Advances in Pharmacy: Journal of Student Solutions to

Pharmacy Challenges
Volume 1 | Issue 1 Article 5

2017

Pharmacy Services in Telepharmacy: how’s it

working, where it’s working, and what’s required to
practice in this new setting.
Aimee Skrei
University of Minnesota - Twin Cities, [email protected]

Michelle M. Rundquist
[email protected]

Follow this and additional works at: http://pubs.lib.umn.edu/advances

Recommended Citation
Skrei, Aimee and Rundquist, Michelle M. (2017) "Pharmacy Services in Telepharmacy: how’s it working, where it’s working, and
what’s required to practice in this new setting.," Advances in Pharmacy: Journal of Student Solutions to Pharmacy Challenges: Vol. 1 : Iss. 1
, Article 5.
Available at: http://pubs.lib.umn.edu/advances/vol1/iss1/5

This work is licensed under a Creative Commons Attribution-Noncommercial 4.0 License

Advances in Pharmacy: Journal of Student Solutions to Pharmacy Challenges is published by the

University of Minnesota Libraries Publishing.
Pharmacy Services in Telepharmacy: how is it working, where is it
working, and what is required to practice in this new setting
Michelle Rundquist1 and Aimee Skrei1
1
University of Minnesota College of Pharmacy, Minneapolis, MN, USA

June 2017

Abstract
Telepharmacy is a rapidly growing area of communication within pharmaceutical care delivery, es-
pecially in rural areas. The purpose of this literature review was to determine where telepharmacy is
currently being practiced within community and ambulatory pharmacy settings and the effectiveness
of it. Additionally, state rules and regulations for the upper Midwest region were compared and con-
trasted to analyze how specific states are addressing the use of telepharmacy practice within the specified
settings. A systematic literature review was performed using PubMed, Ovid Medline, and the Google
Scholar search engine. State specific rules were researched using board of pharmacy and legislative online
resources. Overall, telepharmacy was found to be an effective and safe delivery method to communi-
cate with patients regarding their medications. It has been successfully implemented within community
pharmacy settings through the creation of remote dispensing sites, which is evident through literature
analysis. The focus of state regulations on telepharmacy services and practices shows the growth and ac-
ceptance of this modality of pharmacy practice. There is wide variation among Midwest state regulations
pertaining to the setup and operation of telepharmacies. Trends in telemedicine show that telepharma-
ceutical care is likely to continue to expand as it allows for a better allocation of resources and access
to more patients. Further primary research needs to be completed to specifically analyze telepharmacy
cost-effectiveness

1 Introduction
Telemedicine and telepharmacy are growing in popularity as healthcare becomes more patient centered
and driven by outcome and quality measures. With the technological advances of the past ten years and
broadening of pharmacy services to include direct patient care, telepharmacy is being used to serve patients
who are unable to physically access pharmacists trained to perform clinical evaluations.(1) Telepharmacy
helps health systems expand services at a lesser additional cost by employing one full time pharmacist,
who interacts with patients and professionals through telecommunication across great distances, rather
than several part-time pharmacists.(1,2) Literature shows that telepharmacy services are being provided via
text messaging, email, video conferencing and telephone in a variety of settings.(3) Pharmacists are using
telepharmacy to perform warfarin consults,(1) evaluate psychiatric medications for pediatric patients in
rural settings,(2) perform discharge medication reconciliation,(4) and improve adherence to medications.(5)
As telepharmacy services continue to expand, it is critical that providers know what methods are effective
in their practice setting to ensure quality care is delivered to each patient. A literature review published in
2008 focused on telepharmacy practice within the hospital setting.(6)
To learn more about the prevalence of telepharmacy, research began by determining where telepharmacy
was being utilized within ambulatory and community pharmacy settings. Information regarding which types
of pharmacy services were being provided and the advantages and disadvantages of telepharmacy were sought
out. Next, the effectiveness of providing pharmacy services through telepharmacy pathways in ambulatory

1
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and community settings was determined. Possible changes or improvements in services were identified based
on current telepharmacy offerings. Lastly, current rules and regulations provided by boards of pharmacy
in the upper Midwest region were analyzed in ambulatory/community settings. This region included North
Dakota (ND), South Dakota (SD), Nebraska (NE), Minnesota (MN), Iowa (IA), Wisconsin (WI), and Illinois
(IL).

2 Methods
2.1 Literature Search Strategy
In order to complete the literature review, several online databases were used including Medline (through
PubMed), Embase (using the OVID interface), Cochrane Central Library, and Google Scholar. Additionally,
select citations in each selected article were reviewed to expand upon the references. Key terms and MESH
terms used included telepharmacy, telemedicine, pharmacy services, community pharmacy, clinical setting,
ambulatory pharmacy, outpatient pharmacy, medication therapy management, and pharmacy. Several
limitations were placed within the search. Only English language articles that were published after 2000
were reviewed. Settings that were not designed for ambulatory or outpatient/community pharmacy services
were excluded. All efforts were made to obtain articles. Only full length articles were considered. Both
researchers screened the abstracts for relevance. Differences in opinions were resolved through discussion
between researchers.
Additionally, current rules and regulations listed on board of pharmacy websites were reviewed, including
Boards of Pharmacy (BoP) for states listed in the introduction section as well as the National Association
of Boards of Pharmacy (NABP). If necessary, email or telephone contact was made with each board of
pharmacy to clarify or further address current rules and regulations regarding telepharmacy in the Upper
Midwest Region.

2.2 Study Eligibility Criteria

Case studies, randomized control trials, and pilot projects on the use and effectiveness of telepharmacy
were included in the review. No limitations were placed on sample size for randomized control trials (RCT)
involving telepharmacy implementation or modification. The following PICOD (Population, Intervention,
Comparator, Outcome, and Designs) details were considered as articles were selected:
• Population: ambulatory and community pharmacies using/experimenting with telepharmacy
• Intervention: pharmacy services provided over a distance, which are not face-to-face or in-person, and
include but are not limited to video, phone, email, and text/instant messaging

• Comparator: study-dependent community health outcomes where pharmacy services are traditional
in-person services or are not present, which is dependent on pharmacy setting or study design
• Outcome: qualitative analysis of the success/failure of telepharmacy services
• Designs considered: Case studies, randomized controlled trials, review articles

3 Data Extraction
Two reviewers independently abstracted the data. The Literature Review Abstraction Guide was used as
a template for documenting and organizing data extraction of articles.(7) Several modifications were made
to the Abstraction Guide to better fit the needs of this specific project. The modifications that were made
included adding study objectives, study hypothesis, study limits, and telepharmacy settings. Additionally,
the definition of telepharmacy within each study was noted.

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4 Quality Assessment
Each article was assessed for quality based on the Oxford Centre for Evidence-Based Medicine 2011 Levels
of Evidence table. (7) Data for quality assessment was extracted as articles were read, including questions
answered by the study and level of evidence.

5 Results
Eleven articles were identified that met our inclusion criteria, which is depicted in Figure 1. Twenty-one
full-text articles were identified to be assessed; seven of these were excluded because they focused on acute
care settings or areas of practice outside of pharmacy, including nursing and physician practice. Another
article was excluded due to questionable validity. Two articles were excluded because the full-text was
unobtainable. A summary of these articles is in Table 1. The practice sites of these articles contained
community pharmacies with remote dispensing sites, telephonic medication therapy management (MTM),
and clinical video telehealth used with anticoagulation clinics.
North Dakota State University College of Pharmacy has developed a webpage that shows the abundant
research and development work that has been completed in the field of telepharmacy within the state of
ND.(30) This research was sampled through the Freisner, et al, article included in this systematic review.
Results from this article show that the number of errors completed in a telepharmacy setting is comparable
to that of a conventional dispensing pharmacy, showing that remote supervision of pharmacy dispensing
services is feasible in a community setting.(9) Additional evidence for telepharmacy success comes out of
Washington State where Lam and Rose showed that automated dispensing systems, with remote order
processing and patient counseling, can be successfully utilized in the dispensing of medications, particularly
antibiotics, in clinics that lack pharmacies.(10) Margolis and colleagues showed that patients reported an
appreciation for use of telephone interviews, rather than traveling to a clinic setting, when being counseled on
asthma disease control.(17) In contrast, Clifton and colleagues reported that 55.6% of patients using remote
dispensing sites were satisfied compared to 66% satisfaction at the central site, suggesting less satisfaction
with telepharmacy.(11)
The presence of telepharmacy has also been expanding within ambulatory care settings, especially with
the delivery of MTM. Clinical video telehealth delivery provided high quality services with patient satisfaction
maintained in a study completed by the Maryland Veterans Administration.(12) Singh, et al, stated that
the telehealth model can be implemented into a variety of healthcare settings to deliver pharmaceutical care
services, including therapeutic drug monitoring, chronic disease management, and patient education.(12)
Research shows that many of these tasks are being taken on by managed health care groups who have
departments dedicated to telephone delivered pharmaceutical care services. (19) Goals of these services
include: assessing medications, easing transitions of care, supporting patients in medication adherence,
answering medication related questions and ordering laboratory tests.
The use of telepharmacy is not only being studied in the United States. Several international studies
were also reviewed regarding their experiences with telepharmacy. A study performed in the Netherlands
had great success with their telepharmacy services which lead to increased adherence to new medications
(statins, RAS-inhibitors, bisphosphonates) with telephonic counseling calls performed 7-21 days after therapy
initiation.(15) An Australian telepharmacy project showed the effectiveness of telepharmacy is dependent
upon appropriate technology. Remote sites need adequate access to high quality technology, telephone
connections, and internet speeds.(16)
State specific telepharmacy requirements are in Tables 2 and 3. Common requirements for operation of
remote dispensing sites include two-way audiovisual link and computer link, technology that allows for real
time prescription, and medication verification by the pharmacist and video link for patient counsel. Most
states require remote dispensing sites are staffed by registered technicians with required minimum work hours;
SD and WI allow pharmacy interns to staff remote dispensing sites. Routine inspections of the remote site
by the pharmacist in charge are required in most states, however, inspection frequency varies from weekly
to monthly. It is unclear from the state statutes if MTM services can be performed remotely, however, there

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Advances in Pharmacy

is a trend toward provisions for hospital use of telepharmacy. Some Midwest states are supporting smaller
hospitals with pharmacy services at larger locations via audiovisual and computer connections.
The National Association of Boards of Pharmacy established an initial task force in 1996. This task
force encouraged state pharmacy boards to reexamine definitions regarding pharmacy practice present in
their state practice acts to ensure pharmacy practice is not limited to within a pharmacy. It also lists
information required to be part of a multistate telepharmacy practice registration.(27) A new task force was
established on June 6, 2016 to develop a guidance statement for licensing processes that will protect the
public, retain board of pharmacy jurisdiction for telepharmacy practices, and allow for further development
of telepharmacy models.(28)

6 Discussion
The practice of telepharmacy is rapidly evolving and becoming more widely used. The literature review
showed telepharmacy use in dispensing, MTM, and anticoagulation clinic settings, as well as use in enhance-
ment of medication adherence with specific conditions (table 2). The U.S. Department of Health and Human
Services has created an Office for the Advancement of Telehealth (OAT) to further promote the practice of
telecommunications within medicine. Many of the studies examined in this literature review were funded
by OAT. Throughout our literature review several recurring themes were noticed. North Dakota is at the
forefront for studying, utilizing, and implementing telepharmacy practices which is evident through the col-
laboration between the ND Board of Pharmacy and North Dakota State University. Significant amounts of
research have been completed involving these two entities.(9) North Dakota contains many rural communities
without access to pharmacy services. In ND, telepharmacy is most widely implemented within the commu-
nity and dispensing setting where it has been well accepted by patients and health care professionals.(9,11)
The abundance of work in ND shows that telepharmacies are well received by patients in medically under-
served rural communities.(11,14) The underserved communities most impacted are those with limited access
to pharmacy services due to the limited presence of pharmacies in rural areas. Expanding the application
of telepharmacy technology can improve patient access to pharmaceutical care. Current research regard-
ing telepharmacy services does not yet analyze cost barriers and cost effectiveness related to telepharmacy.
Access and affordability of telepharmacy equipment may be another barrier in these medically underserved
communities that still needs to be addressed.
Friesner, et al, completed a study comparing the safety of remote telepharmacies to traditional pharma-
cies, which suggested that telepharmacies have comparable safety rates to conventional dispensing pharma-
cies. Additionally, this study found that remote pharmacies do not adversely affect public health, patient
safety, nor the quality of care provided. The majority of mistakes made at a remote dispensing telepharmacy
are within the prescription entry process.(9) Several limitations to telepharmacy noted throughout the liter-
ature review included delayed order processing during technology down-time compared to when technology
is fully functioning, as well as adequate time, staffing, and workspace for the pharmacists at the central
site. Additionally, reliable technology and adequate backup are very important features for a telepharmacy
practice to have.(16) The failure of the Australian Telepharmacy project demonstrates a disadvantage of
telepharmacy: a substantial initial investment in technology is crucial to the success of telepharmacy en-
deavors.(16) This is a limiting factor in that telepharmacy services can only be provided to those who have
the necessary infrastructure and can afford the technology required.
In the upper Midwest region, Minnesota is the only state that does not have state-based regulations for the
operation of remote dispensing sites or telepharmacies in a community setting. Minnesota allows for licensed
pharmacies to obtain a variance to operate telepharmacies in underserved locations.(22) North Dakota is a
leader in the telepharmacy world with a program designed and operated in conjunction with the College
of Pharmacy at North Dakota State University.(25) Alternatively, Nebraska was found to have the fewest
regulations regarding telepharmacy, which indicates potential for growth and innovation in telepharmacy in
this state. Details regarding what is required for each state are described in tables 2 and 3. Additionally, when
practicing telepharmacy, it is important to follow specific state requirements regarding staffing, inspection,
counseling requirements, technology, and licensure.

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Advances in Pharmacy

State BoPs show their support for telepharmacy by stating provisions under which telepharmacy can be
practiced. The state BoPs have laid out clear requirements for counseling and prescription verification to
make the practice safe and beneficial for patients. Five of the seven states reviewed required counseling with
every prescription filled in the telepharmacy. This requirement enhances the relationship between patient
and pharmacist by providing contact time and an opportunity for additional pharmaceutical care services.
Telepharmacy services in community settings are a means to expand pharmacy services into communities
unable to support a full service pharmacy. These community based sites have the potential to develop
services to include MTM and point of care testing allowing for additional ways to serve patients. A new task
force was set forth by the NABP in June 2016 which may influence future directions of telepharmacy.(28)
Because of this, now is the optimal time for planting seeds for the expansion of telepharmacy.

7 Conclusion
Telepharmacy is safe, effective, and provides positive outcomes to patients. Many states within the Upper
Midwest Region have addressed telepharmacy and included rules and regulations regarding the practice.
Our review of the literature found eleven studies that helped with the understanding of where and how
telepharmacy is being practiced. We found that telepharmacy offers medically underserved communities a
way to maintain pharmacy access without pharmacist retention difficulties. Other advantages of telephar-
macy include less travel for members of rural communities for access to prescription drugs and point of
care tests, such as INR dosing, and maintenance of a relationship with the pharmacist the most accessible
medical professional. It is the opinion of these authors that counseling with every prescription fill is highly
beneficial in a telepharmacy system and will help patients develop a relationship with their pharmacist, thus
maintaining pharmacist accessibility in underserved communities.
In addition, a good relationship between patient and pharmacist may open the door for additional
services provided at remote dispensing sites. Technology is the both the driver of telepharmacy services and
the limiting factor. Without quality technology, kept in good working order, remote dispensing sites cannot
operate. This may be expensive and require additional infrastructural support. The quality of the studies
reviewed here varied, with many having small sample sizes. Future work in telepharmacy is needed with
larger sample sizes studied over long periods of time. This may shed more light on telepharmacy advantages,
challenges, and how to overcome difficulties. Further research focusing on economic and cost-benefit of
telepharmacy is also needed to determine if the benefits of telepharmacy merits the expense.

8 Acknowledgement
We would like to thank our reviewers, Dr. Christene Jolowsky and Dr. Elizabeth Ambrose, for the feedback
and support provided to us throughout the research and synthesis of this literature review.

9 References
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7. Literature Review Abstraction Guide. Moodle. Phar 6742, Spring 2016. Practice Based Problem
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Hazel Thornto, Olive Goddard and Mary Hodgkinson). The Oxford 2011 Levels of Evidence. Ox-
ford Centre for Evidence-Based Medicine. http://www.cebm.net/wp-content/uploads/2014/06/
CEBM-Levels-of-Evidence-2.1.pdf
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CD, Anderson HC. J Am Pharm Assoc. 2011; vol 51, pp: 580-590. Accessed online February 2, 2017.

10. Telepharmacy services in an urban community health clinic system. Lam AY, Rose D. J Am Pharm
Assoc. 2009; vol 49, pp: 652659. Accessed online February 2, 2017.
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conferencing. Clifton GD, Byer H, Heaton K, Haberman DJ, Gill H. Am J Health-Syst Pharm. 2003;
Vol 60, pp: 2577-2582. Accessed online February 2, 2017.

12. Implementation and outcomes of a pharmacist-managed clinical video telehealth anticoagulation clinic.
Singh LG, Accursi M, Korch Black K. Am J Health-Syst Pharm. 2015; Vol 72, pp: 70-73. Accessed
Online February 4, 2017.
13. Assessment of the Impact of Medication Therapy Management Delivered to Home-Based Medicare
Beneficiaries. Welch EK, Delate T, Chester EA, Stubbings T. Annals of Pharmacotherapy. 2009; Vol
43, pp: 603-610. Accessed online February 6, 2017.
14. Patient And phaRmacist Telephonic Encounters (PARTE) in an Underserved Rural Patient Population
with Asthma: Results of a Pilot Study. Young HN, Havican N, Griesbach S, et. al. Telemedicine and
e-Health. 2012; vol 18, pp: 427-433. Accessed online June 11, 2016.

15. Effects of Telephone Counseling Intervention by Pharmacists (TelCIP) on Medication Adherence; Re-
sults of a Cluster Randomized Trial. Kooji MJ, Heerdink ER, van Dijk L, et al. Front PHarmacol.
2016; vol 7: article 269. Accesssed online February 14, 2017.
16. Can telepharmacy provide pharmacy services in the bush? Nissen L, Tett S. J Telemed and Telecare.
2003; vol 9, pp: 39-41. Accessed online February 14, 2017.

17. A telepharmacy intervention to improve inhaler adherence in veterans with chronic obstructive pul-
monary disease. Margolis A, Young H, Lis J, Schuna A, Sorkness C. Am J Health-Syst Pharm. 2013;
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M, Helling D. Am J Health-Syst Pharm. 2005; vol 62; pp 406-410. Accessed online February 14, 2017.
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K E, Gosian J, Salow M, Sweeney P, Rudolph J, Driver J. J Rural Health. 2016; vol 00, pp: 1-8.
Accessed online February 14, 2017.

20. Illinois General Assembly. Section 1330.510 Telepharmacy. Effective April 23, 2015. Accessed February
1, 2017. http://www.ilga.gov/commission/jcar/admincode/068/068013300E05100R.html
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Services. Effective May 20, 2015. Accessed February 1, 2017. https://www.legis.iowa.gov/docs/
iac/chapter/01-18-2017.657.9.pdf

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Pharmacy.pdf

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Accessed February 1, 2017. https://www.nodakpharmacy.com/pdfs/Lawbook41316.pdf

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//sdlegislature.gov/Rules/DisplayRule.aspx?Rule=20:51:30
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Figure 1. Study Selection Flow Diagram.
 Table 1. Data Extraction Summary
Citation Telepharmacy Pharmacy Study Intervention Results
Definition Setting/Participants Design
& Quality
Freisner DL, Scott SM, A pharmacist at a 14 remote telepharmacy Pilot, cross- Utilization of the Pharmacy The remote telepharmacy group filled 47,078
Rathke AM, Peterson traditional community sites and 8 comparison sectional, Quality Commitment prescriptions and had 631 quality-related events. 78 of
CD, Anderson HC. Do pharmacy (i.e. "central community pharmacies in comparison reporting system to report these mistakes were errors found by the patient after
remote community site") uses real-time North Dakota from Jan study. quality-related events, the medication had left the pharmacy. The
telepharmacies have audiovisual equipment 2005 to Sept 2008. including a near miss community pharmacy group filled 123,346
higher medication error to provide a full set of (pharmacy discovery of a prescriptions with 1,002 quality-related events. 125 of
rates than traditional community pharmacy EBM Level 3 mistake caught before these mistakes were errors found by the patient. The
pharmacies? Evidence services at another site reaching the patient) or an remote telepharmacy group had an error rate of 1.3%
from the North Dakota (i.e. "remote site") at a error (patient discovery of a while the community pharmacy group had an error
Telepharmacy Project.9 distance. mistake). rate of 0.8%. The nationally reported error rate is
1.7%. Both of these error rates are comparable to this
national rate.

Lam AY, Rose D. (No definition Five network clinics Practice Use of automated drug Within the 5 sites, 12,000 patients received 3,282 new
Telepharmacy services specifically stated) without in-house Innovation dispensing systems and prescriptions per month with consultations, 589 refill
in an urban community pharmacies remotely Report webcam technology at five prescriptions, 2,800 pharmacist-provided refill
health clinic system.10 connected to a central community clinics with no authorizations (based on Washington Board of
pharmacy to provide pharmacies previously, to Pharmacy approved protocols), and 250 medication
telepharmacy services in EBM Level 5 allow for remote pharmacy assistance referrals. Antibiotics were the most
suburban western order processing and frequently dispensed medications. Pharmacists
Washington state from medication dispensing, as well reported that webcam-enabled interviews resulted in
2007-2008 as point-of-care patient- longer, more private counseling sessions.
focused consultations.
Clifton GD, Byer H, (No definition Central site and remote Survey 93 patients at remote 66% of the patients at the central site agreed or
Heaton K, Haberman specifically stated) site pharmacies in telepharmacy sites and 106 strongly agreed that they were satisfied with the time
DJ, Gill H. Provision of Washington state during patients at the central required to complete their pharmacy visit. Only
pharmacy services to a 2-week period of March EBM Level 5 pharmacy site completed a 55.6% at the remote sites agreed or strongly agreed
underserved population 2003 within federally questionnaire that they were satisfied. Patient satisfaction was
via remote dispensing funded community health somewhat greater with the pharmacy services received
and two-way centers. at the central site compared with the remote sites.
videoconferencing.11

Singh LG, Accursi M, Clinical video Clinical pharmacy Case Study Clinical video telehealth A patient satisfaction survey was completed, which
Korch Black K. telehealth is a method specialists at the VA technology was used to analyzed items including: comfortableness with
Implementation and of providing services Maryland Health Care provide anticoagulation equipment used, ability to see and hear clinician,
outcomes of a to patients enrolled in System in 2012. EBM Level 4 therapy management to clinical relationship, level of care, and overall
pharmacist-managed community-based patients at an outpatient satisfaction. The mean score for each of the
clinical video outpatient clinics, clinic 12 miles away. questions was 4.77 +/- 0.14, out of a 5-point scale.
telehealth which can be located Pharmacists conducted These results suggest that the use of clinical video
anticoagulation in geographic areas patient interviews, evaluated telehealth did not compromise quality or availability
clinic.12 where access to INR values, and gathered of services delivered.
healthcare services is other clinical data for use in
limited. therapy planning. Telehealth
technicians performed the
physical assessment,
including point-of-care INR
values and vital sign
measurements.
Welch EK, Delate T, (No definition Clinical pharmacists Non- Eligible patients were invited A total of 1231 home-based beneficiaries were
Chester EA, Stubbings specifically stated) employed by a not-for- randomized to receive MTM performed targeted to receive telephonic MTM. 539 patients
T. Assessment of the profit health controlled by a clinical pharmacist over accepted, 365 declined, 68 were ineligible, and 259
Impact of Medication maintenance study the telephone. The study was were unable to be contacted. Of those that accepted
Therapy Management organization giving care designed to measure all-cause and declined, 80 and 29 beneficiaries, respectively,
Delivered to Home- to Medicare mortality 180 days after the were further excluded due to ESRD. Beneficiaries
Based Medicare beneficiaries with 2 or EBM Level 3 beneficiaries had the who opted out of MTM services were more likely to
Beneficiaries.13 more chronic conditions opportunity to receive MTM. die during the 180-day follow-up (p=0.044).
(at least one considered Patients with end-stage renal Beneficiaries who opted in were more likely to
high risk) receiving 5 or disease were excluded from incur an increase in medication costs (p=0.006).
more Part-D medications the results.
and likely to incur $4000
in total Part-D costs in
the Denver/Boulder area
in 2006.
Young HN, Havican Patient and Pharmacist Low income patients Randomized Telephone consultation was Comparisons between control group and
N, Griesbach S, et al. telephonic encounters residing in federally control trial performed by pharmacists intervention group were not statistically significant,
Patient And (PARTE) designated medically pilot study trained in asthma self- though the intervention group trended towards
phaRmaciest underserved regions of management, using a increased adherence to long term controller
Telephonic Encounters north central WI were standardized guide, to help medications. The intervention group viewed the
(PARTE) in an invited to participate if EBM Level 1 patients identify causes and study positively with many participants unable to
Underserved Rural they received their solutions to asthma-related identify anything they disliked about the
Patient Population mediations from the problems. Pharmacists intervention. Patient's knowledge about asthma was
with Asthma: Results Family Health Center of assessed inhaler technique, improved with each call giving them confidence to
of a Pilot Study.14 Marshfield, Inc. (FHC) contacted providers on behalf self-manage their asthma.
or by 340B mail-order of the patient and
pharmacy. documented the encounters.
Kooji MJ, Heerdink (No definition Patients initiating Cluster A telephone counseling Overall, 1054 patients received the telephonic
ER, van Dijk L, et al. specifically stated) treatment with randomized intervention was completed counseling intervention. Comparing the intervention
Effects of Telephone antidepressants, controlled by a pharmacist, pharmacy to usual care, adherence was statistically
Counseling bisphosphonates, RAS trial student, or pharmacy significantly higher for the intervention group for
Intervention by inhibitors, or statins technician 7-21 days after patients starting RAS-Inhibitors, statins, and
Pharmacists (TelCIP) were targeted. This initiation of therapy. bisphosphonates. Patients initiating antidepressant
on Medication study occurred in 53 EBM Level 1 therapy did not show benefit from the intervention.
Adherence; Results of community pharmacies
a Cluster Randomized in the Netherlands prior
Trial.15 to 2016.
Nissen L, Tett S. Can Telepharmacy allows Community pharmacists Pilot project The goal of this project was Only 10 video-phone interactions were recorded in
telepharmacy provide for real-time provided prescription to complete pharmacist- the six-month project timeline. Many technical
pharmacy services in communication services for 3 outlying patient counseling problems were encountered due to telephone
the bush?16 between a community towns in Australia using EBM Level 5 interactions with each network problems in rural areas. Even with
pharmacist and video-phone medication dispensed. technical and logistical difficulties, dispensing
dispensing doctors, interactions. Community Additionally, pharmacist- doctors felt there was a large potential for this
videoconferencing pharmacists also had dispensing doctor technology to be used in the future.
with patients, and video-phone in offices interactions were also
patient counseling at of two general completed and documented.
depot pharmacies. practitioners.
Margolis A, Young H, (No definition Veterans aged 60 and Prospective, Pharmacists contacted Overall, patients reported satisfaction with the
Lis J, Schauna A, specifically stated) older whose inhaler randomized, patients via telephone to counseling intervention. Of the 10 that participated,
Sorkness C. A refill history revealed single-blind counsel on the COPD 9 reported improved inhaler use as a result of the
telepharmacy that fewer than 80% of intervention medications, assess intervention. Participants were appreciative of the
intervention to expected fills were study knowledge of technique, and intervention occurring over the telephone, rather
improve inhaler actually dispensed over determine barriers to use. than having to travel to a clinic.
adherence in veterans the previous 6-month Follow up telephone calls
with chronic period. EBM Level 1 were made 4-8 weeks after
obstructive pulmonary the initial counseling
disease.17 intervention to review items
 with which patients
previously struggled with.
Stubbings T, Miller C, (No definition Health maintenance Description Pharmacists were added to Call center pharmacists at a clinical pharmacy call
Humphries TL, Nelson specifically stated) organization serving of the call center staff to answer center (CPCC) acted as pharmacy care coordinators
KM, Helling D. 405,000 people in three telepharmacy patient questions related to at transitions of care ensuring profiles were updated
Telepharmacy in major Colorado cities: services in a drug therapy needs. and medications were restarted appropriately. MTM
health maintenance Denver, Boulder and health Pharmacists were able to services were provided to all new members to the
organizations.18 Colorado Springs. maintenance directly access medical organization, helping to optimize care coordination
organization records, contact providers, prior to the 1st appointment with a new provider.
make medication changes CPCC has been an integral cost saving program for
and leave notes for future Kaiser Permanente in the Colorado region. The
EBM Level 5 care providers based on their service was well received by patients and helped to
encounters. ease transitions of care for members.
Rebello KE, Gosian J, Phone interview Rural Pharmacological The study is Pharmacists performed a The pharmacy team found that patients discharged
Salow M, Sweeny P, between patient and Intervention in Late Life an extension thorough review of each to rural locations generally took more medications.
Rudolph J, Driver J. pharmacist to review (PILL) program uses of the medication present on the Additionally, they discovered many medication
The Rural PILL medications following telephone based MTM Pharmacologi patient profile. Pharmacists discrepancies following hospital discharge, with
Program: A Post discharge from a VA to serve rurally based cal called each patient included pharmacists addressing concerns for more than 75%
discharge medical center for an veterans age 65 and Intervention in the study and interviewed of patients to primary care. The intervention
Telepharmacy acute care admission. older recently in Late Life them about medication resulted in a statistically significant effect on
Intervention for Rural discharged from VA (PILL) problems and clarified any reducing the number of emergency room and urgent
Veterans.19 medical centers to home. program in a misunderstandings. The care visits at 30-days post discharge. Hospital
Patients with the matched encounter was documented, readmission rates were the same between the two
following characteristics controlled including discrepancies, groups.
were prioritized: trial with medication changes,
polypharmacy (12 or rurally pharmaceutical care issues,
more medications), located potentially inappropriate or
cognitive impairment, patients. unnecessary medications and
congestive heart failure recommendations. Notes
and age greater than or were advanced to the
equal to 75. EBM Level 3 patient’s primary care team
along with necessary
recommendations for follow-
up care.
Table 2. Description of statutes and rules present within each state’s Board of Pharmacy
regarding telepharmacy practice.
State Details on Statutes/Rules

Illinois19 Title 68, Chapter VII, subchapter b section 1330.510 of the Joint Committee on Administrative rules deals
with telepharmacy. Multiple modes of telepharmacy are described in Illinois statutes. Remote dispensing sites
collect, fill and dispense new prescriptions, whereas consultation sites have no inventory for on-site filling.
They only collect prescriptions for filling at central sites then dispense those orders at a later date. Both are
supervised by pharmacists at central sites, who provide counseling at medication pick up. The law also
describes services provided through "vending machine" like dispensing systems. All telepharmacy sites
require computer, video, and audio connection with a pharmacist at the central location for consultation and
verification of prescriptions.

Iowa20 Iowa codes 155A.13, 155A.33 and 147.107 describe the practice of telepharmacy within the state of Iowa.
Iowa BoP licenses remote dispensing sites, which are staffed by certified pharmacy technicians and
supervised by the pharmacist-in-charge at the managing pharmacy. Patients picking up prescriptions at the
remote site are required to consult with the remote pharmacist via a video/audio link. Remote and supervising
sites must comply with all IA dispensing laws. IA codes also have provisions for telepharmacy used within
inpatient settings.

Minnesota21 The practice of telepharmacy in Minnesota is illegal without specific variances in place. MN rule 6800.2150
requires a board certified pharmacist be physically present in a licensed MN pharmacy during all open
business hours. Rule 6800.3850 requires technicians be under direct supervision of a pharmacist. The
pharmacist must perform the final check of the prescription and provide patient counseling.
Variances have been accepted allowing for telepharmacy operation in community pharmacy settings.
Minnesota has a published guidance document to help interested parties seeking variances related to
telepharmacy gain approval.

Nebraska22,23 In 2008 legislative bill 308 was adopted giving licensed Nebraska pharmacists legal approval to participate in
the practice of telepharmacy. A definition of telepharmacy has been incorporated into the Nebraska Pharmacy
Practice Act along with a statement that licensed pharmacists have the power to practice telepharmacy. The
practice act does not describe telepharmacy site relationships in great detail. It does state that pharmacists
may perform order verification for hospital settings, required prospective DUR prior to new prescription
dispensing, and patient counseling via a telepharmacy link.

North Dakota24 North Dakota Board of Pharmacy Administrative Code (Rules/Regulations) chapter 61-02-08 covers
telepharmacy with sections pertaining to purpose, operations, exceptions, suspensions and terminations,
remote dispensing sites, consultation sites (no inventory), hospital telepharmacy, and remote dispensing
machines. ND requires computer link, video-link and audio-link active at all times for all remote locations
and emphasizes that remote sites are to be established based on community needs.

South Dakota25 Chapter 20:51:30 in the South Dakota Administrative Rules outlines requirements for operation of
telepharmacies. Both the remote site and the central site must be licensed. The owner of the central pharmacy
site is required to prove the need for a remote pharmacy and to supervise its operations once approved.

Wisconsin26 WI Phar7.095 allows for the operation of remote dispensing sites, which are not licensed pharmacies, staffed
by qualified technicians, where prescriptions are filled under the supervision of a licensed pharmacy's
pharmacist. All patients are required to talk with a pharmacist each time they pick up a prescription. The
remote site is required to comply with all WI dispensing laws.
Table 3. Summary of components of telepharmacy required for states in the upper
Midwest region as specified in their Board of Pharmacy rules and statues.
Components of Telepharmacy IL IA MNb NE ND SD WI

Requirement for computer link, audio-link x x x x x

and video-link at all times in remote site

Technician staffing at remote site x x x x x x

Pharmacy intern staffing at remote site x x

Counseling required with every Rx pick x x x x New x

up Rx
only

Provisions for Automated dispensing x x x xc

machines in statutes/laws/rules

Must prove need for telepharmacy/remote x x x x

dispensing site

Remote site requires licensure x x x x x d

Remote site allowed to operate only when xa x xa x

supervising site is open

Dispensing considered to be done at x x

supervising site

Provisions for hospital settings included x x x

in statutes/laws/rules

Regular inspections of remote site by x x x x x

supervising pharmacist required
a Remote dispensing sites may be open when the central pharmacy is closed if a pharmacist from
the central site is physically present and working in the remote location.
b Minnesota information is based on the guidance document published by the MN BoP for
obtaining a variance to MN law allowing for the operation of telepharmacies in the community
setting.
c SD rules state remotes sites may utilize automated filling machines.
d WI does not allow remote dispensing sites to be licensed as a pharmacy.