The Potential for Telehealth Within the Pharmacy Space

AUGUST 20, 2015
Jeffrey Kosowsky, MD, PhD
Community Focus
Back in the 1950s and 1960s when Leave It to Beaver was on the living room television set, the local, family-owned pharmacy was a pillar of the community. Patients had a personal, long-term relationship with their pharmacist who, in many ways, was just as trusted as their family physician. Over time, however, pharmacies have become more commercialized and increasingly focused on retail volume and footprint expansion—a focus that has created a host of new challenges. With large chain drugstores on every street corner, pharmacies are looking for new ways to attract, sell to, and retain customers. Although new services are one way to regain customer loyalty, there is a limit to how many services can be brought in-house. Partnering with key players within health care is worth consideration.

Pharmacists have faced unique new challenges as the pharmacy industry has evolved. According to the Kaiser Family Foundation, more than 4 billion prescriptions were filled in US pharmacies in 2014,1 which has inevitably led pharmacists to focus more on volume and efficiency than on delivering personal care. Pharmacists often have little time to provide education about a specific prescription nowadays. Bureaucracy and regulatory procedures within the pharmacy space also make it difficult for pharmacists to provide the same intimacy of care that our parents and grandparents remember.

The Benefits of Telehealth
Telehealth is a cost-saving solution that uses telecommunications technologies to expand health care outside the walls of a retail pharmacy while complementing and enhancing existing retail pharmacy services. When implemented, telehealth can also assist pharmacists with creating and managing new relationships with customers. However, it is important to note that telehealth is not a one-size-fits-all product; there are many different applications for it within the pharmacy environment. As with any new health care investment, the key-use cases should be tailored to the customer population and needs of each specific store and chain:

Customer-Initiated Consultations
Customers with questions about their medication can use online video visits to connect with local pharmacists from the comfort of their own home. Live video conversation provides a much more satisfying and effective experience for the customer who now does not have to drive back to the store and wait in line to see the pharmacist. Telehealth also extends care to include nonpharmacy hours so that customers who take their medication before bed can immediately connect to an available remote pharmacist with any questions at the point and time of administration, with software automatically routing the video call to an available pharmacist at a store with extended hours. This use also benefits caregivers, who may not have been present with the patient when picking up the prescription because they, too, can initiate an online visit to ask questions about a specific medication—including administration, efficacy, adverse effects (AEs), and drug interactions—on behalf of their loved one.

Pharmacist-Initiated Consultations
There are many scenarios in which pharmacists may wish to connect with a customer to ask questions or follow up. Whether a customer has an unclaimed script or is due for a refill, telehealth provides pharmacists with a personalized way to connect in real time. For more complicated specialty therapeutics, a local pharmacist or maybe even a central specialty pharmacist may need to reach out to ensure that patients are taking their medication as prescribed without AEs and are compliant with their treatment plans. Telehealth is an easy way to check in on high-risk patients or those with complicated medication regimens, such as elderly patients with multiple chronic diseases. Observing how a patient looks, acts, and interacts via high-definition video can be a good indicator of whether the medication is effective and a way to identify early signs of subtle side effects or the need for medical follow-up or in-person assistance.

Pharmacist-to-Pharmacist Consultations
Junior pharmacists used to spend several years apprenticing with a more experienced pharmacist. Today, newly minted pharmacists who are dispensing more complicated therapeutics from an ever-expanding drug formulary may not have ready access to experienced practitioners who can answer questions and provide additional information on a specific medication. An effective telehealth solution can immediately connect any pharmacist with a network of available, more experienced, or specialty pharmacists from anywhere within the pharmacy chain. This is especially important today for specialty therapeutics that may be rarely filled at any given store and are often shipped from a specialty pharmacy for local dispensing. With telehealth, local pharmacists can quickly videoconference with a remote specialty pharmacist to address questions or concerns.

Connecting Pharmacists to Care Management Teams
Whereas telehealth initially focused on urgent care conditions, it is now moving toward chronic care and population health management. In many of these medical situations, patients have a pre-established care team with whom they are in regular communication.

When questions arise in the pharmacy arena, telehealth can enable the pharmacist to join remotely and interact with the established care team—independent of geography—via a live video link. (Click here to read more on interoperability.) The pharmacist and patient can discuss the medication regimen with other members of the care team, making any necessary adjustments to drug therapy or dosage in real time at the point of dispensing.

Additionally, the pharmacist can be linked to the care team when medication changes are indicated. For example, consider a patient with congestive heart failure who unwittingly gains several pounds during a weekend spent binging on hot dogs and pickles. Monday morning, when the patient steps on her digital scale, her weight is captured by the Apple Health app on her iPhone. (Click here for more on personal health care technology.) These data can then be shared with the patient’s doctor seamlessly through a mobile telehealth provider, and the physician can then inform the patient and/or pharmacist that the diuretic dosage needs to be increased. From there, a prescription is relayed to the patient’s pharmacy of choice. Thus, care is delivered in a highly informed, well-coordinated manner, with minimal interruption and inconvenience, while mitigating the risk of the patient landing in the emergency department.

On-demand Care via In-store Kiosks
Some retail pharmacies have already established urgent care services within the footprint of the retail store. Such services have been well received by consumers, but limited by the costs and availability of nurse staffing. The economics of nurse staffing do not makes sense for every store. Moreover, although there is an increasing number of 24/7 pharmacies, few pharmacy urgent care services are staffed past the early evening hours to treat patients who present in the middle of the night.

Telehealth kiosks can offer the best of both worlds. In-store kiosks offer an affordable pharmacy urgent care service without the expense and staffing challenges of on-premise nurses, especially for smaller, lower traffic stores. A companion pharmacy-branded mobile or web app is also available to consumers who wish to access the same telehealth platform from home, work, or while traveling, and encourages patients to pick up any prescriptions at the associated pharmacy.

For stores with existing nurse-staffed urgent care, a kiosk-based telehealth interface can be added to exam rooms to extend the hours of coverage via telehealth beyond the staffed nursing hours. Nurses can also use the consoles to consult in real time with a physician when they encounter urgent care situations that they are not trained or licensed to address. This hybrid model combining nurse staffing with telehealth consoles extends both the hours and range of care that can be delivered within a retail pharmacy footprint.

The Value Proposition
For pharmacists, telehealth can enhance patient relationships and maintain customer loyalty while simultaneously improving care and extending patient services. For consumers, telehealth offers convenient, immediate access to the pharmacist and high-quality urgent care services from a trusted, neighborhood source. By implementing a range of pharmacy-related telehealth services, pharmacy chains can move beyond competing as an undifferentiated mass marketer of health and beauty items to becoming a hub for trusted consumer health and pharmaceutical care services.

Positive Steps
Over the past year, there has been substantial movement toward creating a more positive national telehealth environment. The Federation of State Medical Boards (FSMB) has been working on a State Licensure Compact to allow physicians living in states that participate in the compact to provide telehealth care for patients across state lines, making it easier to extend care across geographic boundaries. In April 2014, the FSMB published a Model Policy for Telehealth that highlights the most critical factors for safe telehealth. These factors include patient choice of provider, informed visits, and audio-video capability (phone-only consults are not substantial enough for an effective telehealth consult). In May 2014, the American Medical Association endorsed this policy. The American Telemedicine Association launched the first national accreditation program for telehealth solutions providing online care.

Remaining Challenges
Implementing a telehealth solution and creating a telehealth presence is only the first step. As with any new technology, careful attention to consumer education and marketing is required to change behavior and encourage adoption. Telehealth should be pursued as a long-term investment in consumer-driven health care that evolves and addresses the quartet of key consumer demands: convenience, trust, quality, affordability.

Pharmacy boards have perhaps not been as active as their medical counterparts in discussing and evaluating the proper and safe application of telehealth. As referenced above, the majority of medical boards have already identified the critical components of a legitimate telehealth interaction. The time is now for pharmacy boards to join the discussion regarding the creation of state regulations to support safe and effective telehealth pharmacy care.

These challenges, although relevant, should not deter pharmacies and retailers from integrating telehealth into their business models. If implemented correctly and with the right partner, telehealth is an exciting new way to engage consumers and bring care into the community. Finally, it is important to recognize that telehealth should not be viewed as competition for retail pharmacy, but rather, as a complementary service offering that can build on existing customer relationships and brand recognition to enhance customer loyalty and drive in-store foot traffic (see Table).

Table: Golden Rules for a Successful Telehealth Launch
  1. Start with a simple-use case that identifies high priorities and value for you and your customers.
  2. Set goals and an appropriate timeline for consumer adoption, progress measurement, and fine-tuning of processes as the programs mature.
  3. Invest sufficiently in both consumer and provider/pharmacist education and promotion.
  4. Leverage your existing brand, in-store assets, and customer relationships to extend, rather than compete with, your existing services.
  5. Pool existing underutilized pharmacists and other provider resources and use your existing team to manage the program. New hires should be the exception rather than the rule.
  6. Do not take a do-it-yourself approach to telehealth. Work with an experienced telehealth provider who offers a comprehensive solution and can customize a program to meet your needs. A telehealth solution should be turnkey.
The Last Word
Never lose sight of the main objective: consumer satisfaction. Telehealth, although relatively new to mainstream media and culture, has been around for the past decade. We may not be able to go back in time to the era of Leave It to Beaver, but we can leverage powerful new socially oriented technologies to recreate the intimate relationship between consumers and their pharmacists of years past. Telehealth solutions bring more convenient, affordable, quality, and trusted care to consumers; pharmacies and pharmacists are an important part of this solution.


Jeffrey Kosowsky, MD, PhD, is senior vice president of corporate and business development at American Well, the largest national telehealth company and a key innovator in the industry since its founding in 2007. Dr. Kosowsky is a business management and consulting veteran, with more than 20 years of experience in health care and health information technology, and a former associate principal at McKinsey & Company. He earned his medical degree from Harvard Medical School and his PhD, AM, and AB summa cum laude in applied mathematics from Harvard University.


Reference 
  1. Total number of retail prescription drugs filled at pharmacies. The Henry J. Kaiser Family Foundation website. http://kff.org/other/state-indicator/total-retail-rx-drugs/. Published 2014.




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