Ensuring pharmacist review of all medications produced in rural hospitals can be a significant challenge considering the dearth of pharmacists practicing in such areas. For these communities, implementing a telepharmacy program may be a viable option compared with traditional pharmacy services. Telepharmacy services have been shown to produce the same quality of care as traditional pharmacy by ensuring access to pharmacist oversight, reducing medication errors, and maintaining regulatory compliance.
Regional Health is a five-hospital independent delivery network (IDN) in western South Dakota with a community level II trauma center, a community level III trauma center, and three smaller designated trauma receiving hospitals. The pharmacy departments within the five hospitals work closely together to provide exceptional pharmacy services to the patients in the region. Physician orders are shared health system–wide using a single medication order management system, and a single formulary and electronic health record (EHR) allows order entry from any of the five facilities. Automated dispensing cabinets (ADCs) are used throughout the health system and are replenished centrally from one of the large hospitals; in addition, all facilities have implemented bar code scanning at the bedside.
In April 2010, one of our smaller hospitals experienced the resignation of their part-time pharmacist. At the time, the hospital employed a 0.5 FTE pharmacist and one FTE pharmacy technician. Recruiting pharmacists in western South Dakota is challenging, as the area is not heavily populated and identifying a pharmacist willing to work only part time was equally difficult. At the time, the South Dakota Board of Pharmacy had just implemented telepharmacy rules for retail operations within the state, but had not addressed telepharmacy in the hospital setting. Recognizing that a telepharmacy program could serve as a solution to improve coverage in lieu of hiring a part-time pharmacist, we petitioned the board to consider approving a variance for us to operate a telepharmacy between the trauma receiving hospital and one of the larger facilities. The board asked us to submit a draft of our policies and procedures (P&Ps) for consideration.
Exploring Coverage Options
P&Ps were drafted, building on existing retail rules provided by the state board as a guideline. There are 16 elements in the retail rule describing the requirements for a telepharmacy application to be approved. All of these elements were included in the P&P for hospital-based telepharmacy, but were adapted specifically to our hospital pharmacy operation and environment. The telepharmacy P&P essentially mirrored the retail rules and the board approved the development of our telepharmacy project (see Telepharmacy P&Ps on page 46).
Obtaining administrative support for the project was straightforward, as the only other option was to send a pharmacist from one of the main hospitals to the smaller hospital daily to provide coverage, which was certainly not a long-term time- or cost-efficient option; given the required travel, the health system would need to compensate the pharmacist for this time. Operationally, the decision was made to allow the pharmacy technician full access to the pharmacy, whereas previously the technician was allowed in the medication area only under supervision of the pharmacist (see SIDEBAR). This change improved workflow significantly. In addition, the pharmacist at one of the main hospitals would charge two hours per day of time to the smaller hospital to cover the cost of pharmacist staffing for the telepharmacy service. Historically, staffing costs at the small hospital were approximately $300 per day, while the telepharmacy solution lowered costs to about $240, while simultaneously increasing the availability of daily pharmacy services.
The audio-video equipment required to set up the telepharmacy was purchased for both sites via a USDA Rural Health grant and matching funding from one of our hospital foundations. The equipment consists of a Webcam and a 42-inch monitor at each end of the link. The camera at the trauma receiving hospital pharmacy can be remotely controlled from the larger facility by the supervising pharmacist, and it can remotely pan nearly 360 degrees to view operations in any area of the pharmacy. This allows pharmacists to view the pharmacy as if they were actually present in the room with the technician. The total cost of purchasing and implementing this technology was approximately $25,000.
A second fixed focal length camera at the small hospital allows the pharmacist in the main hospital to view and check the technician’s work. A typical tablet placed under the camera will appear about the size of a ping-pong ball on the monitor in the other facility. The equipment is connected via a T1 data line, which facilitates rapid transmission of audio and video data. It provides crystal clear images at both ends, with virtually no breaks in the video or audio signals. The equipment also allows for split images on the monitor screens; both cameras in the remote location can be used simultaneously in a split screen mode. This allows the technician to continue to interact with the pharmacist while discussing what is under the other camera.
When relying on telepharmacy to deliver pharmacist oversight, a significant challenge exists in determining the process for picking medications for ADC refills. While it is possible to conduct the medication verification remotely, such a process would be labor intensive and time consuming, as each drug picked for the ADC would have to be individually checked and verified by the remote pharmacist. We were able to avoid this dilemma as our system-wide pharmacy distribution is built on a centralized model, wherein all medications for the ADCs are filled by the main pharmacy in our level II trauma center using onsite pharmacist verification. Upon delivery of the medications to our other facilities, the receiving technician can simply replenish the cabinet using bar code verification upon stocking.
Gaining Staff Buy-In
One of the most challenging pursuits when developing a telepharmacy solution is persuading the pharmacists involved of the program’s value. There is a risk that the pharmacists, particularly those who may have had no prior relationship with the proposed site, will need to be convinced to take on these additional duties. In our experience, highlighting the increase in patient safety that would result from this program was a successful approach. We emphasized the pivotal role pharmacy plays in ensuring excellent care is provided to all patients in our health system. For example, we used an analogy describing our large facility as an older sibling that is responsible for supporting the younger facilities, or siblings. Staff in the larger facilities have a responsibility to support the smaller entities in the system. Thus, be sure to educate staff on why the additional responsibilities are required.
Since the volume of orders from the smaller facilities is substantially less than the volume of the main facility, we did not need to increase staffing at the main facility. In addition, complex or high acuity patients were usually transferred to the main facility.
The state board of pharmacy allowed us a three-month grace period to run the telepharmacy program before the first inspection so we could address any unforeseen challenges and tweak the program. The first visit included board inspectors, the executive secretary of the board, and a board member. After reviewing our telepharmacy services, the board was impressed with the functionality of our audio-video link and the quality of the program, and as such, granted a variance allowing us to continue our practice. The variance requires a pharmacist to be onsite in the telepharmacy twice per month for direct supervision of the telepharmacy technician, and requires a controlled substance audit be conducted once per month. The telepharmacy technician keeps a perpetual inventory; during one visit each month, the counts of the inventory, inventory receipts, and dispensations are reviewed by the pharmacist and validated by both the pharmacist and the technician.
Due to the success of our initial telepharmacy program, we expanded this service to a second facility, which operates with a full-time pharmacist and technician. Historically, we had sent a pharmacist there to cover vacation time and sick leave for the pharmacist and technician. The new telepharmacy program allows us to provide such relief coverage remotely.
The original telepharmacy has now been operational for more than three years and we continue to make small procedural changes as needed. In retrospect, there is one feature missing from our current system: the audio-video equipment should allow the remote pharmacist to capture a permanent image or record of the products that have been checked. Our current system does not offer this functionality, thus creating a potential risk to the verification process. A permanent record would help protect both the pharmacist and the technician. We plan to upgrade the system when the current equipment must be replaced.
Administration and pharmacy are pleased with the results of the program. By directing work to where the staff is, rather than directing staff to where the work is, we have gained efficiency while providing cost savings to the health system. In addition, we no longer have to pay a pharmacist travel time to go to the smaller hospitals to verify the technicians’ work. Building the telepharmacy model and gaining board of pharmacy approval for the project was a gratifying and rewarding experience. The most significant result is the safety benefit of ensuring patients at all of the health system’s hospitals receive medications that have undergone pharmacist review.
Dana Darger, RPh, has been the pharmacy director at Rapid City Regional Hospital since 2002 and has worked in hospital pharmacy since 1983. He received a BS in pharmacy from South Dakota State University. Dana and his team established the first telepharmacy in South Dakota. He received the South Dakota Pharmacists Association Innovative Pharmacist of the Year award in 2011.
Qualities of a Successful Telepharmacy Technician
The technician chosen for the specialized role in telepharmacy should be an exceptional staff member. The pharmacy technician employed at our remote facility is a trustworthy employee and has been a certified technician for 14 years. The South Dakota board of pharmacy requires a technician to attain a minimum of 2,000 hours of experience before being allowed to work in a remote telepharmacy. A technician transitioning to this nontraditional role requires broad pharmacy experience and a pioneering spirit. Because the development of a new telepharmacy program is typically uncharted territory, the technician chosen for this role must demonstrate sound judgment and superior decision-making skills.
Regional Health Telepharmacy Policy and Procedure
Hospital 1 will operate the pharmacy department using a telepharmacy model. The telepharmacy will be supervised by Hospital 2 or Hospital 3.
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REGULATIONS / STANDARDS