The North Dakota The North Dakota Telepharmacy ProjectTelepharmacy Project

Restoring and Retaining Pharmacy Services Restoring and Retaining Pharmacy Services in Rural Communitiesin Rural Communities

Charles D. Peterson, Pharm.D.Charles D. Peterson, Pharm.D.

Dean and ProfessorDean and Professor

College of PharmacyCollege of Pharmacy

North Dakota State UniversityNorth Dakota State University

Fargo, North DakotaFargo, North DakotaFunded by the Office for the Advancement of Telehealth, Funded by the Office for the Advancement of Telehealth,

HRSA, of Health and Human ServicesHRSA, of Health and Human Services

North Dakota North Dakota DemographicsDemographics2000 Census Highlights2000 Census Highlights 642,200 population, ranks 47642,200 population, ranks 47thth in nation in nation population growth 0.5% (1990-2000)population growth 0.5% (1990-2000) population shift from rural to urbanpopulation shift from rural to urban only 6 of 53 counties gained populationonly 6 of 53 counties gained population 50% of ND counties lost at least 10%50% of ND counties lost at least 10% 36 of 53 counties classified as frontier36 of 53 counties classified as frontier 14.7% over 65, vs 12.4% nationally14.7% over 65, vs 12.4% nationally

Access to Pharmacy Access to Pharmacy Services in North DakotaServices in North Dakota

Of the 373 cities, 73 have pharmaciesOf the 373 cities, 73 have pharmacies Of the 53 counties, 9 do not have a Of the 53 counties, 9 do not have a

pharmacy and 11 have only one Rxpharmacy and 11 have only one Rx North Dakota 51% ownership lawNorth Dakota 51% ownership law

ND Rural Health Care Crisis:ND Rural Health Care Crisis:Community Pharmacy ClosingsCommunity Pharmacy Closings

26 rural community pharmacy closings26 rural community pharmacy closings 12 additional pharmacies at risk of closing12 additional pharmacies at risk of closing pharmacist retirements - no replacementpharmacist retirements - no replacement national pharmacist shortagenational pharmacist shortage negative impact on rural healthnegative impact on rural health

Exploring Solutions:Exploring Solutions:Telepharmacy RulesTelepharmacy Rules

required changes in pharmacy practice act required changes in pharmacy practice act telepharmacy rules established by NDBDPhtelepharmacy rules established by NDBDPh pilot project in 2001 pilot project in 2001 permanent rules permanent rules

established in June 2003established in June 2003 allow pharmacists to supervise a technician at allow pharmacists to supervise a technician at

remote site remote site dispense prescriptionsdispense prescriptions pharmacist - patient consultationpharmacist - patient consultation

Boards of PharmacyBoards of PharmacyTelepharmacy Telepharmacy RegulationsRegulations

““Approximately 25 states currently either Approximately 25 states currently either have telepharmacy regulations or are have telepharmacy regulations or are very close to adopting regulations. There very close to adopting regulations. There is a good chance by the end of the year, is a good chance by the end of the year, there could be 30 pharmacy boards with there could be 30 pharmacy boards with regulations in place.”regulations in place.”

Carl Geberbauer, V.P.Carl Geberbauer, V.P.

AutoMed Technologies, AutoMed Technologies, IncInc

Telepharmacy Grant Awarded Telepharmacy Grant Awarded

NDSU College of PharmacyNDSU College of Pharmacy

Congressionally mandated federal grant via the Congressionally mandated federal grant via the support of Senator Byron Dorgansupport of Senator Byron Dorgan

Office for Advancement of TeleHealth, Health Office for Advancement of TeleHealth, Health Resources and Services Administration of HHSResources and Services Administration of HHS

First Initiated: September 1, 2002 First Initiated: September 1, 2002

Approximately $2.5 million federal support to dateApproximately $2.5 million federal support to date

Goals of Telepharmacy Goals of Telepharmacy Grant:Grant:

RESTORATIONRESTORATION - - restore pharmacy services in restore pharmacy services in rural communities which have lost their servicesrural communities which have lost their services

RETENTION RETENTION - - retain pharmacy services in rural retain pharmacy services in rural communities which are at risk of losing their servicescommunities which are at risk of losing their services

ESTABLISH – ESTABLISH – establish pharmacy services in rural establish pharmacy services in rural communities which have previously not had servicescommunities which have previously not had services

North Dakota Telepharmacy ProjectNorth Dakota Telepharmacy Project::A Historical Look A Historical Look YearYear Sept 2002- Sept 2002-

Aug. 2003Aug. 2003Sept 2003- Sept 2003-

Aug. 2004Aug. 2004

Sept 2004- Sept 2004-

Aug. 2005Aug. 2005

Sept 2005- Sept 2005-

Aug. 2006Aug. 2006

Total Central Total Central SitesSites

44 77 1111 2121

Total Remote Total Remote SitesSites

66 1111 1717 3636

Total SitesTotal Sites 1010 1818 2828 5757Retail SitesRetail Sites 1010 1818 2525 4444Hospital SitesHospital Sites 00 00 33 1313Interstate Interstate 00 00 11 22

Telepharmacy Telepharmacy Project PartnersProject Partners

NDSU College of PharmacyNDSU College of Pharmacy North Dakota State Board of PharmacyNorth Dakota State Board of Pharmacy ND State Pharmaceutical AssociationND State Pharmaceutical Association Licensed rural community pharmaciesLicensed rural community pharmacies Targeted rural communities Targeted rural communities

Telepharmacy Telepharmacy Grant BudgetGrant Budget

Assist in the telepharmacy start-up costsAssist in the telepharmacy start-up costs 50% OAT Grant/50% North Dakota50% OAT Grant/50% North Dakota Technology: Hardware, Software, ConnectivityTechnology: Hardware, Software, Connectivity Registered Pharmacy TechnicianRegistered Pharmacy Technician Pharmacy FixturesPharmacy Fixtures Drug InventoryDrug Inventory Travel Travel

Pharmacy Technician Pharmacy Technician Responsibilities: Responsibilities:

Remote Telepharmacy SiteRemote Telepharmacy Site

Maintains drug inventory at remote siteMaintains drug inventory at remote site Processes all prescriptions orders including Processes all prescriptions orders including

controlled substancescontrolled substances Computer order entry, filling, billing, labelingComputer order entry, filling, billing, labeling Takes original prescription orders by phoneTakes original prescription orders by phone Prepares prescription for dispensing by Prepares prescription for dispensing by

pharmacistpharmacist Connects patient to the pharmacist for private Connects patient to the pharmacist for private

consultation via audio and video linkconsultation via audio and video link

Pharmacy Technician Pharmacy Technician Training Requirements: Training Requirements:

Telepharmacy SitesTelepharmacy Sites

Registered with Board of PharmacyRegistered with Board of Pharmacy ASHP accredited program or equivalent ASHP accredited program or equivalent Minimum of one year experience in Minimum of one year experience in

dispensing prescriptionsdispensing prescriptions Salaries are $15/hour or moreSalaries are $15/hour or more Reciprocity from other states requires Reciprocity from other states requires

PTCB certificationPTCB certification

Pharmacist Pharmacist ResponsibilitiesResponsibilities

Final check of technician Rx preparationFinal check of technician Rx preparation Dispenses drug to the patientDispenses drug to the patient Drug utilization reviewDrug utilization review Patient education counselingPatient education counseling Remote site visitsRemote site visits

Demographics:Demographics:Remote Telepharmacy SitesRemote Telepharmacy Sites

SiteSite BeachBeach RoletteRolette New EnglandNew England MaddockMaddock GwinnerGwinner

PopulationPopulation 1,1161,116 538538 555555 498498 717717

Distance -Distance -Central RxCentral Rx

95 miles95 miles 240 miles240 miles 60 miles60 miles 196 miles196 miles 10 miles10 miles

Date Date OperationalOperational

Sept. 18, Sept. 18, 20022002

Nov. 2, Nov. 2, 20022002

Nov. 26, Nov. 26, 20022002

May 21, May 21, 20032003

June 18, June 18, 20032003

Size of Size of PharmacyPharmacy

1,400 1,400

sq. ft.sq. ft.

2,000 2,000

sq. ft.sq. ft.

1,200 1,200

sq. ft.sq. ft.

2,500 2,500

sq. ft.sq. ft.

575 575

sq. ft.sq. ft.

Full Full Service Service PharmacyPharmacy

yesyes yesyes yesyes yesyes nono

Demographics:Demographics:Remote Telepharmacy SitesRemote Telepharmacy Sites

SiteSite New TownNew Town MohallMohall New SalemNew Salem Karlstad, MnKarlstad, Mn LidgerwoodLidgerwood

PopulationPopulation 1,3671,367 812812 938938 794794 738738

Distance -Distance -Central RxCentral Rx

49 miles49 miles 316 miles316 miles 34 miles34 miles 155 miles155 miles 13 miles13 miles

Date Date OperationalOperational

November November 20032003

Jan. 26, Jan. 26, 20042004

March 1,March 1,

20042004

Nov. 2, Nov. 2,

20042004

Dec. 6,Dec. 6,

20042004

Size of Size of PharmacyPharmacy

1,5001,500

sq. ft.sq. ft.

1,397 1,397

sq. ft.sq. ft.

800800

sq. ft.sq. ft.

408408

sq. ft.sq. ft.

1,9251,925

sq. ft.sq. ft.

Full Full Service Service PharmacyPharmacy

yesyes yesyes yesyes yesyes nono

Demographics:Demographics:Remote Telepharmacy SitesRemote Telepharmacy Sites

SiteSite BeachBeach RoletteRolette New New EnglandEngland

MaddockMaddock GwinnerGwinner

Rx ‘s Rx ‘s dispensed dispensed per day (45)per day (45)

35-4035-40 10-1510-15 25-3025-30 50-5550-55 13-1513-15

Hours of Hours of serviceservice

8:30 – 5:00 8:30 – 5:00 pm, M-Fpm, M-F

9:00 – 5:00 9:00 – 5:00 pm, M-Fpm, M-F

8:30 – 5:00 8:30 – 5:00 pm, M-Fpm, M-F

9:00-5:30 9:00-5:30 pm, M-Fpm, M-F

9:00 – 5:00 9:00 – 5:00 pm, M-Fpm, M-F

# People # People employedemployed

1.5 FTE’s 1.5 FTE’s tech/clerktech/clerk

3 FTE’s with 3 FTE’s with 3 people3 people

2 FTE’s with 2 FTE’s with 3 people3 people

3 FTE’s with3 FTE’s with

4 people4 people

1.5 FTE’s 1.5 FTE’s tech/clerktech/clerk

Medical Medical CoverageCoverage

Clinic 5d/wk Clinic 5d/wk PAPA

Clinic 3-Clinic 3-4d /wk 4d /wk PA/MDPA/MD

Clinic 5d/wk Clinic 5d/wk MDMD

Clinic 5d Clinic 5d /wk PA/MD/wk PA/MD

Clinic 5d/ Clinic 5d/ wk PA/MDwk PA/MD

Demographics:Demographics:Remote Telepharmacy SitesRemote Telepharmacy Sites

SiteSite New TownNew Town MohallMohall New SalemNew Salem Karlstad, MnKarlstad, Mn LidgerwoodLidgerwood

Rx ‘s Rx ‘s dispensed dispensed per day (45)per day (45)

8080 6262 5050 9494 3030

Hours of Hours of serviceservice

9:00 – 5:30 9:00 – 5:30 pm, M-Fpm, M-F

9:00 – 5:30 9:00 – 5:30 pm, M-Fpm, M-F

9:30 – 5:30 9:30 – 5:30 pm, M; & pm, M; & 9:30 – 5:00 9:30 – 5:00 pm, T-Fpm, T-F

9:00-5:00 pm, 9:00-5:00 pm, M-FM-F

9:00 – 5:30 9:00 – 5:30 pm, M-Fpm, M-F

# People # People employedemployed

2 FTE’s with2 FTE’s with

2 people,2 people,

1 R.Ph. & 1 R.Ph. &

1 tech.1 tech.

1 FTE with 1 FTE with one personone person

1 tech1 tech

2.5 FTE’s 2.5 FTE’s with 3 peoplewith 3 people

1 clerk,1 tech 1 clerk,1 tech

& 1 R.Ph.& 1 R.Ph.

2.75 FTE’s with 2.75 FTE’s with 3 people3 people

2 techs, & 2 techs, &

1 clerk1 clerk

2 FTE’s with 2 FTE’s with 4 people, 4 people,

1 tech, 1 tech,

3 clerks3 clerks

Medical Medical CoverageCoverage

3 Clinics 3 Clinics 5d/wk, 5d/wk, 5MD’s/4NPs5MD’s/4NPs

Clinic Clinic

5d /wk 5d /wk MD/PAMD/PA

Clinic 5d/wk Clinic 5d/wk PAPA

Clinic 5d /wk Clinic 5d /wk 2MD’s/2PA’s2MD’s/2PA’s

Clinic 5d/wk Clinic 5d/wk 1MD/ 1PA1MD/ 1PA

Telepharmacy Telepharmacy TechnologyTechnology

Standard PC’s with Pharmacy SoftwareStandard PC’s with Pharmacy Software Polycom – VSX 7000Polycom – VSX 7000 Sonic Wall TZ170 or Tele 3, Cisco FirewallSonic Wall TZ170 or Tele 3, Cisco Firewall AVerMedia - AVerVision 110 Document AVerMedia - AVerVision 110 Document

CameraCamera DSL over the Internet or dedicated T-1 lineDSL over the Internet or dedicated T-1 line Rx Software and audio video link run in Rx Software and audio video link run in

parallelparallel

Benefits to North Dakota Benefits to North Dakota from Telepharmacyfrom Telepharmacy

Improved access to health care for rural citizensImproved access to health care for rural citizens Rural economic developmentRural economic development Improved quality of care/pharmacist consultsImproved quality of care/pharmacist consults Increased patient & pharmacist satisfactionIncreased patient & pharmacist satisfaction Increase financial viability of rural pharmaciesIncrease financial viability of rural pharmacies Provide relief for pharmacists for vacations, etc.Provide relief for pharmacists for vacations, etc. Increased educational opportunities for studentsIncreased educational opportunities for students Increased retention of pharmacy graduatesIncreased retention of pharmacy graduates

Economic Impact of Economic Impact of TelepharmacyTelepharmacy

Has added a $500,000 per year business to Has added a $500,000 per year business to the rural communitythe rural community

Thus far, has added an estimated total of Thus far, has added an estimated total of $12.0 million annually to the North Dakota $12.0 million annually to the North Dakota rural economyrural economy

Has added an estimated 40-50 new jobs to Has added an estimated 40-50 new jobs to the North Dakota rural marketplacethe North Dakota rural marketplace

Has added 50% increase in prescription sales Has added 50% increase in prescription sales to combined pharmacy operationto combined pharmacy operation

Add’l Economic Add’l Economic Development Development Benefits of TelepharmacyBenefits of Telepharmacy

Helps build the local community & Helps build the local community & economy economy

Helps attract other businesses and Helps attract other businesses and families to community because basic families to community because basic health care infrastructure is presenthealth care infrastructure is present

Pharmacy can be used for other Pharmacy can be used for other business retailing not currently available business retailing not currently available within the communitywithin the community

Student InvolvementStudent Involvement

Incorporate telepharmacy technology in Incorporate telepharmacy technology in NDSU’s new Concept Pharmacy LabNDSU’s new Concept Pharmacy Lab

Trains students on the latest advances in Trains students on the latest advances in pharmacy technology pharmacy technology

Teaches students how to deliver pharmacy Teaches students how to deliver pharmacy services in a unique and innovative way to services in a unique and innovative way to smaller rural communities smaller rural communities

Helps attract graduates to rural practicesHelps attract graduates to rural practices

Student ActivitiesStudent Activities

Provide pharmacists at the Central Provide pharmacists at the Central Pharmacy with drug information and Pharmacy with drug information and disease state management assistancedisease state management assistance

Provide patient education counseling to Provide patient education counseling to remote telepharmacy sitesremote telepharmacy sites

                                                                                                                               

Future Goals of the Future Goals of the ND Telepharmacy ProjectND Telepharmacy Project

50 telepharmacy sites in five years50 telepharmacy sites in five years develop a model for serving rural hospitalsdevelop a model for serving rural hospitals assist other states in implementing assist other states in implementing

telepharmacy services in rural areas telepharmacy services in rural areas establish a state-wide data & video networkestablish a state-wide data & video network establish equipment standardsestablish equipment standards conduct a formal medication error studyconduct a formal medication error study

Telemedicine Technical Assistance Document: Telemedicine Technical Assistance Document: A Guide to Getting Started in TelemedicineA Guide to Getting Started in Telemedicine

Includes 14 Telemedicine Areas Includes 14 Telemedicine Areas

http://muhealth.org/~telehealth/geninfo/TAD.htmhttp://muhealth.org/~telehealth/geninfo/TAD.htmll

35 page chapter providing guidelines for how 35 page chapter providing guidelines for how

to implement telepharmacy servicesto implement telepharmacy services

http://telepharmacy.ndsu.nodak.edu/

For more information visit our website at: