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Can Telepharmacy Reduce Rural Critical Access Drug Mistakes? Yes.

 |  By HealthLeaders Media Staff  
   May 20, 2009

Last year, a Joint Commission review at 15-bed Cross Ridge Community Hospital in Wynne, AR, found unacceptable a practice by which a daytime pharmacist retrospectively reviewed nighttime prescription orders after they were administered.

In St. Louis County, Minnesota, 25-bed Ely-Bloomenson Community Hospital was having trouble recruiting pharmacists because of a requirement they be on call at all times.

At Atoka Memorial Hospital in Oklahoma, officials assumed there were very few medication errors taking place at the 25-bed facility. They soon discovered that was not the case.

And in the Black Hills of South Dakota, 18-bed Lead-Deadwood Regional Hospital had to depend on pharmacy services from 40-bed Spearfish Regional, 15 miles away, a situation that was "untenable as Lead-Deadwood was often dependent on Spearfish's priorities," according to a new report on the use of telepharmacy in rural areas.

These four critical access hospitals in very rural regions of the nation are among some 20 small acute care facilities that are solving their problems with the use of such technologies in an effort to improve the way they dispense medications to their patients. Their situations, and the reasons for executive decisions to transition to remote prescription services, are described in a new report from the Upper Midwest Rural Health Research Center.

The study, "Implementation of Telepharmacy in Rural Hospitals: Potential for Improving Medication Safety" concludes that while such electronic technologies hold high promise for improving quality, very few systems have implemented them in part because of lack of state regulatory guidance or support.

"The use of telepharmacy technology to provide pharmacist services to rural hospitals is not widespread," the report cautioned. Nevertheless, some of the hospitals that have implemented it "have seen improvements in their medication error rates." Additionally, some are tracking whether telepharmacy affects accuracy of order entry, turnaround time, number of after-hours orders, productivity of staff, overrides of automatic dispensing machines and billable revenues.

The lead author, Michelle Casey of the University of Minnesota, defines telepharmacy as the process by which a small rural hospital faxes or otherwise transmits by electronic means a medication order for review by a pharmacist at another hospital. Telepharmacy can involve the use of medication dispensing equipment that is remotely controlled, or long-distance supervision of pharmacy technicians by a pharmacist at another site, perhaps through audio-visual equipment.

For example, a pharmacist service might be shared among hospitals in the same healthcare system, or in different healthcare systems. Or hospitals may join together to contract for telepharmacy services with a commercial telepharmacy company.

Several studies have concluded that such strategies can greatly improve medication safety in rural hospitals. Nationally, there is a growing shortage of pharmacists, but nowhere is that supply as lopsided as it is in remote parts of the country.

Telepharmacy helps resolves the challenge of getting pharmacists to review orders on an as-needed urgent basis when they otherwise would have to drive 45 miles across rugged mountain roads to get to the hospital.

Today, Medicare does not require critical access hospitals to have a minimum level of pharmacy staffing, only to have "pharmaceutical services that meet the needs of the patients" and "a pharmacy directed by a registered pharmacist or a drug storage area under competent supervision," the report said.

Joint Commission rules setting standards for hospital pharmacists are irrelevant for some critical access hospitals that don't seek accreditation, the report said.

The burden of setting hospital telepharmacy standards is left to each state's Board of Pharmacy, which must decide how many hours of pharmacy coverage should be minimally required, the physical location of a pharmacist providing telepharmacy services (such as whether a pharmacist can review orders from his home or from another facility), the types of technology that should be used, the minimum time that a pharmacist must be physically at the hospital, and the roles of pharmacy technicians and nurses.

The report's authors interviewed officials at nine state pharmacy boards and summarized the varying policies or lack of policies, at each.

Until recently, the report said, "the primary focus of telepharmacy regulation (by state pharmacy boards) has been on retail settings."

Boards may also be challenged with deciding whether to limit telepharmacy applications to only those hospitals that are truly in rural areas, with only a dozen or so people per square mile.

Market forces have also been an impediment to implementation, the report said. "Competing interests may come into play and provide barriers...Because of competition with commercial pharmacies, current rules governing outpatient pharmacies are very restrictive."

The report described a situation in Texas, where state rules say a hospitals with more than 100 beds must have a pharmacist on duty at all times the pharmacy is open, but smaller hospitals may have part-time services where a pharmacist must visit the facility at least every seven days.

Having a pharmacist provide long-distance supervision of pharmacy technicians at a rural hospital has not been allowed, except through a pilot project run by a commercial company, Envision Telepharmacy.

Envision provides remote order review and entry, after-hours medication provision, electronic supervision of pharmacy techs and after-hours drug information and consultation.

However, the report said, "It was to recruit hospitals into the Envision telepharmacy pilot. Many hospitals had been operating in violation of state board of pharmacy regulations, but were not being cited. For some hospitals, it was a case of not wanting to solve a problem until it became one."

About half the hospitals funded their initial telepharmacy project expenses with state, federal and private foundation grants. Other hospitals funded them from operating budgets. But other hospitals said lack of funds was a barrier to purchasing the latest dispensing equipment.

The need for creative electronic solutions should only increase, said the report's author Casey. Rapid growth in the volume and complexity of hospital medications, expanding duties for pharmacists to manage medications, the rapidly evolving nature of audio visual technologies will make telepharmacy strategies a natural solution for rural hospitals.

The report concluded, "State regulations that allow rural hospitals to make appropriate use of pharmacy technology are needed if telepharmacy is to realize its potential for increasing access to pharmacist expertise in rural hospitals and helping to achieve the overall goal of improving medication safety.


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