Stephanie Gernant, PharmD, MS

It’s noontime in Connecticut. I type at my dining room table surrounded by 2 laptops and my cell phone, pausing to glance up through the window at the hazy spring sky. Normally, the tinted industrial pane of my office window would save my eyes from distraction during working hours, but it’s day 13 of isolation from the coronavirus disease 2019 (COVID-19) pandemic and I’m working from home.

This morning has been terrible. I had 15 WebEx meetings scheduled with students needing to remediate a practical today, but met each with a “Can you hear me?....No, I can’t see you, but I can hear you.”

My university is being as supportive as possible, giving us faculty training and resources for tele-teaching, but there’s nothing to overcome the e-traffic issues. Eventually I gave up, canceled all the meetings, and asked each student to just write out their answers.

My frustration adapting to changes in daily life isn’t novel, as a third of the global population is on imposed lockdown.

 It’s likely some of these changes will be perpetual (if not semi-permanent) as waves of COVID-19 are projected to last many months, even with mitigation strategies enacted, and other, subsequent global pandemics predicted from increased international travel and rising antibiotic resistance rates.

Recently, the  White House expanded Medicare’s coverage for telemedicine, allowing clinicians to deliver health care services remotely, directly to a patient via digital devices.

 The lack of federal direction on telemedicine typically forces practices to navigate various and inconsistent state-laws; however, the recent and upcoming guidance from the federal government suggests that the nation is placing its bets on telemedicine. As such, pharmacists need to be at the table as part of virtual care teams.

 pharmacists be on virtual care teams, because vast evidence of pharmacists’ positive impact already exists. Rather, we should be asking 

pharmacists can be on virtual care teams.

Because even if all federal guidance were updated to allow clinicians to practice and bill across state lines, we would still face many other barriers to telemedicine implementation.

 For the sake of clarity, “clinician” refers not only to prescribers, but to all professions that provide patient care, including pharmacists. Pharmacists are clinicians who provide health care. Indeed, technical challenges are the most recognizable and common barriers to telemedicine delivery.

This raises the question of whether is it reasonable to expect us clinicians—we who are trained in patient care and not technology&mdash;to operate telemedicine technology? This has certainly been the case with other technology, such as electronic medical records (EMRs). Although EMRs have drastically improved countless variables, the expectation that clinicians operate EMRs has produced unintended consequences, including severe burnout and reduced patient satisfaction.

 In this light, I argue that clinicians, including pharmacists, should not be expected to operate our own use of telemedicine systems because we run the risk of compounding these unintended consequences. Instead, lessons learned from EMR implementation should be heeded by allowing clinicians to focus on patient care and by delegating the management and interfacing of telemedicine technology to support staff, such as telemedicine technicians.

It's important to make a distinction here: pharmacy technicians already regularly participate in telemedicine, but in doing so, usually act as clinician-extenders rather than technology managers.

For example, they may perform preliminary medication reconciliations for pharmacists’ review or practice in telepharmacy, a subset of telemedicine in which a pharmacist remotely provides supervision of technician preparing prescriptions.

Here, pharmacy technicians use technology to help pharmacists deliver services, but they are not readily facilitating, implementing, or operating the technology itself. 

Conversely, telemedicine technicians are trained in IT and are responsible for day-to-day operation and interface of telemedicine services’ hardware and software. These support staff set up, troubleshoot, maintain, and run the technology (eg, microphones, conferencing programs, privacy safeguards), and in doing so, assures that the technology does not interfere with delivering quality services.

Telemedicine technicians could improve patient/clinician satisfaction through streamlined telemedicine delivery, but would likely also save health-systems financially as clinicians could spend time seeing more patients instead of battling technology.

Indeed, these positive outcomes have already been documented with comparable, existing support roles, such as scribes.

As technically trained workers, scribes often operate and interface with EMRs on behalf of a clinician, and scribes have been known to reduce burnout and improve health care service delivery and efficiency.

It is also important to note that professional pharmacy organizations have long believed in the ability of pharmacy technicians to support informatics; however, these roles have not been widespread.

Examples of hybrid pharmacy-telemedicine technicians are few but promising, as these support staff could simultaneously act as care-extenders, assist in billing, and optimize technical aspects of service delivery.

Further, hybrid pharmacy-telemedicine technicians provide patients with IT training and ongoing support, thus improving patients’ comfort with technology—a known facilitator to telemedicine implementation.  

During the COVID-19 pandemic, telemedicine may provide the safest option for patients and health care workers alike, but without a nationwide push to train support staff, successful efforts to scale and sustain telemedicine programs could be limited to large, well-funded health centers. This would be particularly unfortunate as telemedicine could fail to achieve some of its most exciting promises by extending access to rural and underserved populations.

Dedicated telemedicine technician support staff could likely improve clinicians’ acceptance of telemedicine programs by removing IT barriers.

Taken a step further, it is reasonable to believe that some pharmacy technicians could be trained to operate telemedicine systems, allowing us clinicians to practice at the top of our licenses. The COVID-19 crisis may be the final push needed to make these support roles a reality, leading to higher quality care and improved integration of pharmacists into virtual care teams. 

Kaplan J, Frias L, McFall-Johnsen M. A third of the global population is on coronavirus lockdown - here's our constantly updated list of countries and restrictions. Business Insider. 3/28/2020. Accessed 3/30/2020 from: [https://www.businessinsider.com/countries-on-lockdown-coronavirus-italy-2020-3].

Ferguson NM, Laydon D, Nedjati-Gilani G, et al.  Report 9: Impact of non-pharmaceutical interventions (NPIs) to reduce COVID19 mortality and healthcare demand. Imperial College COVID-19 Response Team. 3/16/2020. doi: https://doi.org/10.25561/77482.

U.S. Centers for Medicare & Medicaid Services. Medicare telemedicine health care provider fact sheet.  3/17/2020.  Baltimore, MD. Accessed 3/25/2020 from: [https://www.cms.gov/newsroom/fact-sheets/medicare-telemedicine-health-care-provider-fact-sheet].

Scott Kruse C, Karem P, Shifflett K, et al. Evaluating barriers to adopting telemedicine worldwide: A systematic review. J Telemed Telecare. 2018 Jan; 24(1):4-12. doi: 10.1177/1357633X16674087.

DeChant PF, Acs A, Rhee KB, et al. Effect of organization-directed workplace interventions on physician burnout: a systematic review. Mayo Clin Proc Innov Qual Outcomes. 2019 Sep; 26;3(4):384-408. doi: 10.1016/j.mayocpiqo.

Gernant SA, Nguyen MO, Siddiqui S, Schneller M. Use of pharmacy technicians in elements of medication therapy management delivery: A systematic review. Res Social Adm Pharm. 2018 Oct;14(10):883-890. doi: 10.1016/j.sapharm.2017.

Rural Health Information Hub. Telehealth models for increasing access to pharmacy services. Accessed 3/30/2020 from: [https://www.ruralhealthinfo.org/toolkits/telehealth/2/care-delivery/pharmacy-services].

 American Society of Health- System Pharmacists. ASHP statement on the pharmacy technician's role in pharmacy informatics. Am J Health Syst Pharm. 2014 Feb 1;71(3):247-50.

 Singh LG, Accursi M, Korch Black K. Implementation and outcomes of a pharmacist-managed clinical video telehealth anticoagulation clinic. Am J Health Syst Pharm. 2015 Jan 1;72(1):70-3. doi: 10.2146/ajhp130750.

Articles

Lessons from implementing electronic medical records should be heeded by allowing clinicians to focus on patient care and by delegating the management of telemedicine to support staff, such as pharmacy technicians.
 

Pharmacist Technicians Can Play Key Role in Push Toward Telemedicine During COVID-19 Pandemic

A report from the Accountable Care Organization Research Network, Services, and Education (ACORNSEED).

Medication Therapy Management and Annual Wellness Visit

 services, the third and last section of the Pharmacists in ACOs series will focus on 3 more integration strategies for pharmacists within the ACO setting, including chronic care management (CCM), chronic disease state management (CDSM), and transitions of care (TOC).

CCM is defined as non—face-to-face services provided to Medicare patients. Patients are eligible if they have 2 or more chronic conditions expected to last at least one year or until death. These chronic illnesses pose a significant risk of death, acute exacerbation or decompensation, or functional decline. The qualifying list of chronic conditions include, but are not limited to, Alzheimer’s disease, arthritis, asthma, atrial fibrillation, cancer, chronic obstructive pulmonary disease (COPD), depression, diabetes, heart failure, hypertension, ischemic heart disease, or osteoporosis.

CDSM consists of performing disease state education to the patient or caregiver regarding his or her chronic condition(s), assessing health status, establishing patient-specific goals of therapy, identifying medication-related problems, creating a care plan, monitoring current conditions and progress to the goals of care, and documenting and tracking results of interventions provided.

TOC is the movement of a patient from one setting of care to another. For example, a patient is discharged from the hospital, then transferred to a skilled nursing facility (SNF), then returns home and follow-up with his/her primary care provider.

Q: How can pharmacists help with CCM in an ACO?

Through CCM, pharmacists’ responsibilities are broadened as they play a central role in the multidisciplinary healthcare team. Pharmacists’ impact in improving medication adherence, serves as a vital factor of improved patient outcomes. This comes at a pivotal time because as the number of pharmacists continue to increase, the expansion of their contributions are necessary for the pharmacy profession to thrive.

 In addition, primary care providers do not have sufficient time to obtain, verify or discuss extensive medication lists with a patient during a routine office visit. Some important advantages of pharmacists in CCM are their accessibility to patients with chronic disease and the ability to help patients manage their complex medication regimens in a timely manner. In the primary care setting, including ACO physician offices, pharmacists have begun to collaborate with physicians on medication optimization, polypharmacy, and medication safety. This nonphysician health care professional also has the ability to assist with preventive interventions (ie, vaccinations, lipids, osteoporosis).

 Pharmacists can play a vital role on the CCM teams by assisting with the care of these patients and working to improve quality benchmark measures. Furthermore, if a physician or another qualified health care professional (eg, pharmacist) during clinical staff time spends at least 20 minutes per month with a CCM eligible patient and establishes, implements, revises, or monitors a comprehensive care plan, Medicare will pay for these services under the Medicare Physician Fee Schedule (PFS) using Current Procedural Terminology (CPT) code 99490.

 To bill for this fee, it is required to use a certified electronic health record (EHR) for CCM patient encounters and documentation, offer 24/7 access to staff who have EHR access, appoint a practitioner for each patient, and coordinate care with proper referral to and from the hospital, specialists, or other providers. To maintain CCM services, practices must obtain patients’ consent at least annually.

Q: What is the role for pharmacists in CDSM within an ACO?

 Pharmacists are well positioned to help patients control these chronic diseases by providing education on lifestyle changes, monitoring, and medication adherence. Prior studies have shown that pharmacist involvement in CDSM improves clinical outcomes and reduces direct and indirect health care costs.

An important tool to consider when discussing pharmacist-led CDSM is the development of collaborative practice agreements (CPAs). These agreements create a formal practice relationship between a pharmacist and other health care providers, and specify what patient care services beyond the pharmacist’s typical scope of practice can be provided by the pharmacist.

These patient care services can include modification of current drug therapy, initiation of new therapy, ordering of labs, or performing physical assessment of the patient. Collaborative practice agreements combine physicians’ expertise in disease diagnosis and pharmacists’ expertise in drug therapy and disease management to allow shared responsibility of patient outcomes.

 The extent of the services authorized under the CPA depends on state laws and regulations, which are highly variable between states, and the terms of the specific agreement itself.

Q: What is the role of TOC pharmacists in ACOs?

An ACO may include hospitals, SNFs, primary care physicians and specialists, home health nursing, and hospices. If fragmented care and miscommunication result from poor transitions of a patient from one care setting to another, the inevitable outcome is an avoidable hospital readmission and increased financial cost to the health care system.

 Transitioning patients from an acute-care setting to their homes or a post—acute-care setting, or vice versa, has become a priority for hospitals and ACOs alike, as controlling the transition process can help lower unnecessary readmission rates and avoidable costs drastically. It has been shown that TOC pharmacists make an impact on optimizing clinical outcomes by providing discharge counseling and obtaining medication histories and reconciliations. This is accomplished by services such as follow-up phone calls or at-home visits within 72 hours of discharge, which has been proven to reduce readmissions.

Six Transitional Care Management Services can be performed at a primary care office to Medicare patients, and they are billable, depending on the complexity of the service provided. Pharmacists are able to bill under general supervision of a provider using CPT codes 99495 and 99496 for moderate medical complexity and high medical complexity patients, respectively. To bill for either, there must be communication with the patient or caregiver (can be telephonic) within 2 business days of discharge. The provider can bill 99495 if there is also a face-to-face visit within 14 days of discharge, and the higher code 99496 can be billed if the patient is seen face-to-face within 7 days of discharge. Services may be performed by the physician, other qualified health care professionals, or licensed clinical staff under his or her direction.

Q: What is the future role of pharmacists in ACOs?

 Because pharmacists can reach out to patents and share valuable information with other clinicians, they are in an ideal position to manage multiple aspects of patient care, improve health care quality, and decrease overall health care expenditures. Further integration of pharmacists into patient care teams will provide value to accountable care organizations. As more organizations realize the benefits of integrating pharmacists into patient care, programs involving pharmacists will become an increasingly common approach to improving health outcomes and reducing the financial burden on the health care system.

Tina Joseph, PharmD, BCACP, is Assistant Professor of Pharmacy Practice at Nova Southeastern University, College of Pharmacy, and member of ACORNSEED. Genevieve M. Hale, PharmD, BCPS, is Assistant Professor of Pharmacy Practice at Nova Southeastern University, College of Pharmacy, and member of ACORNSEED. Stephanie Gernant, PharmD, MS,

is Assistant Professor of Pharmacy Practice at Nova Southeastern University, College of Pharmacy, and member of ACORNSEED.

is Clinical Pharmacist of Pharmacy Practice at Nova Southeastern University, College of Pharmacy, and member of ACORNSEED.

 Renee Jones, PharmD, CPh, is Assistant Professor of Pharmacy Practice and Director of Preceptor Development at Nova Southeastern University, College of Pharmacy, and member of ACORNSEED. Matthew Seamon, PharmD, Esq, is Associate Professor and Chairperson of Pharmacy Practice at Nova Southeastern University, College of Pharmacy, and member of ACORNSEED.

American College of Physicians. Chronic care management tool kit: what practices need to do to implement and bill CCM codes. ACP website. acponline.org/system/files/documents/running_practice/payment_coding/medicare/chronic_care_management_toolkit.pdf. Accessed October 3, 2016.

American College of Clinical Pharmacy; Hume AL, Kirwin J, Bieber HL, et al. Improving care transitions: current practice and opportunities for pharmacists. 

2012;32(11):e326-37. doi: 10.1002/phar.1215.

Patwardhan A, Duncan I, Murphy P, Pegus C. The value of pharmacists in health care. 

 2012;15(3):157-62. doi: 10.1089/pop.2011.0030.

Manolakis PG, Skelton JB. Pharmacists’ contributions to primary care in the United States collaborating to address unmet patient care needs: the emerging role for pharmacists to address the shortage of primary care providers. 

Thompson CA. CMS explains Medicare payment for chronic care management services. 

Centers for Medicare & Medicaid Services. Chronic care management services cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/ChronicCareManagement.pdf. Published May 2015. Accessed October 3, 2016.

Edwards ST, Landon BE. Medicare’s chronic care management payment - payment reform for primary care. 

Yu J, Shah BM, Ip EJ, Chan J. A Markov Model of the cost-effectiveness of pharmacist care for diabetes in prevention of cardiovascular diseases: evidence from Kaiser Permanente Northern California. 

Cranor CW, Bunting BA, Christensen DB. The Asheville Project: long-term clinical and economic outcomes of a community pharmacy diabetes care program. 

Fera T, Bluml BM, Ellis WM. Diabetes ten city challenge: final economic and clinical results. 

Schuessler TJ, Rusinger JF, Hare SE, Prohaska ES, Melton BL. Patient satisfaction with pharmacist-led chronic disease state management programs. 

. 2016;29(5):484-489. doi: 10.1177/0897190014568672.

Greer N, Bolduc J, Geurkink E, et al. Pharmacist-led chronic disease management: a systematic review of effectiveness and harms compared with usual care. 

Weaver KK. Policy 101: collaborative practice empowers pharmacists to practice as providers. 

. pharmacytoday.org/article/S1042-0991(15)30671-X/pdf. Accessed October 3, 2016.

Academy of Managed Care Pharmacy (AMCP). Practice advisory on collaborative drug therapy management. AMCP website. amcp.org/WorkArea/DownloadAsset.aspx?id=14710. Accessed October 2, 2016.

Kmetz, A. ACO care transitions: coaching, management, and coordination. 

 psqh.com/analysis/aco-care-transitions-coaching-management-and-coordination/#sthash.3BJlF032.dpuf. Published February 4, 2015. Accessed on October 1, 2016.

Miller DA, Schaper AM. Implementation of follow-up telephone call process for patients at high risk for readmission. 

Centers for Medicare & Medicaid Services. Transitional care management services. cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Transitional-Care-Management-Services-Fact-Sheet-ICN908628.pdf. Published March 2016. Accessed on October 2, 2016.

After discussing the Basics of Accountable Care Organizations and Medication Therapy Management and Annual Wellness Visit services, the third and last section of the Pharmacists in ACOs series will focus on 3 more integration strategies for pharmacists within the ACO setting, including chronic care management, chronic disease state management, and transitions of care.