Interactive telepharmacy could solve staffing problems at remote clinics

Pharmacists are just a videophone call away

In an era of staff cutbacks and consolidation, providing pharmacy services to remote clinics — or even to clinics across town — may seem like a financial impossibility, especially if patient loads don’t justify staffing. At the same time, providers must make their customers happy or risk losing coveted managed care contracts. Until recently, there appeared to be no way to minimize staff while providing far-reaching services. Now, however, a tool is being developed to stretch the pharmacist’s reach without taxing an already full schedule. That tool — telepharmacy — is being tested in Utah.

Many rural clinics of the University of Utah Hospitals & Clinics (UUHC) in Salt Lake City have too few patients to support a full-time pharmacist. Often these clinics are in isolated locations with no local pharmacy. The university hospital wanted a cost-effective way for patients in these remote areas to fill their prescriptions without traveling to the city — a 100-mile round trip for some patients.

Telepharmacy may be an answer. The university has created a pilot program with Park City-based Summit Health Center, an outpatient clinic about 25 miles from Salt Lake City, and with Automated Drug Dispensing Systems (ADDS) in N. Billerica, MA. The system enables UUHC pharmacists to receive and dispense prescriptions to remote clinics through networked computers and — for the first time — counsel patients across an interactive, computer-controlled video monitor.

The Park City clinic is the test site. There pharmacists run the telepharmacy program, test patient/pharmacist communication links, and fix any problems that may arise before the program is implemented in UUHC’s more rural clinics. "We didn’t want to get it set up in our rural sites until we learned on it first," says Bob Bennett, RN, MS, clinic manager at the University of Utah Summit Health Center. "We’re not very far from Salt Lake City, so it doesn’t take much for their [pharmacist manager] to run back and forth between hospitals to work out any glitches if we need to."

The telepharmacy pilot program, which officially began Aug. 1, was set up in Utah Summit’s former medication samples room. Although relatively small, the room is large enough to house the equipment needed to run the ADDS system — a drug dispensing unit, fax machine, computer system, and video monitor — as well as accommodate the doctor and patient.

Setting the telepharmacy scene

The university and clinic are linked by a high-speed data (ISDN) telephone line. The patient and doctor at the rural site enter the telepharmacy room, where the doctor faxes the prescription to the pharmacist at the parent hospital. The pharmacist enters the data into the computer, which triggers the automated dispensing machine at the off-site clinic to release the bar-coded medication, much like a vending machine. A nurse or technician then scans the bottle to double-check the medication type and dosage, while the pharmacist counsels the patient through a video link.

"The interaction between the patient and pharmacist is very important," Bennett says. "They can talk and see one another in real time and answer any questions just like a typical pharmacist would. The system has a program that cross-references other drugs with the prescribed drug to guard against interactions. There’s also a hard copy [of instructions] that patients take with them."

How have the doctors and patients reacted to the program? For the most part, responses have been positive, says Judy Schneider, PharmD, pharmacy manager at the University of Utah.

"We went to the Utah State Board of Pharmacy about a year ago and told them this was something we were looking at doing. At first, they weren’t too keen on it because the state of Utah does not typically allow a nonpharmacist to affix a medication label, which is how the system works," she explains. "But they were willing to work with us as long as it is used in rural facilities where patients don’t have access to other pharmacies."

Patients, although somewhat intimidated by the technology, also have reacted favorably, Bennett says. "The patients we used for demos when we first [began testing the system] seemed a little leery, mainly because patients can see themselves on a small section of the monitor when they are speaking with the pharmacist. But they were also very intrigued. People tend to fear technology a bit, but when this is [offered] to patients in more rural areas, I think they will really appreciate the program."

To ensure patient satisfaction, University of Utah pharmacists plan to administer a series of surveys: one on the initial visit, followed by telephone questionnaires. "This is a very important step because it’s our chance to see how comfortable the patients are with the program and make sure they are not overwhelmed by the technology," Schneider says. "The idea of this [program] is to offer a great service to the patient, so we want to make sure what we’re doing is not backfiring. During the phone surveys, we can assess their medical understanding and answer any questions they may not have thought to ask at the time. We can also see what areas need to be worked on."

Although improving customer service is key, the telepharmacy technique also makes the job of both physician and pharmacist more efficient, says Brian Hart, ADDS president. "For a typical pharmacy, it takes 150 prescriptions per day for it to break even financially," Hart says. "But because the pharmacist is only accessed when he’s needed, and there’s no overhead of a regular pharmacy, it only takes about 25 prescriptions to break even using [telepharmacy]." (See graph at right.)

In addition to the financial gains received by eliminating the need for a rural clinic pharmacist and reducing prescription costs, Bennett says the system also helps ensure that medications are filled. "If a patient in a rural clinic has to travel far to get a prescription filled, it’s likely that the medication [will not be dispensed]," he explains. "If they can get their prescription right after they see the doctor, it’s much more convenient."

With any new technology comes a new set of problems. Through mock scenarios, the University of Utah was able to spot malfunctions and prime the improvement process before the clinic went live with the telepharmacy program. "The [medication dispensing] unit we are using looks and loads like a pop machine on the inside," Schneider says. "Some of the bottles that are loaded into the machine fit too snugly and wouldn’t drop out of the machine. We’re fortunate that we can work on things like this and get them working perfectly before they go into other [clinics]."

How will small rural facilities be able to afford such a luxury? Hart says the costs are relatively minimal.

"Right now, we’re only working with [facilities] on a profit-sharing basis. That means we set them up with all the hardware and software, and the only thing they have to buy is the prepackaged meds that they buy off of their GPO contracts. Then we split the gross profits," he says. "We’re also looking at setting up a lease program, but we haven’t put together any figures for that yet."

Despite the equipment’s convenient applications and apparent accessibility, some patients still will have to rely on outside pharmacies at some point, particularly because the machines can’t store every kind of medication. For example, Utah Summit’s model, called the RCD1, holds only 40 of the most commonly prescribed medications. Larger models can house double to triple that amount but still can’t dispense certain kinds of drugs.

"Most patients will be able to get what they need, but there will be some that can’t," Bennett notes. "For example, some medications need to be refrigerated, and the unit isn’t capable of doing that."

So where and when will the telepharmacy program surface next? Although no dates have been set officially, the most likely location is a rural clinic in Wendover, NV, Schneider says. The small university affiliate is on the Utah border about 120 miles from Salt Lake City, separated by desert.

"Wendover’s population is only about 6,000, and it’s pretty much out in the middle of nowhere," she says. "There aren’t any pharmacies close by, so this system would work very well there. It looks like that will be our next location once we get things squared away [in Utah]. We’re just not sure when that will be."

Also, a homeless shelter near the university hopes to take advantage of the program. "The homeless shelter has a clinic but no pharmacy, which makes it difficult for the people to get their medication," Schneider says. "We’re trying to co-fund for the University of Utah College of Pharmacy students to work at the shelter. There are so many possible applications. Our goal is not to compete with other community facilities, but to offer the [program] where the patients can benefit the most. And so far, people have really been willing to work together to make that happen."

[For more details, contact: Judy Schneider, University of Utah Hospital, 50 N. Medical Drive, Room A050, Salt Lake City, UT 84132. Telephone: (801) 647-5740. Bob Bennett, University of Utah Summit Health Center, 1750 W. Sun Peak Drive, Park City, UT 84098. Telephone: (801) 647-5740. Brian Hart, ADDS Inc., Forest Ridge Research Park, 85 Rangeway Road, N. Billerica, MA 01862. Telephone: (508) 670-0746.]