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At Small, Rural Hospitals, Telepharmacy Technology is Advancing Pharmacy Practice

November 3, 2016
by Heather Landi
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Just as with many other areas of hospital operations, healthcare leaders are increasingly adopting and implementing IT solutions within pharmacy departments to streamline medication-management systems, improve workflow and increase patient safety.

Yet even as many healthcare IT leaders see the benefits of adopting IT solutions such as computerized provider order entry (CPOE) systems, there are numerous barriers and challenges connected to CPOE technology when it comes to pharmacy operations. Indeed, without including the key hospital stakeholders, especially clinical pharmacy and nursing staff, hospitals can find it difficult to realize all the advantages of CPOE systems.

Many hospital pharmacy leaders at small, rural hospitals, in particular, are finding that, as with many other IT implementations, the initial deployment of these technologies can actually create unintended challenges for physicians, clinicians and pharmacists. For smaller hospitals faced with budget constraints and limited resources, transitioning from the traditional paper-based prescription pad to digital processes for prescribing and medication review requires careful consideration of the financial and staffing complexities.

To this end, many hospitals are deploying telepharmacy services to support their CPOE technology and are finding that the combination of telepharmacy and CPOE tools has enhanced provider workflows, medication safety, patient safety and even the financial bottom line.

Kelly Meeks, the director of pharmacy (DOP) at Crawford Memorial Hospital, a critical-access hospital in Robinson, Illinois, says the 25-bed hospital implemented a CPOE system in 2008, yet there were challenges to clinician adoption and use of the technology. “The challenges were prescriber-specific, so doctors who are very tech-savvy took to it. It’s a big change and requires certain thinking and thought processes. Electronic orders don’t always mirror the clinicians’ thought process. So, some doctors easily made that transition and some had trouble. It was not a mandatory thing, until the Meaningful Use criteria hit,” Meeks says.

Many smaller hospitals do not provide 24/7 on-site pharmacy coverage as hospital executives are challenged with rationalizing expanding pharmacy departments and hiring expensive resources when the volume isn’t there. “As a critical-access hospital, we’re a small, rural hospital, we don’t have 24/7 pharmacy services, so from 8 am to 4:30 pm the orders come to pharmacists for verification,” Meeks explains. “After 4:30 pm, the medication orders go to nurses for acknowledgment, but prior to deploying telepharmacy services, those orders waited until 8 am the next morning, at which point the pharmacists, who are trained for looking at drug therapy management and renal dosing, reviewed them. So there was a gap in the pharmacists’ review of the medication orders.”

In 2011, Crawford Memorial deployed a telepharmacy platform working with PipelineRx, a San Francisco-based company that provides medication management services with a focus on clinical telepharmacy. Two years later, in 2013, Crawford Memorial expanded its CPOE systems to the emergency room and physicians, clinicians and pharmacists found that implementing telepharmacy not only filled critical gaps in pharmacy services but also improved the efficiency of the CPOE process.

Kelly Meeks

“Not having a pharmacist here two-thirds of the day, that’s a huge gap in pharmacy services and the telepharmacy service provides 24-hour medication order review and verification by a clinical pharmacist. We were looking to use this telepharmacy platform to close that loop and optimize our operations,” Meeks says. Prior to the use of telepharmacy services, Meeks and her pharmacy staff were spending 30 minutes to three hours in the morning catching up from the orders that came in overnight. “It’s difficult to efficiently care for patients in the morning when you’re spending so much time catching up. This process enhances efficiency and safety,” she says.

At Claxton-Hepburn Medical Center, a 102-bed hospital in Ogdensburg, N.Y., hospital leadership implemented telepharmacy technology while also rolling out an electronic medical record (EMR) system and those implementations occurred six months prior to deploying the CPOE system.

“One reason we brought in telepharmacy services is that, as a rural hospital, we’re not 24/7,” Greg Guimond, director of pharmacy at Claxton-Hepburn Medical Center, says. “Knowing that we were going to an EMR, the chief nurse operator wanted all the information available electronically so orders show up in the EMR to be verified by a pharmacist. So that meant either bringing on a second or third shift as we’re 7 [am] to 5 [pm] seven days a week, or going with a telepharmacy service,” he says.

Claxton-Hepburn Medical Center also uses a telepharmacy platform provided by PipelineRx. The company provide hospitals with a fully managed and staffed remote medication order verification (RMOV) service. The hospitals have access to trained clinical pharmacists, and also specialty pharmacists such as oncology, for continuous medication order review baesd upon each hospitals’ established systems, policies, procedures, protocols and formulary.

Clinician and Pharmacist Workflow

Some hospital leaders have found that the use of CPOE systems can double the workload for the hospital pharmacist and can actually slow down turnaround times.

“With CPOE and the complex pre-built order sets, pharmacists are now not only verifying an increased number of medication orders but are also responsible for entirely new medication order requests from other clinical departments that may have not had real-time 24/7 pharmacy oversight or had negligible medication order volume,” Brian Roberts, CEO and founder of PipelineRx, says.

Guimond has found that remote staffing through telepharmacy is a cost-effective way to supplement pharmacy staff and enables 24/7 medication review. Additionally, medication orders are processed faster and clinician workflow has improved, he says.

“With the old paper format, the doctor writes the order on the form, the nurse will acknowledge the order and later picks up the order and it was a labor-intensive, time-consuming order entry process. Now the physician enters it, the pharmacy and the nursing staff can see the order is in the system and the nurse is available to administer it. The turnaround time from physician order to the patient getting the medication is much quicker,” Guimond says. “And, I think those who have fully embraced it have found it to be a more efficient workflow.”

Typically, when a medication order is entered into the EMR by the physician, it is then routed to a pharmacist for review and verification. However, pharmacy workflow within these systems can be limited and can become further disjointed when non-electronic orders need to be managed. A telepharmacy software platform can be layered over the EMR to manage all pharmacy order types—electronic, fax, hand-written. Additionally, the platform can be integrated with hospitals' CPOE systems, and the remote pharmacists have secure access to the hospitals’ electronic health record (EHR) and other information systems.

“With the medication turnaround time, the order goes right to the e-queue and you know right away that the orders are there and the turnaround times are quite fast,” Meeks says. PipelinexRx reports that with its telepharmacy platform the average turnaround time for medication order review is eight minutes.

Guimond also has found that the use of telepharmacy services with the CPOE system has significantly improved workflow in the pharmacy as well.

“Before we deployed the CPOE system, first thing in the morning, the orders from overnight would be piled up, and the first hour and a half to two hours of the day would be brutal with processing orders and getting the morning round out,” he says. “With the telepharmacy service on at night, there is no longer that backlog of morning orders. It’s dramatically changed the workflow in the pharmacy.”

Guimond says the telepharmacy platform is just one example of how health IT implementations have enhanced operations and address specific challenges faced by small, rural hospitals. “I find that health information technology really helps facilities like mine that are rural and it enables us to work on the same platform and with the same level of expectations as a larger facility would. It helps level the playing field and gives us the same edge. It doesn’t take a lot of bodies anymore to throw at things to make things work,” he says.

Of Crawford Memorial, Meeks says, “For the size and scope of this hospital, we’re very wired. The hospital administration acknowledge the importance of and support the use of technology to improve things and to optimize our operations,” she says, pointing out that the hospital uses a clinical surveillance tool, Sentri7, to provide clinicians with real-time, specific, criteria-based information. “That technology is another step we’ve taken to decrease the time spent in manual look-up and gives the pharmacists more time to focus on other work,” she says.

Prioritizing Patient Care and Patient Safety

Guimond contends that having each medication order reviewed by a trained pharmacist significantly enhances patient safety. “The telepharmacy has helped us tremendously as now I have the entire evening and night covered with a pharmacist and it’s likely that that wouldn’t have happened before. We’re too small to spend that kind of money to pay for a pharmacist to be here 24/7. We would still be reviewing orders in the morning if it were not for remote pharmacy technology that’s available,” he says.

Further, using remote staffing to supplement clinical pharmacy staff enables hospital pharmacists to expand their role and dedicate more time to face-to-face patient interactions and other clinical programs. Essentially, telepharmacy services enable the pharmacist to “get out of the pharmacy,” Meeks says. Onsite pharmacists are able to walk the patient floors and be at the prescriber’s elbow, showing them how to enter the complex orders and help eliminate their initial frustration with CPOE, she adds.

“That’s been huge for us,” she says. “Depending on how many admissions we get overnight, with our census of 25, we might get one or two admissions overnight, or it can be eight, nine or 10 admissions, and we would spend the bulk of the next morning catching up and also the prescribers are writing more orders. Going to 24/7 coverage with telepharmacy, the pharmacists come in in the morning and are able to have a shift huddle and review what happened overnight and then go into the clinical rooms and sit with the hospitalists group to assist with order entry.”

She adds, “From a patient safety issue, it’s safer to have pharmacy reviewing the medications; pharmacists catch more medication errors as it’s what we are trained to do.”

Guimond acknowledges he had initial concerns about using remote pharmacists to supplement his pharmacy department. “With the model that this company works on, there is a pharmacist covering multiple hospitals on a shift, so how are they going to learn our system and quirks? And how well-trained are these people?”

Prior to deploying the technology, the vendor conducted a WebEx to train the remote pharmacists on the hospital’s specific policies and procedures. “They train the pharmacists on just our system and the quirks of our facility. We had to go on faith a little bit, but once we got the training, I began to notice the intelligent questions being asked during the hand-off process and the concern for patients,” he says.

For the pharmacy staff, the process is seamless, Guimond says, as at the end of the day shift, the on-site pharmacy staff give a hand-off to the remote pharmacist and there is another hand-off in the morning. “In addition to learning our policies and procedures, they are trained on any quirky billing issues and physician preferences, so they really are an extension of my pharmacy,” he says.

Roberts says the use case for telepharmacy extends beyond small, rural hospitals. Large integrated delivery networks have deployed telepharmacy software platforms to optimize their in-house pharmacy staff across facilities, basically to run their own telepharmacy service. Larger hospitals can flex up or down their use of telepharmacy services according to their patient volume. Additionally, large health systems have implemented telepharmacy to support smaller hospitals in the region with virtual labor and to support telemedicine programs.

“We work with healthcare delivery organizations from 25-bed critical-access hospitals up to 700-bed academic medical centers,” Roberts says, noting that healthcare delivery organizations are seeing cost savings from 30 to 70 percent by using telepharmacy technology. “We’re just in the early innings of the game. I think with value-based care coming and with an increased focus on the continuum of care, telepharmacy technology can benefit a lot of areas of healthcare, from hospitals to nursing homes and retail and other pharmacy environments, where clinicians need prescription verifications,” he says.

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KLAS: EHR Integration, Enterprise Scalability Key Challenges Facing Telehealth Vendors

December 11, 2018
by Heather Landi, Associate Editor
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Healthcare organizations report high satisfaction with their telehealth virtual care platforms (VCPs), however there are significant differences in how broad the various platforms are and in the quality of the vendors’ service. What’s more, integration with electronic health record (EHR) systems is a key challenge facing every telehealth vendor, according to a KLAS report.

In its report, “Telehealth Virtual Care Platforms 2019: Which Telehealth Vendors Have the Scalability Customers Need?,” KLAS evaluates some of the top telehealth companies including American Well, MDLive and Epic, and analyzes what capabilities will set vendors apart as more healthcare organizations adopt virtual health technology solutions.

Most virtual care platform vendors receive positive performance ratings, but the depth and breadth of their capabilities vary, and this can impact scalability for organizations looking to grow, according to KLAS. No two vendors are alike in their capabilities, offering different combinations of functionality and experience.

Of the companies KLAS evaluated, the most common type of visit varied—most of American Well’s visits were on-demand urgent care, while the majority of Epic’s visits were associated with virtual clinic visits.

A key factor of scalability is the ability to support multiple visit types, KLAS researchers note. While multiple vendors offer support for all three visit types (on-demand or urgent care, virtual clinic visits and telespecialty consultations) no single vendor has a large proportion of customers using all three (only 12 respondents across all vendors said they were doing so).

American Well, a market share and mindshare leader, and MDLIVE, two of the vendors used most frequently for multiple visit types, receive generally positive—but lower than average—performance scores. Vendors more specialized in specific visit types or component layers (e.g., Vidyo and Zipnosis) have high scores but narrower expectations from customers.

No one vendor meets all needs equally well, but several are reaching for “all-purpose” status with internal development and/or recent acquisitions (American Well acquired Avizia; InTouch acquired TruClinic), according to the report.

KLAS’ analysis also uncovered a general trend of poor integration. In most cases, the addition of a virtual care platform also means the introduction of a second EHR into the clinician workflow.

“Although integration between EMRs is generally understood to be important for care quality, patient safety, efficiency, and productivity, few interviewed VCP customers have full bidirectional transfer in place. Most say that they are too early in their virtual care programs to pursue integration or that it simply costs too much,” KLAS researchers wrote.

Only American Well, Epic, and MDLIVE have more than half of interviewed customers currently on an integrated path, KLAS found. Epic has placed virtual care capabilities directly into their top-rated MyChart patient portal, which many patients already use. Epic integration means clinicians are able to stay within their existing workflow environment as well.

Many provider organizations are in the early phases of their virtual care programs where showing an ROI is an important milestone and one that organizations want to achieve as soon as possible, KLAS notes. “A key promise from vendors is that their technology and accumulated expertise will result in a fast start and continuous acceleration. When this comes at significant cost or progress is slower than expected, provider organizations can experience disappointment,” the KLAS researchers wrote.

When it comes to getting their money’s worth and achieving desired outcomes, Epic and InTouch are rated highest among fully rated vendors, and swyMed and Vidyo perform well among their smaller groups of respondents, KLAS researchers note.

“For each vendor, the current value proposition is somewhat narrow but well understood: Epic’s use is limited to existing patients of Epic EMR customers; InTouch is used primarily for consults; swyMed is used by respondents primarily for mobile, first responder needs; Vidyo delivers video-conferencing tools,

which are typically combined with other VCP solutions. SnapMD is seen as a low-cost option, but some customers say the impact has been limited. Commentary from VSee customers suggests a similar experience,” KLAS researchers wrote in the report.

Many healthcare organizations are early on in their virtual care journeys, and their ability to achieve desired results depends on guidance from vendors. According to KLAS’ analysis, swyMed and InTouch receive the most praise for taking initiative in proactively guiding customers and also in quickly responding to support problems.

While respondents praise American Well’s platform scalability, some customers blame the vendor’s “exponentialgrowth for staffing shortages that have led to implementation holdups and backlogged service requests. Some SnapMD customers say hard-to-beat pricing comes with a support model that is spare in terms of providing tailored guidance, according to the KLAS report.

Most vendors offer two additional options that can help accelerate customers’ expansion and growth—supplemental services, including added-cost advisory and outsourced services, and tools that automate patient-facing tasks that traditionally require additional staff. I

KLAS found that few customers mentioned these options in top-of-mind conversations. “Respondents who spoke of their vendor’s supplemental services most often referred to marketing support or strategic planning services from vendors American Well, MDLIVE, or Zipnosis. Those who referred to task automation report patient-self-service capabilities around check-in, scheduling, surveys, and/or patient flow from InTouch Health (TruClinic), Epic, MDLIVE, or Zipnosis,” the KLAS researchers wrote.



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Study: Neonatal Telehealth Reduces Hospital Transfers, Saves Money

December 11, 2018
by Heather Landi, Associate Editor
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Neonatal video-assisted resuscitation reduces transfers from hospitals without newborn intensive care units and provides significant cost savings, according to study published in the November issue of Health Affairs.

The study authors, led by Jordan Albritton of Intermountain Healthcare, examined a newborn telehealth program implemented at eight Intermountain Healthcare community hospitals in November 2014–December 2015 and the impact on the transfer of newborns from those eight hospitals to level 3 newborn intensive care units.

Studies show that 10 percent of newborns require assistance breathing at birth, and 1 percent require extensive resuscitation. At Intermountain Healthcare, approximately 1–2 percent of all babies born in suburban and rural hospitals are transferred to newborn intensive care units (NICUs) for higher-level care, according to the study.

In response to the need to improve outcomes for complex newborn patients, an innovative telehealth program was established at Intermountain Healthcare in 2013 to provide synchronous, video-assisted resuscitation (VAR), bringing a neonatologist to the bedside. As a result, access to specialized neonatal services in rural and suburban settings is no longer limited to telephone calls or the arrival of a neonatal transport team, the study authors wrote.

While telehealth can facilitate video connections between neonatologists at tertiary care centers and providers at smaller hospitals, there is little empirical evidence about the benefits of telehealth programs for neonatal resuscitation, according to the study authors.

Although Intermountain Healthcare began using telehealth technologies in 2013, the current VAR program was implemented in the period November 2014–December 2015. Today, neonatologists from four level 3 NICUs provide VAR support for nineteen referring hospitals.

As part of the study, the researchers evaluated eight hospitals that contained either well-baby (level 1) or special care (level 2) nurseries staffed by physicians, advanced practice clinicians, nurses, respiratory therapists, and other health care professionals. T

The study found that video-assisted resuscitation was associated with a reduction of 0.70 transfers per facility-month and a 29.4 percent reduction in a newborn’s odds of being transferred. Annually, this resulted in 67.2 fewer transfers and an estimated cost savings of $1.2 million per year.

The study authors conclude that reducing transfers keeps families closer to home, increases community hospital revenue, and reduces risk associated with transfers.

“This program helps keep newborns in level 1 or 2 nurseries, which in turn allows families to stay closer to home, improves social support, and increases the revenue of community hospitals while reducing costs and risks associated with transfers,” the study authors wrote. “Payers should consider reimbursement for pediatric subspecialty telehealth consults for neonates in level 1 and 2 nurseries. Through improvements in care quality and cost savings, this service would likely pay for itself many times over.

However, the authors also note that lack of reimbursement for telehealth services limits widespread implementation.

“Policy changes are necessary to align payment incentives and promote the use of telehealth services,” the study authors wrote.

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Can Telehealth Slow the Traffic Between Nursing Homes, Emergency Departments?

December 6, 2018
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The RUSH Act seeks to reduce the 1.3 million transfers from skilled nursing facilities to emergency rooms each year

There are 1.3 million transfers from skilled nursing facilities (SNFs) to emergency rooms each year, and CMS estimates that two-thirds of those are avoidable. The result is as much as $40 billion in unnecessary spending. Could telehealth be part of the solution?

That question led Timothy Peck, M.D., formerly chief resident in the Emergency Department at Beth Israel Deaconess/Harvard, to co-found a startup company, Call9, and become an advocate for legislation, the RUSH (Reducing Unnecessary Senior Hospitalizations) Act of 2018, to support reimbursement for connecting emergency physicians and SNFs.

Peck has spent considerable time studying the issue. “I didn’t know much about nursing homes when I started,” he said.  “I went and lived in one for three months. I wound up sleeping on a cot in a conference room.”

Peck was trying to understand nursing home finances and operations and why the patients are being transferred. They usually have things like urinary tract infections or pneumonia, which could be treated in the outpatient setting, but the SNFs aren’t equipped with the right tools to be able to treat these patients. Those patients come in without their families and 43 percent have dementia, he said. “Most become delirious upon transfer. We don’t have much information about them so we order every test under the rainbow, driving up the bill unnecessarily. We put them in hallways. They get bedsores. We inevitably admit these patients for an average of $15,000 to $20,000 per admission.”

The two-thirds of transfers that are avoidable represent about $40 billion in unnecessary spending for something that harms patients,” he said. “We are spending money on hurting patients.”

Peck zeroed in on three operational issues:

• First, on average, nurse to patient ratios in nursing homes are 1 to 36. If one patient becomes acutely ill and spikes a fever, that nurse does not have time to take care of that patient when they have 35 other patients to take care of. Also, most nursing home nurses are trained to handle chronic care, not emergency or acute care. It is a mismatch of skills, not a people problem in any way, he said.  

• Second, diagnostic equipment is sparse, and EKGs and lab tests take 24 hours to 48 hours to come back. That doesn’t work well for acute care.

• Third, physicians are not present in nursing homes. “When I was living in that nursing home and walking the halls weekends and nights, I never once saw another physician. Long-term care patients are seen once a month by their primary care doctors.”

Peck described the Call9 service: They embed 24x7 a paramedic or EMT or a nurse with emergency experience in the SNF. They go to the patient’s bedside and connect to a remote emergency physician who is available 24x7 and working from home. They can see a patient in nursing home A with a paramedic by the bedside and then jump to nursing home B and see a patient there with a first responder with them. “It makes the physician a scalable resource,” Peck said. “Believe it or not, they are our least expensive resource because they get scaled.”

Call9 has full integration with the three most commonly used EHRs in the SNF world. The solution also deploys a suite of mobile diagnostics and can return lab test results in a few minutes. It offers real-time telemetry and real-time ultrasound.

After treating a few thousand Medicare Advantage patients, he said the model has shown that it can save payers more than $8 million per nursing home per year. That allowed Call9 to get involved with Medicare shared savings value-based contracts with several payers nationally. But he notes that 60 percent of patients in nursing homes are Medicare patients. “We took that data to CMS and showed it to them,” Peck said. “The Ways and Means Committee in the House of Representatives got ahold of the data and got excited and started writing the Rush Act.”  He stressed that Call9 is not the only organization creating a program like this. There are others working on similar solutions.

Peck said CMS is interested in using telehealth in this way, he said. “But they don’t have any way to change payment mechanisms in a quick manner. They would have to ask CMMI to run demos, which takes years. But Congress could pass new legislation.” He described the RUSH Act as creating a value-based shared savings arrangement with Medicare where 50 percent of the savings goes back to Medicare, and 37.5 percent goes to a company like Call9 or a physician group or medical staffing group that administers the program and 12.5 percent goes to the nursing home, aligning all stakeholders, he said. “The bill has been introduced by a bipartisan group, because it is a nonpartisan issue.” With time running out in this session, he said, the bill still has strong support among Democrats set to take over House leadership in 2019.

Besides bipartisan sponsors in Congress, the bill also has support from patient advocacy groups such as the Alzheimer’s Association, Michael J. Fox Foundation for Parkinson’s Research, American Heart Association, the National Alliance on Mental Illness, and the American Telemedicine Association. “They are saying that the patients need it; the taxpayers benefit; why are we not doing this?” Peck said.

As someone who has seen family members and friends make that repeated, disruptive round trip from nursing home to emergency room, I concur.  



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