The Growing Practice of Telepharmacy

Telepharmacy, a subset of telemedicine, refers to providing pharmaceutical care to patients at a distance through telecommunications and information technologies. This model has emerged as a viable solution to the healthcare access challenges faced by rural and remote communities. Telepharmacy enables healthcare services such as medication review, patient counseling, and prescription verification by qualified pharmacists who are not physically present at the point of care.  

Related: Telepharmacy: Serving Underserved Populations in a Community Setting 

Historical context and development 

The concept of telepharmacy is relatively recent, evolving alongside advancements in information and telecommunication technologies during the late 20th and early 21st centuries. Telemedicine, the broader field from which it originated, was devised to provide healthcare services to medically underserved populations in geographically remote locations.  

The World Health Organization (WHO) defines telemedicine as the delivery of healthcare services by all healthcare professionals using information and communication technologies to exchange valid information. This is for the purpose of: 

  • Diagnosis, treatment, and prevention of diseases and injuries 
  • Research and evaluation 
  • Continuing education of healthcare providers 

The initial development of telepharmacy was driven by the need to address the shortage of healthcare professionals and services in rural areas. Rural communities often faced limited access to vital healthcare services, exacerbated by the closure of local pharmacies and the challenges of recruiting and retaining pharmacists in these areas. Telepharmacy allowed for extending pharmacy services to these underserved regions, providing a means to maintain medication access and patient care despite geographical and demographic barriers. 

Models of telepharmacy 

Several telepharmacy models have been developed to address the barriers to accessing pharmacy services. These models vary in structure and implementation but share the goal of leveraging technology to provide pharmaceutical care remotely. 

  1. Traditional full-service pharmacy: This model replicates the services of conventional pharmacies, including filling prescriptions, medication reviews, and patient counseling. These telepharmacy sites maintain a complete drug inventory and utilize audio and video links for remote patient interactions. 
  1. Remote consultation sites: In this model, prescriptions are prepared at a central pharmacy and delivered to remote sites. Audio and video communication tools are used for patient counseling and education, ensuring patients receive the necessary guidance on medication use. 
  1. Hospital telepharmacy: Hospital pharmacists in urban medical centers review and verify prescriptions electronically from rural hospitals. Automated dispensing machines (ADMs) are often used to release prepackaged medications, and remote pharmacists monitor the process and provide consultations via videoconference. 
  1. Automated Dispensing Machines (ADMs): In this model, a central pharmacist reviews the drug order and instructs the ADM to release the medication. Patient counseling uses audio and video links, ensuring patients receive proper medication guidance. 

State regulations 

State regulations for telepharmacy are highly diverse, reflecting the unique market-driven needs of each state. The pioneering effort in telepharmacy regulation began in North Dakota in 2001, addressing the closure of rural pharmacies by allowing remote sites to operate without an on-site pharmacist. This approach required a central pharmacy, staffed by a pharmacist, to be connected to the remote site via telecommunication technologies like computer, audio, or video links. 

Other states have adopted telepharmacy practices without formal regulations. For instance, a community health center in Spokane, Washington, utilized videoconferencing to dispense federal 340B Program drugs remotely in the same year North Dakota initiated its telepharmacy pilot program. Despite the success of such initiatives, many states still lack explicit telepharmacy regulations. Often, this leads to a patchwork of laws that complicate the nationwide practice of telepharmacy. 

Operational issues in licensing requirements 

Licensing requirements for telepharmacy can vary considerably. Some states impose additional licensing criteria for central and remote telepharmacy sites and the pharmacists operating them. For example, in Georgia, pharmacies must obtain a separate license to install and operate telepharmacy kiosks and pay associated fees. These kiosks can only be installed in licensed facilities like skilled nursing homes or hospices that lack on-site pharmacies. 

In Montana, remote telepharmacy sites must secure a distinct license and cannot be located within 20 miles of an existing pharmacy. The complexity increases for interstate telepharmacy practices, where pharmacies and pharmacists must comply with the state’s licensing requirements, where they are located, and where the patient resides. For instance, Louisiana mandates out-of-state pharmacies obtain a permit from their Board of Pharmacy before operating there. 

Operational issues in settings for telepharmacy services 

Telepharmacy services can be provided in various settings, typically through automated dispensing kiosks or staffed remote dispensing sites. Kiosks are mechanical systems that handle medication storage, packaging, and dispensing while electronically maintaining all transaction records. States such as Arkansas, Delaware, Illinois, Iowa, Kentucky, and Oklahoma have specific regulations governing the operation of these kiosks. 

Remote dispensing sites, including clinics, hospitals, and correctional facilities, require increased pharmacist supervision, usually via electronic links. For example, a licensed pharmacist in Colorado must be available via telecommunication to assist pharmacy technicians at remote sites, even though the technicians may not need direct, in-person supervision. 

Operational issues in record-keeping requirements 

Record-keeping is another critical regulatory aspect of telepharmacy. States often mandate that pharmacists maintain records at the central and remote sites involved in the telepharmacy practice. This dual requirement ensures all necessary information is available for state board inspections. In the case of kiosk operations, patient’s transaction data must be stored electronically to comply with state laws. 

Current use of telepharmacy in community pharmacy settings 

Studies have demonstrated that pharmacists’ involvement in telepharmacy significantly reduces adverse drug events. These adverse drug events contribute to thousands of deaths annually and cost the US healthcare system an estimated $2 billion each year. For example, research shows that remote pharmacist review of medication orders during off-hours prevents adverse patient outcomes, including prolonged hospitalization and potential deaths. This proves telepharmacy as an effective alternative to around-the-clock on-site pharmacist presence. 

Telepharmacy primarily enhances healthcare access in rural and remote locations where traditional pharmacy services may be scarce. Many small rural areas in the US have limited on-site pharmacist availability, with nurses often handling medication dispensing. Telepharmacy addresses this gap by enabling comprehensive pharmacy services, including medication utilization review, patient counseling, and education through advanced technologies. This model ensures that rural residents receive the necessary pharmaceutical care without extensive travel. 

As a result, patients in rural areas often express high satisfaction with telepharmacy services. The ability to receive medication counseling and support without leaving their homes enhances trust and satisfaction. Patients appreciate the privacy and extended counseling time provided by telepharmacy, with many preferring this service mode over traveling to distant healthcare facilities. Additionally, telepharmacy has proven effective in-patient education, such as demonstrating proper inhaler techniques via video, which enhances treatment adherence and outcomes. 

Furthermore, telepharmacy mitigates the scarcity of pharmacists in rural areas by shifting some pharmacy responsibilities to remote pharmacists. This approach allows hospitals and clinics to maintain high standards of pharmaceutical care even without on-site pharmacists. This model also offers a flexible solution for staffing challenges, ensuring continuous pharmaceutical service coverage. 

A typical workflow process of community telepharmacy 

The core of telepharmacy revolves around integrating technology to facilitate communication and service delivery between rural sites and central pharmacies. Here’s a step-by-step overview of the typical workflow process in community telepharmacy

  1. Connection establishment: Videophone systems, novel software, and automated dispensing machines (ADMs) connect a small rural pharmacy to a larger urban pharmacy. This connection enables the rural site to access the services of pharmacists who may not be physically present. 
  1. Prescription transmission: The rural site receives the patients’ prescriptions, typically staffed by pharmacy technicians or nurses. These healthcare professionals then transmitted the prescriptions to the central pharmacy via fax or electronic transmission. 
  1. Prescription processing: A qualified pharmacist at the central pharmacy reviews the prescription. Using ADMs, the pharmacist releases the appropriate medications. A tech or assistant prepackages and labels these meds. 
  1. Label and medication matching: The pharmacy technician or nurse at the rural site scans the barcode on the medication to ensure it matches the label provided by the central pharmacy. They then attach the label to the medication package. 
  1. Dispensing to patients: The rural site staff supplies the labeled medication to the patient. The central pharmacist visually monitors the process to ensure accuracy and safety. 
  1. Patient consultation: The central pharmacist provides a two-way video consultation with the patient. This step is crucial for ensuring the patient understands the medication use and administration and for addressing any patient concerns. 

Critical considerations for remote oversight of pharmacy technicians 

In telepharmacy, pharmacy technicians handle a broader range of tasks than traditional ones. They manage daily operations, interact with patients, and handle inventory, billing, and insurance disputes. Techs must demonstrate responsibility and the capability to work independently. 

Despite their autonomy, technicians operate under the supervision of a remote pharmacist who verifies prescriptions and provides patient counseling via telepharmacy software. Effective communication systems are essential to facilitate real-time guidance and ensure regulatory compliance.  

As a result, pharmacy technicians are patients’ primary point of contact, requiring strong interpersonal skills. They must build rapport, manage patient expectations, and ensure smooth interactions with the remote pharmacist, effectively representing the pharmacy’s services. 

Also, technicians must adeptly use telepharmacy software to connect patients with pharmacists for consultations. Clear communication and accurate record-keeping are essential for maintaining patient trust and ensuring the pharmacist can make informed decisions. Technicians must adhere to regulations and ethical standards, ensuring prescriptions are verified by a pharmacist and maintaining patient confidentiality. They should avoid providing medical advice and deferring to the pharmacist for all clinical matters.