When the Englewood, Col.-based Catholic Health Initiatives (CHI)— a health system that operates in 19 states and comprises 105 hospitals—established its Virtual Health Services (VHS) subsidiary in July 2012, one of its initial goals was supporting a telepharmacy operation that it had already started in Fargo, North Dakota.
Indeed, since 2009, the organization’s remote pharmacy program has provided rural hospitals with 24-hour access to the services of licensed clinical pharmacists, as well as real-time, virtual medication order review and verification and clinical intervention services from a central site in Fargo. The program started with a grant from North Dakota State University, and at the time was supporting all critical access hospitals for CHI in two states, North Dakota and Minnesota. The remote pharmacy initiative was operating out of one of CHI’s national offices, but needed a business structure to support sustainability and growth, says Win Vaughan, vice president, business development and financial planning of Catholic Health Initiatives Virtual Health Services. There were a few drivers for the telepharmacy operation, Vaughan says. “First, a lot of hospitals, including our own, recognize that at these facilities where pharmacists were ordering medications and nurses administering them, there wasn’t a pharmacist on site to review and modify the medication for a good percentage of the day or hours of the week,” he says. “That’s the genesis of the program—these facilities couldn’t afford or find a pharmacist in the community to be on site, so we filled that requirement. In some rural areas, the only pharmacist in town is a retail pharmacist, and sometimes they will to the hospital on a scheduled basis to fill dispensing units and things, but it’s not the same as having one there at all times,” he says.
Now, VHS coordinates activity for any virtual health projects across the CHI network at 48 facilities, 24 of which are CHI owned or affiliated and 24 of which are not, making VHS one of the largest providers of telepharmacy in the U.S. Through a two-way video and audio link, a pharmacist at the remote pharmacy’s 24-hour command center in Fargo can verify that the right medication, at the right dose, is being delivered to the right hospital patient at the right time.
At basic level, explains Vaughan, the remote pharmacist is either working from home or from Fargo’s physical hub, where he or she is able to receive the medication order by a number of different mechanisms, depending on what technology the hospital has in place. The pharmacist receives the order remotely, which can happen via the electronic medical record (EMR), or wherever the site has information online. The pharmacist also is able to have a video conversation with the nurse or healthcare professional where the patient is at the original site. What’s more, Vaughan continues, there is a second camera that allows for visual verification (which is required in some of the states VHS is in), so the nurse could actually bring the medication to the high-definition camera at which point the pharmacist can have a conversation and visually verify that what has been ordered is right and is what the nurse will administer, Vaughan says. The pharmacists, he adds, are all employees of CHI VHS, and are licensed appropriately, mostly in multiple states.
What has further helped the remote pharmacists, Vaughan says, is that technology from San Francisco-based PipelineRx now allows them to have a single queue of orders coming in from the customer site thanks to the vendor’s new platform. “That was one of the scalability problems—if we were adding facilities, the pharmacists were [basically] adding a new stream every time we brought on another site,” Vaughan says. “Now, the beauty of the technology is that we can simplify things for our pharmacists, making them that much more efficient. They get alerted more timely since they’re monitoring one single queue. That platform can also receive computerized physician order entry (CPOE) orders, fax orders, and the like.”
Additionally, Vaughan says, VHS has internally developed a site reference database which keeps track of what the policies and procedures are at each specific customer site, something that has also been able to be built into the Pipeline Rx platform. “It’s been a big efficiency upgrade. We track turnaround times and orders processed per hour, and metrics continue to improve with technology,” he say. Specifically, Vaughan notes that turnaround times are comparable to when pharmacists are on site in the hospital. “Our pharmacists are focused on order management—they are not getting calls from the floors and not filling dispensing units. So where we are headed with remote pharmacy in larger hospitals is similar to the teleradiology model where there is no interruption,” he says. Vaughan also notes that VHS was looking at hourly rates and volume-based rates for the pharmacy services provided, and it was significantly less than paying on-site pharmacists. “The value proposition was so easy to show. Now that it’s become established and there is more competition in the market, there is significant price competition from other virtual providers,” he says.
Traditionally, nights and weekends were those times when critical access hospitals didn’t have pharmacists on site. But with CHI’s larger hospitals, now virtual pharmacists are available during the daytime when the on-site pharmacists are pressured to do more clinical activities on the floor and at bedside with the care delivery team. “One thing that we know, that’s been well documented, is that medication reconciliation at admission and discharge is a very effective way on the inpatient side to make sure that the right medications are being ordered, and that patients are comfortable with the new medications they are going home with,” he says. As such, Vaughan adds, it has become a readmission reduction strategy and a patient satisfaction strategy. “We have seen HCAHPS [Hospital Consumer Assessment of Healthcare Providers and Systems] scores increase, and have also seen avoidance of potential adverse drug events by having pharmacists work more closely with patients. We are implementing a virtual pharmacy for these larger [places] so on-site pharmacists can run those clinical programs,” he says.
That being said, Vaughan makes clear that an e-pharmacist should in no way completely replace an on-site one. “We don’t want to replace an on-site pharmacist if it makes sense to have one,” he says. “How can we augment what is available at a facility to make it more effective from an efficiency and quality perspective? It’s a big change, so at times people think it could impact quality or people’s positions. So we try to focus on how are we filling gaps and how are we allowing the overall operations of pharmacy at a facility to be more effective for patients and the community,” he says.