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Editor's note: This is the third installment in a series on transforming pharmacy services across the continuum of care. The first article introduced the new role of pharmacies and pharmacists in hospitals and health systems. The second article explored the strategy of provider-owned outpatient retail pharmacies.

At McBride Orthopedic Hospital, a 75-bed, physician-owned specialty surgery facility in Oklahoma City, the adoption of bar-coded drug administration and electronic prescribing, combined with the challenge of medication reconciliation, drove the need for a 24/7 pharmacy. A key feature of McBride's new pharmaceutical delivery model is an additional pharmacist team, which takes over when the inpatient pharmacy closes at 9:30 each weeknight. Though this expert staff fills orders from the electronic records system and is available for a consult instantly by phone, it is fruitless to stop by its office.

McBride's “third shift” is actually working hundreds of miles away, in a secure, licensed pharmacy, connected via HIPAA-compliant links to McBride's hospital pharmacy system. Its staff members are employees of RxRemote Solutions, a subsidiary of Comprehensive Pharmacy Services (CPS), a national provider of hospital pharmacy management and consulting services.

“Remote Solutions helps with pharmacy order management after hours,” said Tim Anderson, McBride's director of pharmacy. “Whenever the pharmacy is closed, we forward our phones to them so that the nurse just calls the regular pharmacy phone and they answer it. They handle all of the questions that my pharmacist would get, and they enter all of the orders.” The remote pharmacists also counsel patients over the phone on how to manage their medications.

The Remote Solutions team is so well integrated into McBride's pharmacy because its staff undergoes the same education and training processes that Anderson's staff does. “I am pretty surprised at how well they can do formulary compliance. No two hospital formularies will be 100 percent alike, and each is changing all the time,” Anderson said.

Using outside pharmacists to augment hospital staff frees Anderson's team to focus on issues such as medication reconciliation, which involves comparing the patient's current list of medications against the physician's admission, transfer and/or discharge orders. Medication reconciliation is key to achieving federal Meaningful Use certification. “(CPS) is taking over whenever my pharmacists are gone and they will even offer to call the patient and counsel them in their hospital room,” Anderson said. “Sometimes on the weekends especially, they take over some of the remote order entry, which helps free that pharmacist to concentrate on making sure that the discharges are done properly.”

An expert panel of the American Pharmacists Association and the American Society of Health-System Pharmacists in 2012 developed a shared vision of medication reconciliation as “the comprehensive evaluation of a patient's medication regimen any time there is a change in therapy in an effort to avoid medication errors such as omissions, duplications, dosing errors or drug interactions, as well as to observe compliance and adherence patterns.”

For years, the process was approached as an afterthought; now, it is top of mind as hospitals seek to keep populations healthy and patients away from being readmitted --a cause of lost revenue. A 2012 study by the two pharmacy groups, Improving Care Transitions: Optimizing Medication Reconciliation, found a 30 percent reduction in readmissions as a result of a variety of medication reconciliation efforts.

More than 66 percent of emergency readmissions for patients over 65 years old are due to adverse medication events, a 2011 study published in the New England Journal of Medicine1 found.

Here again, Remote Solutions can help, by drawing on a national database of as many as 90 percent of all prescriptions dispensed.

The experiences that Remote Solutions has encountered reflect the wide disparity in care generally offered among all staff day to night. “It's kind of frightening in the things that we see that were going unchecked at night. We see the wrong patient, wrong dose, wrong medication, things that a pharmacy can't afford to have happen,” said Jeff Lackman, CPS division vice president for Rx Remote Solutions. The exhibit shares data gathered by CPS on medication mistakes.
Medication Mistakes

The services offered by Remote Solutions to McBride make up a core piece of what is known as telepharmacy. Services provided under this umbrella term include after hours remote order entry and transition of care services that include admission medication reconciliation, patient discharge counseling on medications and post-discharge follow up with the patient. In addition, longer term, medication therapy management involves ongoing patient counseling and additional medication reconciliation when medication changes occur. The term has also referred to the use of videoconferencing for remote staff education, training and management services to pharmacists and pharmacy staff.

Lackman said most people in the industry believe those elements are all there is in telepharmacy. “This is what I would call the traditional `remote order' and pre-telepharmacy model,” he says.

Where this new service is headed is a more technology-enabled, mobile future, he says. As one example, in the emergency room, real-time access to inpatient, mail order and retail prescription claim data can be made available to pharmacists and accessible through tablet technology. This ensures that physicians are aware of all medication regimens the patient may be on and can factor that information into the diagnosis and treatment. At discharge, face-to-face coaching by a hospital pharmacist eliminates medication redundancies.

Videoconferencing capabilities, whether by using handheld devices, smart phones, tablets or a computer, expand the reach of the pharmacist and allow for greater patient access to pharmacy services. Face-to-face video consultations with patients who have returned home to recover can be easily scheduled within 48 to 72 hours of the patient being discharged, heading off medication management issues before they result in an adverse event and maintaining contact with the patient during the critical 30-day post-discharge period, during which a readmission will count against the facility.

The technology to enable this future is here already, if not universally disseminated, Lackman said. “As people get more used to technology it becomes easier. I think that acceptance is getting higher and higher all the time with people getting used to talking on their phone or on a tablet and staying in touch. I think you're going to see just that constant contact mode for patients and pharmacists where keeping in touch with people is just routine, even via video.”

1 Budnitz DS, Lovegrove MC, Shehab N, Richards CL. Emergency hospitalizations for adverse drug events in older Americans. N Engl J Med. 2011;365:2002-2012.