Innovations in practice: Telepharmacy’s time has arrived

The current COVID-19 pandemic crisis has presented pharmacists with many challenges as well as opportunities to enhance and expand their practice. One of these areas is telepharmacy or the provision of pharmacy services using telephone or videoconferencing technology. Some use the term telehealth, which is the broader umbrella term encompassing the transfer of any health care information via electronic communication.¹ Virtual consulting is one of the health service provisions under this umbrella.² The Canadian Society of Hospital Pharmacists defines telepharmacy as “the use of telecommunications technology to facilitate or enable the delivery of high-quality pharmacy services in situations where the patient or health care team does not have direct (in-person) contact with pharmacy staff.”³

During the current pandemic, there are many situations where a patient consultation or follow-up is needed, but due to physical distancing or self-isolation requirements, it is not possible to arrange for a face-to-face (F2F) discussion. This is where a virtual or remote consultation can work for both the pharmacist and the patient. Examples of “red flag” situations to watch for during the pandemic are found in Box 1. In nonpandemic times, this type of visit can facilitate patient communication when patients have barriers such as living in a rural/remote location, poor access to transportation, mobility challenges, or inflexible work or caregiving schedules.

BOX 1 COVID-19 error/adherence red flags.

When reviewing symptoms and objective measures like blood pressure or blood glucose, remember that during the pandemic, patients may not be using their regular community pharmacy. Watch for:

1. Patients filling the same drug at 2 locations, receiving 2 different brands. They may not recognize the duplication and accidentally double their dose.

2. Patients changing pharmacies and held or discontinued medications accidentally being restarted.

3. Patients who are usually nonadherent but now afraid of going to hospital may suddenly become adherent, leading to a rapid escalation in dose.

Reasons for a telepharmacy visit

In general, virtual consultations are appropriate for low-risk patients with access to technology and the ability to consent to this type of appointment. As well, the patient should not have any overt memory or sensory impairment or anxiety about the technology or platform being used.⁴ Not every consult requires a video visit, particularly if the patient is comfortable receiving information by phone, and has no significant hearing impairments.⁵ However, it will often be necessary to have visual contact with the patient, either to gauge their understanding; to demonstrate something, such as how to use a new inhaler; or to view their adherence packaging.⁶ Performing complicated medication histories often requires visual contact, as patients may have difficulty pronouncing drug names and it may be easier for them to show the vial or tablet via video, for example. In a situation where the pharmacist needs to witness and document the ingestion of opioid agonist therapy such as methadone, but the patient is quarantined, a combination of medication delivery and video consult might support continued therapy.⁷

Preparing for the visit

Beforehand, pharmacy staff can ask patients to prepare by encouraging them to gather their medications, adherence tools and other devices, notepad and pen or other means for recording notes.

Both parties should also be in a quiet, private space where distractions and interruptions can be minimized. Having a dedicated space in the pharmacy for telephone and video visits is recommended (possibly in the private counselling room when not used by F2F patients). If doing a video call, advise the patients to be in a well-lit room and provide a back-up telephone number in case of any transmission problems.⁵

How to connect

Consults can be completed by phone, as per usual pharmacy practices or using a secure platform. In the early days of the pandemic, other nonsecure platforms, including Skype, FaceTime or Zoom, may have been considered, particularly if they were preferred by the patient.⁷ However, over time, pharmacists need to plan to move to a secure platform designed specifically to protect patient privacy and adhere to their jurisdiction’s regulations.⁸ The regulated platforms will usually have a monthly or annual subscription fee.

Consent

Patients need to be made aware of the privacy and security limitations of whatever medium is being used for the consultation and that you will be discussing personal health information over video or phone. Remote services may involve different and/or greater privacy and security risks, and patients should expressly consent to participating in the service. In some jurisdictions, clinicians are being advised to include a standard disclaimer statement in their encounter notes for all virtual visits.^9,10 These may include noting that platforms including video, email, telephone or text are not secure in the same way as a private consultation in a pharmacy and that using these technologies can increase the risk of the patient’s health information being intercepted or disclosed to third parties.¹⁰

Privacy assessments

Pharmacists need to understand their individual responsibilities as professionals as well as their organization’s responsibilities for providing appropriate infrastructure to conduct virtual or remote visits in the most secure way possible. The pharmacy’s designated privacy officer should conduct a privacy impact assessment for any new service or method of communication being used with patients.¹¹ While for some patients, the ability to be in their own home for the session is the key consideration and accommodating their preferences is important, it will always be the pharmacist’s responsibility to ensure that privacy and confidentiality standards are maintained. If others are within earshot, the patient should be asked if it’s okay for the other individual to be in listening range and document that consent was given for another party to be present.¹² Patients should be advised to use their own device (not their work computer or neighbour’s phone) and a secure Internet connection, if possible.¹⁰

Document

The usual elements for any patient encounter or consultation should be documented, using your standard format (e.g., SOAP [Subjective, Objective, Assessment, Plan]). In addition, the details of the patient’s consent and their location, if known, and any others present for the consultation should be noted. As well, the reason for the virtual consult (e.g., patient in self-isolation due to COVID-19 pandemic) and the patient’s reported satisfaction with the platform and willingness to be contacted again via the same medium should be recorded. A case example is included in Box 2.

BOX 2 Case example—Telepharmacy consult.

Patient is JB, a 75-year-old man. JB’s daughter and caregiver requests a refill of all his regular medications at the start of the pandemic lockdown. Within 2 days, the daughter calls the pharmacy to say JB is very dizzy and when they measure JB’s blood pressure, it is around 90/50. The pharmacist schedules a virtual consult visit.

• The pharmacist asks to speak with both the patient and the daughter. The pharmacist reviews the risks of a telepharmacy visit, including the potential risk to patient confidentiality and privacy, given the limitations of the virtual platforms. Both JB and his daughter provide verbal consent to a video visit, and the pharmacist documents this.

• When scheduling, the pharmacist asks for a back-up phone number in case the connection is disrupted and asks the daughter if there is a platform they prefer to use. The daughter says that they often use Skype to talk with family members.

• To prepare for the visit, the daughter sets up the computer in a quiet room away from other family members. She tests the microphone and camera with a family member ahead of time. She also gathers all of JB’s medications next to the computer, along with the blood pressure monitor, and a pen and pad of paper.

• The pharmacist sits in a back office and places a sign on the door that says “Video call in progress, do not disturb.” They use the local electronic health record to download a list of all the medications the patient has filled in the last 3 months and a list from the pharmacy’s computer system. The pharmacist calls the patient on Skype.

• To start, the pharmacist has the patient take his own blood pressure, watching for issues such as cuff size, placement and patient positioning. The pharmacist corrects any issues.

• The pharmacist does a medication reconciliation by comparing the 2 lists they have obtained with the medications JB has at home. The pharmacist identifies 3 issues:

  • Hydralazine dose was previously lowered to 25 mg, but the patient is using an old bottle of 50 mg tablets.
  • JB has not been taking amlodipine regularly but has taken it every day since the “COVID scare” began.
  • JB and his daughter were stockpiling medications, which resulted in JB taking 2 angiotensin-converting enzyme (ACE) inhibitors from 2 different pharmacies.

• The pharmacist explains these errors and reinforces the correct medications and doses to JB and his daughter and schedules a follow-up virtual visit for 1 week later. JB and his daughter agree and comment on their satisfaction with the appointment.

• The pharmacist completes the documentation of the encounter in the patient record system.

Limitations of virtual and remote care

Patients experiencing low income or socioeconomic status or reduced digital literacy may have difficulty taking full advantage of virtual or remote care opportunities. Pharmacists need to be aware when offering these services that disparities may exist, in order to avoid inadvertently magnifying preexisting inequalities of health access.

Examples of potential ways to offer virtual care while being aware of varying levels of ability, skills, resources and literacy:

1. Offering phone call versus video chat for those with reduced digital literacy

2. First visit over phone to walk a patient through what a video visit entails

3. Offering wifi video instead of using cellular data (data overage charges are more expensive)

4. Providing tips for patient to access low-cost data plans or wifi broadband

Conclusion

Research completed to date¹³ generally shows good levels of patient satisfaction with telemedicine consults, primarily due to the perceived convenience for the patient and/or their caregivers. The pandemic is pushing pharmacists to adopt virtual care much faster than the profession would have otherwise. By taking a systematic approach, pharmacists can take steps to protect both themselves and their patients and accomplish something that may support care for many years to come. ■