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Service Delivery Innovation Profile

14-Hospital Telepharmacy Program Reduces Order Processing Time, Frees Up Pharmacists for Quality-Enhancing Initiatives, and Saves Money


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Snapshot

Summary

Via Christi Health operates a telepharmacy program at 14 hospitals that enables offsite pharmacists to review medication orders and patient medical records via computer and then authorize the hospital pharmacy system to dispense the drugs. Pharmacists cover multiple hospitals simultaneously, providing coverage when onsite pharmacists are not available or are occupied with other orders or responsibilities. The program has expanded hours of pharmacy service, reduced order processing times, enhanced pharmacy services, increased nurse satisfaction, freed up pharmacist time for other quality-enhancing initiatives, and saved a projected $1 million a year.

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation comparisons of hours of pharmacist coverage, order processing time, number of pharmacist-initiated interventions (and the estimated cost savings associated with them), and nurse satisfaction.
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Developing Organizations

Via Christi Health
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Use By Other Organizations

North Dakota has a large telepharmacy program (the North Dakota Telepharmacy Project) that currently serves 21 hospitals. More information is available at http://www.ndsu.edu/telepharmacy/.

Date First Implemented

2008
December 15

Problem Addressed

Many hospitals, particularly those in rural areas, cannot provide onsite pharmacist coverage 24 hours a day, 7 days a week; this can have a negative impact on the quality and safety of patient care.
  • Pharmacist shortage, leading to many hours without coverage: A recent survey found a 5.9-percent vacancy rate in hospital pharmacies, with most experts predicting the shortage will become more acute in coming years. In 2008, the average inpatient pharmacy operated for 106.1 hours a week, representing less than two-thirds of the total number of hours (168). Smaller hospitals tend to have even fewer staffed hours, with just over half of all hours covered in those with 50 to 99 beds and about a third covered in those with fewer than 50 beds. In fact, only 1.1 percent of hospitals with fewer than 50 staffed beds provide 24-hour inpatient pharmacy services.1
  • Special needs in rural areas: Rural areas face an especially severe shortage of pharmacists. Rural counties in some states do not even have a pharmacist or pharmacy, and many have only one. In Kansas, for example, 31 counties have only one pharmacist or pharmacy, while 6 have none at all. Via Christi Health has only part-day onsite pharmacist coverage at some of its hospitals.2 The cost of a relief pharmacist to cover for a rural hospital pharmacist's 2-week vacation would be $10,000, which would include salary, hotel, travel, and per diem for food.
  • Negative impact on quality and safety: Providing pharmacy services for only part of the day can result in safety and efficacy problems. The Joint Commission recommends that pharmacists prospectively review each medication order before administration to the patient. Without this process, the risk increases for medication errors such as giving an incorrect drug or dose and for drug–drug interactions. In addition, part-time coverage limits the ability of pharmacists to take a more direct role in clinical care, which has been shown to improve quality by reducing mortality, medication errors, length of stay, and total costs.3

What They Did

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Description of the Innovative Activity

Via Christi Health operates a telepharmacy program at 14 hospitals that enables offsite pharmacists to review medication orders and patient medical records via computer and then authorize the hospital pharmacy system to dispense drugs. Pharmacists cover multiple hospitals simultaneously, providing coverage when onsite pharmacists are not available or are occupied with other orders or responsibilities. Key program elements include the following:
  • Available hours: Telepharmacy services are available 24 hours a day, 7 days a week; however, each hospital requests the hours of coverage that it needs, with some electing complete coverage and others electing coverage during evening and overnight hours. During periods of coverage, telepharmacists provide services to hospitals that do not have an onsite pharmacist available, either because one is not physically present or because they are busy. During these times, the onsite pharmacist uses a call-forwarding function on the pharmacy telephone system to automatically route calls to a telepharmacist. At the start of his or her shift, the remote pharmacist will also call the page operator to have calls transferred to the correct phone number. Although the remote pharmacists are available by phone, onsite staff are encouraged to communicate with pharmacists through scanned messages, except in emergency situations. This process minimizes interruptions and reduces the likelihood of errors.
  • Reviewing and approving orders: In the most common scenario, the telepharmacists review and approve physician orders as outlined below:
    • Order generation: A physician generates a medication order, either by hand (which staff in the patient care area then send to the pharmacy via the hospital's electronic medication order management system) or by entering the order electronically in the computerized physician order entry system.
    • Pharmacist access and review: Telepharmacists receive orders through a secure, virtual private network or terminal server. Scanning or efax technology presents a magnified version of the order on the computer. Telepharmacists handle orders chronologically as they appear in a queue system, with stat orders automatically moving to the head of the queue. The telepharmacist reviews each order, looking at issues such as the patient's age, sex, height, weight, diagnosis, existing drug therapies (to check for potential interactions and duplications), allergies, medication history, and pertinent laboratory results. If necessary, the telepharmacist phones the onsite physician or nurse to clarify information.
    • Pharmacist approval: Assuming the telepharmacist approves the order, he or she enters it into the hospital's pharmacy information system, which creates a medication administration record (paper or electronic, depending on the hospital), initiates the process to provide the correct medication to the nurse for administration to the patient, and provides an electronic record so the nurse can scan the medication barcode at the bedside when he or she administers the dose to the patient.
  • Automated dispensing and administration: If the patient care area at the hospital has an automatic dispensing machine, it releases the correct medication to the nurse for administration to the patient. The nurse selects the medication from the cabinet and scans the barcode at the patient's bedside to ensure the correct drug is being given to the right patient at the right time. He or she will then administer the medication to the patient.
  • Modified process for critical access hospitals: The process is slightly different for critical access hospitals that do not have automatic dispensing machines or barcode technology. In these hospitals, a nurse or unit secretary will enter the medication order into the pharmacy information system, and the remote pharmacist will log in once a day to verify that the medication has been entered properly. (Kansas regulations require all medication orders to be reviewed at least every 7 days, so without the remote pharmacist reviewing the medication on a daily basis, some patients did not have their medications reviewed until after discharge.) Once this verification occurs, a pharmacy nurse will usually retrieve the proper medications from the pharmacy to be administered to the patient and then document the removal of these medications.
  • Electronic supervision of technicians: According to a May 2013 update, the first electronic supervision of pharmacy technicians was implemented at Hiawatha Community Hospital in November 2011. Telepharmacists provided remote order entry and electronic supervision. In a typical transaction, the pharmacy technician sends a scanned medication refill list to the remote pharmacist after they both establish a virtual connection with secure audio and video link. The technician gathers all of the medications on the refill list and shows them to the remote pharmacist to be verified. The pharmacy technician delivers the medication to the automated dispensing cabinets on the nursing units. The nurse then has access to the medication to administer to the patient. The technician may also put away the medication delivery from the wholesaler.

Context of the Innovation

A nonprofit health delivery network in Kansas, Via Christi Health operates 11 hospitals in urban and rural areas, ranging from a large community hospital with more than 400 beds that offers multiple services (e.g., trauma, burn, oncology, adult and pediatric intensive care, cardiac, surgical) to a 40-bed rehabilitation facility. The hospitals use a cartless model of drug distribution, with automated medication storage cabinets and a barcode-assisted medication administration system. Although the two largest hospitals provide 24-hour, onsite pharmacy services, staffing at the other facilities allows only part-day coverage. The telepharmacy program developed as a result of growing awareness among pharmacy and hospital leaders that part-time coverage can undermine safety, efficacy, and cost-effectiveness and that such an approach did not meet The Joint Commission recommendation that pharmacists prospectively review each order before administration of the drug to the patient. In addition, Via Christi officials wanted to find ways to increase the level of clinical services provided by pharmacists at its hospitals.

Did It Work?

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Results

A 4-month study (between December 2008 and April 2009) at five hospitals found that the program expanded hours of pharmacy service, reduced order processing times, increased nurse satisfaction, freed up pharmacist time for other quality-enhancing initiatives, and saved a projected $1 million a year.
  • Expanded hours: The program led to an additional 45 hours per week of pharmacy services at four urban hospitals and to an additional 10 hours per week at a small rural hospital.
  • Faster order processing: Telepharmacists handled an average of 42 orders per hour. Mean processing time for routine orders decreased by nearly 50 percent, from 26.8 to 14 minutes, while mean processing time for stat orders decreased by nearly 25 percent, from 11.6 to 8.8 minutes.
  • Higher nurse satisfaction: Nurse satisfaction with pharmacist services increased from 3 to 4 on a 5-point Likert scale after program implementation.
  • Freed-up pharmacist time: The program freed up enough pharmacist time to allow pharmacists to play a more active role in direct patient care, as outlined below:
    • More interventions: Pharmacists have taken a more active role in clinical care since implementation of the program. For example, a comparison of two 1-week periods (one right before implementation and one right after) found that the number of pharmacist-initiated interventions increased by 42 percent, from 619 to 881. The biggest increases came in the areas of chart review, clarification of orders, dose adjustments, education related to medications and discharge, and followup with patients on warfarin.
    • New anticoagulation service: Thanks to time savings generated by the program, one hospital reassigned an onsite pharmacist to its anticoagulation service and other clinical duties, supporting its ability to meet The Joint Commission National Patient Safety Goal for improving anticoagulation safety.
    • New medication reconciliation process: At another hospital, the program reduced the need for pharmacists to review overnight medication orders in the morning, thus allowing it to launch a pharmacist-led medication reconciliation process on its largest unit.
  • Significant cost savings: The program saves the five hospitals an estimated $1.13 million a year. This figure was derived by calculating the cost savings associated with the increase in clinical interventions outlined above, which average roughly $23,400 a week, and then subtracting the cost of the service. (See the Resources Used section for more information on program costs.)
  • Electronic supervision cost savings: A rehabilitation hospital that began regularly using the electronic supervision of pharmacy technicians estimated savings of $30,000 per year, according to a May 2013 update.

According to a May 2013 update, Via Christi conducted a followup study at two additional hospitals in 2011 to determine if similar turnaround results were achievable. Hospital A was a newly constructed 68-bed facility with onsite pharmacist coverage from 7 a.m. to 7 p.m. seven days a week. The data were collected between November and December 2011. No nursing surveys were conducted or interventions tracked during this evaluation of the service turnaround time. Hospital B is a licensed 188-bed facility with onsite pharmacist coverage from 6:30 a.m. to 8 p.m. during the week and 7 a.m. to 4 p.m. on weekends. Both hospitals have the same hours of remote coverage per day and the pricing models are identical.

  • Order efficiency: The average order turnaround at hospital A for telepharmacy between 7 p.m. and 7 a.m. was 5 minutes. The average order turnaround time at hospital B was 10 minutes during telepharmacy hours, based on data collected during February 2012.
  • Cost savings: By using remote medication order entry, hospitals A and B save $160,500 per year on salary costs.
  • Increased coverage: In 2011, hospital A entered a total of 95,982 medication orders, of which the telepharmacy service entered 29,913, or 31.17% of all orders. The number was similar in 2012; the total number of orders entered was 105,769, and the remote medication order team entered 30,618, or 28.95%. The number of medications orders reviewed per day was not available for hospital B.

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation comparisons of hours of pharmacist coverage, order processing time, number of pharmacist-initiated interventions (and the estimated cost savings associated with them), and nurse satisfaction.

How They Did It

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Planning and Development Process

Key elements included the following:
  • Early planning at one hospital: In 2006, hospital leaders and the pharmacy director at the Via Christi hospitals in Wichita began exploring the possibility of handling pharmacy orders remotely at one of the Wichita hospitals. They formed a planning team that included officials from Via Christi Health, the hospital, and representatives of the pharmacy, information technology (IT), nursing, and human resources departments. The team met regularly and also consulted with the Kansas State Board of Pharmacy and a private vendor specializing in telepharmacy to develop a program that could meet legal requirements in an efficient, cost-effective manner.
  • Revised planning to include multiple facilities: As discussions proceeded, it became clear by 2007 that the program would be more effective if implemented at multiple facilities. To that end, Via Christi hired a co-owner of the aforementioned vendor (a pharmacist) to direct the expanded program. At the same time, pharmacy directors at three other hospitals joined the planning team, which began working toward implementation at the four facilities.
  • Developing policies and procedures: In June 2008, team members held a full-day multidisciplinary planning meeting to establish a consensus vision, policies, expectations, and standard operating procedures. Following the meeting, the pharmacy directors held a series of weekly conference calls designed to move the project toward implementation.
  • Hiring and training: Via Christi hired a telepharmacy director in October 2008 and then hired nine pharmacists to fill the telepharmacy positions the following month. Some came from Via Christi hospitals, while others came from outside the system. IT staff installed computers and secure access to hospital information systems at the hired pharmacists' homes. The pharmacists received training on the telepharmacy system through modules that simulated the order process.
  • Program rollout: The program launched at four hospitals in December 2008, with coverage initially provided from 10 p.m. to 2 a.m. In January 2009, operating hours expanded, with coverage beginning at 5 p.m.
  • Program expansion: Once the system worked well, program leaders gradually expanded it, both by covering additional hours at the four hospitals and by introducing it at other hospitals. As of January 2011, the program employed 14 pharmacists, including 6 who also work at Via Christi hospitals. The telepharmacists cover 14 hospitals, which include 8 Via Christi facilities and 6 outside the Via Christi network. According to a May 2013 update, Via Christi has implemented electronic pharmacy technician supervision in two hospitals that have a need for a relief pharmacist.

Resources Used and Skills Needed

  • Staffing: Currently, the program employs a full-time director and 14 full- and part-time telepharmacists. Some telepharmacists work exclusively from home while others split their time between a hospital and home office. Most pharmacists live in Kansas, although some live in other states. (Kansas law allows out-of-state pharmacists to perform this role as long as they are licensed in Kansas.) IT staff also spend some time on the program, primarily to update software on a periodic basis.
  • Costs and equipment: Upfront program-related costs include the purchase of computers and software for each telepharmacist (which costs $1,200 to $1,500 per pharmacist). Ongoing operating costs average roughly $443,000 annually. The vast majority (95 percent) of these costs consist of salary and benefits for the pharmacists (which average $55 an hour, 30 hours a week). Liability insurance represents an additional 4 percent of costs. Telepharmacists pay for their own high-speed Internet access. The cost for the electronic supervision of technicians at one of the facilities where it was initiated is $75 per hour, according to a May 2013 update.
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Funding Sources

The health system funds the program through its internal operating budget and through payments from participating hospitals, which are charged on an hourly basis or a flat monthly rate depending on hospital size. Medicare covers a portion of ongoing program costs for critical access hospitals through reimbursement for patient care services.end fs

Adoption Considerations

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Getting Started with This Innovation

  • Make sure sufficient demand exists: The program requires an adequate number of orders to justify its existence. As Via Christi's experience shows, the banding together of multiple hospitals can help in meeting the threshold. As a rule of thumb, combined medication order volumes of 40 to 50 orders per hour will keep one telepharmacist busy.
  • Hire pharmacists with onsite experience: Seek pharmacists who have previously worked for at least 5 years in a hospital. This experience will prove valuable in handling the wide range of issues specific to inpatient care (including emergencies) that will inevitably arise.

Sustaining This Innovation

  • Build in system updates: Via Christi uses a "virtual desktop" system that allows simultaneous updating of the computer software for all pharmacists, thus saving time and reducing the risk that individual pharmacists will neglect to install an update or have trouble doing so.
  • Visit participating hospitals: Although telephone conferences can be helpful, the telepharmacy program manager should regularly visit participating hospitals to talk to pharmacists, doctors, and nurses about their experiences with the program and to resolve any problems they may be having in a timely manner.
  • Expand program as possible: Adding hospitals can make the program more cost effective, as fixed costs get spread over a larger volume of orders. To generate interest, contact pharmacy managers and hospital administrators at other hospitals in the region to schedule demonstrations of how telepharmacy works. Program marketing materials may also be useful in increasing awareness.

Use By Other Organizations

North Dakota has a large telepharmacy program (the North Dakota Telepharmacy Project) that currently serves 21 hospitals. More information is available at http://www.ndsu.edu/telepharmacy/.

More Information

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Contact the Innovator

James C. Garrelts, BS, PharmD, FASHP
Senior Director of Pharmacy,
Via Christi Hospitals Wichita, Inc. & Via Christi Health
929 North St. Francis
Wichita, KS 67214
(316) 268-5580
E-mail: jim.garrelts@viachristi.org

Mark Gagnon, BS, PharmD
Director of ePharmacy
Via Christi Health
8200 East Thorn Drive
Wichita, KS 67226
(316) 858-4984
E-mail: mark.gagnon@viachristi.org

Innovator Disclosures

Mr. Garrelts and Mr. Gagnon have not indicated whether they have financial interests or business or professional affiliations relevant to the work described in this profile.

References/Related Articles

Garrelts J, Gagnon M, Eisenberg C, et al. Impact of telepharmacy in a multihospital health system. Am J Health Syst Pharm. 2010;67(17):1456-62. [PubMed]

Footnotes

1 Pedersen CA, Schneider PJ, Scheckelhoff DJ. ASHP national survey of pharmacy practice in hospital settings: dispensing and administration—2008. Am J Health Syst Pharm. 2009;66(10):926-46. [PubMed]
2 Garrelts J, Gagnon M, Eisenberg C, et al. Impact of telepharmacy in a multihospital health system. Am J Health Syst Pharm. 2010;67(17):1456-62. [PubMed]
3 Bond CA, Raehl CL. 2006 national clinical pharmacy services survey: clinical pharmacy services, collaborative drug management, medication errors, and pharmacy technology. Pharmacotherapy. 2008;28(1):1-13. [PubMed]
Comment on this Innovation

Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: March 16, 2011.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: July 16, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: May 23, 2014.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.

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