The Role of Telepharmacy in the Delivery of Clinical Pharmacy Services Following the COVID-19 Pandemic: A Descriptive Report

Abstract

Background: Telepharmacy, which utilizes telecommunication technology to provide pharmaceutical care remotely, has gained significance in expanding access to pharmacists, particularly in areas with limited health care facility access. The COVID-19 pandemic, with its restrictions on in-person interactions, underscored the importance of telepharmacy in ensuring continuity of care. Objectives: The objective of this study was to determine the impact of telepharmacy on the delivery of clinical pharmacy services before and after the COVID-19 pandemic. Methods: This study explores the use of telepharmacy in delivering medication therapy management (MTM), chronic disease management (CDM), chronic opioid analgesic therapy (COAT), and transitions of care (TCM) visits. Data from electronic health records (EHRs) was collected to analyze the number referrals, number and type of visits, mode of visits, and locations served using correlations and descriptive statistics. Results: The findings indicate an increase in the number of referrals and visits following the pandemic, with a shift toward telepharmacy visits. The study highlights the convenience and accessibility provided by telepharmacy, resulting in improved patient access to clinical pharmacy services at 1 Midwest health system following the COVID-19 pandemic. Conclusions: The continued use of telepharmacy is important to ensure that patients, especially those in rural locations, have access to health care services and can be a positive factor in growing clinical pharmacy services.

Introduction

Advancements in telecommunication technology have revolutionized various industries, including health care. One of the notable applications of this technology is telehealth pharmacy practice or telepharmacy, a practice that involves the delivery of pharmaceutical care and services remotely. Telepharmacy is defined as a method used in pharmacy practice in which a pharmacist utilizes telecommunication technology to oversee aspects of pharmacy operations or provide patient-care services. ¹ It was developed in response to growing concerns regarding health care disparities, especially in remote or rural areas where health care facility access is limited and has been utilized as a means of expanding access to pharmacists for many years. ²

The COVID-19 pandemic greatly impacted health care systems, workers, and communities. ³ During the pandemic, the virus was highly transmissible and virulent, requiring communities to incorporate mitigating strategies such as social distancing and quarantining to limit the virus’ exposure; thus, limiting the access for patients to receive the care they needed, including pharmacy services. ⁴ The role of the pharmacist expanded throughout the pandemic to help to meet health care needs. ⁵ The use of telepharmacy has also helped to fill this care gap by allowing increased convenience, enhanced patient safety, improved access, better cost management, and reduced burden on health care facilities.^6,7

The impact that the COVID-19 pandemic had on telepharmacy visit volume in New York City has been demonstrated in the literature with a dramatic increase in visits conducted virtually from 51 in 2019 to 2997 in 2020. The authors cast a vision for the evolving role of pharmacists to not only include practice expansion but also the incorporation of telepharmacy into standard workflow.^8,9

The use of virtual visits has been shown to be important in multiple health care settings as well as multiple areas of pharmacy practice, including both inpatient and outpatient services. ⁶ The Association of Health System Pharmacists (ASHP) issued a position statement in 2022 regarding telehealth pharmacy services, supporting its use to expand pharmacy access, enhance patient safety, and improve patient outcomes. The ASHP has also cited the need for additional research related to telehealth to work to establish best practices. ¹

Researchers have shown the use of telepharmacy services aids in increasing medication adherence, particularly in patients with chronic health conditions such as diabetes, hypertension, and/or dyslipidemia. ¹⁰ Medication nonadherence is estimated to cost the United States over $500 billion annually. ¹¹ Telephonic outreach has been shown to be one of the most successful modalities in increasing medication adherence. ¹⁰

There is a lack of information in the literature regarding the impact of telepharmacy in rural areas. ¹² This work seeks to contribute to the existing body of knowledge by showing the use of telepharmacy as a method to deliver clinical pharmacy services in a health care system that serves rural and urban areas and demonstrate the impact of the COVID-19 pandemic on pharmacy services at 1 health system.

Methods

Setting

This study took place at an integrated health system in the Upper Midwest that served patients in both urban and rural areas. The health system spanned 3 states and consisted of 14 hospitals and 71 clinics that provided services to primarily rural locations. ¹³ Prior to the COVID-19 pandemic, 7 of the clinics housed clinical pharmacists who provided medication therapy management (MTM) services. Of these 7 clinics, 4 were located within the same metropolitan area, where the ambulatory care pharmacy practice for the health system started and were referred to as the “East Market.” The remaining 3 clinics served were located 150 to 225 miles away and known as the “West Market.” Two of these clinics were located in rural areas and provided health care access in medically underserved areas as designated by the United States Health Resources and Services Administration (HRSA). ¹³

Telepharmacy services have been provided by the health system for almost 10 years as a part of their MTM program. Prior to the COVID-19 pandemic, these visits were conducted using telehealth connectivity (TCON) equipment including a computer, video camera, and microphone. To access the TCON equipment, patients had to present to a clinic for a TCON visit. They were placed in a room by the nursing staff, who assessed the patient’s vital signs and assisted in setting up the video connection to a clinical pharmacist. The clinical pharmacist logged into the visit from their home clinic and conducted the visit via Zoom. The Health System contracted with Zoom to offer Health Insurance Portability and Accountability Act (HIPAA) compliant telepharmacy visits. This process required the clinic where the patient presented to not only have TCON equipment but also nursing staff educated on its use. Similarly, the pharmacist clinician needed access to a computer with a video connection and microphone capabilities. The TCON process allowed patients to have access to a clinical pharmacist, even when there was not 1 located at their clinic. Patients were able to self-select the mode of visit based on personal preference and availability of TCON equipment at their clinic. To grow the clinical pharmacy practice, all visits were completed at no cost to the patient as a way to increase the quality of care for the overall organization.

The clinical pharmacists saw patients for a variety of reasons including polypharmacy or MTM visits. There were Collaborative Practice Agreements (CPAs) in place for the management of hypertension, diabetes, and dyslipidemia that allowed pharmacists to complete chronic disease management (CDM) visits. Clinical pharmacists also used a CPA to complete chronic opioid analgesic therapy (COAT) taper visits. Finally, the clinical pharmacists completed transitions of care (TCM) visits for patients who were discharged home after an inpatient stay. Patients could be referred to the MTM team by a health care professional, be identified by the pharmacy team, or self-refer to the service.

The COVID-19 pandemic reduced the offering of face-to-face visits and forced the delivery of health care into patients’ homes with the offering of virtual telehealth visits. Telepharmacy visits were no exception. As of March 2020, patients were able to meet with a clinical pharmacist from their home either via video through HIPAA compliant Zoom or telephonic means, based on patient preference, needs, and access to technology. All visits were completed at no cost to the patient, regardless of modality or visit type.

Study Design

Data were collected via electronic health record (EHR) generated reports from the health system to determine the number of referrals placed for MTM or clinical pharmacist visits and number of visits completed by the clinical pharmacists. Referral location was generated through an EHR report and was based on the clinic location of the referring provider. Descriptive statistics were used to characterize and quantify the number of locations served. The type of visit was extracted via automated reporting from the documentation completed by clinical pharmacists following their visits. Data sets were generated yearly for the years 2019 through 2022. Data were analyzed using percentage change and Pearson’s correlation. The number of visits completed per clinical pharmacist full-time equivalent (FTE) was calculated using descriptive statistics. Full-time equivalent information was obtained from the organizations’ Human Relations department. The mode of visit (telephonic, telepharmacy, or face-to-face) was extracted from visit documentation through automated reporting monthly from September 2020 through November 2022 and was analyzed using a scatterplot and Pearson’s correlation. This study was approved by the health systems institutional review board (IRB).

Results

Number of Referrals and Visits

In 2019, the clinical pharmacist team received 646 referrals. By the end of 2022, this number had increased to 1800. This equates to a 178% increase in referrals over the 3-year time span. Results of a Pearson’s correlation coefficient indicated that there was a nonsignificant, large positive relationship between time and number of referrals r(1) = 0.98, P = 0.121. At the start of the study, 64% (n = 2.7) of the FTE was in the East Market urban area where the ambulatory care clinical pharmacy practice originated. At that time, 85% of the clinical pharmacy referrals were coming from the East Market whereas the remaining 15% came from the West Market. At the end of 2022, 7 clinical pharmacists were employed leading to 6.2 FTE with 76% (n = 4.7) located in the East Market; the remaining 24% were in the West Market. In 2022, 76% of referrals originated from the West Market and 24% from the East Market.

A total of 5354 patient visits or encounters were completed in 2019. In 2022, this number increased to 9987, a growth of approximately 78%. A Pearson’s correlation coefficient was used to measure the linear relationship between time in years and number of visits completed. There was a positive correlation between the 2 variables, r(2) = 0.99, P = 0.004. The FTE increased by 42.5% over this same period from 4.2 to 6.2. The number of visits completed per year was compared with the quantity of FTE to determine the number of encounters per FTE as illustrated in Figure 1.

Figure 1.

Completed patient visits (encounters) and encounters per FTE per year from 2019 to 2022.

Abbreviation: FTE, full-time equivalent.

Type of Visits

Visit types were placed into 4 distinct categories by the pharmacist completing the visit: COAT, MTM, TCM, or CDM. All CPA visits completed by the pharmacists were included in the CDM category. A Pearson’s correlation coefficient was computed to assess the linear relationship between time in years and quantity of each of the visit types. There was a negative correlation between time and MTM visits completed, r(2) = −0.95, P = 0.047. Figure 2 depicts the percentage of each type of visit completed per year over the study period. In 2019, 69.7% of visits completed by pharmacists were MTM and 18.0% were CDM. By 2022, the percentage of CDM visits completed had grown to 45.4% of all encounters, whereas the percentage of MTM visits decreased to 33.2%. Meanwhile, a positive correlation between time and the quantity of CDM visits was shown, r(2) = 0.99, P = 0.005. The number of COAT visits increased from 7.6% in 2019 to 8.7% in 2022. There was a statistically significant positive correlation between time and COAT visits completed, r(2) = 0.98, P = 0.015. The percentage of TCM visits also increased from 2019 to 2022, moving from 4.7% to 12.8% and showed a positive correlation with time r(2) = 0.96, P = 0.037.

Figure 2.

Types of visits completed by the clinical pharmacists each year.

Abbreviations: CDM, chronic disease management; COAT, chronic opioid analgesic therapy; MTM, medication therapy management; TCM, transitions of care.

Locations Served

In 2019, clinical pharmacists were physically located in 6 clinics. Services were utilized by 42 of the 71 (59.2%) family and internal medicine clinics throughout the health system. An additional 5 clinics placed referrals by the end of 2022, a growth of 11.9%, or 66.2% of clinics placing referrals.

Mode of Visits

Starting in September of 2020, the mode of visit—defined as face-to-face, telephonic, or telepharmacy—was tracked monthly. The results of a Pearson’s correlation indicated that there was a significant positive relationship between time in months and the number of telepharmacy visits completed, r(22) = 0.885, P < 0.001. Figure 3 shows a scatterplot of the number of telepharmacy visits completed monthly with a line indicating the overall trend over time.

Figure 3.

Scatterplot showing the number of telepharmacy visits completed monthly from September 2020 (month 1) through November 2022 (month 27).

Discussion

The findings of this study demonstrate the impact of the COVID-19 pandemic on clinical pharmacy services within an integrated health system. The increased number of referrals and patient visits, along with changes in visit types and modes, were likely multifactorial. The increased acceptance of clinical pharmacists as a member of the interprofessional team and the growth in acceptance and utilization of telepharmacy as a viable alternative to in-person care likely drove this change. One limitation to this study was that only 1 health system was included.

The increase in CDM visits suggested a shift toward interprofessional management, indicating the expanded role and increased acceptance of clinical pharmacists in chronic disease care. The potential for delayed presentation to health care following the pandemic could also have contributed to an increase in referrals as disease states were potentially not as well controlled.^14,15 This could have led to a larger number of patients not reaching health outcome goals and a larger number that, in turn, were referred to clinical pharmacists for support. The pandemic resulted in many patients losing their jobs, income, and insurance benefits.^16,17 This could have contributed to affordability issues resulting in more referrals to pharmacists to identify cost-effective medication regimens for patients. The stability in the percentage of COAT visits completed implied a continued need for opioid taper services throughout the study.

One confounding variable was the operationalization of offering targeted TCM services involving a clinical pharmacist during the study period. Pharmacists were able to contact patients telephonically following hospital discharge for a TCM visit, while the patient remained in their home. Historically, patients were seen face-to-face in conjunction with their provider visit. This limited the offering of TCM visits to the clinics that had a clinical pharmacist on staff and was dependent on the clinical pharmacist and the provider having openings in their schedules that allowed for back-to-back visits, with priority placed on the provider visit availability.

Increased provider awareness due to changes in the locations that housed a clinical pharmacist may have also had an impact on the number of referrals. Although this health system spanned 3 states and served a largely rural population, most of the clinical pharmacists worked out of clinics located in urban areas. The expansion of pharmacy services to previously underserved areas, such as the West Market, increased access to clinical pharmacists in rural regions. The increase in the percentage of referrals coming from the West Market over the study period could have been due to the expansion of clinical pharmacists into that region.

The FTE increase in clinical pharmacists allowed services to be established at 1 new clinic over the 3-year time span from 2019 through 2022. During this time, pharmacy services were also discontinued at 1 location. This shift resulted in a net gain of 2.0 FTE, while operating out of the same number of clinics. This adjustment in locations may have impacted the number of referrals and, subsequently, the number of encounters completed by the clinical pharmacists. Establishment of services in a new clinic increased visibility to the provider team, increasing the likelihood of referrals; however, the opposite was true for the clinic that no longer had a pharmacist presence.

Prior to the beginning of the pandemic, most visits completed by pharmacists were done face-to-face. Because of this, the mode of visit was not reported or tracked. As a variety of options for mode of visit were developed, the quantity of each mode of visit was tracked. The shift from face-to-face and TCON visits to telephonic and home-based telepharmacy visits demonstrated the adaptability of both patients and health care providers in embracing remote care. The change in delivery of telepharmacy visits allowed patients to be seen from their home vs coming into the clinic to use the TCON equipment. This change may have contributed to an increased level of convenience for patients while decreasing the health care burden associated with TCON visits. This could have had a positive impact on the number of patients who were able to be reached as patient distance to a clinic and availability of TCON equipment at the clinic was no longer a barrier.

The COVID-19 pandemic forced many people to become more familiar with video-streaming technologies to connect with others at a distance. This also may have contributed to an increase in usage of the telepharmacy visit option by patients. Telephone calls remained a mainstay of visit delivery likely due to convenience. This visit type did not rely on the patient having to navigate technology; only to answer their phone when it rang.

Conclusions

Telepharmacy use has increased patient access to clinical pharmacy services at 1 Midwest health system following the COVID-19 pandemic. This shows the importance of virtual clinical pharmacy visits and the need for continued use of this modality to ensure that patients, especially those in rural locations, have access to health care services. Future studies are needed to show the long-term impact of the COVID-19 pandemic on the practice of telepharmacy and the associated clinical outcomes.