Hold the phone! Will tomorrow’s telepharmacy be too complicated?
Pharmacy can lead the way in defining its use in clinical practice
It’s an electronic jungle out there, full of ringing phones, voice-mail menus, fax machines, computers, e-mail, the Internet, and video conferencing. Where telemedicine fits in, and why it should be considered at your institution, is a growing concern.
Whether referred to as "telehealth" or "interactive health communication," definitions of its use can be narrow or broad, from equating telemedicine with videoconferencing or defining telemedicine as using any or all forms of electronic technology in the delivery of health care services. That includes video, audio, and data.
The American Telemedicine Association defines it this way: "Telemedicine is the use of medical information exchanged from one site to another via electronic communications for the health and education of the patient or health care provider and for the purpose of improving patient care."
Or, as defined by the Science Panel on Interactive Communication and Health as published in Wired for Health and Well-Being: The Emergence of Interactive Health Communication (U.S. Department of Health and Human Services. Washington, DC: U.S. Government Printing Office, April 1999): "The interaction of an individual-consumer, patient, caregiver or professional, with or through an electronic device or communication technology, to access or transmit health information or to receive or provide guidance and support on a health-related issue."
There’s no doubt the scope of telemedicine can seem overwhelming, but under these broader definitions, pharmacists have been practicing their branch of telemedicine, called "telepharmacy," for a quite a while simply by providing care over the phone. Experts will tell you, however, that even using the phone isn’t as simple as it used to be.
"It isn’t just dial-and-talk telephone anymore," says David Angaran, M.S., FCCP, FASHP. Angaran spent a year studying the implications of telemedicine for pharmaceutical care as the American Society of Health System Pharmacists’ managed care practitioner in residence. He is now managing director of Angaran Associates in Powell, OH.
"Pharmacists are going to have to figure out how this technology will be integrated with in-person care. You may need an automated voice messaging system, which can dial patients and ask them three or four questions about how they are doing. The machine takes the information, and the call costs pennies instead of dollars. That is just one example of what using the telephone is about now," he says.
Angaran has another warning, this one for the entire health care profession: Health care provid ers are not using the full spectrum of available technology. He says hospitals and managed care organizations lag behind other professions when it comes to using technology such as automated answering systems, voice messaging, and the Internet. Pharmacists are a bit ahead of the curve among health care providers when it comes to using technology for filling prescriptions. But Angaran says pharmacists will have to expand their use of technology to other aspects of delivering patient care.
"Communication is going to be a multiple choice event. You are going to have to use all forms. So it won’t be an either-or question. It will be all of the above — telephones, Internet, e-mail — because it will all be interactive."
The next seemingly simple question one might ask is, "Where do I start?" As you may have guessed, that question doesn’t have a simple answer, either. But all kinds of innovations are out there.
According to the president of the Association of Telemedicine Service Providers (ATSP), Douglas A. Perednia, MD, teleradiology, or electronically transmitting X-ray or ultrasound images is so common now, no one is even keeping track of how often it is done. "Home health care is also common, using the technology to check on people in their homes to see if they are OK. You can see a lot more patients that way than if you are driving from place to place."
Perednia says prisons also are using telemedi cine to cut down on the extremely high costs of moving people from prisons to see health care providers. He says the use of telemedicine in general is doubling every year.
Putting telemedicine to work: A case study
Scott & White in Temple, TX, is the primary teaching hospital and clinical facility for the Texas A&M University System College of Medicine. It is using an interactive telemedicine system designed by VidiMedix, a privately held company in Austin.
Gregory D. Hobbs, MD, chair of the department of emergency medicine and director of telemedicine, says the technology is a perfect fit for Scott & White because the main clinic is located in a rural part of Texas while serving 19 regional clinics.
Scott & White is using a desktop-based system, with a computer on each end that has a camera mounted on the monitor. On the rural end is a variety of peripheral devices, such as cameras, scopes, and film digitizers, so health care specialists can thoroughly examine the patients.
"I can look at X-rays and other images while I examine the patient," Hobbs says. " I can sit down and review your tests with you, or look in your eyes and ears and tell you what needs to be done."
Installation of the system is just being completed, although a pediatric neurologist at Scott & White has been seeing patients via computer for about a year. Hobbs says both the doctor and the patients have been pleased with the process. Other specialty areas available for consultations will include cardiology, emergency medicine, orthopedics, and plastic surgery. Hobbs says there is also an educational component, which will allow people in remote areas to access information about subjects like diabetes and congestive heart failure.
Scott & White also is using technology to provide pharmaceutical care. It operates a drug information call center and a poison control center, and there are plans to expand telemedicine at the poison control center.
"The technology is always more complicated than it seems," Hobbs says. "But the biggest challenge is educating people about the capabilities and limitations of the system. At first, there was a lot of skepticism among the providers, so we had to do a needs assessment and a lot of educating. Now my biggest challenge is that everyone wants it."
In the emerging clinical pharmacy, "seeing" patients is becoming more pertinent. "Pharm a cists are involved in taking care of patients beyond just filling prescriptions," Angaran says.
"They are involved in ongoing counseling. Maybe the pharmacist wants to review the medication with the patient and isn’t sure the patient understands what to take when. With the camera on the computer, you can have the patient hold up the bottle, and you can read the label. Or you can have the patient read it and then double-check it to really make sure they understand what they need to do. Or if you are unsure whether the patient is drawing up their insulin dose correctly, you can watch them draw up the dose and administer it," he says.
Regulation, quality control catching up
As telemedicine and telepharmacy continue to grow, concerns about privacy, liability, quality control, and regulation will have to be addressed.
One major issue is licensing. Telemedicine allows practitioners to cross state or even national borders. Will traditional state-based licensing systems be up to the challenge?
The National Association of Boards of Phar macy (NABP) is among the host of industry and government agencies beginning to address this issue. Recently, NABP surveyed 30 states on telepharmacy. The survey revealed that telepharmacy is unregulated for the most part, but states are considering how to handle it. Up to 13% of states responding said in-state licenses were required for services such as out-of-state pharmacy Web pages or toll-free out-of-state call centers.
Twenty-three percent require the locations from which such providers work to be registered as nonresident pharmacies, and another 23% to 33% said they’d address the issue in the near future.
Similar to industry responses to on-line pharmacy, one of the reasons the legal and regulatory issues surrounding telemedicine are so complex is the challenge of keeping pace with technological advances.
Elizabeth H. Saindon, associate attorney with the Washington, DC, law firm Arent Fox, which represents many telemedicine providers and advises them on technology and information law, says providing better information and quicker access to patients is a good thing, but there are caveats. For example, she has serious reservations about drugs being prescribed over the Internet.
"I think it’s a bad idea. Someone can say they are a 45-year-old obese woman and get diet drugs, when in reality they might be a 19-year-old anorexic. But by the time a law is written to deal with this, there will be video technology available so that people’s identities can be checked and verified. The process of writing laws takes so long that by the time the law is enacted, it won’t address the way things are being done anymore."
Perednia agrees that the case scenario Saindon describes is realistic, but he says good judgment is always key, no matter what kind of technology you are using.
"The burden is on you as a provider to use due care in managing a patient. So if people act stupidly as providers in a remote setting, chances are they may act stupidly as providers in a face-to-face setting. If someone calls me and says, I’ am a big obese person, and I need diet drugs,’ I am going to insist they come in and see me. You really can’t legislate common sense."
Another area of concern is reimbursement. The technology is out there, as are companies who can bring it to health care providers and consumers. Medicare will pay for rural telemedicine consultations and some teleradiology, and other services are under review. But for now, many telemedicine services aren’t covered.
"There is technology right now, telehomecare, that can help elderly rural people, so they don’t have to go driving in a snow storm to get their blood pressure checked," says Saindon. But it isn’t being used because no one will pay for it. There are so many innovations out there that I think will fall into place when the reimbursement issue is resolved."
Angaran agrees. "Medicare has been cautious about the expansion of new technology into the payment structure. Their experience is that introducing new technology costs them more money. It isn’t that they don’t realize the potential, but they feel the initial investment outstrips the benefit."
Even though experts don’t always agree on how to define telemedicine or how to regulate it, they do agree that this roadblock must be cleared for telemedicine to reach its full potential.
Telemedicine involves many services and encompasses many different specialties and technologies. As Perednia puts it, "Saying you want to evaluate telemedicine is like saying you want to evaluate all of Western medicine. You have to think about specific contexts and specific applications. The more specific you can get, the more useful it is."
What it may boil down to, however, is access and choice. "It won’t be long before we can see our doctors from our homes," says Saindon. "We won’t have to drag our sick, screaming child into a doctor’s waiting room where they will be miserable and they will make everyone else miserable. The doctors will be on-line, and they’ll be able to see you immediately."
Perednia shares that vision. "Say you are located in a remote place and you get cancer, and the specialist [you need] is in San Francisco. The way things are now, there would be a huge cost involved in getting his opinion. That is where telemedicine has a huge advantage. Instead of only getting a single option, you’ll have lots of options. People will no longer be trapped if there is no one near them who has answers."
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