- CONDITION CENTERS
Although the scope of telemedicine encompasses many fields of technology, it most commonly describes the practice of medicine using videoconferencing, telephones, and the Internet.1 Telepharmacy, a more recent concept, is analogous to telemedicine. The National Association of Boards of Pharmacy defines telepharmacy as "the provision of pharmaceutical care through the use of telecommunications and information technologies to patients at a distance."1 Already, telepharmacy has had a significant impact, and its influence is beginning to show promise in a particularly underserved population?rural communities.
Rural communities have been losing vital access to health care for several years, at least in part due to the disappearance of local pharmacies.2 In fact, some rural pharmacies have become increasingly difficult to sustain. Older pharmacists working in these communities cannot find their replacements because of the overall nationwide pharmacist shortage and because salaries for new pharmacists have become too competitive. Why have mail-order pharmacies and rural health clinics not filled this ever-increasing gap? They have to some extent, but both of these alternatives fail to provide an essential pharmacy service: interaction with a pharmacist. Telepharmacy provides pharmacists with a means to counsel patients, perform druguse review, and verify prescriptions reliably for patients located at a distance from the pharmacist.3
How Does Telepharmacy Work?
Small pharmacies or clinics in remote, isolated areas are connected to a central pharmacy (models have included both retail and hospital central pharmacies) through novel software, videophone systems, and automated dispensing machines.4 Patients bring their prescriptions to the remote sites, which are staffed by either pharmacy technicians or nurses, depending on whether the rural site is a pharmacy or a clinic. The central pharmacist provides oversight via teleconferencing systems and processes the prescription faxed from the rural site. Then, the pharmacist releases several items at the rural site, including the prescription label and the prepackaged medication from the automated dispensing machine. The pharmacy technician scans the bar code matching the prescription with its label, attaches the label, and dispenses it to the patient. Finally, the central pharmacist conducts a 2-way video consultation with the patient.
Advantages and Disadvantages of Telepharmacy
As suggested earlier, the primary advantage of telepharmacy is that pharmacists can provide high-level pharmaceutical care services in rural environments that have lost or are losing access to health care services. Access to a pharmacist is essential in rural areas because there are risks inherent in medicationuse systems that do not include a pharmacist. These risks include increased medication errors and drug interactions, unresolved adverse effects, and potential therapeutic interchanges not used.
Furthermore, telepharmacy can save money. One report showed that the cost of equipment and a pharmacy technician is about 15%, compared with opening a new store and staffing with a pharmacist.5 Telepharmacy uses the skills of one pharmacist for multiple sites without the additional expense of hiring a pharmacist for a rural site. Also, telepharmacy can eliminate an underused inventory in a rural setting. The automated dispensing machine could dispense only the most used medications and could enhance inventory control and record keeping.
Improved access to medications in rural areas has led to another advantage for telepharmacy systems: patient satisfaction. An assessment of one telepharmacy program revealed that >75% of the patients were satisfied with their communication with pharmacists through videoconferencing.6 Patients benefited financially from this program too, as 63% responded that they would have difficulty affording their medications if their telepharmacy program did not exist.6 Another study showed that telepharmacy counseling via compressed video was more effective than using package insert instructions to explain the metered-doseinhaler technique.7
In contrast, one of the biggest disadvantages is that laws that regulate pharmacy operation in most states still do not address the growing telepharmacy industry. By 2004, only 15 states had approved telepharmacy regulations or pilot projects.5 Twenty states at that time were actively investigating regulations, and 15 states had no activity centered on developing regulations for telepharmacy. Unfortunately, this is not an easy fix. Complex issues must be resolved before laws can be created in many states.8 For example, the act of a pharmacy technician giving a medication to a patient in a remote setting could describe an illegal dispensing action. Programs have successfully petitioned, however, to their respective state boards of pharmacy that each patient would receive pharmacist counseling through 2-way videoconferencing.6
Although telepharmacy is a great concept, it is sometimes challenging to put into practice. One pharmacist overseeing several rural pharmacy sites could significantly increase workload, and management may involve timeconsuming travel requirements to the rural sites?especially when the pharmacy law dictates a monthly on-site visit. During the on-site visit, managers perform several duties such as restocking the automated dispensing machine, training or retraining personnel and patients at the site, and monitoring inventory. Finally, the startup of a telepharmacy takes considerable time, effort, and money. One article suggests that a rural pharmacy filling 30 prescriptions per day would take approximately 3 years to break even.4
Considerations for Implementing Telepharmacy
Would telepharmacy be a promising alternative for providing medication access to the rural population in your area? Before launching a campaign for your hospital or retail pharmacy to develop fledgling rural outposts, there are a few considerations that will require an action plan.3 Here are some points to consider:
?The community itself should have a sufficient need for these services. Is there already a well-established rural pharmacy within the community, or have these pharmacies closed without a replacement? Do many residents use mail-order services? These needs can be analyzed succinctly through questionnaires that have already been developed.9
?Do laws and regulations already exist for the state in question, or do these laws need to be developed? State laws usually require remote telepharmacy sites to have a license and program in place to receive thirdparty reimbursement and are sometimes very specific regarding the physical location and establishment of such a pharmacy.
?Inventory and technology will be key considerations when designing the site. Adequate space should be available for the computer, video equipment, and dispensing machine, as well as communication needs with the central pharmacy.
?Consider the unique environment?and skills needed?when hiring the central pharmacist and rural-working pharmacy technicians. Also, other personnel may be needed such as a courier for transport between the pharmacies and an accessible expert in information technology.
?Do not forget the patients and local physicians. Remember that rural patients and physicians will not be familiar with such an advanced system for providing pharmaceutical care and may require additional education and training.
Developing technology has made telepharmacy a promising alternative for providing access to pharmaceutical care in rural communities. Inherent in a unique system of providing services is the fact that many issues will have to be resolved first. A well-developed system, however, can be beneficial to both the potential patients of rural communities and the hospital or retail pharmacies that provide these services.
Dr. Sherman is an associate professor of pharmacy practice at the University of Louisiana at Monroe College of Pharmacy.
1. Angaran DM. Telemedicine and telepharmacy: current status and future implications. Am J Health Syst Pharm. 1999;56:1405-1426.
2. National Advisory Committee on Rural Health and Human Services. 2006 Report to the Secretary. Available at: http://ruralcommittee.hrsa.gov/nacpubs.htm. Accessed October 28, 2006.
3. North Dakota Telepharmacy Project. Telemedicine technical assistance documents: a guide to getting started in telemedicine. Chapter 10. Available at: http://telepharmacy.ndsu.nodak.edu/publications/TELEPHARMACY-TAD1.pdf. Accessed October 10, 2006.
4. Peterson CD, Anderson HC. The North Dakota telepharmacy project: restoring and retaining pharmacy services in rural communities. J Pharm Technol. 2004;20:28-39.
5. Retail Pharmacy Management. Telepharmacy making headway in remote states. Available at: www.retailpharmacymgmt.com/indexpub.cfm?pubid=10. Accessed October 26, 2006.
6. Clifton GD, Byer H, Heaton K, Haberman DJ, Gill H. Provision of pharmacy services to underserved populations via remote dispensing and two-way videoconferencing. Am J Health Syst Pharm. 2003;60:2577-2582.
7. Bynum A, Hopkins D, Thomas A, et al. The effect of telepharmacy counseling on metered-dose inhaler technique among adolescents with asthma in rural Arkansas. Telemed J E Health. 2001;7(3):207-217.
8. Gulliford SM, Schneider JK, Jorgenson JA. Using telemedicine technology for pharmaceutical services to ambulatory care patients. Am J Health Syst Pharm. 1998;55:1512-1515.
9. North Dakota Telepharmacy Project. Is a telepharmacy right for my community? Available at: http://telepharmacy.ndsu.nodak.edu/publications/communitymanual.htm. Accessed October 9, 2006.