beresolved first. A well-developed system,however, can be beneficial to both thepotential patients of rural communitiesand the hospital or retail pharmacies thatprovide these services.

Dr. Sherman is an associate professorof pharmacy practice at theUniversity of Louisiana at MonroeCollege of Pharmacy.

References

1. Angaran DM. Telemedicine and telepharmacy: current status and future implications. Am J Health Syst Pharm. 1999;56:1405-1426.

2. National Advisory Committee on Rural Health and Human Services. 2006 Report to the Secretary. Available at: http://ruralcommittee.hrsa.gov/nacpubs.htm. Accessed October 28, 2006.

3. North Dakota Telepharmacy Project. Telemedicine technical assistance documents: a guide to getting started in telemedicine. Chapter 10. Available at: http://telepharmacy.ndsu.nodak.edu/publications/TELEPHARMACY-TAD1.pdf. Accessed October 10, 2006.

4. Peterson CD, Anderson HC. The North Dakota telepharmacy project: restoring and retaining pharmacy services in rural communities. J Pharm Technol. 2004;20:28-39.

5. Retail Pharmacy Management. Telepharmacy making headway in remote states. Available at: www.retailpharmacymgmt.com/indexpub.cfm?pubid=10. Accessed October 26, 2006.

6. Clifton GD, Byer H, Heaton K, Haberman DJ, Gill H. Provision of pharmacy services to underserved populations via remote dispensing and two-way videoconferencing. Am J Health Syst Pharm. 2003;60:2577-2582.

7. Bynum A, Hopkins D, Thomas A, et al. The effect of telepharmacy counseling on metered-dose inhaler technique among adolescents with asthma in rural Arkansas. Telemed J E Health. 2001;7(3):207-217.

8. Gulliford SM, Schneider JK, Jorgenson JA. Using telemedicine technology for pharmaceutical services to ambulatory care patients. Am J Health Syst Pharm. 1998;55:1512-1515.

9. North Dakota Telepharmacy Project. Is a telepharmacy right for my community? Available at: http://telepharmacy.ndsu.nodak.edu/publications/communitymanual.htm. Accessed October 9, 2006.