The virtual pharmacist: How remote access technology is improving care, saving costs and creating new business opportunities for pharmacy

On a sunny August day this year, a drone successfully delivered a life-saving medication.It was an Epi Pen—from British Columbia’s city of Duncan to a rural area in Salt Spring Island. It took less than 11 minutes to travel the six kilometres over the Pacific Ocean, and in one of three test cases that day, the medication was delivered directly to a patient’s home.This first of its kind collaboration between London Drugs, Canada Post and InDro Robotics is testament to a new genre of pharmacy services unfolding in Canada, says Chris Chiew, London Drugs general manager of pharmacy. He believes using drones for medication delivery will be especially beneficial for underserved communities or during natural disasters when medication access becomes a critical issue. “We are always looking at ways to service communities that don’t have pharmacies or where patients have to drive too far for services—this is where telepharmacy fits in.” (If you haven’t heard much about the term telepharmacy yet, see "What is telepharmacy" at the end of this article.)Next up London Drugs will test drone delivery of high-cost Hepatitis C medications from one of its pharmacies to a remote community 55 kms away. “This is the type of medication where if you miss a dose, it can cause real issues,” says Chiew. “We were lucky the first time with perfect weather, so we want to ensure we can keep packages at a constant temperature necessary to maintain the integrity of the medication no matter what.” Future iterations will involve drones with high-definition cameras with facial recognition to ensure medications are reaching the right people, as well as drones with screens to allow pharmacists to counsel patients on site. “The possibilities are pretty incredible,” he says.While community-based drone pharmacy services like these are still in their infancy, other telepharmacy services are fast becoming an increasingly common way of providing care in rural hospital and out-patient settings throughout Canada. One example is the pharmacist assisted warfarin-dosing system, initiated by NorthWest Telepharmacy Solutions, that’s been successfully running in under-resourced communities since 2007. Pharmacist and program lead Chole Campbell is based in Ottawa, but assists patients in Moose Factory more than 700 kms away. “Patients on warfarin are registered for the program through their physician and then as a group of pharmacists [working remotely] we have access to their blood work and we determine how to adjust their blood thinner to work with other medication,” she says. “Depending on how stable patients are, we may speak to them by phone once a month or once a week.”Campbell, who works from home and sees her patients in person once a year if that, says telepharmacy programs like these mean patients don’t have to visit their physicians as often, and have continuity of care despite the high turnover of physicians typical in these areas. “We have all their medical history and that’s a key benefit of us looking after them,” she says. “Physicians appreciate having us there to help with that part of their workload.”One of Campbell’s patients, 77-year-old Roy Turner who lives in Moose Factory, says he appreciates the fact he can have his pharmacist check-in from the comfort of home. “I have type 2 diabetes, a pacemaker, and I’m in a wheelchair due to a spinal injury,” he says. “Getting out is not so easy.”Another recent pilot program that patients are appreciating is a pharmacist-led best possible medication discharge plan (BPMDP) via tele-robot. The technology was tested at the Lady Dunn Health Centre, which has only 10 acute care beds and is 225 kms away from the nearest tertiary hospital. The robot was equipped with an iPad so the pharmacist could interview the patient via screen. “The great thing is that the pharmacist could be in Kitchener and driving the robot in Wawa, Ontario,” says Kevin McDonald, director at Northwest. “And overall, patients were satisfied having that conversation with the pharmacist in this way.” In fact, in a post-pilot survey, 80% of patients said it was a positive experience.McDonald says the physicians and clinic staff working in northern communities also appreciate pharmacists’ input. “When we first got into business, it was the communities asking for help because they didn’t have access to care,” he says. “The sites themselves are generally very approachable and willing to innovate if it improves patient care.”Case in point, many rural hospitals do not have on-site pharmacists to support medication reconciliation upon discharge, which significantly increases the probability of medication-related adverse events. Using pharmacists remotely helps reduce the probability of errors happening during that transition of patient to home, which is a win for everyone.By the looks of it Canada’s telepharmacy work isn’t going unnoticed either. Not only have US chains like Walgreens since announced similar drone-testing of health product delivery after the London Drugs pilot, countries like Jordan are looking to replicate Canada’s entire telepharmacy model. Shadi Al-Hawari, pharmacist/owner of seven B.C. pharmacies, including two telepharmacies in the province, will be taking a group of physician colleagues to Jordan in October to offer advice to government on how to implement some 200 tele-clinics there, which include telepharmacies and labs.In the meantime, Al-Hawari is working on opening up a third telepharmacy site in Williams Lake, B.C., next summer that will service some 3,500 indigenous patients. “Not only does telepharmacy make practical sense in delivering pharmacy services to remote areas, it is a money-saver for government,” he says. “It’s a concept that’s been proven to work.”Future applications of remote pharmacy services could be a game-changer too, especially in dealing with major health issues, such as the opioid crisis in Canada. Paula Newman, research specialist and clinical pharmacist at NorthWest, is currently part of a team working on the implementation of a pharmacist-led opioid stewardship program via videoconference. Funded by the Canadian Foundation for Pharmacy, the pilot is geared to patients with chronic non-cancer pain and will target a rural population near Sudbury where opioid mis-use is particularly high and there are few pharmacy support services. “We’ve developed a comprehensive tool to interview patients and provide a follow-up assessment,” says Newman. “We want to determine if this can be done remotely in a population that isn’t used to having a lot of contact with a pharmacist—and whether patients and providers will be satisfied with the service.”Key barriers to telepharmacy growth Shadi Al-HawariWhile telepharmacy initiatives are proving that remote pharmacy services can have a major impact, some key challenges remain. The lack of adequate bandwidth in remote areas hinders some technologies from operating optimally. Meanwhile, community telepharmacy operators say strict government regulations around licensing and staffing (all remote pharmacies must have a regulated pharmacy technician on site) means setting up these sites is an arduous and expensive endeavour. “It’s a real struggle to get a telepharmacy license and in one case we had to apply four times before we got approved,” says Al-Hawari, noting that in BC, a remote site has to be at least 25 kms away from the nearest pharmacy. “We need more incentives to open in remote areas instead of barriers.”Finding pharmacists to work in telepharmacy settings can be a challenge too, says NorthWest’s Kaminsky. In Nunavut, for example, there are five brick and mortar pharmacies serving the entire population that rely on a remote distribution model. “If there is no pharmacist to oversee that and we have to close down, the whole care model becomes compromised and services go back to the nursing centres,” she says. “A few of our pharmacists and physicians have been with us for 10+ years but it’s rare.”With the cost of doing business in the north at three times the standard in the south, Kaminsky says pharmacists in these positions are paid a premium wage, with additional provisions for housing, food and household supplies. “We try to set up multiple-year contracts, but when they get up north it’s a whole different environment for them and some will take an early leave,” she says. “We also always try and hire local folks and have a tuition reimbursement program if they want to go further and get accredited.” Those pharmacists who do stay for the long-term have been able to practise at the top of their scope and tend to be “everything to their community,” she adds.Ultimately, Kaminsky says she envisions a hybrid model of care with pharmacists in the community and those in remote settings working together to keep up with the “swell of healthcare need” in remote areas “For pharmacists today, it’s about keeping an open mind that technology should never be considered a barrier or threat to the deliverance of healthcare, but rather a way to enhance our service model.”What is telepharmacy?Telepharmacy refers to the provision of pharmacy care through the use of information technologies and telecommunications to patients at a distance. Telepharmacy can be used to clinically review new orders, remotely check sterile IV preparations and provide counselling to patients at discharge from hospital. The term can also refer to using videoconferencing to provide training, education and management to other pharmacists and pharmacy staff.A telepharmacy operates like a traditional pharmacy except for the fact the pharmacist reviewing and verifying prescriptions is in another location. All remote pharmacies must have a regulated pharmacy technician on site, however. Interestingly, the research shows(1) that telepharmacies experience fewer dispensing errors than traditional pharmacies.1. https://www.ndsu.edu/fileadmin/telepharmacy/APhA_article_2011_-_Copy.pdfRemote pharmacists mitigate medication riskA new software program called MedMonitor, launched this fall, is expected to prevent medication risks, lower absenteeism and significantly improve savings when it comes to benefits and disability costs by using pharmacists’ remote intervention.HumanisRx, a division of Remedy Holdings Inc., developed the program which uses some 150 clinical algorithms to identify employee medication risks based on their insurance claims. Then, provided the employee has given consent, it triages these issues and initiates an intervention with a HumanisRx pharmacist.“When someone has a gap in care or a safety issue, an alert is sent to our call centre where a pharmacist will reach out to an employee via phone,” says Jeff May, president of HumanisRx, adding that there is potential for video conferences as well. “Our research finds that employees are not optimizing their use of prescription medications—and that’s a huge cost driver for Canadian employers and insurance companies.”The pharmacist works with the employee and his/her prescriber as needed to resolve medication-related issues and reduce overall health risks. That could mean dealing with adherence problems, making medication changes or suggesting behavioural changes to improve outcomes. The service is available across Canada (outside of Quebec).Click here to read more articles about innovative pharmacists.

The virtual pharmacist: How remote access technology is improving care, saving costs and creating new business opportunities for pharmacy

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