Health system develops telepharmacy model that works for ICUs

It saves money and expands reach

Rural and smaller hospitals struggle with covering all pharmacy staffing needs around the clock, often paying for contract pharmacy services to fill in on weekends and night shifts.

Now there is a successful model that shows a different, more efficient, and, at least for large health care systems, a more cost-effective way to provide these services.

Aurora Health Care in Milwaukee, WI, has developed a telemedicine model for providing pharmacy services to rural and outlying hospital intensive care units (ICUs). Their model has saved the hospital money.

Called the electronic ICU (eICU), the program has satellite hospitals within the health system install technology that provides audio and video connections with a central telemedicine office location, says Thomas W. Woller, MS, FASHP, vice president of pharmacy services at Aurora Health Care, which is a 15-hospital health system.

"So if you go into the hospital's ICU, you'll see a camera and microphone," Woller says. "These are linked electronically to a central location where we have nurses, physicians, and pharmacists."

The health system has 246 ICU beds, and all of these are connected to the remote eICU monitoring facility.1

In 2007, the eICU's first year, the program saved the health care system approximately $300,000, Woller says.

There were about $500,000 in drug cost reductions plus about $600,000 savings from not having to pay an outside contractor to do pharmacy order entry work, and the total cost for the service was less than $800,000 for the year.

The cost included salaries for eICU pharmacists, pharmacy technicians, and minimal supplies.

"We documented over 1,000 interventions that were initiated by a pharmacist at the eICU location," Woller says.

When the health system first began to contract with the software vendor who provides eICU services, there weren't plans to include pharmacists in the eICU site, Woller notes.

"The services were only designed to be for a physician and nurse and only for ICU patients," he explains. "There would be a microphone and camera at every ICU bed, and these would link back to this office setting."

When Woller heard about these plans, he spoke with the pharmacy clinical director about how it would be ideal to have a pharmacist involved, as well.

"But we couldn't make the numbers work," Woller recalls. "We didn't think we could offset the costs of a pharmacist position."

Then about six months later, the health care system had made changes that made it an even more integrated system, and a new opportunity arose: "We looked at doing order entry for smaller hospitals and saw an opportunity there clinically," Woller says.

They reviewed the costs of providing medication review services for night and weekend shifts at the system's smaller hospitals and saw that they were paying hundreds of thousands of dollars a year to contractors.

"Physicians write these orders in the middle of the night, and these have to be verified by a pharmacist to make sure the orders are right and the proper warnings are attached," he says.

Traditionally, these approvals would be delayed until 7 a.m. when the hospital's pharmacist reported for work. But in recent years the Joint Commission of Oakbrook Terrace, IL, has required a prospective order review program, and this has forced even small hospitals to contract with services that provide pharmacy review around the clock, he explains.

Woller and the clinical director determined that if they added the prospective order review services to pharmacists staffing the eICU then this would make it cost-effective, while improving patient safety.

"If we didn't have to pay an external vendor, then we could use the money to pay for this project," Woller says. "And we improved the quality of care, so it was a win-win-win."

Even the start-up costs were feasible, costing an estimated $40,000 for the electronic equipment dedicated to the pharmacist and pharmacy technician, Woller says.

"I believe we were the first organization to apply both clinical and distribution activities in a virtual environment, and we were the first to incorporate pharmacy into a full telemedicine unit that included nursing and physician participants," he adds.

The central eICU office operates 24 hours a day, every day, and it's staffed by people who juggle their eICU schedules with traditional clinical care in the main hospital. Pharmacists staff the office most hours of the day, and during busier times, from 6 p.m. to 2 a.m., there will be two pharmacists on duty, he says.

While in the office-based eICU, they look at as many as six different video screens, which include a look at the ICU patients, as well as their medical records, monitoring equipment, and other data.

"The patient is in a traditional ICU bed that might be 100 miles away," Woller explains. "The patient still receives direct patient care, and this is a secondary level of care."

The eICU pharmacists wear telephone headsets and speak into microphones when communicating with staff at the bedside. They monitor their remotely located patients' drug therapy, provide medication order verification, and provide all the safety checks they normally would in an ICU setting.

"A high percentage of interventions are questions we have from physicians or nurses about drug therapy being ordered for the patient," Woller says. "These are the typical questions an ICU bedside pharmacist would handle."

The difference is that the pharmacist will handle these questions simultaneously from five to 10 different hospitals, located hundreds of miles apart.

Also, the eICU pharmacist provides recommendations about antimicrobial coverage and provides formulary support services.

Reference

  1. Meidl TM, Woller TW, Iglar AM, et al. Implementation of pharmacy services in a telemedicine intensive care unit. Am J Health Syst Pharm 2008;65:1464-1469.