The North Dakota Telepharmacy The North Dakota Telepharmacy ProjectProject

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 & ProfessorDean & Professor

College of PharmacyCollege of Pharmacy

Sandy Sprafka, Information Tech ServicesSandy Sprafka, Information Tech Services

North Dakota State UniversityNorth Dakota State University

Fargo, North DakotaFargo, North Dakota

North Dakota DemographicsNorth Dakota Demographics2000 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% 27 of 53 counties classified as frontier27 of 53 counties classified as frontier 14.7% over 65, vs 12.4% nationally14.7% over 65, vs 12.4% nationally

Pharmacy Services in NDPharmacy Services in ND

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

North Dakota Rural Health Care Crisis:North Dakota 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 within 50 milesremote site within 50 miles Dispense prescriptionsDispense prescriptions Pharmacist - patient consultationPharmacist - patient consultation

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

$1,671,621 federal support to date$1,671,621 federal support to date

Goals of Telepharmacy Grant:Goals of Telepharmacy Grant:

RESTORATION - RESTORATION - 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

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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 Grant BudgetTelepharmacy Grant 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 Responsibilities: Pharmacy Technician 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

Technician Training Requirements: Technician 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 ResponsibilitiesPharmacist Responsibilities

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

Demographics:Demographics:Remote Telepharmacy SitesRemote Telepharmacy Sites

SiteSite BeachBeach RoletteRolette New New EnglandEngland

MaddockMaddock GwinnerGwinner

PopulationPopulation 1,1161,116 538538 555555 498498 717717

Distance -Distance -Central RxCentral Rx

95 miles95 miles 32 miles32 miles 60 miles60 miles 48 miles48 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 Service Full 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 dayper day

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 – 5:30 9:00 – 5:30 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 3 FTE’s with 3 with 3 peoplepeople

2 FTE’s 2 FTE’s with 3 with 3 peoplepeople

3 FTE’s 3 FTE’s withwith

4 people4 people

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

Medical Medical CoverageCoverage

Clinic Clinic 5d/wk PA5d/wk PA

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

Clinic Clinic 5d/wk MD5d/wk MD

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

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

Benefits to North Dakota with Benefits to North Dakota with the Telepharmacy Programthe Telepharmacy Program

Improved access to health care for rural citizensImproved access to health care for rural citizens Provides rural economic developmentProvides rural economic development Improved quality of care/pharmacist consultsImproved quality of care/pharmacist consults Increased patient & pharmacist satisfactionIncreased patient & pharmacist satisfaction Increased financial viability of rural pharmaciesIncreased financial viability of rural pharmacies Provides relief for pharmacists for vacations, etc.Provides 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 TelepharmacyEconomic Impact of Telepharmacy

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 $7.5 million annually to the North Dakota rural $7.5 million annually to the North Dakota rural economyeconomy

Has added an estimated 30-40 new jobs to Has added an estimated 30-40 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

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

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

Pharmacy Student InvolvementPharmacy Student 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 Trains students on the latest advances in pharmacy technology in pharmacy technology

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

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 Future Goals of Telepharmacy in North DakotaTelepharmacy in North Dakota

5-10 new community sites each year5-10 new community sites each year 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

Recent PublicationRecent Publication

If you would like more information:If you would like more information:

Peterson, CD and Anderson HC. The North Peterson, CD and Anderson HC. The North

Dakota Telepharmacy Project: Restoring and Dakota Telepharmacy Project: Restoring and

Retaining Pharmacy Services in Rural Retaining Pharmacy Services in Rural

CommunitiesCommunities

J. Pharm. TechJ. Pharm. Tech 2004:20:28-39 2004:20:28-39

From the technical side …. From the technical side …. Project parametersProject parameters

Independent, privately owned Independent, privately owned businessesbusinesses

Keep costs downKeep costs down

Keep prescription processing separate Keep prescription processing separate from consultationfrom consultation

Independent Pharmacy Clusters

Issues to AddressIssues to Address

HIPAAHIPAA AuthenticationAuthentication Secure connectionsSecure connections Reliability Reliability Internet1Internet1 CostsCosts

Network Network managementmanagement

TroubleshootingTroubleshooting StandardizationStandardization Growth Growth FlexibilityFlexibility

Telepharmacy TechnologyTelepharmacy TechnologyHardwareHardware

Polycom Viewstation (VSX7000Polycom Viewstation (VSX7000

Second cameraSecond cameraDocument cameraDocument camera2 mics (mute separately)2 mics (mute separately)PC & printerPC & printer2 TV monitors2 TV monitorsVPN – for encrypting Rx and videoVPN – for encrypting Rx and video

Telepharmacy Technology Telepharmacy Technology – – cont’dcont’d

Prescription ProcessingPrescription Processing

Standard Pharmacy Operations SoftwareStandard Pharmacy Operations Software

Patient Consultation Patient Consultation

Polycom ViewStationPolycom ViewStation

Prescription VerificationPrescription Verification

PolycomPolycom ViewstationViewstation

HIPAA/PrivacyHIPAA/Privacy

Virtual Private Network (VPN) – Sonic FirewallVirtual Private Network (VPN) – Sonic Firewall

Telepharmacy TechnologyTelepharmacy TechnologyConnectivityConnectivity

Local telephone companyLocal telephone company

Prescription ProcessingPrescription ProcessingDedicated POTS with 56K modemDedicated POTS with 56K modem

Patient ConsultationPatient ConsultationSymmetric DSL at 512K bandwidthSymmetric DSL at 512K bandwidth

Lessons learnedLessons learned Not all pharmacies the same, unique Not all pharmacies the same, unique

componentscomponents Customers prefer talking to a “TV”Customers prefer talking to a “TV” Separate prescription processing - consultationSeparate prescription processing - consultation Polycom units need flexibility (speakers, mics)Polycom units need flexibility (speakers, mics) Video works – VPN, firewall, 512K SDSL, 256KVideo works – VPN, firewall, 512K SDSL, 256K Different local phone companiesDifferent local phone companies

• Different pricing, solutionsDifferent pricing, solutions• Internet1 a quality problem beginning at 3pmInternet1 a quality problem beginning at 3pm

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Identified NeedsIdentified Needs

Standards (except pharmacy software)Standards (except pharmacy software) Video links to allVideo links to all

Network solutionsNetwork solutions

Statewide Private IP NetworkStatewide Private IP Network Connection to Internet2 for out-of-stateConnection to Internet2 for out-of-state

DCNT1 Internet Access

DCN Core RouterDCN Core Router

VPN Accelerator

Killdeer PharmacyNDSU

Beach Pharmacy

Access Device With integrated VPN

ISP Connected to DCN IP Core

Access Device With integrated VPN

Access Device With integrated VPN

DSLAM

ISP Connected to DCN IP Core

512X512 DSL

512X512 DSL

Radius Authentication Server

Radius Authentication Server

VPN Headend

Killdeer PharmacyNDSU

Beach Pharmacy

IP Tunnel

Access Device With integrated VPN

Access Device With integrated VPN

Access Device With integrated VPN

IP Tunnel

New England Pharmacy

Access Device With integrated VPN

IP Tunnels

IP T

unnel

Student or Instructor

Pharmacy Tech

Pharmacy Tech

Pharmacist

FeaturesFeatures

Data encryption, authentication & security Data encryption, authentication & security provisions – HIPAAprovisions – HIPAA

Secure videoconference between pharmacies Secure videoconference between pharmacies – patient consultation– patient consultation

Secure data connection with document Secure data connection with document camera, database – dispensingcamera, database – dispensing

Management, growth, redundancy, reliability, Management, growth, redundancy, reliability, QoS (video)QoS (video)

Internet accessInternet access

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Future DirectionsFuture Directions

Connect to other statesConnect to other states• CollaborationCollaboration• InstructionInstruction• ServicesServices

Internet2 – enabling technologyInternet2 – enabling technology Research UniversitiesResearch Universities SEGP participantsSEGP participants

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High Speed NetworksHigh Speed Networks

Attract researchers, faculty, students Attract researchers, faculty, students Provide increased grant opportunitiesProvide increased grant opportunities Provide greater access to resourcesProvide greater access to resources Fuel economic developmentFuel economic development Facilitates innovative & progressive Facilitates innovative & progressive

projectsprojects

Thank youThank you

Dr. Charles PetersonDr. Charles Peterson

charles.peterson@ndsu.nodak.educharles.peterson@ndsu.nodak.edu

Sandy SprafkaSandy Sprafka

sandy.sprafka@ndsu.nodak.edusandy.sprafka@ndsu.nodak.edu

(701) 231-8688(701) 231-8688