How rural pharmacies are providing 24/7 service

Where there is crisis, there is also opportunity, and one Wichita, Kan., pharmacist sees plenty of that. Only a handful of Kansas hospitals can afford 24-hour pharmacy service. "Once the day-shift pharmacist goes home, many hospitals have a tech or a nurse taking over," Mark Gagnon said. "They don't want to do the pharmacist's job, but what do you do when there's no pharmacist until tomorrow or even next Monday?"

The opportunity lies in finding a way to fill the pharmacy gap for smaller and rural hospitals. Gagnon, who works in an urban hospital, joined two other hospital pharmacists and the state board of pharmacy to create Kansas' first telepharmacy service. "Some smaller hospitals can barely afford a daytime pharmacist," he said. "They will never have that third shift covered. Companies that do remote order review across state lines raise questions about practicing without a license. Using Kansas pharmacists to review Kansas orders eases regulatory questions."

When the operation goes live, perhaps early next year, hospitals will be able to e-mail or fax orders for immediate pharmacist review. Once approved, the orders can be filled from unit-dose stock or an automated dispensing unit.

"We are going to see more proposals to utilize technology to let a pharmacist in a remote location do drug utilization review," predicted Carmen Catizone, executive director of the National Association of Boards of Pharmacy. "Most state boards see this as being in the best interest of patients."

Iowa is one of several states reviewing and changing practice acts to allow drug utilization review. A new rule allows Iowa-licensed pharmacists to review and verify drug or device orders from a remote location. The remote pharmacist must have access to the same patient information that an on-site pharmacist would use to review the order. Iowa's new rule took effect July 27. It followed an advisory notice warning hospitals against allowing nurses, technicians, and other nonpharmacists to perform pharmacist-only duties.

"The new rule allows hospitals to provide full pharmacy services without having a pharmacist on site 24/7," said Therese Witkowski, executive officer of the Iowa Board of Pharmacy Examiners. "A smaller hospital with one full-time pharmacist and a tech or two is considered to be well-staffed. The pharmacist shortage is critical."

The pharmacist supply gap worries the ASHP. "We are concerned with limited access to pharmacists," said Teresa Rubio, director of ASHP's section of inpatient care practitioners. "The use of hospital pharmacists 24 hours a day reduces medication errors. It is strictly a patient safety issue."

Problem areas included filling routine drug orders, working in the pharmacy without a pharmacist, preparing and distributing compounded and sterile products without pharmacist oversight, and a lack of written policies or procedures to allow nonpharmacists access to the pharmacy without a pharmacist.

What ASHP would like to see is a hospital pharmacist in every hospital every hour of every day of the year. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) considered a similar standard in 2004 but dropped the idea earlier this year.

The proposed standard would have required 24/7 review of drug orders, said JCAHO spokesman Mark Forstneger. DUR could be provided by remote pharmacists or done on-site, but the idea died during field review. There are no similar proposals in the JCAHO pipeline, Forstneger added.

ASHP would like to see the federal Office of Rural Health Policy (ORHP) require 24-hour pharmacy services. ORHP is currently drafting an advisory report on pharmacy access for the Department of Health & Human Services. In a comment letter to ORHP's National Advisory Committee on Pharmacy Access, ASHP recommended setting minimum standards for rural hospital pharmacies, developing and expanding clinical residencies in rural hospitals, and recognizing pharmacists as Medicare providers.

ASHP is also considering policy proposals that would set minimum standards for remote medication review. Policy could be presented to the house of delegates for approval in 2006.