Telepharmacy Eases Staffing Shortages at Rural Clinics and Hospitals

With a shortage of pharmacists and clinicians in rural areas, telepharmacy and telehealth clinical pharmacy services can fill the gap.

Telepharmacy and telehealth approaches to clinical pharmacy services are helping to address pharmacist and clinician shortages in rural areas of the country.

Telepharmacy, which features the dispensing of medications and other pharmacy services, has allowed Scotland County Hospital in Memphis, Missouri, to establish a 24/7 pharmacy after years of being limited to a part-time service.

"We tried to hire a full-time pharmacist for about a year to have an on-site pharmacist. We knew it would create a larger cost center, but we also knew it would improve care. We had one or two people interview, and neither one took the position," says Randall Tobler, MD, CEO of Scotland County Hospital.

In September 2017, the hospital launched a hybrid pharmacy model, with a part-time pharmacy director and a telepharmacy service provided by San Francisco­–based PipelineRx.

"Decisions related to formulary are done with our pharmacist of record. Pipeline certifies and validates oncology orders, checks for drug interactions, and makes dosing adjustments," Tobler says.

At the University of Iowa in Iowa City, the College of Pharmacy is operating a telehealth clinical pharmacist service called Centralized Healthcare Solutions. CHS is under the umbrella of the College of Pharmacy and any revenue generated flows to the university.

"We expand the types of clinical services to rural communities that they either don't have access to, can't afford, or can't staff," says Christopher Parker, PharmD, executive director of operations at CHS.

CHS, which started out focusing on patients with cardiovascular disease, was launched in November 2016.

"We would work with patients who had a past history of cardiovascular disease—a previous heart attack or a previous stroke—and we would help to lower their risk by getting their blood pressure under control and making sure they were on the right medications," Parker says.

Telepharmacy service
 

Contracting with a telepharmacy provider has helped Scotland County Hospital fill a critical need, Tobler says.

For several years, the hospital had relied on the local retail pharmacy to also serve as the hospital's pharmacy. "The pharmacist did the best he could to meet our 24/7 needs such as reviewing orders, but he wasn't a 365/24/7-guy-in-town all the time," he says.

The lack of continuing coverage created a compliance problem.

"Many times, we had to invoke the emergency rule to have orders reviewed after the fact. Under Medicare, all first-dose orders—whether it is the patient's own medication or something a doctor prescribes—have to be reviewed by a pharmacist unless there is an emergency," Tobler says.

"When I took over here about three years ago, I just felt that was not optimal, and we looked for ways to make it work financially. The way we made it work was by employing PipelineRx as a telepharmacy service," he says.

The telepharmacy service works on a daily basis with pharmacy technicians at the hospital.

"The techs have a daily call with Pipeline and they discuss whether ordered medications have been administered," Tobler says.

Although the critical access hospital is too small to generate statistically significant data about the telepharmacy service, he says gains have been realized.

"In general, we have stepped up the scrutiny of our prescribing. In essence, it gives me and our physicians a sense that there is someone looking over our shoulders to give a second opinion on prescribing," he says.

Pharmacy technicians are also functioning in a more optimal manner, Tobler says.

"The pharmacy techs have always been conscious of which drugs are going in the bins, but some of the burden of the pharmacist role has been taken off of them. They also have a new backstop that gives them peace of mind to focus on their core duties for patients," he says.

Patients have definitely benefited, Tobler says. "The turnaround times are much better. Now, the nurses can take routine orders, and they are not waiting. Patients are not getting delayed dosing because they are waiting for verification."

Telehealth service
 

CHS has expanded its clinical pharmacy services far beyond lowering the cardiovascular risk of patients.

"We have expanded to areas like focusing on tobacco cessation. We are working now to set up a contract to provide a tobacco cessation program for patients at high risk for hospitalization because of COPD," Parker says.

"We also focus on targeted disease interventions. In the rural settings, a lot of the clinics have trouble focusing in certain areas—uncontrolled blood pressure, diabetes, asthma. We will help them identify where they are struggling clinically, then figure out ways for our team to help," he says.

In addition to expanded services, CHS has expanded the number and variety of its clients.

"We have the gamut. We have privately owned rural primary care clinics. We have rural health systems that have hospitals and clinics. We have larger health systems that have rural clinics as part of their systems," he says.

Although CHS does not provide dispensing, it does ease staffing shortages at rural clinics, Parker says.

"The feedback we have gotten from the clinics in rural settings revolves around them not being able to hire enough primary care physicians. When we work with these clinics, the providers can refer patients to us for chronic diseases like diabetes. Then the patient may only need to see a primary care physician once or twice a year," he says.

Based on research conducted at rural clinics, Parker says CHS has generated several positive results:

• Diabetes patients were able to achieve lower hemoglobin A1C values compared to patients in a control group.
   
• Patients who were on guideline adherence for their disease state achieved double adherence compared to patients who did not work with CHS pharmacists.
   
• Some clinics allowed CHS to manage patients independently. In those situations, CHS had a greater impact on lowering cardiovascular disease risk.

CHS is offering health systems, hospitals, and clinics an unconventional service, Parker says. "This model expands the role that a pharmacist plays."