The long-standing shortage of pharmacists in the United States has impacted rural areas in particular, where many counties must do without a single pharmacy or pharmacist. Pharmacists working in rural areas often provide coverage for multiple counties and locations, from community pharmacies and small hospitals to skilled nursing facilities. These regional shortages mean that many locations benefit from the expertise of a pharmacist on an infrequent basis (eg, an hour or two a day, once weekly). This leaves rural pharmacists at a high risk for burnout due to excessive workloads and the difficulty of taking time off given the challenges and costs associated with arranging coverage. For these, and other reasons, effective telepharmacy or remote order entry operations can have positive, wide-reaching influence.
At Via Christi Health, based in Wichita, Kansas, we initially established our ePharmacy program to provide pharmacist remote order entry (ROE) services, both for the hospitals within our health system and for other small hospitals in Kansas. We also wanted to position ourselves to provide telepharmacy services, such as remote supervision of pharmacy technicians, when such regulations are developed and approved in Kansas. The primary goal for our ePharmacy service is to improve patient safety and medication therapy outcomes in a cost-efficient manner by leveraging our resources to extend the provision of pharmacist services to locations and times of the day not currently covered.
Establishing and Troubleshooting the Electronic System
In order to create a reliable platform for the remote pharmacists to work from, we needed to develop a computer system that would provide consistent uptime. Working with our information technology (IT) team, all of the needed pharmacy applications for both internal and external hospitals were installed onto the computer system, but the program setup varies according to the hospital receiving services. For example, the set up for the Via Christi hospitals in Wichita includes the VPN (virtual private network), PIS software, medication order management software, medication administration checking software, drug information software, the virtual desktop, and other hospital-specific information such as a therapeutic interchange table. Alternatively, the small hospital setups in Kansas include a simpler set of tools. In any case, the suite of applications was then duplicated onto all the computers used by ePharmacy staff in order to ensure consistency. Once the suite of applications was loaded onto all of the computers, the system was frozen so that any time the computer was rebooted, it would automatically revert to the original programs.
The pharmacists working from their remote offices simply needed a high-speed Internet connection to connect to the ePharmacy VPN. While this connection helped get the program up and running quickly, every system upgrade required an IT staffer to unfreeze the computer and manually update each of the 20 computers deployed. To solve this problem, we worked with IT to develop a virtual desktop that allowed pharmacists to have access to all of the necessary applications from any work location, as long as they had Internet access. With a virtual desktop, ePharmacy-issued computers were no longer necessary. This also helped improve our ability to rapidly apply upgrades, since only the virtual desktop needed to be updated, as opposed to individual computers.
Selecting and Training Remote Pharmacists
We began the initial recruitment for pharmacists to work remotely for our ePharmacy program by simply posting a job opening on our health system’s Web site. While we were prepared to send out postcards to every pharmacist licensed in the state of Kansas, this turned out not to be necessary, as 16 people applied for the openings in the first two weeks. The interviews were all conducted by telephone, and physical exams and drug screens were set up in each pharmacist’s hometown. Currently, we have pharmacists working from as far away as Oregon, Minnesota, and Pennsylvania. While going through this process, we observed that many of the pharmacists that work for ePharmacy have similar work characteristics. That is, they tend to be very flexible, are willing to help each other out, are able to adapt to change successfully, and are very open to innovation.
All of the training for the remote pharmacists was done virtually as well. We set up a method by which the director of ePharmacy can monitor and supervise the medication orders in real time as they are entered by the remote pharmacist, just as if they were onsite and working side-by-side. This method of training has allowed us the opportunity to hire candidates from across the US, requiring only that they have a current Kansas pharmacy license.
The original concept for staffing revolved around the belief that a remote pharmacist could profile an average of 45-50 physician medication orders per hour. Depending on the size and acuity of a hospital, we determined that a pharmacist working the third shift could successfully manage three or four community hospitals with an average daily census of approximately 60-70 patients each. We also determined that one pharmacist could manage 12 critical access hospitals, based on volume and an agreement that the orders would be reviewed on a daily basis.
Providing Consistent Quality
The goal has always been for our remote pharmacists to provide the same level of quality and service as our onsite pharmacists. In addition, we wanted the remote service to be seamless and transparent to the caregivers who are working onsite. Therefore, pharmacists working for our ePharmacy program are expected to know and follow local policies and procedures, formularies, therapeutic interchanges, etc. We monitor the effectiveness and productivity of each pharmacist, and provide rapid feedback to them anytime there is a problem or service issue. We monitor the number of orders entered per hour, and all of our pharmacists are averaging around 45-50 orders per hour. However, that can be misleading, as a low patient census does not provide as many opportunities for order entry, so the number of orders per hour can be substantially above or below the average. For some of the smaller hospitals that lack sophisticated automation technology, it can be very difficult to quantify the number of orders entered. We also track the number and quality of clinical pharmacy interventions performed and documented. Finally, we receive routine feedback from each site regarding the quality of the service provided. For non-Via Christi hospitals, the director of ePharmacy will contact the director of nursing to review how things are going and to ensure they are receiving excellent service. In addition, the hospitals’ executive leadership knows that they can call or email our ePharmacy director at any time if they have questions or concerns.
With quality of service in mind, as well as the apparent shortage of pharmacists, we developed two staffing models to run concurrently—one that involved ePharmacy hiring their own employees, who would be cross-trained to provide services to all contracted hospitals, and another model that incorporated the creation of a group of dually employed pharmacists (ie, they would work both as an onsite pharmacist at one of our health-system hospitals, and for the ePharmacy program on a revolving basis). The first ePharmacy pharmacist hired was assigned to work Monday through Friday from 22:00-02:00. This time of the day was identified as a critical time of coverage at our larger hospitals, as the volume of medication orders was still high, but most of the second shift team went home by 23:00, leaving the onsite, third shift pharmacist alone with a heavy workload. Therefore, the ePharmacy staff would provide additional coverage for the third shift team so that medication orders could be processed in a timely manner. Our existing pharmacists who wanted to take part in the program, instead of moonlighting at an outside pharmacy, began to work a few hours a week for ePharmacy covering a specific day of the week. In general, this group covers the hospitals from 17:00-22:00, and have done so for the past two and a half years. Of note, the staffing model for our smaller hospitals is somewhat different, such that to provide consistent coverage to those that are critical access hospitals, only one or two remote pharmacists were trained on the variety of computer systems they had in place.
Creating StandardizationOne of the biggest challenges faced by pharmacists working remotely is the lack of standardization among the hospitals they are serving. The pharmacist must be aware of and be able to deal with differences in hospital formularies, computer systems, policies, personnel, et al. This is one of the reasons our health system has decided to work toward standardizing pharmacy services. However, we will always need to work with the different systems and processes that we encounter when serving hospitals outside of our health system. Thus, it is critical that the pharmacists who are hired to work remotely understand that they will need to be flexible and fully engaged in learning to work with disparate systems and processes.
While dealing with multiple formularies, order entry systems and processes, and therapeutic interchange practices has created numerous challenges for our team, working toward standardization has greatly benefited both the remote pharmacists and the onsite pharmacists. For example, one hospital numbered all of their order sets, making it easy for the pharmacist to look up and enter the order set by its number, while another used the physician’s name and procedure to identify orders. To make it easy for the remote pharmacist to quickly locate the proper order set, we asked the second hospital to use the existing order set number as the order identifier. This standardization helps the team increase productivity while ensuring the correct order set is chosen for patient safety. It is worth noting that moving towards significant standardization often raises concerns that pharmacist jobs could then be outsourced to other countries. Accordingly, we believe it would be in the best interests of each state board of pharmacy to require all pharmacists providing services in that state to be licensed to practice in that state (rather than just requiring the business to be licensed in that state). This is the only way that the state board will be able to control the quality and safety of the services being provided to their patients. Each state board of pharmacy may also wish to consider specific regulations addressing this issue.
Impact Regulatory Development
For hospitals accredited by the Joint Commission (TJC), standard MM.05.01.01 indicates that a pharmacist must review the appropriateness of all medication orders for medications to be dispensed in the hospital. Although this standard supports the need for expanded pharmacist services, many small and rural hospitals do not seek accreditation by TJC. Nevertheless, many individual state boards of pharmacy require certain levels of pharmacist service. Additionally, hospitals with patient safety technology, such as bar coded medication administration at the bedside, certainly benefit from pharmacist-provided review and profiling of medication orders in a timely manner.
Further to this, the American Society of Health-System Pharmacists (ASHP) formally advocates that “boards of pharmacy adopt regulations that enable the use of United States-based telepharmacy services for all practice settings.”1 In addition, the National Association of Boards of Pharmacy (NABP) includes “the practice of telepharmacy within and across state lines” in its definition of pharmacy practice. Despite this, the availability and consistency of telepharmacy regulations across states is lacking.2 If your state does not currently have regulations that cover telepharmacy and remote order entry, there are several things you can do to help change this. First, remember that each state board of pharmacy is independent and has its own priorities and methods for developing regulations, thus it would be worthwhile to contact one or more of your state’s board members to learn more before developing an action plan. Give consideration to the fact that the needs and concerns surrounding telepharmacy regulations may be different in the hospital and community settings. Be sure to focus on the importance of expanding the reach of pharmacist services in order to meet patient needs and enhance safety. Finally, offering to serve on a task force to help research and draft regulations may be appreciated and help move the process forward.
Extend the Reach of Telepharmacy Services
Establishing coverage for the hospitals in our organization was our primary task, but building a client base of hospitals outside the organization was also very important to the ongoing growth and development of the program. In one instance, reviewing and validating orders for a local hospital helped that facility improve their financial performance by processing the billing cycle on a daily basis instead of waiting 3-4 days for the orders to be reviewed and charged. Pharmacist coverage has also helped outside hospitals implement additional safety initiatives, such as bedside medication verification.
Cost justification of ROE and telepharmacy services will vary by the needs and current capabilities of each facility and setting. Each ROE/telepharmacy service provider will have its own pricing models, so it is worthwhile to get bids from and evaluate several providers. In addition to cost, quality and flexibility should be carefully assessed. In our health system, we have demonstrated that ROE improves service levels and allows more time to provide clinical pharmacy services.3 The cost-savings associated with expanded clinical pharmacy services more than offset the cost of providing the service. For other hospitals, the primary benefit may come from allowing them to meet regulatory requirements for 24-hour coverage, or from attendant patient safety improvements.
We have continued to expand our ePharmacy program since its inception, to hospitals both within and outside our health system. We have worked with our state board of pharmacy to help draft telepharmacy regulations, which we expect to be approved in the near future. Telepharmacy regulations will greatly expand the types of services we can provide remotely, and will bring added value and efficiency. Medications will be able to be dispensed for patient administration in smaller hospitals with a real time pharmacist check, rather than a retrospective review. In addition, we foresee opportunities to reach patients directly via a two-way audiovisual link to provide education, medication therapy management, drug information consultation, and other valuable services. We also believe the availability of ROE and telepharmacy services will be of great value to pharmacists, patients, and other members of the health care team in the form of increased patient safety, better accessibility to a pharmacist, and reduced burnout for pharmacists living and working in rural areas. We have found it easy to recruit pharmacists to work for our ePharmacy program, thus creating a pool of pharmacists with a broad range of experience and expertise, which in turn allows us to meet the needs of a variety of hospitals and settings.
Jim Garrelts, PharmD, FASHP, is the executive director of pharmacy for Via Christi Health system and the director of pharmacy for the Via Christi hospitals located in Wichita, Kansas. He obtained a BS from the University of Kansas and a PharmD and post-doctoral residency training from the University of Texas at Austin and the University of Texas Health Science Center in San Antonio, respectively.
Mark Gagnon, PharmD, is the director of ePharmacy at Via Christi Health. He obtained his BS and PharmD from the University of Kansas.
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