do common questions equal missed opportunities: tales from ... · march 2015 opa medication...

Do common questions equal missed opportunities: Tales from Telehealth

Allan H. Malek, B.Sc (Bio)(Pharm), R.Ph

SVP, Professional Affairs

Ontario Pharmacists Association

Learning objectives

At the conclusion of this session, pharmacists will have a greater knowledge and understanding of the: • Background and history of pharmacists’ role in Ontario’s Telehealth

services to patients

• Most common categories of questions posed by patients calling Ontario Telehealth

• Consequences of discontinuation of pharmacist support to Telehealth

• Opportunities available to pharmacists AND pharmacies to close the gaps, and

• Patient benefits that accrue from closing the gaps and providing a standardized approach to medication therapy management

Presenter disclosure

• Employee of the Ontario Pharmacists Association

• No conflicts of interest

• No honourarium paid for this presentation

Commercial support disclosure

• This session has received no financial or in-kind support from any commercial or other organization

Provincial/territorial Telehealth services PROVINCIAL/TERRITORIAL SERVICE ACCESS NUMBER

British Columbia HealthLink 8-1-1

Alberta Health Links 1-866-408-5465

Saskatchewan Healthline 1-877-800-0002

Manitoba Health Links 1-888-315-9257

Telehealth Ontario 1-866-797-0000

Quebec Info-santé 8-1-1

New Brunswick Tele-Care 8-1-1

Nova Scotia Health Links 8-1-1

Prince Edward Island 8-1-1 8-1-1

Newfoundland-Labrador HealthLine 1-888-709-2929

Northwest Territories – Nunavut – Yukon NOT AVAILABLE

Telehealth Ontario (1)

What is Telehealth Ontario?

• Telehealth Ontario is a free, confidential telephone

service you can call to get health advice or general

health information from a registered nurse.

• 24/7/365

Telehealth Ontario (2)

When was the Medication Information Service (MIS) to

Telehealth introduced?

• February 15, 2001:

– Initial implementation in Metro Toronto • Area codes 416 and 905 initially (five calls on Day #1)

• Area codes 705 and 807 added very shortly after initial launch

• December 2001

– Expansion to remainder of the province

Simple framework (1)

MEDICATION-RELATED QUESTION?

PATIENT/AGENT

TELEHEALTH PHARMACIST TELEHEALTH NURSE

• TELEPHONE • FACSIMILE • EMAIL

• TELEPHONE • TELEPHONE

Simple framework (2)

TELEHEALTH PHARMACIST TELEHEALTH NURSE

1. Caller demographics

2. Summary of caller’s issue/question

3. Any advice provided by RN to caller

Overview of the Issue (pre-transfer)

• As presented by the RN

Call Transfer to Telehealth Pharmacist

• RN is disconnected upon transfer to Telehealth Pharmacist

RN and Caller Demographics • Full name of TH Nurse • Full name of caller (?) • Caller’s telephone number • Caller relationship to patient (if

different) • Caller and/or patient gender and

age

Rigid

documentation

I will need to

capture a little bit

of background

health status information.

1. Allergies

2. Medical conditions (if any)

3. Pregnancy/lactation status (if applicable)

4. Medication status • Rx

• OTC and vitamins

• Herbal and NHPs

5. Alcohol status

6. Smoking status

Relevant medical

and medication

history

1. What is the exact question/issue? • Presented by caller but informed by the RN • Potential for misinterpretation • Potential for some info to be missed on triage • Pharmacist to document ALL info provided

2. Identify the product(s) in question • If more than one type, list based on most relevant

to the question/issue

3. Identify the nature of the question/issue

• Drug interaction, ADE, dosage, administration, etc. • Paediatric / pregnancy / breastfeeding

QUESTION

ANSWER & REFERENCES

Telephone triage

PATIENT/AGENT

TELEHEALTH PHARMACIST

TELEPHONE

URGENT REFERRAL

ER/911

NON- URGENT

REFERRAL

PATIENT SELF CARE

MONDAY 15.2%

TUESDAY 16.1%

WEDNESDAY 11.3%

THURSDAY 12.2%

FRIDAY 13.9%

SATURDAY 14.9%

SUNDAY 16.4%

Calls per day of week (%) – March 2015

OPA Medication Information Service Telecare Program, March 2015 Report

Telehealth statistics Apr 2014 – Mar 2015

Total Annual Call Count

19,462

Average Monthly Call Count

1,622

Average Daily Questions

52 (31 - 93)

Average Call Duration

11 min

Calls answered by hour of day April 2014 – March 2015

0

200

400

600

800

1000

1200

1400

1600

1800

0700 -0800

0800 -0900

0900 -1000

1000 -1100

1100 -1200

1200 -1300

1300 -1400

1400 -1500

1500 -1600

1600 -1700

1700 -1800

1800 -1900

1900 -2000

2000 -2100

2100 -2200

2200 -2300

# C

alls

Hour of Working Day


Nature of calls for FY2014-15 (percentage of total)

0.7 1.7

13.5

1.3

20.5

0.7

22.3

7.3

0.8 1.1

11.7 14.0

1.7 2.6 0.0

5.0

10.0

15.0

20.0

25.0


Top categories for FY2014-15

1. Dose/administration (22.3%)

2. Drug interaction (20.5%)

3. Pregnancy/breastfeeding (14.0%)

4. Adverse drug reaction (13.5%)

Top subjects for March 2015

1. Analgesics (17.3%)

2. Antibiotics (10.8%)

3. Contraceptives (12.9%)

4. GI drugs (6.2%)


DOSE & ADMINISTRATION

DRUG INTERACTIONS

PREGNANCY & LACTATION

ADVERSE DRUG REACTIONS

PAEDIATRICS DRUG OVERVIEW

THERAPEUTIC USE / DRUG OF

CHOICE

HERBAL & NATURAL HEALTH

PRODUCTS OTHER

Dose / administration (1) • Missed dose

- “I can’t remember if I took my warfarin or not today. What should I

do?”

• Double dose

- “I took an extra dose of atenolol by mistake this morning. Anything I

have to watch out for?”

• Administration of drugs in relation to meals and time of

day

- “What am I supposed to do if it doesn’t say on the vial either way to

‘Take with food’ or ‘Take on empty stomach’?

Dose / administration (2) • Vomited doses

- “I threw up two hours after taking her BCP. Do I need to redose?”

• Delayed vaccine doses

- “I forgot to get my last dose of Hepatitis B vaccine. Do I need to

restart the series?”

• Spacing from other drugs

- “I just finished taking the morning after pill. When should I start

taking my birth control pills?”

• Adjusting birth control pills cycles

- “I don’t want my period during my vacation next month. Can I adjust

my BCPs to delay my period?”

Drug interactions (1)

• Drug-drug interaction

– “Is there an interaction between clarithromycin and atorvastatin?”

• Drug-food interaction

– “Is it fine for me to drink grapefruit juice with my Ca++ channel blocker?”

• Drug-alcohol interaction

– “I am taking metronidazole. Can I go out and have a drink tonight?”

Drug interactions (2)

• Drug-herb interaction

– “Can I try glucosamine for my arthritis? I am currently on warfarin.”

• Drug-disease interaction

– “Which antihistamine is best for my allergies? I have high BP and glaucoma.”

Pregnancy and lactation (1)

• Use of over-the-counter medications

– “I have a cold. What kind of over-the-counter cough syrup can I

take? I am 32-weeks pregnant.”

• Use of topical medication

– “I am three-months pregnant. Can I use hydrocortisone cream for

my rash?”

Pregnancy and lactation (2)

• Use of antibiotics

– “My doctor prescribed nitrofurantoin for my bladder infection. Is it

safe for me to take while I am breastfeeding my four-week old

daughter?”

– “I have some nitrofurantoin left over from a bladder infection three

months ago. I now have another bladder infection and am 30

weeks pregnant. If it was safe three months ago, it’s probably safe

now, right? I just want to double check.”

• Use of antidepressants

– “I just found out I’m pregnant. Should I stop taking my

escitalopram?”

Pregnancy disclaimer

There is a 2-3% baseline risk of the

development of major abnormalities in babies

of women not taking any medications.

Adverse drug reactions (1)

• Withdrawal reactions

- “I missed one dose of my venlafaxine. I am feeling dizzy, and have nausea,

headache and difficulty sleeping. Are these side effects?”

• Serious adverse reactions

- “I have been taking atorvastatin for four months. Recently, I experienced

muscle pain in my upper arm. My friend told me I might be having a heart

attack. The pain is quite bothersome, but I am otherwise feeling okay. Am I

really having a heart attack?”

Adverse drug reactions (2)

• Minor side effects

- “I woke up this morning and went to pee and saw that my urine was a rusty

brown colour. I was going to go to the Emerg but thought you might be able

to help. Is this blood? Should I go to the hospital? My only health problem is

a bladder infection and am taking nitrofurantoin for it. I’m about half-way

through the course”

Paediatrics

• Use of over-the-counter medications

– “Can I give my nine-month-old something for his cough and congestion?”

• Verification of dosage

– “The doctor prescribed liquid prednisone for my three-year-old son’s

asthma attack. Prednisone is a steroid, right? The dose seems to be quite

high for such a little guy. Would you verify it for me?”

– “What dose of diphenhydramine can I give my child who is three years

old?”

• Product recommendation

– “My son is two months old. What can I use for his diaper rash?”

Drug overview

• New product information

– “Can you tell me something about the new diabetes medication _________?

I saw an ad for it on TV last night.”

• Onset of action

– “I received a prescription for an oral vaccine for traveller’s diarrhea. How

long before my trip do I have to take it for it to be effective?”

• Mechanism of action

– “What is the morning after pill? How does it work?”

Therapeutic uses / drug of choice

• Product indication

– “Can Valtrex be used for cold sores?”

• Alternative therapeutic use

– “My doctor prescribed me letrozole and metformin for infertility, saying

they work together and are quite effective. But the information sheets I

got from the pharmacy say that letrozole is used for breast cancer and

metformin is for diabetes. I have neither. Is my doctor on crack? Did he

make a mistake? What should I do?”

• Selection of products

– “I have both acetaminophen and ibuprofen at home. Which one is

better for my fever?”

Other requests (1)

• Compatibility/stability/formulation

– Excipients

• “I am taking a medication called amlodipine. Does it contain

lactose?”

– Expired medication

• “I have some acetaminophen in my medicine cabinet that expired in

2013. Is it ok to take for my headache?”

– Improper storage conditions

• “I left my vaccine outside the fridge overnight. Is it still ok?”

Other requests (2)

• Identification, availability and Canadian/foreign

– Generic versus brand

• “My MD said he was going to give me ‘Altace™’ but the pharmacist

prescribed ‘Ramipril’. Is this the same thing?”

– Canadian equivalents for foreign drugs

• “My son got ‘Augmentin™’ when he was in Florida and had an ear

infection. I think he has another ear infection. What is the

equivalent to ‘Augmentin™’ in Canada?”

Herbal and natural product disclaimers (1)

• Regulated under the Natural Health Products Regulation

(2004)

• Generally, NHPs have been considered safe and

reportedly have fewer side effects than traditional

medications

– “They are NATURAL, so they must be SAFE”

• To be sold, NHPs must have a product licence

– Specific labelling and packaging requirements

– Good manufacturing practices (GMP)

– Evidence of safety and effectiveness

BUT….

• Not nearly as well understood as traditional Rx/OTC

products

• Not risk-free:

– Manufacturing problems

• i.e., contamination, incorrect ingredients or dosage

– Unproven claims, which can lead people to use the wrong products

for serious conditions or to delay proper treatment

– Not enough information for people to make an informed choice

• i.e., incorrect or vague instructions, no warnings that product and/or its

ingredients may not be suitable for certain groups

– Interaction with prescription drugs or other natural health products

– Unwanted side effects and potential allergic reactions


• No guarantee on the quality of the product.

• Variation could exist between what it says on the label

and what it actually contains.

• Often unclear as to which part of the plant the ingredient

was derived

• Herbal and drug/disease interactions

– Information on these products/ingredients is still limited and is

often theoretical.

– Potential to interact with other medications and medical

conditions in ways that are not known or well defined.

– They should be used with caution


So now what?

Can a telepharmacy service fit

into the community pharmacy

workflow?

(i) RN/PHM TRIAGE, 0.5

(ii) PHM/CALLER TRIAGE, 2.0

(iii) DEFINE THE QUESTION, 0.5

(iv) FIND REFERENCES, 3.0

(v) CONVEY RESPONSE, 2.0

(vi) DOCUMENTATION, 3.0

27.3%

18.2%

27.3%

4.5%

18.2%

4.5%

AVERAGE CALL

DURATION ~11 mins

Illustrative Call Segmentation (minutes, % total time)

STEP TIME

(i) RN-PHM TRIAGE

0.5 MIN

(ii) PHM-PT TRIAGE

2.0 MIN

(iii) DEFINE QUESTION

0.5 MIN

(iv) FIND REFERENCES

3.0 MIN

(v) CONVEY RESPONSE

2.0 MIN

(vi) DOCUMENT CALL

3.0 MIN

From Telehealth to community pharmacy:

Workflow impact and opportunity KNOWN PATIENT

RN to PHM 0 min (0.5 for TH)

Medical/Rx History 0.5 min (2 for TH)

Find the Question 0.5 min (0.5 for TH)

Find References 0 - 3.0 min* (3 for TH)

Convey Response 1.5 min (2 for TH)

Documentation 0 - 1.5 min* (3 for TH)

TOTAL TIME 2.5 to 7.0 minutes*

UNKNOWN PATIENT

RN to PHM 0 min (0.5 for TH)

Medical/Rx History 2.0 min (2 for TH)

Find the Question 0.5 min (0.5 for TH)

Find References 0 - 3.0 min** (3 for TH)

Convey Response 1.5 min (2 for TH)

Documentation 0 - 1.5 min** (3 for TH)

TOTAL TIME 4.0 to 8.5 minutes**

Worth the investment in patient RETENTION

Worth the investment in patient RECRUITMENT

• Finding references may be discretionary • Total time may be less if documentation

is done post-call completion

Not seeing the forest for the trees?

Many patient questions are very simple and straightforward…WHY?

• Am I spending enough time with my patients or am I simply too rushed in

my work?

• Am I taking the easy route to medication counselling?

• Do I think outside the box for possible scenarios and pitfalls facing the patient?

• Do I actively listen to my patient to hear if there are any miscues?

• Am I sure my patient has actually understood my counselling?

• Did I let the patient ask me questions during my counselling or did I do all the talking?

• Did I inquire of my patient what their doctor told them?

• Do I invite the patient to call us at the pharmacy if they have any questions? Was it a sincere offer?

• Does our pharmacy offer an Rx follow-up service with new Rx’s?

Leverage yourself on the call

When permitted in your jurisdiction, offer:

• Medication reviews

• Chronic disease management services

• Travel consultations

• OTC recommendations

• Smoking cessation services

• Pharmaceutical opinions

• Rx adaptations

• Therapeutic substitutions

• Emergency prescribing

Inappropriate pharmacist interventions

(especially for unknown patients)

• Recommendation for a change in Rx drug dosage

• Discontinuation of a Rx drug

– Except for obvious serious ADR or allergy

• Recommendation re: Rx drug taken by the wrong person

• Inquiry regarding another person’s medications

– i.e., trying to figure out indication for use

• Calls from a nursing home

This list is NOT exhaustive. • Use your professional judgment.

• Document everything you say/recommend

Patient benefits

• Strengthened patient-pharmacist relationship

• Greater sense of empowerment and personal control

• Improved medication management

• Decreased negative health outcomes

– Avoided ED or MD visits

• Healthcare closer to home and on their schedule

Keep an active listing for

local service referral centres

PREGNANCY & LACTATION SERVICES

ADDICTION SERVICES

POISON CENTRES

PHARMA

MFRS

DI SUBSCRIPTION

SERVICES

EMERG DEPARTMENTS

EMERG DEPARTMENTS

WALK-IN CLINICS

URGENT CARE CLINICS

TELEHEALTH-TYPE LINES

SUICIDE HOTLINE 9-1-1

Summary (1)

• We cannot predict EVERY question that will come up

• Active listening and parking your biases at the door can help ... don’t assume your message is straightforward!

• Analgesics, antibiotics, contraceptives and GI drugs are always the trouble spots for patients ... so anticipate them – People are human – forgetting to take one’s meds is foreseeable

… prepare them for these inevitabilities

• Key areas of focus: – Dose and administration

– Drug interaction

– Pregnancy and breastfeeding

– Adverse drug reactions

Summary (2)

• Embrace telepharmacy services

– There are some pitfalls and cautions such as privacy and

confidentiality and performing a thorough triage

– Use your professional judgment if the patient is unknown to you

– Leverage your in-store services

– Telepharmacy is an excellent pharmacy recruitment service,

and word of mouth from a successful interaction can be

profound

Allan H. Malek SVP, Professional Affairs

Ontario Pharmacists Association [email protected]

1-877-341-0788

Twitter @OPAProfAff

@OntPharmacists

Got questions?

mailto:[email protected]

Additional resources for

patients and pharmacists

• Website:

– http://www.motherisk.org/

• Alcohol and substance:

– 1-877-327-4636

• Morning sickness:

– 1-800-436-8477

• HIV and HIV treatment:

– 1-888-246-5840

• Motherisk Helpline:

– 1-877-439-2744 (national)

– 1-416-813-6780 (GTA)

• Monday - Friday

• 9 a.m. – 5 p.m. in each of

Canada's time zones

http://www.motherisk.org/

• Website:

– http://www.camh.ca/en/hospital/Pages/home.aspx

• CAMH main switchboard: – (416) 535-8501 or 1(800) 463-2338 toll free

• ACCESS CAMH: – (416) 535-8501 press 2 for information about accessing CAMH services.

– Mon-Fri 8:30 a.m. - 4:30 p.m.

• CAMH information officer: – 1 (800) 463-6273 toll-free or (416) 535-8501, press 1 for general

information.

– Mon-Fri 8:30 a.m.- 5:00 p.m.

http://www.camh.ca/en/hospital/Pages/home.aspx

http://www.camh.ca/en/hospital/Pages/home.aspx

• Website:

– https://www.eatrightontario.ca/en/default.aspx

• For questions about nutrition, food or healthy eating:

– 1-877-510-510-2 to speak to a registered dietitian at EatRight Ontario

– Email-a-dietitian service on the website.

The registered dietitian service is only available to residents of Ontario.

https://www.eatrightontario.ca/en/default.aspx



Additional resources for pharmacists

DRUG INFORMATION RESOURCE SUBSCRIPTION (i.e., DIRC)

E-THERAPEUTICS+

CANADIAN PHARMACIST’S LETTER

RXFILES

LEXI-COMP

UPTODATE

Canadian poison control centres (1)

BC

• British Columbia Drug and Poison Information Centre

• Toll Free 1-800-567-8911

• Vancouver (604) 682-5050

AB

• Poison and Drug Information Services (PADIS)

• Toll-free 1-800-332-1414


SK


• Toll-free 1-866-454-1212

MB

• Manitoba Poison Control Centre

• Toll-free 1-855-7POISON (1-855-776-4766)


ON

• Ontario Poison Centre

• Toll-free 1-800-268-9017

• (416) 813-5900 (GTA)

QC

• Québec Poison Control Centre (Centre antipoison du Québec )

• Toll-free 1-800-463-5060


NB

• 911

NS

• IWK Regional Poison Centre

• Toll-free 1-800-565-8161 or call 911 and ask to speak to the Poison Centre


PEI

• IWK Regional Poison Centre

• Toll-free 1-800-565-8161

NL

• Poison Information Centre

• Toll-free 1-866-727-1110 or (709) 722-1110


NWT


• Toll-free 1-800-332-1414

Nunavut

• 1-800-268-9017

Yukon

• Yukon Poison Control Centre - Whitehorse General Hospital

• 1-867-393-8700

do common questions equal missed opportunities: tales from ... · march 2015 opa medication...

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