Technology helps combat pharmacist shortage

Faced with the realization in the early years of this decade that 26 community pharmacies had recently closed and 12 more were at risk of closing, the North Dakota Board of Pharmacy started looking for a solution. A problem, according to North Dakota State University College of Pharmacy dean Charles Peterson, PharmD, was that many pharmacists in rural areas of the state were reaching retirement age and wanted to leave the profession. But there was great difficulty in finding replacements because of the pharmacist shortage generally and because of the difficult economic conditions in some of the rural areas.

"The board started talking with stakeholders in terms of a decision that had to be made," Peterson tells Drug Formulary Review. "Either we needed to find a creative solution or we could allow the situation to continue and become an even greater crisis."

Telepharmacy came up as a possible solution, he says, and the board agreed to a small pilot program to test it. That pilot turned out to be so successful that the board scrapped it in less than a year and wrote rules so the process could be implemented statewide.

North Dakota, like many states, had rules requiring that licensed pharmacists be present in the pharmacy when support personnel are performing the mechanical functions involved in dispensing a prescription. For telepharmacy to work, the pharmacy board had to take a leap of faith and accept that a registered pharmacist could supervise the work of a pharmacy technician from a remote site using real-time audio-video communications technology.

The project now is in the fifth year of a federal grant from the Health Resources and Services Administration's Office for the Advancement of Telehealth. It has grown to 57 participating sites, including 44 community pharmacies and 13 hospitals, and serves more than 40,000 rural citizens who otherwise would not be likely to have access to traditional pharmacy services. And the project has added an estimated $12.5 million to the economies of small towns in the state by adding jobs and restoring pharmacy services.

Under new rules established by the Board of Pharmacy, a pharmacist at a central site supervises a registered pharmacy technician at a remote site through use of audio-video Internet conferencing equipment and digital imaging cameras. And, Peterson tells DFR, it is being done at a cost well below that of automated dispensing technology while still keeping pharmacists in the loop for the important job of consultation and professional expertise.

"It is important to understand when dispensing actually occurs in telepharmacy," Peterson wrote in a Journal of Pharmacy Technology report. "Dispensing of the product to the patient is always the professional function of a licensed pharmacist and must not be delegated to the technician. As with tele-medicine, nobody would define surgery as being conducted by a technician who lays the patient on the table in preparation for the physician to operate the computer-assisted surgery equipment over the long distance communication link. Likewise, nobody would ever consider the radiology technician, who is assisting with a patient's scan (e.g., mobile MRI) at a remote location, to be doing the actual diagnosis of the scan. In the same manner, the dispensing of the pharmaceuticals (an important professional function in the practice of pharmacy) should not be assigned to the technician, when the duty is actually performed by the pharmacist, using the telepharmacy tools. The pharmacy technician prepares the prescription for final dispensing, and the pharmacist does the actual dispensing, at the same time the patient education is provided."

The distance from the central pharmacy site to the remote telepharmacy site ranges from 13 to 95 miles. The remote telepharmacies are staffed by one technician and one or two store clerks and generally dispense 15-55 prescriptions per day. The remote telepharmacy communities have populations ranging from 498 to 1,367 people, and have a medical clinic staffed work days by either a physician, physician's assistant, or nurse practitioner.

Ongoing dialog and supervision

A pharmacy technician at a remote site prepares a drug for dispensing, including entering the prescription and patient information into the pharmacy system, preparing the container label, and filling the medication container. The pharmacist is able to have an ongoing dialog with the technician, answer any questions, and verify the technician's work over the secure Internet connection.

Technicians also send the pharmacist digital images of the health care provider's written prescription, the medication's original manufacturer container, the prepared label, and one of the tablets or capsules, if appropriate. Peterson said receiving those images helps a pharmacist be sure the patient is receiving the correct medication in the correct dosage. And the digital photos can be stored for later recall if necessary.

Once the pharmacist has completed a final check of the prepared prescription, approval is given to the technician to release the medication to the patient care area.

Peterson tells DFR the use of technicians over the years has allowed pharmacists the time to concentrate on more professional tasks. While some have expressed concerns about patient safety in the telepharmacy model, Peterson insists the process is exactly the same as it would be if the pharmacist and technician were together in the same building. "Pharmacists in the store make the final check on the technician's work," he says. "Why not do the same thing from a distance but with the same checks and balances? We're just using technology to make the same process work. The pharmacist can view all the work the technician does and have a constant dialog. In reality, the process is exactly the same as the standard procedure and protocol for filling prescriptions."

Remote site techs need more experience

Pharmacy technicians working at remote sites must be registered with the Board of Pharmacy and be a graduate of a training program accredited by the American Society of Health-System Pharmacists. Technicians also must have at least one year of work experience before practicing at a remote site.

Peterson told the American Journal of Health-System Pharmacy that he believes the telepharmacy model is actually safer than when a pharmacist in a large hospital's central pharmacy releases a medication from an automated dispensing machine because many of those units don't have the audio-video connection facilitating conversation between the pharmacist in the central pharmacy and the nurse or technician at the patient care unit. "And we think that's problematic," he said. "Part of the feature of the North Dakota telepharmacy model is to keep the pharmacist in the health care loop in providing professional expertise, counsel, and guidance related to proper drug selection and monitoring. And that requires a verbal conversation."

He also says the North Dakota project enhances patient safety because in pharmacies patients are free to reject offered pharmacist counseling, while at a remote site patients can't leave until they have received counseling from the pharmacist over the audio-video connection.

In addition to closure of community pharmacies in rural areas, communities also face severe pharmacist shortages in their hospitals. While experienced hospital pharmacists are a critical part of a hospital's health care team, bringing extensive knowledge on complex issues that arise when dealing with severely ill patients who are on multiple medications and have complicating health factors, attracting and keeping hospital pharmacists in rural communities is as difficult as attracting and keeping retail pharmacists.

When a hospital has only one pharmacist, Peterson says, there is severe pressure on that person to meet all the facility's needs and burnout is a real problem. The rate of pharmacy staff turnover in small hospitals is twice as large as it is in large hospitals.

Telepharmacy also is being used in North Dakota to help solve the hospital pharmacist shortage. Peterson says the state has 39 rural hospitals. Most have only one pharmacist and some are so small that they contract for pharmacy services from a local pharmacy. Regulations generally say that to promote patient safety, pharmacists should make a first dose review of all medications before they are dispensed. But this presents a nearly impossible challenge when facilities operate 24 hours a day, seven days a week, and there is only one pharmacist to do all that work.

"We now have a group of hospitals each having only one pharmacist that is cross-covering for each other," Peterson tells Drug Formulary Review. "They have created a telepharmacy network with audio-video links in their hospitals and also in their homes so they can cover for each other." He adds that the pharmacists are working out schedules so individuals can go to professional meetings or take some time off. And they're available to cover for each other if someone has to call in sick. In the harsh North Dakota winters, pharmacists who are stranded at home can still do their work via the secure audio-video link in their homes.

"This has not been easy to arrange," Peterson says. "Hospitals want to each maintain their own identity and administrators aren't always sure they want to allow competitors to work on behalf of their facility. They also all have their own procedures and rules and it was necessary to work out agreements so the pharmacists are doing things the way each hospital wants them done."

Can this model be expanded into other areas of the hospital? Because Peterson thinks it may be possible, he has been invited to submit a proposal to the state hospital association to explore other avenues of cooperation. "We're very excited about this proposal," he tells DFR. "We don't know where it will end up, but the possibilities are tremendous."

Peterson and his College of Pharmacy colleagues also are working with rural networks in other states that are looking for reasonable and responsible ways to satisfy new Joint Commission requirements.

Peterson has developed a step-by-step guide to creating a successful telepharmacy program, included in the article in the January 2004 Journal of Pharmacy Technology. Steps he identified include:

  • Becoming familiar with laws and regulations. To operate a telepharmacy program, a state must have laws and rules in place for allowing telepharmacy services to operate in the state, and remote sites must be properly licensed with the State Board of Pharmacy.
  • Assessing the need. Questions to be asked include: Are pharmacy and pharmacist services currently available? Are health care providers authorized to prescribe medications sufficient to support a telepharmacy operation? Is there a convenient cost-effective location for a remote site? Is there stakeholder support for a telepharmacy project? Is there a licensed pharmacist available who is willing to take accountability for delivering remote services?
  • Developing community partners. Peterson says that in choosing partners it is important to consider community need, interest, and investment in the project; availability of a pharmacist at a central pharmacy site in a nearby community willing to deliver telepharmacy services to the remote site; and support from the state Board of Pharmacy. It may be helpful, he says, to obtain feedback from individual patients, senior citizen groups, rural health clinic personnel, community business leaders, local community leaders, local government officials, pharmacists practicing in the area, the state Board of Pharmacy administrator, the state Pharmaceutical Association, and any School of Pharmacy in the state.
  • Securing a physical location. Selection criteria, Peterson says, for choosing a site for a remote pharmacy should include convenient access for the public, proximity to other health clinic facilities, proximity to nursing homes, financing arrangements, and technology transfer or connectivity capabilities, such as the availability of high-speed Internet access.
  • Selecting personnel. The North Dakota Board of Pharmacy has established higher standards for pharmacy technicians working in remote telepharmacy sites than for technicians working in traditional pharmacies where a licensed pharmacist is present. Pharmacists working at a central pharmacy are responsible for performing a final check of the prescription prepared by the technician, performing a complete drug utilization review on the patient's medication profile, and performing mandatory patient education counseling. Although Peterson reports that licensed pharmacists at central pharmacy sites have been very excited and quite positive about delivering telepharmacy services to another remote community, they have expressed concern about the significant extra workload falling on them. North Dakota's telepharmacy rules allow a pharmacist to manage up to four remote sites.
  • Considering patient response. Peterson says it's important that patients be comfortable with the telepharmacy technology before receiving services. Consideration should be given, he says, to formally marketing the telepharmacy concept to the public before implementing services. Proper information and education of patients can assist in alleviating any questions or concerns on how it works and what it looks like, including the similarities and differences between telepharmacy services and traditional pharmacy services.

Peterson tells Drug Formulary Review that success is related to the availability of committed project partners who are willing to think outside the box and not believe it's always necessary to do things the way they have been done in the past. It's also necessary, he says, to have good patient support, because if they balk at using the technology, it will be impossible to implement a program.

"Any time you incorporate innovation and creativity it raises people's anxiety," Peterson concludes. "People need to be willing to face the rules and change them if necessary. They need to be willing to take charge of their own destiny."

Download Peterson's article from the Journal of Pharmacy Technology at www.jpharmtechnol.com. Contact Peterson at (701) 231-7609 or e-mail him at Charles.Peterson@ndsu.edu.