A Systematic Review of ICU and Non-ICU Clinical Pharmacy Services Using Telepharmacy

Abstract

Objective: To assess the impact of telepharmacy services in the acute care setting. Data Sources: EMBase, MEDLINE, and SCOPUS database searches were performed through April 2018. Study Selection and Data Extraction: PRISMA guidelines were applied for this systematic review. All English-language studies meeting the criteria of the following population, intervention, comparison, and outcome question were included: What impact does the provision of inpatient clinical pharmacy services delivered via telemedicine have on patient outcomes compared with standard of care? Data Synthesis: A total of 11 studies were identified for the acute care setting, including 3 for critically ill patients. All studies demonstrated a positive impact on patient outcomes, nursing satisfaction, and disease management. Varying modes of telepharmacy technology were used, such as remote access to electronic medical records, faxing or scanning documents, pictures or webcams. For communication purposes, telepharmacists used email or electronic communication, facsimile, video review, or telephone to speak directly with hospital personnel and patients. Relevance to Patient Care and Clinical Practice: Inpatient telepharmacy is feasible and should be leveraged to further enhance patient care by complementing existing service models. Conclusions: Telepharmacy services enhanced patient outcomes, improved nursing satisfaction, and expanded services within inpatient settings. Similar technologies were leveraged in non–intensive care units (ICUs) and ICUs, but the goals of telepharmacy appeared to differ. ICUs focused on an expansion of services in the ICU and non-ICUs addressed improved patient outreach in rural areas.

Keywords

critical care communication pharmaceutical care

Background

Telemedicine, defined by the American Telemedicine Association (ATA) as “the remote delivery of health care services and clinical information using telecommunications technology” can provide the opportunity for improvements in patient outcomes.¹ Health care professionals have utilized telemedicine to bridge the gap between patients and optimal health care by performing interactive physician visits remotely, providing patients the ability to view laboratory values online, and building alert systems to prompt bedside evaluations. Medication management might be enhanced with telemedicine or mobile technology to provide counseling services or to enhance medication adherence.^2,3 Pharmacists are embracing this novel health care approach to aid in providing patient-centered care for safe and effective medication use.

Telepharmacy is a subset of telemedicine and defined by the Model State Pharmacy Act and Model Rules of the National Association of Boards of Pharmacy as “the provision of pharmacist care by registered pharmacies and pharmacists located within U.S. jurisdictions through the use of telecommunications or other technologies to patients or their agents at distances that are located within U.S. jurisdictions.”^{4(p e236)} Telepharmacy has been instrumental in the outpatient setting to improve outcomes such as increased access to care in rural areas, patient satisfaction with chronic disease state management, and medication adherence.³ However, the application of telepharmacy services in the acute care setting, including both intensive care units (ICUs) and non-ICUs, is not clear because of differing patient needs, monitoring parameters, and medication use and greater risk of medication-related events.⁵ For example, TeleICUs, or “network of audiovisual communication and computer systems that provide the foundation for a collaborative, interprofessional care model focusing on critically ill patients”^{6(p 972)} are growing in number, but lack long term data.^6,7 It is, therefore, likely that the structure of inpatient telepharmacy services and pertinent outcomes also differ. Telepharmacy in the ICU poses an additional opportunity to work collaboratively within a clinical team and provide consistent pharmacy expertise to expand continuity of evidence-based patient care in line with clinical model guidelines.^6,7

Despite limited data regarding inpatient telepharmacy, stakeholders are interested in implementing these technologies. During the assessment of 58 systematic reviews concerning telemedicine services, the Agency for Healthcare Research and Quality identified mortality and quality of life benefits but emphasized the paucity of corresponding reviews within the inpatient setting and consequent lack of understanding of its impact in this environment.⁸ The American Society of Health-System Pharmacists has also recognized and made a push to strengthen telepharmacy services in its incorporation of the Practice Advancement Initiative.⁴ The purpose of this systematic review of telepharmacy services in the acute care setting is to broadly define the effect, highlight opportunities for pharmacists, and compare the different services offered in both general wards and ICUs.

Methods

Adhering to the PRISMA guidelines for a systematic review, the authors set out to identify articles that fit the population, intervention, comparison, and outcome (PICO) question as follows: What impact does the provision of inpatient clinical pharmacy services delivered via telemedicine technologies have on patient outcomes compared with standard of care? EMBase, MEDLINE (via PubMed), and SCOPUS databases were reviewed with the search terms telepharmacy or telehealth or telemedicine or telephone and either pharmacist or pharmacy.

This search includes data from the inception of databases to April 2018 and was conducted in 2 phases, as depicted in Figure 1. Titles and abstracts selected from the initial search of all studies were reviewed for appropriateness and bias using the Risk of Bias in Non-randomised Studies—of Interventions (ROBINS-I).⁹ Articles were included in this review if they were written in English, utilized telemedicine technologies (as defined by ATA), and incorporated a pharmacist in a capacity beyond the traditional roles of medication dispensing or preparation. Publications were excluded if they did not include patient interaction or care and if they did not take place in an inpatient setting (eg, occurred solely in clinics or community pharmacies and/or referenced medication therapy management). Studies were also excluded if they did not report a comparator, defined as previous standard of care and/or baseline statistics. Titles and abstracts were then reviewed, and the remaining articles were read in full. Extraction of relevant information, particularly facility setting, type of communication platform used, participants involved with the intervention, a description of the intervention, comparator group, brief summary of outcomes, and study design was done manually. Additional comments were made when necessary to provide context and clarity. Both phases of review were completed by 2 independent reviewers. Discrepancies in selection were resolved by discussion between reviewers until consensus was reached. A meta-analysis was planned a priori but was not performed because of heterogeneity of the included studies. The authors did not obtain any funding for the production of this systematic review and have no financial or nonfinancial conflicts of interest to disclose.

Figure 1.

PRISMA flow diagram describing study selection process.

Results

A total of 4423 articles were retrieved from the databases. After applying the PICO question and inclusion criteria, 11 articles were ultimately included in this review (Figure 1). Overall bias was assessed as either low (n = 1), moderate (n = 9), or serious (n = 1), but no studies fell in the range of critical. All these articles involved inpatients with 3 (27.3%) specifically including patients within an ICU. Seven studies (63.6%) included patients from institutions self-identified as rural, community, or critical access hospitals, and 1 (9.1%) took place in a long-term acute care hospital.

Telepharmacy staff received information (Tables 1 and 2)^10-20 either by remote access to the electronic medical record (n = 4), faxed or scanned documents (n = 2), picture/webcam (n = 1), or some combination (n = 4). On the other end, communication between telepharmacists and institutional personnel was conducted either by email/electronic communication or facsimile (n = 2), video/picture review (n = 1), telephone (n = 1), some combination (n = 6), not explained (n = 1). Studies were mostly prospective and observational in design (n = 8), but also included interrupted time series analyses (n = 1), prospective proof-of-concept (n = 1), and retrospective cross-sectional (n = 1) studies.

Table 1.

Articles Included in Systematic Review, ICU Setting.

Citation; Setting; and Study Design	Mode of Communication	Communicating Parties	Description of Intervention	Description of Comparator	Outcomes Summary	Additional Comments
Forni et al,¹² 2010; tertiary referral academic medical center with 5 ICUs; prospective, observational	Electronic task list, telephone and/or email	Clinical pharmacists with ICU providers at medical center	Overnight medication order review, drug information answers, pharmacotherapy and pharmacokinetic consultation, systematic medication and allergy reconciliation, education on drug therapy guidelines, and sedation protocol management for ICU patients	Preintervention vs postintervention	● ↑ In total pharmacist interventions (36/100 patient-days vs 49.4; P < 0.0001), therapeutic interventions (20.4 vs 26.1; P < 0.0001), and sedation interventions (0.9 vs 4.4; P < 0.0001) ● ↑ In number of sedation interruptions (45% vs 54%; P < 0.0001) and documentation related to sedation interruptions (43% vs 49%; P < 0.0001)	● Quality improvement initiative, nonblinded intervention ● Excluded patients who had received cardiac surgery ● Intervention defined as any recommendation made by a pharmacist that was acted on by the primary team
Keeys et al,¹⁴ 2002; 350-bed acute care facility with an ICU; pharmacy coverage 7:00 to 23:30 hours, 7 days a week; prospective, observational	Telephone, facsimile	Clinical pharmacists with hospital staff at community hospital	Nighttime on-call service available for prospective medication order review, drug information, consultations	Preintervention vs postintervention	● 1039 Orders were reviewed by telepharmacy service in the first 3 months ● 21.7% Of reviewed orders required clarification or intervention ● 29% Of reviewed orders were high risk and targeted medications ● Drug information questions ranged from 0 to 4 per day compared with, historically, less than once per day	● Implemented standardized communication tools ● A mean of 12 orders were reviewed daily by telepharmacy service ● 32.7% Of problem orders were identified by telepharmacy service but were left to be resolved by daytime pharmacists
Keeys et al,¹⁵ 2014; 350-bed acute care facility with an ICU; prospective, observational	In person, telephone, facsimile, or email	Clinical pharmacists with hospital staff at community hospital	Reconciliation of discharge medication list	Preintervention vs postintervention	● 634 Medication discrepancies were identified ● 6402 Medication discharge lists were reconciled (on average 331 per month; 8-30 per day) ● Each discharged patient’s medication list averaged 10 medications	● Pharmacist intervention was not clearly delineated between on-site pharmacists and telepharmacists ● Most common drug class associated with a discrepancy were the opiate agonists

Abbreviation: ICU, intensive care unit.

Table 2.

Articles Included in Systematic Review, non-ICU Setting.

Citation; Setting; and Study Design	Mode of Communication	Communicating Parties	Description of Intervention	Description of Comparator	Outcomes Summary	Additional Comments
Beaulac et al,¹⁰ 2016; 212-bed LTACH; interrupted time-series analysis	Email	AS team (ID physicians and ID clinical pharmacists) with providers at LTACH regarding LTACH patients	Daily antimicrobial stewardship reports were run with intervention recommendations sent by emails	Preintervention vs postintervention	● ↓ In hospital-acquired CDI rates/1000 patient-days (PDs), 0.57 [95% CI = 0.35-0.92], P = 0.02) ● ↓ In defined daily doses (DDDs)/1000 PDs concerning all antibiotics (−6.58 DDDs/1000 PDs [95% CI = −11.48 to 1.67], P = 0.01)	● Limited availability of on-site ID consult service ● AS team employed 5 d/wk ● 72-Hour intervention acceptance time potentially confounding
Cole et al,¹¹ 2012; rural hospital system 20-45 beds each; prospective, proof-of-concept demonstration	Facsimile, telephone	Clinical pharmacist with nurses and physicians at rural hospitals regarding rural hospital inpatients (including those in observation units)	Prospective medication review	Preintervention vs postintervention	● ↓ In medication error incidence (30% vs 19.2%)	● Included patients in observation units ● Rural hospitals did not use EMR ● Only compared “after hours” medication errors
Garrelts et al,¹³ 2010; health system (35-410 patients each) including 1 rural hospital; prospective, observational	Telephone, electronic communication	Pharmacists with hospital staff at health network system	Evening and overnight medication order review and prospective chart review	Preintervention vs postintervention	● ↓ In mean order processing time (26.8 vs 14 minutes; P < 0.0001) and STAT order processing time (11.6 vs 8.8 minutes; P = 0.007 ● ↑ In pharmacist-initiated clinical interventions by 42% ● ↑ In nursing global satisfaction with pharmacist availability (3 vs 4 on 5-point scale); P = 0.028	● Weekly cost avoidance with pharmacists’ salary and increased interventions estimated at $21 772 ● ↑ In pharmacists’ expressed global job satisfaction (3 vs 3.5 on 5-point scale) though not significant ● One week data collection
O’Neal et al,¹⁶ 2009; institution not specified; prospective, observational	Digital camera	IV room technician with clinical pharmacist	Implementation of inspection camera to view various steps of compounding IV admixtures	Preintervention vs postintervention	● Pharmacist intervened to adjust 4/363 (1.1%) doses per month ● Previously 310 reported errors (over an unknown time frame)	● Uncertain if adjustments would have been made with old system ● New system only adds additional 50 s per dose
Poulson et al,¹⁷ 2010; two rural hospitals; prospective, observational	Facsimile, scanning, video-conferencing, telephone	Clinical pharmacist with inpatient nurse and inpatients themselves when necessary	Remote pharmaceutical review of inpatients	Preintervention vs postintervention	● ↑ In major interventions (23% vs 43%; P = 0.03) ● ↓ In number of activities performed before successful major intervention (1 in 17 vs 1 in 9) ● ↑ In accuracy of discharge medication reconciliation (41% vs 81%; P = 0.001) ● ↓ In percentage of patients with ⩾1 medication history discrepancy (61% vs 49%)	One pharmacist performed tasks during both the preintervention and postintervention phases, potentially introducing bias
Sankaranarayanan et al,¹⁸ 2014; 8 rural access hospitals (all with 25 or fewer beds); retrospective, cross-sectional	Facsimile or telephone	Clinical pharmacist with rural hospital providers	Clinical pharmacist telemedicine services included any combination of: prospective medication order review, entry, or verification, visual inspection of medi cations prior to administration, videoconferencing, policy development, medication safety, or clinical consultations	Preintervention vs postintervention	Hospitals with both an on-site and remote pharmacist had ↑ number of interventions during study period (3% vs 36% vs 55%) compared with hospitals with a remote pharmacist alone	Telemedicine services are requested individually and may vary across sites
Schneider,¹⁹ 2013; community hospitals; prospective, observational	Not explicitly stated	Clinical pharmacist with nursing staff of community hospitals	Prospective medication review for medications available in automated dispensing cabinets and on-call response to drug information questions	Preintervention vs postintervention	● ↓ In frequency of high-risk medications obtained without pharmacist review (9.6% vs 8%; P < 0.05) ● ↓ In medication errors from high-risk medication overrides (37 vs 5; P = 0.0004) ● Approximated annual cost avoidance of $261 109 per hospital ● Nurse satisfaction scores increased from 6.6 to 7.3; P < 0.05 on a 10-point scale, with higher numbers indicating less concern about medication errors and patient safety and increased job satisfaction ● Pharmacist satisfaction scores decreased from 7.8 to 5.4; P < 0.05 on the same scale	Preintervention data relied on pharmacist recall about interventions from the previous day High-risk medications were selected from the Institute for Safe Medication Practices list
Stratton et al,²⁰ 2008; critical access hospitals; prospective, observational	Facsimile, hospital’s electronic information system	Clinical pharmacist with nurse as small critical access hospitals	Technician electronic order entry with pharmacist review of drug interactions, checking, medication dispensing via automated dispensing cabinets, and formulary and inventory management Pharmacist on call drug information questions and dosage recommendations based on pharmacokinetics, and visual verification of home medications	Preintervention vs postintervention	↑ In nurse satisfaction within a variety of domains, including interactions with remote pharmacists (4.44 vs 6.3 on a 10-point scale, with higher numbers indicative of greater satisfaction; P = 0.003), quality of patient care provided by both on-site (6.37 vs 8.68; P < 0.001) and remote pharmacists (3.94 vs 6.17; P < 0.001), and overall satisfaction with pharmacy services (7.04 vs 8.06; P = 0.024)	Pharmacist coverage was not available from 4:00 am to 7:00 am 56 Surveys were received before implementation, and 51 were received after implementation; a total of 385 were distributed Nursing satisfaction was also enhanced on several metrics relating to on-site pharmacists as well

Abbreviations: AS, antimicrobial stewardship; CDI, Clostridium difficile infection; EMR, electronic medical record; ICU, intensive care unit; ID, infectious diseases; IV, intravenous; LTACH, long-term acute care hospital.

Table 1 provides detailed information included in the 3 articles containing patients within the ICU. Two of these studies identified direct benefits to inpatient care during their stay.^12,14 One study¹² demonstrated that during these times, the number of pharmacist interventions (broadly defined as any recommendation made by a pharmacist that was acted upon), therapeutic interventions (defined as any intervention relating to medication management), and sedation interruptions were all increased. Another study of nighttime telepharmacy services¹⁴ pointed out that more than 20% of orders reviewed required clarification or pharmacist intervention, and nearly 30% of all orders were classified as either high risk or targeted medications.

Table 2 provides detailed information included in the remaining 8 articles involving general ward patients. One study, through the introduction of remote antimicrobial stewardship, decreased hospital-acquired Clostridium difficile infections and defined daily doses of antimicrobials.¹⁰ Other studies used remote order verification that decreased medication error incidence,^11,16,19 mean order processing time,¹³ and medication cost.¹⁹ These same remote services also demonstrated an increased pharmacy-based clinical intervention rate,^13-18 medication history and discharge completion and accuracy,¹⁷ and cost avoidance between $21 772 weekly¹³ and $261 109 annually.¹⁹ Nursing satisfaction with telepharmacy was enhanced,^13,19,20 but pharmacist satisfaction was mixed.^13,19 One study suggested that telepharmacists benefited hospitals with current pharmacists on staff by providing care that was even more patient centered.¹⁸

Discussion

The applicable studies that have effectively used a comparator to assess patient-centered outcomes have demonstrated a positive impact of telepharmacy for a variety of outcomes in a diverse collection of inpatient settings. Notably, telepharmacists in the ICU setting were able to expand on existing services. For example, remote telepharmacists expanded pharmacist coverage throughout the overnight hours. Critically ill patients require intensive care around the clock. Pharmacists aid with this care, most commonly during first and second shifts, but it stands to reason that they can also do so during the overnight hours when patients remain critically ill. Pharmacist care can also be operationalized, as performing interventions and assisting with protocol review. In the non-ICU setting, telepharmacists were able to improve patient outreach, particularly to remote areas. In understaffed or underserved areas, off-site pharmacists implemented services previously not provided to these institutions. Examples include antimicrobial stewardship, prospective medication review, and discharge medication reconciliation. These services were also completed during off hours where on-site pharmacists may not be physically present. Overall, the use of telepharmacy services may be further explored following the Health Information Technology for Economic and Clinical Health (HITECH) Act as well as expansion of electronic health records and growing interoperability.

From a nursing perspective, remote access to pharmacists and the use of telepharmacy demonstrated self-reported improvements in job satisfaction.^13,14,19,20 The authors of these studies commented that nurses felt more comfortable when traditional pharmacist tasks they were asked to perform were designated to the telepharmacist instead. Pharmacists had some mixed reviews on their job satisfaction for unclear reasons but were mostly in favor of the additional service.^14,19,20

Benefits from the use of telepharmacy were maintained at institutions that already employed on-site clinical pharmacists. One study specifically demonstrated a net benefit of interventions at hospitals that employed both on-site and remote pharmacists.¹⁸ With this structure, off-site pharmacists are able to free up on-site pharmacists to complete other tasks, such as providing enhanced patient care, serving on hospital committees, and educating future students and practitioners. This example suggests that telepharmacy can benefit hospitals with varying pharmacy staff resources.

Justifying the cost of an added on-site pharmacist is a major barrier that can be exacerbated in remote areas struggling to retain or obtain the services of full-time pharmacists.¹¹ This review identified both indirect and direct cost savings gained through the use of telepharmacy (Tables 1 and 2), which may make pharmacist utilization slightly more feasible. Another barrier cited to the implementation of telepharmacy is that of purchasing and implementing the necessary technology.¹³ These factors were not apparent because the studies reviewed predominantly relied on remote access to the local institution’s electronic health record, and communication was primarily driven by fax, email, or telephone. Demonstrated cost savings to an institution provide the fiscal backing for the implementation of telepharmacy. One final concern that is beyond the scope of this article is the potential for malpractice and violation of pharmacy law. More specifically an added risk, such as communication errors, is introduced into an already hectic work environment. There is little precedent relating to such possible malpractice claims.²¹

Use of the ROBINS-I tool demonstrated varying degrees of potential bias among the studies, as depicted in Table 3. This tool, specifically designed for nonrandomized studies follows a structured assessment of 7 key domains to determine if there is the potential for bias at either the preintervention, at intervention, or postintervention phase. It is likely, though not confirmed, that any bias would favor a positive result and demonstrate a stronger benefit of telepharmacy. Taking into account that this bias assessment was subjective, it should not take away from the overall conclusions.

Table 3.

Bias Assessment of Articles Included in Systematic Review.^a

Trial	Preintervention	At intervention	Postintervention	Overall
Beaulac et al¹⁰	Moderate	Low	Moderate	Moderate
Cole et al¹¹	Serious	Moderate	Serious	Serious
Forni et al¹²	Moderate	Moderate	Moderate	Moderate
Garrelts et al¹³	Serious	Low	Moderate	Moderate
Keeys et al, 2002¹⁴	Serious	Low	Moderate/No information	Moderate
Keeys et al, 2014¹⁵	Serious	Low	Moderate/No information	Moderate
O’Neal et al¹⁶	Moderate	Low	Moderate	Moderate
Poulson et al¹⁷	Moderate	Low	Low	Low
Sankaranarayanan et al¹⁸	Moderate	Low	Moderate	Moderate
Schneider¹⁹	Moderate	Moderate	Moderate	Moderate
Stratton et al²⁰	Moderate	Moderate	Serious/No information	Moderate

Each domain rated on a scale as having either low, moderate, serious, critical, or no information. Preintervention bias refers to bias caused by confounding or during selection of participants into the study. At intervention bias refers to bias in classification of interventions. Postintervention bias refers to bias caused by deviations from intended interventions, missing data, or measurement of outcomes or in selection of the reported result.

There were several limitations to the studies reviewed. Primarily, the majority of these studies were retrospective and small in nature making broad-scale conclusions potentially difficult to ascertain. The heterogeneity of these studies and telepharmacy operations may have also compounded the comparison difficulty and potential impact of inpatient telepharmacy. On the other hand, there is a risk of publication bias because these studies had predominantly positive results. Assessment methods included nonspecific outcomes such as “interventions” or “discrepancies” that may not necessarily share the same definition across studies or institutions.

Additionally, there are possible limitations associated with the search terms used to capture trials for inclusion in this review. Terms such as remote pharmacy or remote dispensing were used in some studies but were not identified a priori in our search. A large number of studies were excluded because they failed to meet the designed PICO question. It is possible that the implementation of novel and innovative telepharmacy services are derived out of necessity to bridge a gap and consequently lack any baseline comparison. Finally, the technical definition of telepharmacy is reserved for pharmacists or services with US jurisdiction. Several of these studies took place outside of this jurisdiction, but for the sake of comparison, the authors felt comfortable broadly applying this definition to those studies as well.

A core function of a pharmacist is to enhance patient safety through prospective medication review. At minimum, increasing pharmacist access whether on-site or remotely, increases the accessibility of this safety feature and adds a greater deal of order scrutiny. However, there is much more potential in this field. At the current state, few institutions take advantage of telepharmacy despite clinical, operational, safety, emotional, and financial benefits. In most cases, only relatively basic technology has been implemented. Further research should examine other ways in which these pharmacists and additional technology can aid the health care system. With a landscape shifting toward patient-reported outcomes as a quality measure clouded by an unclear financial future, telepharmacists are in a unique position to bridge this gap. Stakeholders are interested in this technology and may provide the support necessary to move forward. Once established, telepharmacy services presence can be leveraged with current clinical pharmacist duties to expand care into different areas and further improve patient outcomes.

Relevance to Patient Care and Clinical Practice

The available studies illustrate that telepharmacy services in all settings (ICU vs non-ICU) improved specific patient outcomes, led to greater nursing satisfaction, and expanded the provision of services. With increasing financial pressures on the health care system, inpatient telepharmacy is a useful tool to enhance current pharmacist services.

Conclusion

Technology and communication methods were similar in both ICU and non-ICU settings and assisted with the expansion of services in the former and improved patient outreach, particularly to remote areas in the latter. It is important to understand the clinical and financial benefits of inpatient telepharmacy services and how telepharmacy and in-person pharmacist services can complement each other. This review serves as a call to further examine in a rigorous manner the impact telepharmacy services may have on inpatient settings, including ICU and non-ICU populations.

Footnotes

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Bethany R. Shoulders

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