North Dakota Telepharmacy North Dakota Telepharmacy ProjectProject

Hospital Telepharmacy Hospital Telepharmacy ModelModel

Slide presentation by John S. Skwiera, Slide presentation by John S. Skwiera, R.Ph., Heart of America Medical R.Ph., Heart of America Medical Center, RugbyCenter, Rugby

What Is Hospital What Is Hospital Telepharmacy?Telepharmacy?

Is it a means to provide access to medications Is it a means to provide access to medications via automation?via automation?

Is it a means to provide ready access to Is it a means to provide ready access to medications and professional services?medications and professional services?

IT CAN BE BOTH!IT CAN BE BOTH!

AutomationAutomation

Pyxis, Omnicell -- automated dispensing Pyxis, Omnicell -- automated dispensing equipmentequipment

ExpensiveExpensive Data entry with verification necessaryData entry with verification necessary Is not the answer to everythingIs not the answer to everything

ND Telepharmacy ModelND Telepharmacy Model

Utilizes the unique skills and knowledge Utilizes the unique skills and knowledge of technicians, nurses, pharmacists, of technicians, nurses, pharmacists, physicians, and related health physicians, and related health professionals to optimize the care of the professionals to optimize the care of the patient while overcoming current and patient while overcoming current and future barriers to patient carefuture barriers to patient care

ND Telepharmacy ModelND Telepharmacy Model

Recognizes that technology is limitedRecognizes that technology is limited Recognizes that the practice of pharmacy Recognizes that the practice of pharmacy

is still an artis still an art Utilizes people and technology, each one Utilizes people and technology, each one

complementing the other in the service of complementing the other in the service of the patientthe patient

Why Do It?Why Do It?

Maintaining quality of careMaintaining quality of care Easing pharmacist shortagesEasing pharmacist shortages Improving of the pharmacist’s lifeImproving of the pharmacist’s life Maintaining the bottom lineMaintaining the bottom line Complying with regulationsComplying with regulations

Pharmacist Pharmacist DemographicsDemographics

There are not enough pharmacistsThere are not enough pharmacists We can’t “burn out” the pharmacists we haveWe can’t “burn out” the pharmacists we have Pharmacists in many rural hospitals are aging Pharmacists in many rural hospitals are aging Recruitment of young pharmacists to rural Recruitment of young pharmacists to rural

areas is laggingareas is lagging

Maintaining Maintaining Quality of CareQuality of Care

Using the best personnel possible for Using the best personnel possible for medication order entry, evaluation, and medication order entry, evaluation, and dispensing of medicationsdispensing of medications

THE PHARMACY TECHNICIANTHE PHARMACY TECHNICIAN THE PHARMACISTTHE PHARMACIST Their unique skills and talents complement Their unique skills and talents complement

those of nursing and other health care those of nursing and other health care professionalsprofessionals

Easing Pharmacist Easing Pharmacist ShortagesShortages

Telepharmacy may be the only feasible Telepharmacy may be the only feasible option for:option for:

Emergency coverageEmergency coverage After hours coverageAfter hours coverage Weekend coverageWeekend coverage Vacation coverageVacation coverage Routine pharmacy operationsRoutine pharmacy operations

Improving the LivesImproving the Lives of of Hospital PharmacistsHospital Pharmacists

Reducing stressReducing stress Assisting in staff retention and Assisting in staff retention and

recruitmentrecruitment Keeping openKeeping open

Maintaining the Maintaining the Bottom LineBottom Line

Staffing a pharmacy with a technician is Staffing a pharmacy with a technician is cost-effectivecost-effective

Pharmacist coverage via telepharmacy Pharmacist coverage via telepharmacy may cost less than an on-site pharmacistmay cost less than an on-site pharmacist

Complying With Complying With RegulationsRegulations

Stringent CMS and JCAHO guidelines for Stringent CMS and JCAHO guidelines for pharmacist review of orders prior to the pharmacist review of orders prior to the administration of any medications, except in administration of any medications, except in emergenciesemergencies

Possible restriction of access to the pharmacy Possible restriction of access to the pharmacy of non-pharmacy personnelof non-pharmacy personnel

State and federal regulationsState and federal regulations

Telepharmacy in the Hospital Telepharmacy in the Hospital SettingSetting

First StepsFirst Steps

Commit to following through!Commit to following through! Seek out partnersSeek out partners Seek assistance from NDSU College of Seek assistance from NDSU College of

Pharmacy and the ND Board of Pharmacy and the ND Board of PharmacyPharmacy

Educate administrators, corporate Educate administrators, corporate executives, and staffexecutives, and staff

Next Steps Next Steps

Apply for funding (ND Telepharmacy Project)Apply for funding (ND Telepharmacy Project) Determine components (both hospital and Determine components (both hospital and

home units) and equipment needshome units) and equipment needs Develop policies and procedures and business Develop policies and procedures and business

associate agreements/contractsassociate agreements/contracts Choose an internet providerChoose an internet provider Obtain bids for equipment, installation, and Obtain bids for equipment, installation, and

servicingservicing

Telepharmacy Telepharmacy ComponentsComponents

Institutional componentInstitutional component Hospital to hospitalHospital to hospital Community pharmacy to hospitalCommunity pharmacy to hospital

Provides services between two sites for Provides services between two sites for scheduled telepharmacy operationsscheduled telepharmacy operations

Telepharmacy Telepharmacy ComponentsComponents

Pharmacist’s home to institution for Pharmacist’s home to institution for unscheduled absences of a pharmacist unscheduled absences of a pharmacist due to illness, inclement weather, etc.due to illness, inclement weather, etc.

Equipment NeedsEquipment Needs Polycom unit with a document camera (optional Polycom unit with a document camera (optional

at home sites)at home sites) Personal computer and/or institutional network Personal computer and/or institutional network

accessaccess Equipment and software Equipment and software Security (VPN, firewalls, anti-virus software) Security (VPN, firewalls, anti-virus software)

and access and access Satellite dish (optional at home sites)Satellite dish (optional at home sites)

Approximate Costs Approximate Costs

Polycom VSX, PCs, monitors, high resolution Polycom VSX, PCs, monitors, high resolution document camera(s), misc.: $12,000+document camera(s), misc.: $12,000+

DSL: up to $150/mo.DSL: up to $150/mo. Virtual Private Network (VPN): $1,000Virtual Private Network (VPN): $1,000 Equipment Installation: $1,500+Equipment Installation: $1,500+ Software as neededSoftware as needed Remodeling as neededRemodeling as needed Counter space: ca. 5 linear feetCounter space: ca. 5 linear feet

Paperwork/Paperwork/DocumentationDocumentation

Telepharmacy Policy/Procedure -- establishes Telepharmacy Policy/Procedure -- establishes standards of pharmacy practicestandards of pharmacy practice

Business Associate Agreement -- establishes Business Associate Agreement -- establishes contractual agreements and outlines contractual agreements and outlines adherence to HIPAA regulationsadherence to HIPAA regulations

Grant requirements -- expense tracking and Grant requirements -- expense tracking and reimbursementreimbursement

Error/near-miss trackingError/near-miss tracking

Telepharmacy PolicyTelepharmacy Policy

Must insure maintenance of quality careMust insure maintenance of quality care Must insure adequate evaluation and Must insure adequate evaluation and

verification of technician workverification of technician work Must incorporate policies for resolving Must incorporate policies for resolving

any questions, discrepancies, or errorsany questions, discrepancies, or errors Must be in accordance with law to the Must be in accordance with law to the

satisfaction of the Board of Pharmacysatisfaction of the Board of Pharmacy

Telepharmacy PolicyTelepharmacy Policy

Can delineate the qualifications and Can delineate the qualifications and training of stafftraining of staff

Can have anything that the partners want Can have anything that the partners want in it (within reason)in it (within reason)

Can not contradict current policies within Can not contradict current policies within each participating hospitaleach participating hospital

Recommended Reading Recommended Reading

“ “Rural Hospitals and Telepharmacy” by Rural Hospitals and Telepharmacy” by Petra S. Berger (Risk Management and Petra S. Berger (Risk Management and Patient Safety Institute)Patient Safety Institute)

www.rmpsi.comwww.rmpsi.com

The ProcedureThe Procedure

Order entry by the technicianOrder entry by the technician Verification of order entry by the Verification of order entry by the

supervising pharmacist -- this is supervising pharmacist -- this is accomplished by placing a hard copy of accomplished by placing a hard copy of the physician’s order under the document the physician’s order under the document camera and comparing it to the camera and comparing it to the technician’s computer entrytechnician’s computer entry

The ProcedureThe Procedure

Verification of the drug and label by the Verification of the drug and label by the supervising pharmacist -- this is done by supervising pharmacist -- this is done by placing the drug and label under the placing the drug and label under the document cameradocument camera

Release of the drugRelease of the drug Documentation of the transaction by the Documentation of the transaction by the

technician or pharmacisttechnician or pharmacist

Who Sees What?Who Sees What?

Each pharmacist can have access to another Each pharmacist can have access to another site’s pharmacy information system, as allowed site’s pharmacy information system, as allowed by the software -- ideally, it would be by the software -- ideally, it would be compatiblecompatible

The pharmacist can view and approve a The pharmacist can view and approve a technician’s work at the other sites, as allowedtechnician’s work at the other sites, as allowed

EvaluateEvaluate

VerifyVerify

Identify MedsIdentify Meds

PitfallsPitfalls Institutional resistance Institutional resistance Corporate resistanceCorporate resistance Staff resistance Staff resistance Lack of time to implementLack of time to implement Lack of ongoing financial commitment Lack of ongoing financial commitment Challenges in terms of systems compatibility Challenges in terms of systems compatibility

and connectivityand connectivity

Future PossibilitiesFuture Possibilities

The addition of sites to existing hospital The addition of sites to existing hospital telepharmacy networktelepharmacy network

Other hospitals will provide this or similar Other hospitals will provide this or similar servicesservices

As pharmacists retire in rural settings, As pharmacists retire in rural settings, expansion may include full time telepharmacy expansion may include full time telepharmacy coveragecoverage

The servicing of hospitals by community The servicing of hospitals by community pharmacists without needing to be on site pharmacists without needing to be on site

Hospital Telepharmacy Hospital Telepharmacy Network Network (as of 9/1/06)(as of 9/1/06)

Heart of America Medical Center, RugbyHeart of America Medical Center, Rugby Mercy Hospital, Devils LakeMercy Hospital, Devils Lake St. Aloisius Hospital, HarveySt. Aloisius Hospital, Harvey Towner County Medical Center, CandoTowner County Medical Center, Cando Presentation Medical Center, RollaPresentation Medical Center, Rolla Carrington Health Center, CarringtonCarrington Health Center, Carrington SCCI Hospital, MandanSCCI Hospital, Mandan

ConclusionConclusion

Telepharmacy is a way to provide superior Telepharmacy is a way to provide superior pharmacy services to rural NDpharmacy services to rural ND

Telepharmacy is adaptable to a wide range of Telepharmacy is adaptable to a wide range of practice settingspractice settings

This is only the tip of the iceberg in terms of This is only the tip of the iceberg in terms of possibilitiespossibilities

RESOURCESRESOURCES

Ann Rathke, Telepharmacy CoordinatorAnn Rathke, Telepharmacy CoordinatorNDSU College of Pharmacy, Nursing, and NDSU College of Pharmacy, Nursing, and

Allied SciencesAllied Sciences123 Sudro Hall123 Sudro HallFargo, ND 58105Fargo, ND 58105701-231-5863701-231-5863ann.rathke@ndsu.eduann.rathke@ndsu.edu

RESOURCESRESOURCES

Howard Anderson, Executive DirectorHoward Anderson, Executive Director

North Dakota Board of PharmacyNorth Dakota Board of Pharmacy

PO Box 1354PO Box 1354

Bismarck, ND 58502-1354Bismarck, ND 58502-1354

701-328-9535701-328-9535

ndpoph@btigate.comndpoph@btigate.com

RESOURCESRESOURCES

John Skwiera, R.Ph.John Skwiera, R.Ph.

Heart of America Medical CenterHeart of America Medical Center

800 South Main800 South Main

Rugby, ND 58368Rugby, ND 58368

701-776-5261, ext 2262701-776-5261, ext 2262

pharmacy@hamc.compharmacy@hamc.com

Telepharmacy EquipmentTelepharmacy EquipmentRyan JilekRyan Jilek

Custom Data, Inc.Custom Data, Inc.

677 10th Street East677 10th Street East

Dickinson, ND 58601Dickinson, ND 58601

701-483-3036701-483-3036

www.telepharmacyconcepts.comwww.telepharmacyconcepts.com

www.customdata.comwww.customdata.com

jilek@customdata.comjilek@customdata.com