Pharmacy Telehealth Services — Efficient and Safe Quality Care Before and During the COVID-19 Pandemic

Michelle K. Azar, Doctor of Pharmacy Candidate 2021
University of Michigan College of Pharmacy
Ann Arbor, MI

Introduction
Telehealth is the use of electronic information and telecommunication technologies to provide long-distance health care and education to patients.¹ The use of technology within the healthcare system has become a fundamental part of providing safe and effective patient care.² Telehealth services increase access to healthcare, enhance coordination of care, decrease the burden of travel, reduce the overall cost of care, and bring specialized individuals into areas that initially lack access to them.³

The use of telehealth services has become even more critical with the COVID-19 pandemic and the need to provide quality care that keeps both providers and patients safe. Within a short period of time, many pharma-cy services have transitioned to telemedicine in order to meet patient care needs while maintaining a safe environment. While outcomes of many remote pharmacy services are not published, several publications demonstrate the effective implementation of telehealth services to provide exceptional patient care.

Pharmacy Services within Primary Care
Approximately 33% of military veterans live in rural areas that lack access to specialty care providers. Employing telehealth technology to provide pharmacy services can increase access and improve outcomes for this patient population. The Northwest Regional Virtual Integrated Multisite Patient Aligned Care Team (V-IMPACT) Hub stationed in Boise, Idaho, is a multicenter program that reaches remote locations across the United States.³

A study of the remote clinical pharmacy services in this program included 544 unique patients and 3,400 visits where encounters were conducted via clinical video telehealth (CVT) or telephone from October 2014 to March 2017. In the diabetes group, 242 patients were seen by a pharmacist, and the mean absolute reduction from baseline in HbA1c values was 1.61%. Fifty-five percent (132/242) of patients were discharged at goal. At discharge, 59 patients (42%) had achieved tobacco cessation, and 55 (39%) had achieved a reduction in tobacco use but not complete cessation. These results suggest that pharmacists providing primary care comprehensive medication management services via telehealth improved disease management and was an effective tool for providing patient care.

Pharmacy Services within Anticoagulation Clinics
Clinical pharmacists at a VA medical center implemented telehealth services to provide anticoagulation therapy management services to patients off-site.⁴ The clinical pharmacy specialist provided direct patient care, guided the telehealth technician in performing physical assessments when necessary, conducted interviews, evaluated the patient’s warfarin therapy, and formulated a therapeutic plan.

The impact of the use of video technology on patients’ INR values and patient satisfaction was evaluated; the mean percentage of time patients’ INR values were within the therapeutic range and remained stable (about 81%, compared with about 77% under the previous in-person model). Implementation of remote anticoagulation monitoring services enabled pharmacist resources to be reallocated to other duties and expanded access to healthcare in rural areas while maintaining positive patient outcomes and satisfaction.

Remote Pharmacy Services during the COVID-19 Pandemic
Healthcare systems were pressed to develop innovative ways to provide high-quality patient care that were both safe and effective within a short period of time as the COVID-19 pandemic unfolded. The University of Washington (UW) Medicine was one example of a medical center that altered their delivery of clinical services.

In early March, the Centers for Medicare and Medicaid modified its regulations to expand pharmacists’ ability to provide telehealth services. UW credentialed and trained pharmacists to provide comprehensive medication management via telehealth to patients in primary care and specialty clinics. From March 31 through April 28, 2020, clinical pharmacist telehealth services including anticoagulation, pain management, primary care, oncology, and other specialty areas were offered to 139 patients of which 83% (n = 116) completed these visits.⁵ These visits offered significant advantages during the pandemic, including flexibility in scheduling appointments, decreased burden of traveling, personalized communication, increased caregiver participation, the ability to visually review the patient’s medications or injection technique remotely, and avoidance of office space limitations for in-clinic visits. While outcomes and metrics are needed to evaluate the impact of this transition on patient care, telehealth services created an avenue for meeting patient needs.

Oncology Practice during the COVID-19 Pandemic
According to Al-Shamsi et al., patients with cancer have an estimated two-fold increased risk of contracting COVID-19 than the general population.⁶ One method to decrease risk is to use telemedicine to minimize face-to-face visits which can help mitigate exposure and further transmission. Examples of successful telemedicine in oncology include remote chemotherapy supervision and education, symptom management, survivorship care, palliative care, and clinical trials.

The University of Rochester Specialized Oncology Care and Re-search in the Elderly (UR SOCARE) clinic, an interdisciplinary care team that receives referrals from oncologists, was able to switch to telehealth services during the pandemic.⁷ As part of the care team, a pharmacist meets with a patient via telephone for medication re-view and to identify potential interventions. This system provided elderly patients with a safe alternative for oncology care without putting them at risk for exposure to COVID-19.

A team at Memorial Sloan Kettering Cancer Center (MSK) created a program to detect patients who tested positive for the virus and a protocol for providing at-home care.⁸ Each day patients completed a 10-question electronic or telephone survey to report any COVID-19 symptoms. Based on severity of symptoms, an automated alert was sent to the care team, which would determine follow-up.

Between March 26 and June 17, 2020, the team enrolled 763 patients who filled out 10,044 questionnaires. Of the 239 patients who completed the satisfaction survey, 92% felt the time and effort to report symptoms was worth it, 93% of those with a pulse oximeter agreed that it made them feel more comfortable being at home, 90% felt connected and safe with the COVID-19 management team, and 62% felt that taking part in the program helped prevent visits to the emergency room or urgent care center. This program allowed successful monitoring of cancer patients diagnosed with COVID-19 while keeping healthcare providers and other patients safe from potential infection.

Conclusion
Telemedicine services have expanded rapidly in recent years, with the COVID-19 pandemic drastically accelerating this process. Several studies have demonstrated the benefit of utilizing telemedicine for providing safe and effective patient care in various settings, however, further studies are needed to demonstrate the wide-ranging benefit to patients with cancer. In addition, more studies are needed to measure specific outcomes and metrics for programs implemented. Oncology pharmacists are in a prime position to continue to cultivate and utilize telehealth services to provide high-quality patient care while demonstrating outcomes.

1. Badowski ME, Walker S, Bacchus S, et al. Providing Comprehensive Medication Management in Telehealth. Pharmacotherapy. 2018;38(2):e7-e16. doi:10.1002/phar.2071
2. Wechkunanukul K, Parajuli DR, Hamiduzzaman M. Utilising digital health to improve medication-related quality of care for hypertensive patients: An integrative literature review. World J Clin Cases. 2020;8(11):2266-2279. doi:10.12998/wjcc.v8.i11.2266
3. Litke J, Spoutz L, Ahlstrom D, et al. Impact of the clinical pharmacy specialist in telehealth primary care. Am J Health Syst Pharm. 2018;75(13):982-986. doi:10.2146/ajhp170633
4. Singh LG, Accursi M, Korch Black K. Implementation and outcomes of a pharmacist-managed clinical video telehealth anticoagulation clinic. Am J Health Syst Pharm. 2015;72(1):70-73. doi:10.2146/ajhp130750
5. Segal E, Alwan E, Pitney C, et al. Establishing clinical pharmacist telehealth services during the COVID-19 pandemic, Am J Health Syst Pharm. 2020; 77(17): 1403–08. doi.org/10.1093/ajhp/zxaa184
6. Al-Shamsi HO, Alhazzani W, Alhuraiji A, et al. A practical approach to the management of cancer patients during the novel coronavirus disease 2019 (COVID-19) pandemic: an international collaborative group. Oncologist. 2020;25(6):e936-e945. doi:10.1634/theoncologist.2020-0213
7. DiGiovanni G, Mousaw K, Lloyd T, et al. Development of a telehealth geriatric assessment model in response to the COVID-19 pandemic. J Geriatr Oncol. 2020;11(5):761-763. doi:10.1016/j.jgo.2020.04.007
8. Majeed J, Garcia J, Holland J, et al. When a cancer patient tests positive for Covid-19.” Harvard Business Review, July 16, 2020. hbr.org/2020/07/when-a-cancer-patient-tests-positive-for-covid-19. Accessed September 20, 2020.