Putting Pharmacists in the Cloud

Telepharmacy began as a pilot project to bring pharmacy services to rural North Dakota communities too small to support a fulltime pharmacist. Two decades later, telepharmacy is an everyday reality across the country. The concept remains the same: a pharmacist in one location provides services electronically to patients in another location. But pharmacists, providers, patients, prescribers, payers, and regulators are all recognizing the benefi ts that virtual services can bring to pharmacy

There is a wide spectrum of needs that telepharmacy can meet, according to Adam Chesler, PharmD, MBA, the director of regulatory and legislative a­ airs for Cardinal Health and former vice president of operations at TelePharm, an early telepharmacy technology provider. Cardinal acquired TelePharm in 2016 and is now among the largest telepharmacy technology providers in the United States.

Do you have a deaf patient who needs an American Sign Language consultation? How about freeing up pharmacists for clinical activities or to spend more time on immunizations? Telepharmacy does all that and more, and can be further used to:

• Balance work load across multiple pharmacy locations

• Open an urban location that seems unlikely to support a pharmacist

• Take over an independent pharmacy whose owner is ready to retire

• Provide pharmacy services inside a physician practice or clinic

• Consult with patients who can’t leave home

• Bring pharmacy services to disaster relief and homeless shelters

“We have seen a surge in remote consultation, especially during COVID-19 [coronavirus disease 2019],” Chesler said. “Patients needed telepharmacy more than ever when physician o™ffices were closed and pharmacy was the only place to get any kind of access to care. The reality is that we can have a pharmacist just about anywhere to get questions answered on prescription or OTC medications, get an interactions check, adjust therapies for patients, [or] verify a product before dispensing. Telepharmacy puts pharmacists in the cloud. That means they can be anywhere that you ever wanted a pharmacist to be.”

Balance the Load

Devin Trone, PharmD, took a familiar route into telepharmacy. He used telepharmacy out of one of his Medicap Pharmacies in Meridian, Idaho, to provide remote services for a new store in Garden Valley, a rural mountain town about 50 miles away. Pharmacy technicians in the new store took care of customers, while a touchscreen video link brought in a pharmacist as needed to check prescriptions before dispensing, provide consults, and answer patient questions.

“It didn’t take us long to realize we could use the same telepharmacy system as part of our quality control workfl ow for all our prescriptions,” Trone said. “We have 4 locations, so you know that some aren’t as busy as the others. Instead of having scripts back up on the busier location, why not use telepharmacy to distribute the workfl ow? Putting all of our pharmacists in the cloud helps keep any one pharmacist from getting overloaded. Telepharmacy gives pharmacists more time with patients and cuts wait times at all of our locations.”

With 4 stores, Trone has at least 3 pharmacists in the cloud during all open hours. But even the smallest location doesn’t depend entirely on telepharmacy. All 4 locations have a pharmacist physically on site at scheduled times. It helps remind patients that there really is a pharmacist available, he explained. And there are some services, such as immunizations, that can only be provided in person.

What can be done virtually and what must be done in person depends on the state, Trone said. In Idaho, technicians who have completed a certification program may provide immunizations under the supervision of a pharmacist, which can be done virtually. But in Oregon, for example, where Trone also has a pharmacy, immunizations can only be administered by pharmacists.

Telepharmacy is also an easy route to growth. Taking the pharmacists out of the local workflow and putting them in the cloud removed them from the physical dispensing flow. What no one had recognized is that they had been doing part of the technicians’ jobs as well as their own.

“When we put our pharmacists in the cloud, we discovered that 40% to 50% of their time had been spent on mundane things like stuffing bags, stickering, applying labels,” Trone said. “Working in the cloud helps them focus on pharmacist-only activities. We could easily add another 500 prescriptions a day without making our pharmacists work harder. We will be able to continue growth without over taxing or adding pharmacist labor.”

Expand Hybrid Pharmacy Services

NuCara focuses on rural, small-town health care with pharmacies in Illinois, Iowa, Minnesota, North Dakota, and Texas. The company looks at telepharmacy as a tool to improve patient care and extend the reach of pharmacists. But instead of relying entirely on virtual services, NuCara is developing a hybrid model that combines telepharmacy with in-person pharmacist services to provide the best of both.

“We had the second pilot telepharmacy in Iowa, a little town called Zearing, population 500,” said Brett Barker, PharmD, vice president of pharmacy at NuCara Management Group. “When we got into telepharmacy, we were looking at the majority of rural independent pharmacies in the Midwest being owned by pharmacists in the later stages of their career. They wanted an exit strategy, but they didn’t want to abandon their communities. Telepharmacy can meet both those goals.”

The obvious approach is to take over an existing pharmacy from the retiring owner and convert directly to telepharmacy operations, Barker continued. But telepharmacy also o’ffers more options and more flexibility. Some rural pharmacists had cut their operations to half-days, whereas others split their time between retail operations and the local hospital.

A town of 500 may not be able to support a full-time pharmacist, Barker said, but there is no lack of demand for pharmacy services. A small medical clinic in Zearing had a call list of 3 dozen pharmacies that patients used that were within a 60-minute driving radius.

Few patients were using any one pharmacy consistently, Barker said. Which pharmacy they used for which prescription depended on where they had to go that day or week. And if they didn’t have to go to a larger town, they may not have filled a prescription at all.

“What we were seeing was patients using a combination of mail order, whatever happened to be in prescribers’ sample closets, multiple pharmacies, and maybe not getting to a pharmacy at all,” he explained. “And that’s definitely not better. Telepharmacy can bring all those prescriptions to 1 place, with 1 pharmacist or 1 group of pharmacists looking at them all. And even if you don’t have a pharmacist in town every day, you have technicians who know the patients who can oftentimes identify problems they can refer to the pharmacist.”

However, the flexibility that telepharmacy can provide is not a panacea, he continued. A live pharmacist in the pharmacy is still the gold standard for pharmacy practice, but that isn’t always economically viable. Telepharmacy gives patients and providers options they might not have had before.

“Obviously, there’s a learning curve for patients and prescribers,” Barker said. “But people grasp the concept immediately, especially with the broad push for telehealth services during COVID-19. We also train our technicians to walk patients through the process because there are people out there who have never used a touchscreen device before. Patients get so used to remote counseling that they walk right up to the station expecting to use it. It’s a surprise on days when we have a pharmacist on site and they can talk to the pharmacist in person.”

“The hybrid telepharmacy model maintains a pharmacist in those locations at least part of the time and pharmacy services all the time,” he continued. “Too many people think ‘all or nothing’ when it comes to telepharmacy. Just like there’s a spectrum of pharmacy services, there’s a spectrum of telepharmacy. If there’s an unfilled need for pharmacy services, there’s a good chance telepharmacy can help fill that gap.”