Telepharmacy services help ensure every medication order is reviewed by a pharmacist, especially in health care facilities without 24/7 pharmacy services. Moreover, telepharmacy can produce the same quality of care as traditional pharmacy services, help in maintaining regulatory compliance, and offset staffing challenges in locations where employing off-hours FTEs may not be possible due to a lack of pharmacists.

CGH Medical Center is a 100-bed, rural community hospital in northwestern Illinois. The organization recently implemented computer prescriber order entry (CPOE), which requires that a pharmacist verify all orders entered into the system by a physician before they can be removed from the dispensing device for administration to patients. Since CGH does not have a 24-hour inpatient pharmacy, pharmacy administration explored three options to accomplish this goal: expand pharmacy hours and staffing internally, liaise with other small hospitals in the area to provide coverage, or contract with a telepharmacy service.

• Expanding the Inpatient Pharmacy. Pharmacy determined that expanding coverage internally would cost CGH approximately $200K-250K (1.5 FTE pharmacists), a price beyond our means. In addition, at the time, recruiting qualified pharmacists in our rural area was challenging.
• Partnering with Other Hospitals. Pharmacy felt that forming a liaison with other area hospitals would be a daunting task, as working in an entrepreneurial manner with separate organizations would be new for us. Starting a new business and committing to 24-hr/365-day coverage was not seen as a realistic possibility.
• Contracting with a Telepharmacy Vendor. Telepharmacy vendors were becoming increasingly prevalent, and our state pharmacy-licensing agency had recently made it possible for out-of-state companies to provide telepharmacy services in Illinois.

CGH determined that partnering with an outsourced telepharmacy provider would be the best choice to ensure 24/7 pharmacy coverage and began the process of evaluating vendors.

The Vendor Selection Process
Outsourced telepharmacy providers range from small, local businesses, to large, national providers. One of the most important considerations was experience; CGH sought an established vendor that had multiple clients within our state and was knowledgeable about our local telepharmacy laws. Cost also was a significant factor. Because pharmacy already had determined the price of expanding coverage internally, the telepharmacy vendor had to cost less to be a viable option. Third, CGH sought a vendor that did not require order quotas and instead focused on clinical interventions. Finally, it was important that the vendor be able to provide consistency by using the same group of pharmacists daily, who would function as an extension of our in-house pharmacy staff.

Ultimately, CGH identified a vendor by networking with other pharmacists in the area. A pharmacist known and respected by CGH staff worked for the vendor; she explained that the organization had screened her thoroughly to assess clinical competency, did not employ quotas, and assigned dedicated teams to each client, allowing the telepharmacy pharmacists to integrate seamlessly with the client’s in-house pharmacists. After contacting similarly sized facilities for references and specifying our requirements through the vendor’s questionnaire—eg, hours of operation, volume, etc—CGH signed a contract with the vendor to supply after-hours telepharmacy services.

Mechanics of the Program
After the contract was signed, the implementation process began. The vendor provided an onsite implementation specialist, who met with pharmacy to discuss every aspect of operations: drug formulary, policies and procedures, drug protocols, order sets, and remote access. Thereafter, the vendor assigned CGH a team of pharmacists and provided copies of their licenses and credentials.

In-house pharmacy hours are 7am to 8:30pm, Monday through Friday and 8am to 8:30pm on weekends. At 8pm each day, a telepharmacist logs on remotely to our pharmacy system and calls to inform us that she is on duty, whereupon we can discuss any hand-off issues. At 7:00 the next morning, the telepharmacist calls again and faxes a hand-off sheet that communicates any issues encountered during the night.

Billing Strategy
Each month the vendor provides a summary of the number of orders processed, the clinical interventions that occurred, a log of phone calls made, etc. CGH is billed monthly on an hourly basis; the cost is approximately $45 per hour.

Telepharmacy services typically use one of two methods for billing: charging by line item (ie, order, phone call, intervention) or by the hours they are logged on. Many vendors prefer billing by line item, as any increases in orders processed will result in increased billings. Generally, the size of the hospital dictates the volume of orders that can be expected. The telepharmacy vendor will establish the number of orders its pharmacists can process in a set time frame and staff accordingly. However, hourly billing often is simpler, as it can be negotiated prior to implementation and adjusted should order volumes change. The hospital receives a monthly bill that varies little (unless there are holidays that month or the number of workdays varies from the norm). This method streamlines any auditing should billing be questioned, and eases the budgeting process.

Contracting
The most significant consideration in the contract is longevity. As telepharmacy and health care arenas change rapidly, signing an extended contract may not be prudent. When CGH first considered partnering with a telepharmacy service, there were two vendors in Illinois. Now, a plethora of vendors are available with an ever-expanding menu of services.

CGH Medical Center has a two-year contract with its telepharmacy provider. Typically, a 2- to 3-year contract with a 6-month volume review may suffice. If an organization is charged per hour of telepharmacy coverage, it is important to reexamine volume periodically to ensure staffing levels remain appropriate.

Data Sharing
Hospitals have a responsibility to protect patient information; unfortunately, health care data is particularly valuable to hackers. When sharing patient data from the EHR with telepharmacy providers, be sure to provide only necessary information; that way, minimal information becomes vulnerable to hacking. Likewise, limit access only to the vendor’s staff that provides the hospital’s telepharmacy services. If a member of the provider’s team resigns or is terminated, the provider should notify the hospital immediately and remove their access to data within 24 hours. Educate yourself on the legal ramifications in your state. Should the telepharmacy be hacked, what is your organization’s liability?

Gaining Buy-In
The decision to implement CPOE at CGH was driven by members of the administration, who were aware that adopting CPOE would necessitate 24-hour pharmacy services. As such, they supported pharmacy’s efforts to explore the available options to accomplish this. Upon evaluation, administration agreed that the most efficient, cost-effective solution was to establish a partnership with a telepharmacy service. CGH pharmacy staff also was in favor of a telepharmacy solution, as opposed to implementing a night shift, and welcomed telepharmacy assistance to answer clinical questions after hours, as previously they had been on call at these times.

Addressing Challenges
The most significant challenge with using a contract telepharmacy agency is ensuring consistency in the execution of policies and procedures (P&Ps). For example, before partnering with our telepharmacy vendor, if a physician did not include a reason for a PRN order, pharmacy often let it go, as staff members were confident that they knew what the physician intended. However, our P&P states that all PRN drugs include a reason on the order. Because the telepharmacists follow procedure to the letter and contact the physician to clarify any incomplete PRN orders, in-house pharmacy staff members now do so, as well. Thus, outsourcing has raised the pharmacy’s internal bar to match the high standards of our vendor.

Coordinating P&Ps between the provider and the hospital is crucial. Provide the vendor with a copy of your P&Ps and discuss these policies in detail, including their expected level of adherence. CGH hosts a weekly conference call with the service to discuss challenges and ensure both parties are consistent in interactions with medical staff.

Benefits and Future Goals
By utilizing telepharmacy, CGH has ensured that a pharmacist reviews all orders in an expeditious manner, no matter when they are received. In addition, the pharmacy has extended its coverage, while maintaining the same quality of service, at a lower cost than implementing a third shift staffed by in-house pharmacists. CGH has been overwhelmingly pleased with the quality of our telepharmacy services. The telepharmacists’ broad clinical skills and regulatory knowledge have improved our operation, and telepharmacy services have enabled increased flexibility and allocation of pharmacy’s limited resources to other areas in the hospital.

Pharmacy’s success with telepharmacy inspired the administration to consider the benefits of using this type of teleservice in other areas of the facility. CGH now employs a similar service for remote physician monitoring of ICU patients and is considering another remote monitoring program for psychiatric patients. Moving forward, telepharmacy may expand to other areas of pharmacy service, including providing emergency staffing assistance and remote checks for oncology medications compounded in the IV cleanroom.

While telepharmacy is still in its infancy, it will undoubtedly continue to expand, consolidate, and improve, as it increases its presence in health care. n

Tim Dunphy, RPh, is the director of pharmacy, inpatient and home infusion, at CGH Medical Center in Sterling, Illinois. He graduated from the University of Illinois College of Pharmacy and is a member of ASHP and the Illinois Council of Health-System Pharmacists. Tim’s professional interests include expanding telepharmacy and ambulatory pharmacy services.