Nearly 25 percent of American hospitals lack an overnight pharmacist, says Christopher A. Keeys, PharmD, BCPS, RPh, president, Clinical Pharmacy Associates and CEO of MedNovations, Inc. “It’s a scary proposition,” he told attendees of the Telemed Leadership Forum 2018 in Washington, D.C.
Fortunately, telepharmacy is emerging as a powerful tool to help bridge that gap, even as it can also help to reduce prescription filling errors, Keeys said.
However, telepharmacy must be understood to be maximized, he said. “The intersection between tele-pharmacy and medication reconciliation requires us to recognize there are four to five major steps in medication management that all of us are involved and responsible for if we are engaging in healthcare delivery…the ordering, prescribing, preparation, dispensing, and patient education,” Keeys said.
It’s a big challenge on many levels, he said. “Lack of information, knowledge and/or inadequate time by physicians, nursing and hospital staff can frequently cause errors of omission and commission on the medication list of patients,” Keeys said, citing his 2011 report, “After-Hours Pharmacy Service Models in U.S. Hospitals.”
Making things even more complex, it’s important to remember that over 10,000 medications exist in practice with the average hospital pharmacy stocking about 1,500 medications, some which are various dosage forms and strengths of the same product.
Keeys cautioned against technicians leading the medical history intake and analysis, with a nurse helping in the middle, and the physician concluding it. Under that scenario, there is no pharmacist oversight. “We’ve talked to pharmacy technicians who have been in those models and largely they don’t even feel comfortable doing that,” Keeys told attendees.
For many years a severe shortage of pharmacists has existed in different parts of the country, “but more importantly, pharmacists frankly have not been groomed and trained for the most part to do medicine reconciliation until recent years,” he added.
That could be changing for the better. “The retail pharmacy community has recognized the growing need for 24/7 access to care and responded by markedly expanding the number of pharmacies and personnel available after hours in the U.S.,” he told conference attendees.
Some good news: there are multiple technologies that have advanced telepharmacy and medicine reconciliation, including the proliferation of databases with patient records that can help to reduce the risk of prescribing medications with bad interactions.
Keeys also provided a comparison of various service models for after-hours pharmacy and medication use in hospitals, highlighting some of the advantages for those going the telepharmacy route:
- RN Managed with on-call R.Ph.
- Staffing requirements: Workload is low for R.Ph, but the opening of pharmacy each morning is often heavy, and it can be inconvenient with more liability for RNs.
- Technology requirements: Usually limited to phone consults; may have emergency remote access to pharmacy profile, labs, automated dispensing technology, and computerized MD order entry.
- It’s not designed to meet “best practice and standards.”
- Telepharmacy with on-call R.Ph.
- Staffing requirements: Higher R.Ph. workload, improved use of R.Ph. staff via shared service between hospitals or outsourced companies, more convenient and less liability for RNs.
- Technology requirements: Routine access to computerized pharmacy/hospital records, work through phone, fax and internet; can interface routinely with automated dispensing machines and CPOE; more drug information and clinical support.
- Designed to meet best practices and standards. Routine R.Ph order review before medication given; consistency for drug information/clinical consults; supports RN in proper preparation and dispensing procedures.
- Pharmacy open 24/7
- Staffing requirements: Highest R.Ph. workload but may be underutilizing staff for slower facilities; most difficult to staff with R.Ph.; most convenient for RNs including dispensing support.
- Technology requirements: Maintains major technology support for pharmaceutical services 24/7; often some or all decentralized services and major clinical activities are limited based on hospital’s choice after-hours.
- Recognized as the original design to meet best practices and standards.
There remains a long way to go in improving access to 24/7 care for all Americans, but “without telepharmacy models, we would not be anywhere near [the improvement] where we are today,” Keeys said.