Telepharmacy: Bringing the Most Accessible Health Care Provider to Rural Areas

Like most states, North Dakota has not avoided the diabetes or obesity epidemics, or other common chronic health problems. The difference in treating patients in the 70,699—square-mile state, however, is the amount of rural areas: a one-way trip to the pharmacy could exceed 50 miles for some patients.

“Telepharmacy has allowed us to extend pharmacy services where it wouldn’t be otherwise,” Howard Anderson, Jr, RPh, executive director of the North Dakota Board of Pharmacy, said in an interview with Pharmacy Times. “[Patients] don’t have to go outside of their area or rely on mail order if they don’t want to.”

The Telepharmacy Program

Developed in 2001 and launched in 2002, North Dakota’s telepharmacy program extends pharmacy services to 38 counties in the state and to 2 in neighboring Minnesota—and provides access to health care services that would not otherwise be available to approximately 80,000 patients. It is the first program of its kind to be instituted in the United States.

The telepharmacy system, developed by the North Dakota Board of Pharmacy and the North Dakota State University College of Pharmacy, relies on central and remote telepharmacy sites linked by computer, audio, and video connections. The program comprises 81 pharmacies, including 25 central pharmacy sites and 56 remote telepharmacy sites in retail and hospital settings. When it began its program, North Dakota received several federal grants from the Department of Health and Human Services’ Office for the Advancement of Telehealth, Anderson noted.

The Board of Pharmacy does not allow telepharmacy sites to open in areas that already have an existing community pharmacy, as it considers it unfair competition to the full-time pharmacist.

“We don’t want telepharmacies to be an excuse not to have a full-time pharmacist,” Anderson said. “[In towns that do not have a pharmacy,] it has actually been an excuse to have a pharmacist there because people like having a pharmacist there, so they patronize [the telepharmacy]. It has been a good business model for those pharmacists.”

North Dakota’s program allows for different methods of pharmacy operations, so the pharmacy setup can vary depending on the business model the central pharmacy chooses. The models permit a full-service telepharmacy site, staffed by registered pharmacy technicians, with a computer, video, and audio link to the central pharmacy. In this model, the pharmacist at the central site is in charge of the remote site, conducts monthly inspections of the remote site, and is responsible for maintaining records and prescription numbers at the remote site. The central site pharmacist also compares the stock bottle, drug dispensed, and drug strength via the video link before the prescription is dispensed to the patient.

Jody Doe, RPh, owns Killdeer Drug in Killdeer, North Dakota; the central pharmacy location for Beach Pharmacy, located 56 miles away in Beach, North Dakota; and New England Drug, located 95 miles away in New England, North Dakota. The community in New England had not had a pharmacy for 10 years when the telepharmacy opened, whereas Beach patients did not want to lose their local pharmacy when health reasons forced their former pharmacist to leave, Doe said. The setup at his remote locations include cameras near the filling and dispensing counters that allow him to check prescriptions, and a camera in each pharmacy’s counseling room. Doe uses Polycom video hardware in his remote sites, as well as the typical pharmacy equipment seen in traditional pharmacies.

Creating a telepharmacy remote site is definitely an investment, and can quickly become an expensive setup, Doe added. At New England Drug, his first telepharmacy, he started small and increased his services as the business grew.

Since opening his remote sites, Doe has had only 2 operational hurdles. The first was a slight delay in transmitting the video feed when the system launched, which would cause communication gaps.

“At first, the technology wasn’t real-time,” Doe said. “Everything was sent by picture, so that was a little hard. That was only the first few months, though.”

Next, Doe discovered that if the Internet goes down, he cannot receive video feeds from the remote site, which brings operations to a halt—luckily, that does not happen very often, he said.

The biggest challenge is finding a registered technician to handle the remote locations, Doe said. North Dakota requires telepharmacy technicians to be registered with the North Dakota Board of Pharmacy, have 1 year of experience as a pharmacy technician, and have graduated from an approved pharmacy technician education program or complete an application to the board demonstrating their knowledge and experience.

“It’s hard when you’re talking about a community that’s in the middle of nowhere,” Doe said. “It’s hard to get people to move there. That’s why you start in the community. You want someone who is going to be there their whole life.”

Doe said he’s worked with his technicians to register and train them via online courses, though he was also fortunate in that one of his experienced technicians was relocating to an area near one of his remote sites.

“There’s a ton of trust involved when you are not there physically,” Doe said. “You have to find good people that you can trust.”

Telepharmacy Satellite Consultation

The other community pharmacy model allowed in North Dakota is a Telepharmacy Satellite Consultation site, which has no prescription inventory. Instead, the central pharmacy site fills the prescriptions and delivers them to the satellite site, where a trained manager stores them in a locked drawer or cabinet until patients pick them up. At these sites, telepharmacy is used for patient counseling.

Nathan Schlecht, RPh, runs Gwinner Gift and Telepharmacy in Gwinner, North Dakota, which is 10 miles from Forman Drug, his central pharmacy site in Forman, North Dakota. Forman Drug is the only full-service pharmacy in Sargent County, North Dakota—for patients who do not live nearby, driving to another location is a 30-mile trip.

“I was a fairly new business owner at the time,” Schlecht said. “I had recently come back to North Dakota and had recently purchased a pharmacy, and was looking to expand my business.”

The area, home to Bobcat Company, houses several medical clinics without pharmacy services. Prior to Schlecht opening his consultation site, physician dispensing was relatively common, but the physicians couldn’t check for drug interactions, and treatments were limited to what local physicians had on hand.

“The doctors were happy for us to be able to do this,” Schlecht said. “They know that their patients are happy knowing they can get their prescriptions in their town.”

Prescriptions from Gwinner Gift and Drug tend to be faxed to Forman Drug, although some have been picked up on deliveries. The clinics often use e-prescribing, too, and specify that the script will be picked up at the remote site.

Deliveries occur 1 to 2 times per day, Schlecht said. North Dakota pharmacy law requires pharmacist consultations with prescription dispensing, so Forman Drug’s video link system is used for those, as well as for fielding patient questions about OTC products.

“We did have some patients, especially older patients, who thought it was a little strange, going into the consultation room and facing a TV screen,” Schlecht said. “That was before we had Skype and FaceTime, though. Now, I have patients who will use those to talk to their grandkids.”

Like Doe, Schlecht’s only problems operating his telepharmacies have been with the video feed, especially before high-speed Internet became popular. He admits there have been times when the weather interfered with deliveries as well, but patients tend to be very accommodating about weather delays.

Regardless of the model, pharmacists should be aware of the costs involved in setting up a remote site, as well as the business’ expenses, Schlecht said. His decision to open a remote consultation site rather than a full-service site came down to the expense to create the full-service site.

“Be realistic about your costs and how fast your business will grow,” he said. “In our towns, people can be reluctant to change. Sometimes, you have to be realistic about your goals.”