Telepharmacy Business Model Allows Satellite Operation and Increased Patient Convenience

At the Shoshone Pharmacy in Shoshone, ID, a patient arrives to pick up his prescription. The technician asks him to wait, explaining that the pharmacist would like to discuss potential drug interactions with him. The patient is ushered into a private room where he sits across from a 20 inch video screen. Before long, the pharmacist, who is at another pharmacy, appears on the screen, and the discussion commences.

Telepharmacy scenarios, like that take place regularly at Shoshone Pharmacy, and are becoming more common at chain, retail, and health-system pharmacies nationwide.

Currently, 23 states allow telepharmacy, though requirements vary, according to the National Association of Boards of Pharmacy. Several other states have telepharmacy pilot programs in place.

“Telepharmacy can help bring back pharmacy services to areas that are underserved, such as rural areas,” says Lisa Schwartz, PharmD, senior director, professional affairs, NCPA.

In fact, the first state laws surrounding telepharmacy started with a pilot program in North Dakota in 2001. The program brought pharmacy services to 80,000 citizens in medically underserved, remote, and rural communities. Following the success of the pilot program, the North Dakota Board of Pharmacy established permanent rules in 2003 that allowed telepharmacy to be practiced on a broader scale.

In Idaho, the Shoshone pharmacy operates as a satellite pharmacy to R&R Pharmacy in Jerome, ID, about 18 miles away. Shoshone serves a community of 1,500 people who were previously without pharmacy services. While a community of only 1,500 wouldn’t justify a fully-staffed pharmacy, the staffing by technicians, along with the videoconferencing, ensures that those in the community are not deprived of pharmacy care.
How it Works
The pharmacy is set up like a regular pharmacy, but is staffed by technicians, explains Jason Reading, PharmD, owner of the two pharmacies. Prescription orders are transmitted to the pharmacist at the main pharmacy for verification. “We have a good system of checks and balances in place,” says Reading. “Setting up a remote pharmacy makes sense from a business standpoint, from a pharmacy professional standpoint, and from a patient care standpoint.”

From a business standpoint, a satellite location can bring a pharmacy up to capacity in terms of filling prescriptions. “If a pharmacy has the capacity to fill 300 scripts a day, but is only filling 200 based on patient volume, why not get paid for the additional 100 scripts?” he says. From a professional standpoint, a pharmacy staffed by technicians frees the pharmacist to perform clinical interventions.

In addition to Shoshone Pharmacy, Reading recently opened a small satellite pharmacy at North Canyon Medical Center in Gooding, ID, about 26 miles from Jerome. It operates mainly as a discharge pharmacy, but provides other services to the community, such as immunizations. As a further reach toward the provision of patient care, Reading recently placed a pharmacist on site at a local medical clinic with physicians, which would not have been possible had the remote pharmacies not been staffed by technicians.
In the Chains
In chain pharmacies, CVS Health has innovated by allowing patients to consult with a healthcare provider via a mobile device through the CVS App. The MinuteClinic Video Visits are geared to patients ages two and older who use the app seeking treatment and advice for a minor illness, minor injury, or a skin condition, according to the company.

After completing a health questionnaire through the app, patients are matched to a board-certified community-based healthcare provider in their state, who reviews the questionnaire and proceeds with the video-enabled visit via the patient’s smartphone. When relevant, the physicians call prescriptions into the patient’s pharmacy or refer patients to providers in their community. The program, which has been in place since August, has recently expanded.
Hospital Telepharmacy
Videoconferencing can be a powerful tool in a discharge setting, says Brian Roberts, CEO of PipelineRx, a San Francisco-based provider of cloud-based telepharmacy services, primarily in the hospital setting. In addition to allowing pharmacists to consult with patients, videoconferences may take place between nurses and pharmacists, and physicians and pharmacists. Videconferencing may also be arranged with pharmacists once a patient is home, helping to ensure continuity of care, he says.

“While some health system pharmacists may find outsourcing to be threatening, it is empowering,” Roberts says. Rather than eliminate pharmacists, pharmacists are deployed to other areas of the hospital. “Pharmacists are able to work at the top of their game,” he says.

In the inpatient setting, telepharmacy usually involves order entry from a remote site, generally during the hours when the regular pharmacists aren’t on duty. Delta County Memorial Hospital, in Delta, CO, a 50-bed rural hospital, has 24/7 pharmacy coverage since pharmacists from PipelineRx process orders overnight. “We’re able to offer outstanding seamless care when the pharmacy staff is not able to be physically present,” says Philip Neary, PharmD, a clinical pharmacist at the facility.

The remote pharmacists also perform services such as pharmacokinetics, renal assessments, therapeutic interchanges, and IV to oral changes. The overnight pharmacists also check for duplication of therapies, do medication reconciliations, check for patient allergies, and evaluate laboratory results. The PipelineRx platform allows the hospital to collect data, perform clinical interventions, and track cost-savings, says Neary. “These are all activities we might not have been able to justify at a smaller facility.”
In a similar scenario, at Memorial Hospital of Salem County in Salem, NJ, telepharmacists take over when the inpatient pharmacy closes at 10:30 pm., says Jon Margolin, MS, director of pharmacy at the facility. In addition, the telepharmacists answer questions from nurses and other practitioners. “Basically, the remote pharmacists mimic what we do during the day,” says Margolin. “The screening they do allows us to catch more errors in real time. This is huge.”

Margolin hopes telepharmacy will allow the hospital’s pharmacists to expand the services they provide. “It is our goal for pharmacists to be more involved in inpatient counseling, discharge counseling, and be able to go on rounds and respond to hospital emergency codes with other members of the healthcare team,” he says. 
Pushing Back on Telepharmacy
Convincing directors of pharmacy in hospital settings to use telepharmacy can be a challenge, says Roberts. “They tend to have more of an entrepreneurial approach. They want the pharmacy to grow bigger with the hiring of more staff, but bigger is not necessarily better.”

There is resistance in the retail setting, as well, says Reading. “There are those who say we’re killing the profession by staffing the pharmacies with technicians, but the concept lets pharmacists expand their capabilities,” he says.

Patient resistance can also be a barrier to telepharmacy. While patients don’t seem to mind talking to pharmacists via a video screen, they do sometimes get upset if they must wait, Reading says. “They don’t see the inside of the pharmacy where the pharmacist is; they just see the video screen so it’s easy to assume the pharmacist is sitting there with his feet up,” he explains. “The technicians need to be careful how they talk to the patient when they bring them into the video room.”

Reimbursement for telepharmacy services, and lack of it in many cases, is another barrier. Currently, many of the telehealth payment models involving pharmacists have been implanted in managed care organizations such as Kaiser Permanente.

As the private sector shifts away from fee-for-service in favor of value-based care, there is likely to be increased interest from insurance payers to explore telehealth models, according to the study, “Pharmacists providing care in the outpatient setting through telemedicine models: a narrative review,” published in Pharmacy Practice in 2017.

Legislation is another impediment to telepharmacy. “Since the telepharmacy concept is still in its early growth stages, in many cases, the legislation is not keeping up with the technology,” says Neary.

Roberts agrees. “Our pharmacists are licensed in multiple states and work across multiple sites,” he says. “We need to comply with individual state regulations, some of which are more stringent.” Some states, for example, require that a call center be set up; others require that prescriptions be saved for seven years.  

On the health system side, telepharmacy is still an underpenetrated market, so has plenty of room to grow, says Roberts. Currently, it is in about 20% of U.S. hospitals, he says.

Down the road, he sees the technologies expanding to nursing homes, psychiatric facilities surgery centers, and hospital outpatient pharmacies. The technology will also be used more across the individual hospitals in a system. “Orders may be shared across a hospital with a blend of services and technology,” Roberts says. “Telepharmacy is here to stay.” 

Kathleen Gannon Longo is a contributing editor.