November 25, 2013
By: Kevin E. McCarthy, Principal Analyst
You asked for a description of telepharmacy and telepharmacy initiatives in other states. We also describe telepharmacy initiatives in Connecticut.
The Model State Pharmacy Act and Model Rules, developed by the National Association of Boards of Pharmacy (NABP, the organization of state pharmacy regulatory agencies) defines the practice of telepharmacy as “the provision of pharmacist care by registered pharmacies and pharmacists located within U.S. jurisdictions through the use of telecommunications or other technologies to patients or their agents at distances that are located within U.S. jurisdictions.” Telepharmacy is typically based in hospital or retail pharmacies. Telepharmacy in retail settings has primarily occurred in rural states with pharmacist shortages.
This report describes telepharmacy initiatives in Kansas, North Dakota, and Washington. The initiative in Kansas is administered by a nonprofit health delivery network and covers pharmacies in 14 hospitals. In North Dakota's Telepharmacy Project, a licensed pharmacist at a central site communicates with remote site pharmacy technicians and patients through videoconferencing. The project currently involves 81 participants (25 central pharmacies and 56 remote sites), including both retail and hospital pharmacies. The initiative in Spokane, Washington provides for the remote dispensing of medications and counseling via a two-way interactive videoconferencing system to patients at six urban and rural clinics.
State laws and regulations vary on the definition of telepharmacy, licensing requirements, education and training for participating pharmacists and technicians, and practice setting restrictions, among other things. This report describes telepharmacy laws in California, Idaho, Illinois, and Nevada, as well as Connecticut.
In California, the law bars a health insurer or health care services plan from requiring that in-person contact occur between a pharmacist or other health care provider and a patient before payment is made for the covered services appropriately provided through telehealth. It also bars insurers and plans from limiting the type of setting where services are provided for the patient or by the health care provider before payment is made for the covered services appropriately provided using these methods. Under Idaho's law, pharmacists licensed in other states can practice telepharmacy in Idaho if they register with the state Board of Pharmacy, pay a fee, and sign a statement attesting that they will abide by Idaho's pharmacy laws and rules. Illinois law defines telepharmacy as the provision of pharmacist care by a pharmacist through the use of telecommunications or other technologies to patients or their agents who are at a distance and are located within the United States. It describes, in detail, the duties of the pharmacist in charge of providing services through telepharmacy. Legislation passed in 2013 in Nevada requires the Pharmacy Board to adopt regulations to authorize (1) registered pharmacists to engage in the practice of pharmacy electronically or by telephone or fiber optics from within or outside the state and (2) prescriptions to be filled and dispensed to patients as prescribed by practitioners electronically or by telephone or fiber optics from within or outside the state.
Connecticut law allows the practice of telepharmacy under limited circumstances. It allows a hospital that operates a hospital pharmacy to use telepharmacy at its satellite or remote locations to allow a clinical pharmacist to supervise pharmacy technicians in preparing intravenous (IV) admixtures and other all sterile products.
Telepharmacy can be used to enable pharmacists to:
1. become involved in selecting medication for patients at geographically remote locations,
2. review new medication orders transmitted by fax or electronically,
3. remotely enter new orders into the patient's electronic medication profile,
4. remotely release the ordered medication from an automated medication dispensing cabinet, and
5. electronically supervise technicians providing full-service pharmacy operations.
Telepharmacy routinely uses the Internet and teleconferencing tools to deliver the expertise of pharmacists remotely to hospitals that do not have around-the-clock pharmacist coverage. A 2012 national survey of hospitals conducted by NABP found that 34% of hospital pharmacies did not offer 24-hour coverage. Telepharmacy can thus extend pharmacy coverage in hospitals that do not offer pharmacy services around–the-clock.
STATE TELEPHARMACY INITIATIVES
Via Christi Health, a nonprofit health services network, operates 11 hospitals in Kansas, ranging from a large community hospital with more than 400 beds to a 40-bed rehabilitation facility. Although the network's two largest hospitals provide 24-hour, onsite pharmacy services, staffing at the other facilities allows only part-day coverage. The network established a telepharmacy program in 2008 due to concerns that part-time coverage can undermine safety, efficacy, and cost-effectiveness and does not allow pharmacists to prospectively review each order before administering drugs to a patient, as recommended by the Joint Commission on Hospital Accreditation.
Under the program, telepharmacy services are available 24 hours a day, seven days a week. Each hospital requests the hours of coverage that it needs, with some electing complete coverage and others electing coverage during evening and overnight hours.
In the most common scenario, a physician generates a medication order, by hand or electronically. Telepharmacists receive orders through a secure, virtual private network or terminal server. The telepharmacist reviews each order, checking the patient's age, sex, height, weight, diagnosis, existing drug therapies (to check for potential interactions and duplications), allergies, medication history, and pertinent laboratory results. If necessary, the telepharmacist phones the onsite physician or nurse to clarify information. Assuming the telepharmacist approves the order, he or she enters it into the hospital's pharmacy information system. The system creates a medication administration record, which begins the process to provide the correct medication to the nurse to administer to the patient, and provides an electronic record so the nurse can scan the medication barcode at the bedside when he or she administers the dose to the patient.
The program was expanded in 2011 to allow for electronic supervision of pharmacist technicians. In a typical transaction, the technician sends a scanned medication refill list to the remote pharmacist after they establish a virtual connection with a secure audio and video link. The technician gathers all of the medications on the refill list and shows them to the remote pharmacist to be verified. The technician delivers the medication to the automated dispensing cabinets on the nursing units. The nurse then has access to the medication to administer it to the patient.
A 2009 review of the program, then operating at five hospitals, found that it expanded hours of pharmacy service, reduced order processing times, increased nurse satisfaction, freed up pharmacist time for other quality-enhancing initiatives, and saved a projected $1 million a year.
As of January 2011, the program employed 14 pharmacists, including six who also work at Via Christi hospitals. The telepharmacists cover 14 hospitals, which include eight Via Christi facilities and other hospitals. The January 2013 edition of Pharmacy Purchasing and Products has a detailed article on this program.
In 2001, North Dakota became the first state to pass regulations allowing retail pharmacies to operate without requiring a pharmacist to be physically present. In response to an increasing number of rural community pharmacy closings, the state Board of Pharmacy established pilot telepharmacy rules to explore the feasibility of using telepharmacy to restore and retain pharmacy services in medically underserved remote rural communities.
In September of 2002, the state College of Pharmacy received a federal grant to implement a statewide program to save rural pharmacies from closing and to test the new telepharmacy pilot rules. Ten rural communities were involved in the first year of the grant. The next year, state agencies and grants established the North Dakota Telepharmacy Project, which now supports more than 50 remote retail and hospital
pharmacy sites throughout North Dakota. In this program, a licensed pharmacist at a central site communicates with remote site pharmacy technicians and patients through videoconferencing.
In 2003, due to the success of the pilot project, the state Board of Pharmacy established permanent rules allowing telepharmacy to be practiced on a broader scale (N.D. § 61-02-08-01 et seq.). The permanent rules allow (1) a retail pharmacy to open and operate in certain remote rural areas of the state without a licensed pharmacist being physically present in the store and (2) a pharmacist to supervise a registered pharmacy technician at a remote telepharmacy site using telepharmacy technology to dispense prescriptions to patients, provide drug utilization review, and counsel patients. Among other things, the rules require that:
1. the pharmacy and remote site be connected by a computer, video, and audio links;
2. a registered pharmacy technician be present at the remote site;
3. the pharmacist compare the stock bottle, drug dispensed, and its strength via the video link, with the entire label checked for accuracy; and
4. the pharmacist must counsel the patient or his or her agent on all new prescriptions and refills using the video and audio links.
The project has expanded over time and there are 81 pharmacies currently involved (25 central pharmacies and 56 remote sites). Of the pharmacies, 53 are retail pharmacies and 28 are hospital pharmacies. Thirty-eight (73%) of the state's counties are involved in the project, as well as two counties in Minnesota. Since the project began, approximately 80,000 rural residents have had pharmacy services restored, retained, or established through the project. According to the project's website, it has restored access to health care in remote, medically underserved areas and added approximately $26.5 million in economic development to the local rural economy.
Community Health Association of Spokane (CHAS), a federally qualified community health center, began its telepharmacy program in January 2001. The program, known as Telepharmacy at CHAS, provides for the remote dispensing of medications and counseling via a two-way interactive videoconferencing system to patients at six urban and rural clinics.
The program was reviewed in 2003. Over a two-week period, 93 patients seen at remote sites and 106 seen at the base site completed a customer service questionnaire. Over 75% of patients seen at the remote sites were satisfied with their videoconference interactions with the pharmacist. Of the patients seen at the base site, 66% agreed or strongly agreed that they were satisfied with the time required to obtain medications and counseling. A high percentage of patients at both the base site (94%) and remote sites (63%) agreed or strongly agreed that they would have difficulty affording their medications without this program. According to the review, Telepharmacy at CHAS has been well received by most of the patients and improved their access to medications and pharmacy services.
STATE TELEPHARMACY LAWS
State laws and regulations vary on the definition of telepharmacy, licensing requirements, education and training for participating pharmacists and technicians, practice setting restrictions, and geographical limitations for the remotely-practicing pharmacist. State laws and regulations also vary widely regarding the technology required to implement telepharmacy. Although most require a camera and some audio exchange between the pharmacy and the remote pharmacist, the laws vary in the types of technology to be used and the types and amounts of information captured. Some state boards of pharmacy have identified specific training, certification, or experience that pharmacy technicians engaged in telepharmacy must possess. As an example, we describe telepharmacy laws in California, Idaho, Illinois, and Nevada, as well as Connecticut.
Connecticut law allows the practice of telepharmacy under limited circumstances. PA 11-242 (§ 50) authorized a pilot program allowing a hospital that operates a hospital pharmacy to use telepharmacy at its satellite or remote locations to allow a clinical pharmacist to supervise pharmacy technicians in preparing IV admixtures. PA 12-28 made this program permanent and expanded it to cover (1) all licensed hospital pharmacies and (2) the dispensation of all sterile products, not just IV admixture preparations as under the pilot program. The act allows pharmacists at hospital pharmacies to use electronic technology at the hospital, its satellite, or remote locations to supervise pharmacy technicians in dispensing sterile products.
Under the law, “telepharmacy” means the process (1) by which each step involved in the dispensing of sterile products is verified by a bar code tracking system and documented by digital photographs that are electronically recorded and preserved and (2) which is monitored and verified through video and audio communication between a licensed supervising pharmacist and a pharmacy technician. A pharmacist must supervise a pharmacy technician by using electronic technologies. A supervising pharmacist must monitor and verify the pharmacy technician's activities through audio and video communication. If the electronic technology malfunctions, no sterile products prepared by the technician during the malfunction period could be distributed to patients unless an appropriately licensed person could (1) personally review and verify all of the processes used in dispensing them or (2) after the technology is restored, use the electronic technology mechanisms that recorded the pharmacy technician's actions to confirm that all proper steps were followed in dispensing the sterile products. All orders for medication must be verified by a pharmacist before delegating to a pharmacy technician for sterile product dispensing.
A hospital participating in the program must ensure that appropriately licensed health care personnel administered medications at the hospital's satellite or remote locations. All processes involved in operating the program are under the purview of the hospital's pharmacy director.
California passed legislation in 2006 authorizing certain types of health professions, but not pharmacists, to engage in telemedicine. In 2011, the legislature passed A.B. 415, which updates the legal definitions of telemedicine (renamed telehealth), simplifies approval processes for telehealth services, and broadens the range of medical services that may be provided via telehealth to include pharmacy, among other things. The act thus establishes legal parity between the direct and remote delivery of pharmacy care.
Under the act, telehealth is the delivery of health care services and
public health via information and communication technologies to facilitate the diagnosis, consultation, treatment, education, care management, and self-management of a patient's health care while the patient is at the originating site and the health care provider (e.g., a pharmacist) is at a distant site. The provider must verbally inform the patient that telehealth may be used and obtain his or her verbal consent for this use.
By law, a health insurer or health care services plan may not (1) require that in-person contact occur between a health care provider and a patient before payment is made for the covered services appropriately provided through telehealth or (2) limit the type of setting where
services are provided for the patient or by the health care provider before
payment is made for the covered services appropriately provided through
telehealth. Both of these provisions are subject to the terms and conditions of the contract entered into by the affected parties. At the same time, a health insurer may not require the use of telehealth when the health care provider has determined that it is not appropriate.
Registered or licensed pharmacies or pharmacists located within the United States practice telepharmacy under Idaho law by providing pharmaceutical care through the use of telecommunications or other technologies to patients who are also located within the United States. (Id. Rev. Stat. § 54-1705).
Pharmacists licensed in other states can practice telepharmacy in Idaho if they register with the state Board of Pharmacy, pay a fee, and sign a statement attesting that they will abide by Idaho's pharmacy laws and rules. By law, a registered pharmacist must comply with the board's laws and Idaho rules unless compliance would violate the laws or rules in the state in which the registrant is located (Id. Rev. Stat. § 54-1723A). But:
1. a pharmacy technician may not exceed the practice limitations for technicians in Idaho;
2. a pharmacist may only substitute drug products and select drug products in accordance with Idaho law; and
3. a pharmacist may not exceed the pharmacy staffing ratio, as defined in the board's rules.
Illinois law defines telepharmacy as the provision of pharmacist care by a pharmacist through the use of telecommunications or other technologies to patients or their agents who are at a distance within the United States (225 Ill. Code § 85/25.15). Telepharmacy must follow all federal and state laws, rules, and regulations regarding privacy and security.
By law, any pharmacy engaged in telepharmacy must ensure that all events involving the contents of an automated pharmacy system are stored in a secure location. The events may be recorded electronically. An automated pharmacy or prescription dispensing machine system may be used in conjunction with the pharmacy's practice after inspection and approval by the Department of Financial and Professional Regulation.
The pharmacist in charge must:
1. be responsible for the practice of telepharmacy performed at a remote pharmacy, including supervising any prescription dispensing machine or automated medication system;
2. ensure that the home pharmacy has sufficient pharmacists on duty to safely operate and supervise all remote pharmacies;
3. ensure, through the use of a video and auditory communication system, that a certified pharmacy technician at the remote pharmacy has accurately and correctly prepared any prescription for dispensing according to the prescription;
4. supervise and train certified pharmacy technicians at remote pharmacies; and
5. ensure that patient counseling at the remote pharmacy is performed by a pharmacist or student pharmacist.
Nevada adopted legislation in 2009 authorizing telepharmacies, which are defined as a pharmacy or the office of a dispensing practitioner (e.g., a physician) that is accessible by a remote site or a satellite consultation site. Legislation passed in 2013 (2013 Nev. Stat. p. 2020) broadens these provisions. It allows dispensing practitioners at the telepharmacy or remote site to be employed by any entity, rather than just by a nonprofit federally qualified health center. By law, unaffected by this act, the telepharmacy or remote site can also be a pharmacy. The act allows the remote site to be located outside of the United States.
The act requires the state Pharmacy Board to adopt regulations to authorize (1) registered pharmacists to engage in the practice of pharmacy electronically or by telephone or fiber optics from within the state and (2) prescriptions to be filled and dispensed to patients as prescribed by practitioners electronically or by telephone or fiber optics from within or outside the state or the United States. It bars the board from conditioning, limiting, restricting, or otherwise denying the issuance of a certificate, license, registration, permit or authorization to prescribe controlled substances or dangerous drugs to a prescribing practitioner because he or she is located outside the state.