Abstract
Telepharmacy services were developed and adopted to compensate for the absence of a pharmacist in rural Cancer Centers. Preparation included the formation of an advisory committee, development of a training and certification process, establishing new policies and operating procedures, collecting utilization data and a survey of patient and user satisfaction. Pharmacy technicians at two remote community cancer centers were connected by telehealth with pharmacists at one of the two coordinating centers to oversee the compounding of intravenous (I.V.) chemotherapy and provide clinical review of physician orders. In 8 months of telepharmacy use, 247 intravenous preparations were compounded for 47 cancer patients during 109 treatment visits. Approximately 45,000 km (27,000 miles) of patient travel were averted. Pharmacy staff estimates requires an average of 10 additional minutes to process and compound each chemotherapy preparation. Nurses estimate an average of 27.5 additional minutes required to coordinate information for each patient order.
Keywords
Introduction
The shortage of trained health care professionals is recognized worldwide and is especially acute in developing countries and remote locales as identified by the World Health Organization and the United Nations. 1 This often impedes appropriate treatment and care for patients. Increasingly, technology is regarded as a means of overcoming this obstacle to patient care. In 1997 the US National Association of Boards of Pharmacy defined telepharmacy as ‘the provision of pharmaceutical care through the use of telecommunications and information technologies to patients at a distance.’2,3 One example of a telepharmacy application is the supervision of pharmacy technicians performing compounding and dispensing activities in remote centers by pharmacists at coordinating centers.4,5
The provincial Community Cancer Network includes Tertiary and Associate Cancer Centers (TCC and ACC) in larger cities but also includes 11 Community Cancer Centers (CCC) affiliated with smaller rural hospitals (Figure 1). After initial consult at a TCC or ACC chemotherapy treatment orders and medication for rural patients are sent to the CCC closest to the patient’s home. Many CCCs face health care staffing challenges including recruitment, retention, and coverage during vacation and illness. As a safety precaution, Network policy dictates that a pharmacist must verify, in real time, the volume and identity of solutions used by the compounding technician. When a pharmacist is not available the patient treatment may be delayed or require returning to the TCC or ACC. Rarely another health care professional such as a nurse or physician may oversee chemotherapy preparation but this is seen in the Network as undesirable. The importance of real-time verification was identified in an article by O’Neil, Worden and Couldry.
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Treatment delays and unnecessary patient travel raise concerns about therapeutic and personal outcomes.
Alberta Community Cancer Network Sites.
Purpose
To establish and evaluate a telepharmacy program for remote Community Cancer Centres preparing I.V. chemotherapy when a pharmacist is not on site.
Methods and materials
A survey of the community cancer network was conducted to determine which Health Care Regions and CCC sites had a need for telepharmacy services and would like to participate in this initiative. An advisory committee was established consisting of the lead pharmacist, the telepharmacy coordinator, and representatives from pharmacy, telehealth and facility managers in the participating health regions. Interested remote sites without a pharmacist were paired with pharmacists at a coordinating site.
Approval was obtained from the Alberta College of Pharmacists to proceed with the initiative
Training needs were evaluated and a telepharmacy training and certification program established. Results of initial training and certification were presented in a poster at the 2008 ISOPP/HOPA meeting. 7 Training was undertaken by the lead pharmacist and telehealth staff. The newly developed telepharmacy policies and procedures were outlined via video-conferencing or an in-person visit to the telepharmacy sites. Instruction was provided regarding setup, manipulation, and maintenance of the telehealth equipment. A simulation of intravenous chemotherapy preparation via telepharmacy was demonstrated by each site prior to actual use in a clinical setting. A telepharmacy user manual was developed and provided to each site. A Telepharmacy Process Map was developed (Appendix 1). Technician and pharmacist checklists were adapted to telepharmacy needs (Appendices 2 and 3). Nursing and Medical staff at the sites were oriented. Telehealth coordinators at each site provided technical backup.
Funding was provided by a grant from Alberta Health and Wellness Clinical Grant Fund Phase 6. Funding covered start up costs including the purchase of telepharmacy equipment, software and maintenance agreements, infrastructure upgrading and installation of ports at participating sites, hiring of a temporary part-time telepharmacy coordinator. The lead pharmacist and pharmacy staff at participating sites did not receive extra funding.
Equipment required at telepharmacy sites.
Telepharmacy monitor in shipping case.
Telepharmacy equipment at remote site (left to right: document camera, Tandberg WAVE II® camera, Tandberg Tactical Unit®).
Fax machines were used to communicate technical and clinical information between the remote and coordinating sites. Primarily this included the completed technicians checklist, associated patient records and lab data, copies of the prescription label and the pharmacist checklist. Release of the prepared I.V. mediation from the remote pharmacy to the nursing unit required the signed pharmacist checklist to be received by the remote technician.
A variety of parameters to evaluate utilization were recorded. The number of kilometers patients saved by not having to travel to the referring TCC or ACC for treatment was documented. A satisfaction survey was completed by clients, physicians, nurses, and pharmacy staff comparing telepharmacy to normal practice patterns. Treatment delay was chosen as the alternative in the patient survey since there was capacity and distance difficulties inherent in sending patients back to the tertiary sites. It was anticipated that telepharmacy use would be short term until the staff member returned or was replaced. Nurses at the remote sites were to distribute patient surveys after treatment and forward them to the lead pharmacist or telepharmacy coordinator who also distributed and gathered satisfaction surveys from participating health care staff.
Results
Telepharmacy equipment utilization (1 January to 31 August 2008).
Telepharmacy workload tracking (1 January to 31 August 2008).
Patient telepharmacy satisfaction survey (1 January to 31 August 2008).
Pharmacy staff telepharmacy satisfaction survey (1 January to 31 August 2008).
Medical and nursing staff telepharmacy satisfaction survey (1 January to 31 August 2008).
Discussion
Telepharmacy was acceptable to patients, pharmacy staff, and health professionals at participating sites, 100% of whom preferred telepharmacy to the alternative of treatment delay. Medical and nursing staff still preferred to have a pharmacist on site if possible. All of the pharmacy staff considered the visual checking of telepharmacy as good as (75%) or better than (25%) the unaided eye. Many commented on the clarity of the image and the advantage of being able to remotely zoom in on objects in the biological safety cabinet (BSC). Processing time was impacted by telepharmacy. Pharmacy staff noted on average, an additional 10 min per preparation was required to prepare checklists and fax documents back and forth. Nursing observed that much of the additional time (average 27.5 min per patient) related to preparing patient information for the reviewing pharmacist at the coordinating site. This was substantively mitigated at one pair of sites that shared the same computer network system thus allowing the coordinating pharmacist access to the electronic health record for the patient at the remote site. Pharmacists performed a clinical review of the medication based on the information provided by the remote site. Pharmacy technicians, nurses, and physicians at the remote site knew who the coordinating pharmacist was and there was interaction between them including direct contact by telephone. The results of the Medical Staff and Nursing Satisfaction Survey in Table 6 indicate that while telepharmacy is acceptable, their preference is to have a pharmacist on site.
Over the 8-month study period 47 Albertans received chemotherapy during 109 visits to the remote centers. An estimated 44,580 km (27,700 miles) of patient travel was avoided. Out of the completed satisfaction surveys 100% of the patients (22/22), nurses and physicians (28/28), and pharmacy staff (60/60) preferred telepharmacy to treatment delay. Of the 47 patients who visited a total of 107 times for treatment only 27 patient surveys were carried out. This speaks to the busy environment of front-line nursing staff who often were so focused on their primary responsibilites the surveys were not given to the patients.
The duration of telepharmacy use exceeded the anticipated need at both sites due to hiring difficulties.
Initially there were a few technical hurdles. The local staff were unable to open the locked transport case due to not having the combination, a site pressed the presentation button on the remote control when switching between the document camera and the Wave camera resulting in temporary loss of the picture. This was quickly corrected. One of the units had a faulty cable that needed to be replaced. A remote control unit also needed to be replaced. The wheel on one of the transport cases broke. One site had some telehealth compatibility issues that were resolved with network upgrades prior to clinical use. The same region required extra work to configure the telepharmacy equipment for use in their network. Since that time there has been a substantial upgrade in the telehealth network in Alberta alleviating connectivity issues.
With regards to safety, in one instance a technician prepared chemotherapy according to written orders; however, new orders were written while the medication was being processed. The initial order was released from pharmacy but the discrepancy was noted in the day care unit and returned to pharmacy with the updated orders. A final check was inserted into the process to confirm when the medication was picked up by nurses or delivered from pharmacy that there were no changes in the orders. In another instance a technician pulled an outdated bag of solution for use; however, the checking pharmacist noted the expiry date on the bag while checking via telepharmacy and a new bag was selected. Pharmacists reported they did not need to use the document camera to verify and were impressed with the clarity of the images.
Anecdotally there was some initial trepidation by users about working with another site via telepharmacy; however, after a few sessions they became very comfortable not only with the use of the equipment but in their relationship with the staff at the other centres.
Conclusions
Telepharmacy allowed CCC sites without a pharmacist to treat patients while maintaining the required provincial pharmacy standards for clinical and technical oversight. Patients, physicians, nurses, and pharmacy staff accepted telepharmacy as a preferred alternative to treatment delay when a pharmacist is not present on site. Significant travel time and associated costs were avoided by not referring patients to other sites. Telepharmacy images are perceived by checking pharmacists to be as good as or better than the unaided eye. The transfer of clinical and checking information by fax adds additional time to the processing of prescriptions and would be reduced if both sites shared access to electronic patient records and laboratory data. Telepharmacy will yet find many innovative applications in pharmacy practice including intra-facility use.
Subsequent to this study a provincial initiative has been undertaken to deploy permanent telepharmacy equipment at all Community Cancer Network centers in the province with the intent that they may be used in an intra- or inter-facility basis as needed. Intra-facility use allows the pharmacist to check I.V. preparation from outside the clean room allowing greater efficiencies and saving the time required to gown and scrub in. Inter-facility use allows staff at one site to check chemotherapy production at another site experiencing a staff shortage. Other novel applications are under consideration including remote training and certification of pharmacy staff in the handling and preparation of chemotherapy.
Footnotes
Funding
This work was made possible by funding from Alberta Health and Wellness Clinical Grant Fund Phase 6.
Acknowledgements
Participating patients and health care professionals in the Aspen, David Thompson and Chinook Health Regions, The Alberta Cancer Board (ACB) Division of Medical Affairs and Community Oncology, and the ACB Departments of Pharmacy and Telehealth.
Conflict of Interest
The authors declare that there is no conflict of interest.