For the success of any telepharmacy program, it’s important that your patients clearly understand what it encompasses and the value and scope of telepharmacy services. Having this understanding helps to yield the kind of patient engagement that’s necessary for achieving desired benefits and outcomes. Let’s start by exploring the various ways telepharmacy can be defined.
The National Association of Boards of Pharmacy's Model Pharmacy Practice Act defines telepharmacy as
“… the provision of pharmacist care by registered pharmacies and pharmacists located within U.S. jurisdictions through the use of telecommunications or other technologies to patients or their agents at distances that are located within U.S. jurisdictions.”
However, there is much more for patients to understand if they are to truly grasp the value and advantages of telepharmacy.
Still, other definitions can expand on this original one. In its statement on telepharmacy, the American Society of Health-System Pharmacists (ASHP) references the Model Act's definition but then goes on to provide its own definition for the purposes of the statement document: "… ASHP defines telepharmacy as a method used in pharmacy practice in which a pharmacist utilizes telecommunications technology to oversee aspects of pharmacy operations or provide patient care services."
An article in Pharmacy Times that defines telepharmacy includes an important caveat about broad definitions of telepharmacy when it states the following:
“Practically speaking, telepharmacy can be defined as the provision of pharmacy services through telecommunication. However, state laws usually define telepharmacy more narrowly, based on pharmacy practice in the states.”
As you can see, the definitions are similar, yet they incorporate slightly different angles. With varying definitions at work, it’s a good idea to plan how you will define telepharmacy to your patients.
When communicating with your patients, we recommend taking a straightforward approach to the definition. For example, you could definite telepharmacy as follows: "Telepharmacy is the use of technology to deliver pharmacy services to patients located at a distance." Some of these services can include comprehensive medication management (CMM), comprehensive medication reviews (CMRs), disease-specific CMM and counseling, and all other medication-related assessments and interventions.
Understanding the delivery of telepharmacy is essential for patients to comprehend the full scope of services. Pharmacists use telecommunications to deliver services; however, the type of telecommunications used can vary from program to program.
It’s important to define the types of technology your practice employs —particularly important if you intend to use technology other than a phone. While patients are generally comfortable speaking on a telephone, they may need to be educated about other audio and video platforms, such as Skype for Business, Microsoft Teams, Zoom for Healthcare, GoToMeeting, and Amazon Chime. In some cases, you’ll need to provide instructions to patients for installation for solutions to ensure the process runs smoothly.
Be sure to also communicate and define the many services that your pharmacists can deliver through telepharmacy, such as:
Drug review and monitoring
Drug information
Medication dispensing
Medication therapy management
Patient assessment and counseling
Compounding medication verification
Decision support
All of this communication goes a long way toward building rapport with your patients.
Patients who are unfamiliar with telepharmacy or have yet to personally participate in a telepharmacy session may have doubts about whether a telepharmacy experience can match that of an in-person experience.
Creating patient trust is an important part of achieving success with your program. When defining telepharmacy, make it clear to patients that your telepharmacy services are provided by registered pharmacists who possess similar training, experience, and knowledge of the professionals they have learned to trust during in-person visits to pharmacies. Consider including photos, bios, and even videos of those pharmacists who will be providing telepharmacy services to create a personal connection between patients and telepharmacists.
Another way to engender patient trust is to highlight the value that can be gained from their participation in telepharmacy. Communicate the fact that pharmacists working in a brick-and-mortar pharmacy only have insights into the prescriptions filled at that pharmacy/chain, which can lead to blind spots in a patient's medication regimen. In contrast, telepharmacists, specifically those leveraging Cureatr's Meds 360°, access a complete view of a patient's medications, irrespective of the filling pharmacy. This information greatly helps a pharmacist optimize a patient's medication regimen and avoid potential adverse events caused by said blind spots.
To round out patient education, it’s wise to give your patients some context of how telepharmacy has evolved over the years.
To better understand where we are today with telepharmacy, it’s wise to take a look back at the history and assess where it stands today.
Did you know that telepharmacy began to take shape as early as 2000? That year the North Dakota State Board of Pharmacy reported that 26 of the state's rural communities had lost their community pharmacies and more were at risk. In response, the board established pilot rules for telepharmacy in 2001 in the hopes that the virtual service could help the state's medically underserved remote rural communities restore and retain pharmacy services.
The following year, the North Dakota State University (NDSU) College of Pharmacy received a federal grant to implement a statewide telepharmacy program and test the new telepharmacy pilot rules. The pilot project proved successful, prompting the state's board of pharmacy to establish permanent rules allowing telepharmacy to be practiced on a broader scale. As NDSU notes,
“These permanent rules allow a retail pharmacy to open and operate in certain remote rural areas of the state without a licensed pharmacist being physically present in the store and allows a pharmacist to supervise a registered pharmacy technician at a remote telepharmacy site using telepharmacy technology for the purposes of dispensing prescriptions to patients, providing drug utilization review, and patient education counseling.”
The study concluded in 2008, NDSU states, with the pharmaceutical industry recognizing that telepharmacy was a safe and effective method for delivering pharmacy services in areas lacking a full-time pharmacist.
This conclusion promoted other states to change or revise their laws to permit telepharmacy, but not all states embraced telepharmacy at that time. In fact, 16 states — or about one in three — did not authorize the use of any telepharmacy or the pursuit of telepharmacy initiatives.
Fast-forward to 2019 and that number had shrunk significantly. Drug Topics reported early in the year that 45 states allowed telepharmacy, but with rules and requirements for operation continuing to vary widely. The future for telepharmacy growth looked "bright," the publication stated. By January 2019 article in The National Law Review noted, “Telepharmacy, while not necessarily a new concept, is beginning to gain more attention in the healthcare industry as a tool to improve patient care and coordination of pharmacy patient care and medication adherence.”
And then, of course, COVID-19 hit.
Though the use of telepharmacy was already on the upswing before 2020, the pandemic certainly punctuated its usefulness. The federal government quickly championed telepharmacy as a way for pharmacists and patients alike to minimize their risk of exposure to the novel coronavirus. As the Centers for Disease Control and Prevention's "Guidance for Pharmacists and Pharmacy Technicians in Community Pharmacies during the COVID-19 Response" online resource notes,
“Pharmacists who are providing patients with chronic disease management services, medication management services, and other services that do not require face-to-face encounters should make every effort to use telephone, telehealth, or telepharmacy strategies.”
To further support telehealth, the U.S. Department of Health and Human Services approved the Coronavirus Preparedness and Response Supplemental Appropriations Act, which removed many of the coverage, licensing laws, and reimbursement barriers that were stifling telehealth. The federal government also helped fund the "COVID-19 Telehealth Toolkit," designed to help organizations implement telehealth during the crisis.
Many states have issued their own public health emergencies that changed Medicaid, private payer, and licensure rules for telehealth as well insurance companies that have made adjustments to telehealth coverage. With this momentum, patients are also getting on board.
A survey of Medicare-eligible seniors by healthinsurance.com found that prior to COVID-19, only about 1 in 10 had used telemedicine. During the pandemic, 44% have used telemedicine, and about the same percentage say they intend on using it after the crisis is over. That's a 340% increase in telemedicine usage among Medicare recipients since the start of health crisis.
While much of the news has focused primarily on usage of the broader concepts of telehealth and telemedicine, telepharmacy has received its own share of attention. In an article in Pharmacy Today, Dr. Sandra Leal, president-elect of the American Pharmacists Association (APhA), states,
“Pharmacists are a great resource for patients who have questions about drug interactions, vaccines, and testing. Telepharmacy allows those conversations to happen in a safer way, with patients located in the comfort of their home, keeping the public and pharmacists safe.”
An article from the American Pharmacists Association (APhA) notes, "Just like telemedicine has been essential during the COVID-19 crisis, the same can be said for telepharmacy."
Patients are increasingly seeking telepharmacy services, which is one of the reasons why we just recently announced that Cureatr was expanding our COVID-19 response program by offering complimentary, virtual medication (i.e., telepharmacy) reviews to primary care practices.
The good news is that telepharmacy has seen increased adoption by organizations, embracing by patients, and greater support on the federal, state, and private payer levels.
Unfortunately, as we previously wrote, federal COVID-19 legislation has yet to grant national provider status to pharmacists. This, we said, constrained their abilities to help in the front-line response to the pandemic. Provider status would add undeniable value during the health crisis, one which concerned delivering telepharmacy services.
We strongly believe telepharmacy's "time is now," but view the lack of provider status as a lingering and substantial barrier to unleashing the potential for telepharmacy to make a significant difference in the fight against COVID-19 and achieving larger improvements in the way we deliver and coordinate care.
To realize the best future for telepharmacy services, the present and potential value for patients and providers must be examined. Let's review six ways telepharmacy is currently adding value for patients in our healthcare delivery system.
The potential gains that telepharmacy may bring to healthcare cannot be overstated. In 2018, an article in Perspectives in Health Information Management, the research journal of the American Health Information Management Association, stated the following: “Telepharmacy may have significant potential to transform the delivery of pharmaceutical services.”
The common types of telepharmacy services that are making the biggest difference include medication therapy management; medication selection, order review, and dispensing; patient counseling and monitoring; drug review/monitoring; verification of oral and sterile compounding; and patient assessment.
Though we discussed benefits of telepharmacy in Chapter One, let’s take a closer look at the top 4 telepharmacy benefits that will matter the most:
“Pharmacists can play a critical role in monitoring medication concerns at the beginning of use, allowing for problem solving, reinforcement, and greater patient satisfaction with and adherence to medication therapy.”
With cost considered one of the most significant drivers of medication non-adherence, the savings achieved by reducing or eliminating travel to a pharmacy can help patients better cover expenses, including those associated with their medications.
Extending Pharmacy Support
Telepharmacy's benefits apply to healthcare providers, not just patients. For example, some hospitals do not offer 24-hour pharmacy services. A 2012 national survey of hospitals conducted by the National Association of Boards of Pharmacy found that roughly one-third of hospital pharmacies lack such coverage. As an Integrated Pharmacy Research and Practice article notes,
“Telepharmacy acts as a potential alternative to around-the-clock on-site pharmacist medication review for remote hospitals. …The emerging electronic health information systems and related technologies, such as fax, and electronic health records make information more readily available to pharmacist for review before a dose is available for administration to a patient. These technologies are advancing telepharmacy services and enabling pharmacist to contribute efficiently in improving medication use.”
Other hospitals provide 24-hour coverage but with reduced staffing during slower hours (e.g., overnight). Then there are those hospitals that maintain consistent 24-hour coverage but do so with a lean staff. Telepharmacy can provide off-hours support to hospitals that take the former approach and can provide surge support or fill in when short staffing occurs for hospitals that take the latter approach.
One area that bears examining is the software improvements that are contributing to increasingly efficient delivery of telepharmacy.
Let's discuss the vital role that software plays in telepharmacy delivery. On a basic level, the delivery of telepharmacy services requires access to an interactive communication platform that enables the use of audio and/or video to connect pharmacists and patients in real time. Some commonly used HIPAA-compliant communication products include Microsoft Teams, Updox, VSee, Zoom for Healthcare, Doxy.me, and Spruce Health Care Messenger.
The good news is that there is a growing number of solutions available. One particular telepharmacy service —medication reconciliation post-discharge (MRP) — is helping pharmacists to better support patients.
Medication reconciliation post-discharge "assesses whether adults 18 years and older who were discharged from an inpatient facility had their medications reconciled within 30 days," according to the National Committee for Quality Assurance. Performing MRP is critical for catching potentially harmful omissions or changes in prescribed medications.
This becomes even more essential for for elderly patients who are typically prescribed a greater quantity and variety of medications. A frequently referenced, peer-reviewed study published in the Drug Safety medical journal revealed that approximately 53% of adults have at least one medication error in their record, 027% of patients suffer an adverse drug reaction post discharge, and 20% of patients are readmitted due to ADEs. Despite these alarming statistics, the study goes on to reveal that only 50-60% of discharged patients receive an MRP, meaning that close to half of all patients are at an elevated risk of experiencing an adverse drug event (ADE) and preventable readmission.
Three of the reasons why MRP is not being performed for all patients are as follows:
Providers are often unaware that a discharge occurred.
Pharmacists, leveraging telepharmacy software like Cureatr's Meds 360°, can play a significant role in better ensuring medication reconciliation post-discharge is performed consistently and correctly.
To understand how a software platform can help a team of telepharmacists improve medication reconciliation post-discharge for our clients' patients, let’s explore how Cureatr's Meds 360° does so:
As a result of more effective medication reconciliation post-discharge, patients can expect fewer harmful adverse drug events, lower readmission rates, and increased quality and patient satisfaction scores.
For further proof as to how telepharmacy can provide substantial benefits, we need look no further than how it has helped (and is helping) to deliver care during the coronavirus pandemic.
As the COVID-19 pandemic unfolded, federal and state governments ramped up their efforts to combat the spread of the disease. As a result, there were a slew of new legal and regulatory developments concerning telehealth. These developments are generally aimed at helping ensure patients can remain at home without jeopardizing their access to critical services. Some of the most significant changes to telehealth services were as follows:
When considering implementing a telepharmacy program, it’s a good idea to be fully informed. In the interest of clarity, let’s take an objective look at the drawbacks and benefits of pursuing telepharmacy. When you better understand the few drawbacks, you can determine if you can take steps to tackle any obstacles. Equally important is to weigh the many benefits a program can provide. Here are six telepharmacy benefits and drawbacks that you should understand:
Benefit: Expanded access to care
As mentioned previously, telepharmacy can help make healthcare more accessible to those who live in rural or isolated communities and makes pharmacy services more readily available and convenient for those with limited mobility, time, or transportation options.
Drawback: Some Americans still lack broadband access
While not necessary for the delivery of telehealth services, broadband internet greatly improves the speed and convenience, and, in turn, adoption of telepharmacy. Among the benefits of broadband is that it provides a higher speed for data transmission, which is needed for quality videoconferencing and the exchange of large quantities of healthcare information; access is constant, so there's no need to reconnect to the Internet, as is required for dial-up internet; and it does not impede phone lines. Unfortunately, millions of Americans do not have broadband access; however, this is expected to change. As the Federal Communications Commission's latest annual Broadband Deployment Report notes, the number of Americans without access to fixed broadband decreased 30% during 2017 and 2018. In addition to this momentum, lawmakers are also aggressively pushing for the expansion of broadband access.
Benefit: Substantial increase to services and patient satisfaction
Common beneficial services provided via telepharmacy include comprehensive medication management (CMM); medication therapy management (MTM); medication reconciliation post-discharge (MRP); drug information, review, and monitoring; and patient assessment and counseling. These and other telepharmacy services can help patients in a variety of ways, including, improving medication adherence, more timely access to pharmacists, reduced need for emergency care, reduced travel costs, and increased engagement in care.
Drawback: Lack of federal provider status for pharmacists
As previously mentioned, pharmacists currently lack national provider status. Without national provider status, pharmacists, including those filling telepharmacy roles, will need to be more selective of the services they offer and provide to Medicare beneficiaries to better ensure services are covered (i.e., reimbursable). While the lack of national provider status is frustrating and can reduce the benefits of telepharmacy for patients and organizations that offer telepharmacy services, there is a significant effort underway aimed at educating lawmakers about the importance of granting pharmacists provider status. The Patient Access to Pharmacists' Care Coalition (PAPCC) is a multi-stakeholder and interdisciplinary initiative aimed at developing and helping enact a federal policy proposal that would enable Medicare beneficiary access to, and pay for, Medicare Part B services by state-licensed pharmacists in medically underserved communities. In addition, there's bipartisan federal legislation — H.R. 592/S. 109 — that, as PAPCC notes, would "… amend Medicare and increase medically underserved seniors' access to healthcare through pharmacist-provided care."
Benefit: Many benefits for other stakeholders – patients, pharmacies, providers and payers
Strong arguments can be made that telepharmacy helps pharmacies, providers with telepharmacy programs, payers, and the healthcare system as a whole. For example, pharmacies that leverage telepharmacists gain the ability to cost-effectively expand the hours they can provide services to patients without needing to keep the physical pharmacy location open, reach even more patients thanks to these expanded hours, and support more patients since there will be more pharmacists available to deliver services. Provider organizations with telepharmacy programs can provide the aforementioned enhanced convenience for patients; reduce overall costs, decrease readmissions, and drive better outcomes, which are critical to achieving the goals of value-based care; boost their Healthcare Effectiveness Data and Information Set (HEDIS®) and Medicare Star ratings; and improve collaboration across the patient care team, including physicians and specialists. Finally, payers migrating toward value-based care or considering doing so are likely looking for provider organizations to offer programs that help achieve proactive management of patient health and keep patients healthy, while reducing total cost of care — all of which telepharmacy delivers.
Drawback: Inconsistent state rules
Because rules vary from state to state concerning the services pharmacists are permitted to provide and what services are permissible via telehealth, this inconsistency can create a barrier. As Drug Topics notes, "Pharmacists are already classified as providers in most states … But what that means depends on just where in state law pharmacists are classified as providers. It depends on pharmacists' scope of practice under state law. And most importantly, it also depends on what states do or do not require in terms of reimbursement for pharmacist services." When rules lack uniformity, confusion emerges. Organizations launching telepharmacy programs will need to ensure they understand the rules for their state(s) and will also need to put an increased emphasis on patient education concerning available and covered services. Patients who attempt to conduct internet research into telepharmacy services may come away with a misunderstanding of the services available to them.
It's important to note that with each drawback is that there are efforts on the state level to have all states recognize pharmacists as providers, and the push for national provider status should only help with these endeavors. In addition, the appreciation for telehealth has never been higher (thanks to the pandemic), which should serve to motivate the federal government and state governments to loosen unnecessary restrictions on services delivered via telehealth, including telepharmacy.
All of the aforementioned benefits can only be achieved by hiring the best staff to implement your program, so let’s review why talented professionals may want to join a telepharmacy.
As demand for telepharmacy has increased, so has the need for professionals to provide these virtual pharmacy services. The door is open for pharmacists and pharmacy technicians to pursue new opportunities associated with filling the role of a telepharmacist.
Here are six of the reasons why pharmacists and pharmacy technicians should strongly consider becoming telepharmacists.
The benefits realized by patients and providers from increased use of telepharmacy have only just begun to be realized. And they will not be forgotten after the pandemic. Though we anticipate that at least some of the federal, state, and private payer decisions that eliminated barriers and/or improved access to telepharmacy, during the pandemic will be rolled or scaled back once the worst of the pandemic is behind us, this will only slightly slow the momentum behind virtual care services.
Centers for Medicare & Medicaid Services Administrator Seema Verma told STAT News that she favored keeping in place the expanded telehealth access following the pandemic: "People recognize the value of this, so it seems like it would not be a good thing to force our beneficiaries to go back to in-person visits." As Healthcare IT News notes, a recent Kyruus survey found that about three-quarters of patients who have received virtual care during the pandemic said they want to see it become a standard part of care.
All of this is encouraging, but as long as pharmacists lack federal provider status, telepharmacy will be hampered. Even considering other potential barriers to growth and adoption, such as inconsistent rules from state to state and private payers varying in whether, how, and to what extent they choose to cover telepharmacy services, no obstacle is as significant as pharmacists not being permitted to practice at the top of their license and bill Medicare for their services.
Rose Abraham, PharmD, Cureatr's director of clinical pharmacy operations, sees it this way:
"We need provider status for pharmacists so they can be reimbursed for the many important services they are providing. The pandemic has led to accelerated growth of telemedicine and telepharmacy, and we are seeing the significant benefits of allowing patients to leverage these services. … We have pharmacists who are available and qualified to deliver these critical services virtually. The most significant obstacle standing in their way is lack of reimbursement. It's time to remove that obstacle."
As noted, pharmacists are playing a pivotal role in our nation's response but are being handcuffed because they lack such provider status, thus "preventing them from maximizing their contribution to this battle."
Now let's highlight some of the more significant ways that granting pharmacists with national provider status and eliminating state-level limitations on pharmacist provider status will improve delivery of care following the pandemic.
Granting pharmacists with provider status would help eliminate many of the obstacles hindering telepharmacy while motivating and enhancing the ability of pharmacists to deliver virtual services that can improve patient wellness and access, strengthen care coordination, and reduce costs, among many other benefits."Telepharmacy has demonstrated value in medication selection, order review, and dispensing; sterile admixture verification; patient counseling and monitoring; and the provision of clinical services."
Meds 360° shows everything a patient has been taking for the last 12 months, whether they went through insurance or not, which for Abraham, is a vital component.“As I learned more about Cureatr and Meds 360°, I was impressed not just by the platform, but the data it contained. It's typically very difficult to determine exactly what medications patients take because most see multiple doctors and often use multiple pharmacies to fill prescriptions.”
“With information about medications obtained with and without insurance, you can perform a complete drug utilization review since you are accessing all of the medications a patient is taking, not just some or most of them. When you're missing a piece of the medication history puzzle, you can't fully determine the potential drug interactions a patient may experience. You can only effectively educate the patient based on what you see and what you know.”
If patients had easier and expanded access to vaccines, and received regular education about their importance, vaccination and immunization rates would rise. Granting pharmacists with provider status would help eliminate logistical, financial, and regulatory roadblocks to vaccination that are jeopardizing health and wellness."Although pharmacists in all 50 states have been given the authority to administer influenza vaccines to adult patients, pharmacists in some states are still limited by which vaccines outside of influenza they are able to administer, the age of patients they are able to administer to, and whether a patient needs a prescription before getting a vaccine at the pharmacy."
Considering all of the current and potential benefits of telepharmacy, it’s clear to see that the future looks very bright, even with the obstacles such lack of provider status for pharmacists. Despite this and other challenges, it seems that telepharmacy's day is here — sooner than many expected. And that's great news for patients, healthcare providers, and our healthcare system as a whole. From what’s been prescribed to what’s being picked up — and what’s not. It’s revolutionary for clinicians, but moreover, potentially life-saving for patients. What we are able to do with this platform is changing and will continue to change healthcare for the better.
