OCTOBER 01, 2007
Barbara Sax

Independent pharmacies are few and far between in rural communities. Even the community drug stores that remain in sparsely populated areas are threatened with extinction by a shortage of qualified pharmacists.

In underserved rural areas, it is all too common for pharmacy owners to shutter their stores once they retire, since new owners are difficult to find. As a result, patients are forced to drive long distances to the nearest pharmacy or to rely solely on mail order pharmacy services for all their medication needs.

Fortunately, technology is changing all that?particularly in North Dakota, where the state has passed a law that allows pharmacists to use cutting- edge telecommunications technology to provide full-service care to patients at a distance.

Under state law, retail pharmacies can operate in certain remote areas without a pharmacist physically present, as long as a supervising pharmacist can monitor activities from another location. Through the use of video-conferencing technology, licensed pharmacists at a central pharmacy site can supervise registered pharmacy technicians at a remote site. Technicians prepare the prescription and an off-site pharmacist verifies it and provides traditional drug utilization review through realtime video. The pharmacist can communicate with the technician and the patient face-to-face in real time through both audio and video links.

?It is very much pharmacy as usual, except it is done remotely,? said Ann Rathke, telepharmacy coordinator at North Dakota State University?s (NDSU?s) College of Pharmacy, Nursing, and Allied Sciences.

Working together, NDSU, the North Dakota Board of Pharmacy, and the North Dakota Pharmacists Association created the North Dakota Telepharmacy Project to address the issue of underserved rural communities using this cutting-edge technology. Through the project, pharmacies that meet specific criteria can get a grant to adopt telepharmacy to better serve their patients.


?A survey done by the state board of pharmacy revealed that 24 small communities in North Dakota had lost pharmacy services entirely, and a dozen were at risk of losing services,? said Rathke. ?Communities served by an independent pharmacy are often at risk when the pharmacist/owner wants to retire and no one wants to take his or her place. One community has been without an independent pharmacy for 18 years. Our goal is to restore and retain pharmacy services for underserved communities.?

The program has accomplished that goal in Arthur, ND, where Kathy Nelson, owner of Casselton Drug in nearby Casselton, has opened a telepharmacy. ?When I read about the program, I wanted to put a pharmacy in Arthur to serve the nursing home and the residents,? said Nelson. ?The area has a population of about 180 people, and some residents were driving up to 50 miles to get their prescriptions filled. They had a pharmacy in Arthur 20 years ago, but when the pharmacist retired, it closed.?

Mail order and Internet services, although useful in many circumstances, cannot take the place of patient/pharmacist interaction. In addition, quality pharmacy services can be at risk when a pharmacist is left out of the health care loop. This is particularly true in rural locations.

?Casselton has one doctor, and he is only here in the mornings,? said Nelson. ?There is no doctor in Arthur, so having a pharmacist available, even through teleconferencing, is important. The patients need accessibility.?

Through telepharmacy, Nelson is accessible on a 19-inch monitor to counsel patients while she is in her office in Casselton, and the patient is in a private consulting room in Arthur. ?Patients are tickled pink about the service,? she said. ?They may call me on the phone later?they know where to get me. This is a town where, like the Cheers theme song says, ?everybody knows your name.??

Teleconferencing technology has allowed Dakota Pharmacy and Wellness Center to continue to serve patients in New Salem, ND?a town with a population of between 800 and 900 that was in danger of losing its only pharmacy. ?The pharmacy in New Salem had been around for many years, but with the pharmacist shortage, it was a challenge to keep it open,? said Tony Welder, owner of the pharmacy and its parent pharmacy located in nearby Bismark. ?We have a semi-retired pharmacist who goes out there once or twice a week, but that is not sufficient. With telepharmacy, we can continue to serve those patients instead of requiring them to drive 35 miles to Bismark and back.?

Welder said that patients have come to embrace counseling from a pharmacist on camera. ?We have a private consulting area on both ends and a high-resolution camera,? he said. ?The only difference is that the pharmacist is not physically there. The patients also trust the technician, who has been with us for many years. My goal is still to get a full-time pharmacist out there, but since that is proving difficult, this is a big advantage to our patients, and that is my main concern.?


Econodrug in Wahpeton, ND (population 8500), has reached out to patients in Ottertail, Minn, through the new technology.

?We are really a part of the whole change in technology,? said Brian Steeves who owns the pharmacy with his sister, Polly Steeves, RPh. ?If we did not offer this service, people would have to drive for 20 to 30 miles or use mail order exclusively.? Brian Steeves said that the expense of gas and the limitations of mail order pharmacy services provide another option necessary for many patients.

?So many pharmacies are closing,? said co-owner Polly Steeves. ?There is no way you can afford to keep a pharmacy running with a full-time pharmacist when you are filling only 30 to 50 prescriptions a day.?

Ottertail, a lake community comprised of year-round residents whose ranks swell in the summer months, needed a pharmacy to serve its patients. The Steeves opened a telepharmacy there in 2005.

?It is really a diverse population,? she said. ?We serve vacationing families, as well as seniors and lowincome patients. Patients really need pharmacy services, and mail order is not adequate in many situations? especially when a vacationing child has an ear infection and needs medication immediately or when someone has gone on vacation and forgotten their prescription.?

She said that at first, some of her older, year-round patients were reluctant to use the teleconferencing capabilities, but most have accepted the change and have begun to embrace the new technology.


?The counseling aspect is really important to the patients,? she said. ?We can talk to patients about splitting their pills to save money or switching to a generic. We also are available to counsel on OTC products, since the store has a full supply of OTC drugs, and the patient often needs to speak with a pharmacist for a recommendation.? Pharmacists also counsel patients on Medicare D through the pharmacy?s teleconferencing technology.

Polly Steeves said the telepharmacy services have helped a number of patients. ?There are some patients that get care they would not otherwise be getting if we did not provide remote pharmacist interaction,? she said. ?We have one patient with severe diabetes.We were able to convince him of the importance of taking his medications.We also got him on Medicare Part D. That is really rewarding.?

So far, the North Dakota Telepharmacy Project has been successful in restoring valuable access to health care in remote, medically underserved areas of the state. ?About 40,000 rural citizens have had their pharmacy services restored, retained, or established through this project,? said Rathke.

Nelson is proud of the impact she has had on health care in her part of the state. ?It makes work so much more fun when you can make a difference in someone?s life. There is such a need in rural health care that you know you are making a significant contribution. You are not just here to make a buck, but to make a difference.?

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