By Sandra Calenda, PharmD, CACP; Chasitie Levesque, PharmD; Julie Groppi PharmD, CDE; Helen Kasimatis, PharmD; Donna Leslie, PharmD
History of Telepharmacy
The Veterans Health Administration (VHA), the largest integrated healthcare system in the United States, focuses on patient centered & evidence based care. 1 The use of telehealth technologies in the VHA is among the newest methods of providing patient-centered care. The term telehealth is defined as “the use of telehealth technologies to provide clinical care in circumstances where distance separates those receiving services and those providing services.” 2
Telehealth modalities include clinical video telehealth (CVT), home telehealth (HT) and store and forward (SFT) telehealth.
Telehealth technology is being used by a variety of healthcare providers, including clinical pharmacists (CP), to expand access to care for patients. The benefit of a CP role in medication therapy management (MTM) has been well documented in the literature. 3, 4
Telepharmacy services include any clinical pharmacy encounter that is performed in a virtual capacity by a CP or clinical pharmacy specialist (CPS). Examples of telepharmacy services include videoconference consultations on medication therapy management (MTM), providing comprehensive MTM services through two-way interactive systems, e-consult services to provide MTM advice or to answer a medication-related question, or the use of HT technology to monitor disease states. There are tremendous benefits to telepharmacy services including, but not limited to:
- Improved access to pharmacy services in rural areas and community-based outpatient clinics (CBOC);
- Increased frequency of visits allowing for more aggressive MTM;
- Ability to provide the same standard of clinical pharmacy services across the healthcare system;
- Provide clinical pharmacy expertise without requiring a traditional face-to-face visit;
- Offering more readily available medication education to veterans in need;
- Improved patient satisfaction; and
- Reduced travel time.
- Current Achievements & Looking Ahead
Telepharmacy continues to expand all across the United States. To date, every Veteran’s Integrated System Network (VISN) in the VHA provides telepharmacy services. During the past several years, the standardization of coding for these encounters has improved markedly, with an increase of 135% between FY11 to FY13.
Telepharmacy services have expanded outside primary care to include other specialties such as mental health, heart failure, hepatitis C, women’s health and anticoagulation therapy management. Furthermore, Telepharmacy has been incorporated into multidisciplinary group clinics, such as pain clinics, smoking cessation, MOVE! Programs and diabetes management classes.
The Tennessee Valley VA Healthcare System (TVHCS) is one of many sites that have demonstrated tremendous benefits from the integration of telepharmacy services. In 2012, McFarland and colleagues published a study which compared the effect that telepharmacy had on patients with poorly controlled type 2 diabetes. Results showed positive outcomes in achieving goal hemoglobin A1c (HgbA1c). 5
VISN 12 serves veterans in Illinois, Wisconsin and the Upper Peninsula of Michigan and has recently implemented several telepharmacy programs. One program utilizes a VISN 12 CPS based at the Hines VA to provide MTM in the primary-care setting to five outlying CBOCs for three VA facilities (Hines, Tomah and Iron Mountain). Due to the rural location and smaller patient panels of these clinics, it hinders the ability to have a full-time CPS for each of these locations. This project, started in March 2013, provides the benefits of clinical pharmacy services at multiple sites while using one full-time equivalent (FTE) CPS at a centralized location. The CPS provides comprehensive MTM services for a variety of primary care disease states including but not limited to hypertension, dyslipidemia, diabetes mellitus, thyroid disorders, respiratory conditions and heart failure. In Q4FY13, 88 unique rural veterans who previously did not have access to clinical pharmacy services, received MTM in some capacity. Positive effects in surrogate markers such as HgbA1c, systolic blood pressure (SBP) and low-density lipoprotein (LDL) have already been noted.
Furthermore, VISN 12 has focused on the expansion of telepharmacy services among rural female veterans. This model utilizes multiple CPSs stationed at three individual facility locations. The project began in 2011, initially focusing on chronic disease state management including gender disparity indicators. Results from December 2011 through November 2013 indicate that the number of female veterans with HgbA1c>9% has decreased throughout the VISN including the following rural sites from 18.6% to 13.2% in Iron Mountain and 26.7% to 15.2% at Tomah. Additional success was demonstrated to include the expansion of patient and provider reproductive health education (e.g. teratogenic medications) at these rural locations.
Recommendations for Success
Telepharmacy programs can be developed in a variety of ways, however the successes demonstrated in VISN 12 brought forth some lessons learned along the way. Some recommendations for implementing a successful Telepharmacy program include:
- Organize — Create and use a checklist
- VISN 12 developed a CVT checklist that is used as a template for the creation of any new Telepharmacy clinics. The checklist includes a list of each service that needs to be contacted and what tasks each service must complete. The checklist also includes the necessary training and paperwork requiring completion, as well as the day-of procedures that need to be established.
- Communicate — Ensure all parties involved have a good understanding of telepharmacy and outcomes you are trying to achieve.
- Develop a method for discussing need and benefit of telepharmacy services with key stakeholders.
- Set achievable goals — Identify the quality and humanistic outcomes you want to achieve and determine methods of obtaining that information.
- VISN 12 utilizes information from the data warehouse to collect data such as number of encounters completed, demographics of patients, surrogate markers of HgbA1c, SBP, LDL, access to care and consult completion.
Technology is expanding at a rapid pace, and healthcare is striving to meet the needs of our patients that is timely, forward thinking and provides improved access to care. The CP possesses the knowledge, skills, ability and training needed to manage the complex medication issues faced by our veterans. Utilizing telepharmacy improves access to essential MTM services and allows rural veterans and those in special populations access to CP expertise closer to their home. The VHA Strategic Goals and Objectives for FY2013-18 include expansion of innovation and health technologies nationally. VHA has demonstrated the benefits of telepharmacy modalities and future initiatives are anticipated to expand thus highlighting the value of clinical pharmacy providers in improving the quality of care for our veterans.
1 About VHA. Va.gov. N.p., n.d. Web. 18 Oct. 2013
2 VA Telehealth Services. VA Telehealth Services. N.p., n.d. Web. 18 Oct. 2013.
3 Manolakis PG et al. Am J Pharm Educ. 2010 December 15; 75(10): S7.
4 Giberson S, Yoder S, Lee MP. Improving Patient and Health System Outcomes through Advanced Pharmacy Practice. A Report to the U.S. Surgeon General. Office of the Chief Pharmacist. U.S. Public Health Service. Dec 2011.
5 McFarland MS, Davis KJ, Wallace JL. Utilization of Home Telehealth Monitoring with Active Medication Management by Clinical Pharmacists in Poorly Controlled Diabetic Patients. Pharmacotherapy 2012; 32:420–426.