Integration of Telehealth into Contemporary Pharmacy Practice

in Telehealth: Strategies for Establishing Pharmacy Practice Models in Ambulatory Care Settings
Author: Christina E. Deremer
DOI:
https://doi.org/10.37573/9781585286928.003
Free access

Pharmacists have been providing telehealth services for more than 20 years. As the use of the World Wide Web increased in the early 2000s, medication therapy management (MTM) platforms were developed in order to allow pharmacists to complete comprehensive medication reviews and targeted medication interventions for patients as a part of Medicare and some state Medicaid MTM programs. Health-system pharmacists have provided comprehensive medication management and disease state management services via telehealth pharmacy practice (primarily telephone visits) for much longer.

The COVID-19 epidemic accelerated the use of telehealth by health systems for various visits that would otherwise have been in person. Previously, many of these visits were conducted in person to allow the provider to use physical examination as part of the visit. Most pharmacist visits were conducted in person also because prior to the pandemic, telehealth visits were not reimbursed by insurance companies to a large extent. COVID-19 forced providers to become creative in the use of physical examination via telehealth. It also allowed a mechanism for reimbursement for these types of visits, making them more financially viable.

During the COVID-19 pandemic, Medicare temporarily lifted several restrictions on the types of services that were reimbursed when conducted via telehealth. Medicare also relaxed Health Insurance Portability and Accountability Act (HIPAA) privacy laws that allow the use of smartphones for telehealth visits. They allowed video-conferencing platforms such as Zoom and messaging services like WhatsApp to be used for telehealth visits. Regulations were also relaxed to allow for the provision of care across state lines in 48 states.1

An analysis conducted by Brigham Health in Boston estimated that 50% of visits could be conducted virtually, as they did not require physical examination or testing in order to establish a diagnosis and treatment plan. Because many of the medication management services provided by pharmacists do not require a physical exam, they are ideal candidates for remote care. Tele-video visits with high-quality video may be preferred to audio-only visits by some pharmacists and patients because it allows the pharmacist to instruct on the administration of various medication delivery devices and to see the patient's medication bottles and home environment, which can give the pharmacist valuable information when formulating their assessment and plan.2,3

COMPARISON OF PLATFORMS

Many methods can be used to provide pharmacy telehealth services, including video, secure texting, telephone or Internet-audio, and remote monitoring systems (see Table 3.1 for examples of platforms). Each of these methods has benefits and drawbacks. Within each of these methods, there are many options to choose from, and the market is evolving rapidly in order to keep up with the growing pace of telehealth utilization.

Table 3.1.

Examples of Telehealth Platforms5–10

Mode

Platform

Characteristics

Video

Zoom

Healthcare Zoom requires a paid subscription

HIPAA compliant

Integrates within some EHRs

Closed captioning available

Sessions can be recorded onto a desktop hard drive

Passcodes and waiting rooms provide security

Doximity

Free and paid subscription options available

No recording capability

No downloads or sign-on required for patients

Video or audio-only calls available

Electronic medical record (EMR) integration available with paid option

OhMD

No downloads or sign-on required for patients

EMR integration available

doxy.me

Free and paid options available

Can schedule and bill for appointments within the platform with the paid version

Mend

Requires a paid subscription

Can integrate with EHR

Allows for scheduling and billing

EVisit

Requires a paid subscription; integrates with some EHRs, allows for scheduling and billing

Texting

OhMD

HIPAA compliant

Can use practice phone number

Conversations can be saved in the EHR through EHR integration options

Secure patient messaging

Many EHR platforms

Requires sign-in

Typically asynchronous communication

Remote patient monitoring (RPM)

DexCom

ResMed

Medtronic

Phillips Healthcare

Optimize Health

Weight, blood pressure, heart rate, pulse oximetry, blood glucose, medication adherence, behavioral health surveys

Some of these platforms integrate directly into the electronic health record, while others do not. For example, Zoom provides a way to conduct HIPAA-compliant video calls with patients, but it does not have capability for scheduling or billing, which may be done separately within the electronic health records (EHRs).

Some systems require a patient to download an app onto their device in order to participate in the visit, while others only require a camera, microphone, and Internet connection. One must consider both the ease of use for the consumer and the training required for the healthcare professional who provides the service. Some platforms provide IT support, while others require more support from the healthcare setting's IT department.4 (For more information, refer to Section 2: Telehealth Pharmacy Practice Workflows.)

Preferred Platforms for Different Types of Healthcare Settings

There are many aspects to consider when determining the “best” platform for a telehealth pharmacy practice encounter. Does the practice site already have a functioning EHR and practice management system? If so, one may only need to add a video platform with which to provide telehealth. If the practice site does not have an EHR or practice management system, one might consider purchasing a system that integrates telehealth visits within the platform but also gives all of the other features that are important to running a successful ambulatory practice, such as documentation, scheduling, and billing.

Privacy and Security of Telehealth Visits

Before beginning a discussion of privacy and security during pharmacy telehealth visits, it is important to define these terms. Security is protection against the unauthorized access of data, whereas privacy relates to who has access to specific data. These terms can be difficult to define, and the two overlap.11,12

Privacy and security of health information during telehealth encounters can be addressed in several ways. Digital communication between providers and patients is often encrypted to reduce the risk of unauthorized access to data. Patients are frequently required to sign a consent before participating in telehealth, acknowledging how their digital information may be used. However, patients often do not read or understand privacy policies. Health information can be available through multiple methods, including the use of apps for remote patient monitoring or telehealth encounters.13

Skype, FaceTime, Facebook Messenger Video, Google Hangouts Video, and some Zoom applications may not meet all of the requirements of HIPAA. During the COVID-19 pandemic, the Department of Health and Human Services (DHS) has not fully enforced these requirements, while healthcare professionals are working to provide telehealth services to an increasing number of patients. However, when the public health emergency ends, providers will need to transition to a HIPAA-compliant telehealth platform. Public-facing platforms are never acceptable for providing telehealth. Those providers who choose to use those platforms (such as TikTok, Facebook Live, and Twitch) may be subject to enforcement actions for violations of HIPAA.14

BENEFITS OF TELEHEALTH PHARMACY PRACTICE

There are many benefits to telehealth pharmacy practice visits that can help the pharmacist to provide better care for patients. These benefits may include the following:

  1. The pharmacist is able to see the patient's home environment. Where does the patient store their medications? Are there safety concerns? Who else lives in their home who would never accompany them to their in-person appointments but may play a role in the patient's ability to manage their medications?3

  2. The patient is less likely to miss their appointment. One clinician reported that their no-show rate was less than 10%, which is lower than in-person visits. Some of these patients have missed their in-person appointments in the past due to transportation, work, or child care challenges. Telehealth is an easier option for those patients.15

  3. The patient may be more comfortable in their own environment. The process of traveling to a clinic, checking in, and being in an unfamiliar exam room surrounded by medical equipment causes anxiety for some patients. The ability to conduct a visit with a healthcare provider within the comfort of their own home may result in improved interaction between the patient and provider.16

BARRIERS TO TELEHEALTH

There are many barriers to wider implementation of telehealth encounters. These barriers may include the following:

  • Telehealth is viewed as impersonal. A subset of patients and providers view telehealth visits as more impersonal and disconnected when compared to in-person interactions. This can be related to blurry video images, audio or video lag time, and an inability to clearly see the other's nonverbal communication, such as facial expressions, gestures, and body language.

  • Technology poses challenges. There may be insufficient Wifi or cell signal strength in the patient's home for real-time video. The resolution of the video may make it difficult to see each other clearly. The patient may not have a smartphone and thus will be unable to send photos of derm concerns, surgical sites, medication bottles, and so on, to the clinician. A recent Kaiser Family Foundation poll found that only 68% of older adults have a way to engage in video visits from home using a computer, tablet, or smartphone with adequate Internet access. The patient may also lack the technological literacy to utilize the telehealth platform to its fullest potential.17–19

  • Distractions may emerge. If conducting telehealth via the phone, the patient may become distracted by other things or people in their home and not give the provider their undivided attention.

The National Telehealth Technology Assessment Resource Center gives some helpful tips for making the most of a telehealth visit, including lighting, camera position, and how to focus on objects of interest to the clinician, such as skin lesions or medication bottles.20

Technology Literacy and Access

The patient's ability to successfully use telehealth platforms has a direct impact on the ability of the healthcare professional to impact health outcomes and to identify and resolve medication-related problems. Many patients, particularly the elderly, have challenges with accessing the platforms used for telehealth. They may not have experience with downloading applications, using a webcam, and adjusting audio to allow for optimal communication during telehealth visits. During pandemics such as COVID-19, where younger family members or neighbors are not able to help due to social distancing, healthcare organizations may find that these visits cannot meet their goals because of the time that it takes to troubleshoot technical issues during the visit. The Vanderbilt University Health System solves these challenges by utilizing medical student volunteers to connect with patients prior to their scheduled telehealth visits to set up and test the telehealth platform.21,22

Even when the technology is tested ahead of time, however, there can still be challenges during the visit. Unanticipated barriers may arise at any point during scheduled telehealth pharmacy practice visits within a large health system. Although the test was successful prior to the visit, a lack of adequate bandwidth resulted in the provider and patient being unable to use video during the visit.

Access to Technology Resources

In addition to the lack of technology literacy, lack of access to hardware, software, and reliable broadband services results in challenges when conducting telehealth visits. This is typically thought of as a rural challenge, but it can also occur in urban and suburban areas. Smartphones can be utilized for telehealth visits, but many patients own cellular phones that are not capable of real-time video interaction. Both patients and providers may find that using a bigger screen on a desktop computer, laptop computer, or tablet may provide for a better video experience. If the patient does not have sufficient Internet speed in their home, due to either cost constraints or lack of adequate broadband connection, video and audio can break up, impacting the ability of the patient and provider to communicate effectively.

For patients with limited English proficiency who require interpreter services, telehealth visits can present an additional challenge. Many telehealth platforms were not designed to easily integrate a medical interpreter into the visit. One health system in California was able to successfully integrate medical interpreters into video visits using both the Epic MyChart and Zoom platforms by developing a workflow that allowed the provider to schedule an interpreter via the electronic medical record (EMR) and allowed the interpreter to join an existing encounter without compromising privacy and security concerns. The Health Resource Services Administration (HRSA), a division of Health and Human Services, offers tips for how to effectively provide telehealth to patients with limited English proficiency.23–25

Billing for Pharmacy Telehealth Services

Billing for ambulatory pharmacist services has always been a challenge and often must be pieced together using various methods depending on the setting and patient population. This is no difference when discussing pharmacist billing for telehealth services. Hospitals may bill as the originating site of care when the patient is located at homes through Medicare Part A. Medicare Part B also pays for video and telephone E &M services and education services. Medicare telehealth services are paid at the same rate as visits occurring in the office. Medicare also pays for virtual check-ins via telephone discussions, secure patient portal, or secure video. These can be synchronous or asynchronous. E-visits are non-face-to-face visits conducted through a patient portal. Medicare will reimburse for these visits. Medicare maintains a list of services for which providers may bill for telehealth services on their website. Some of these services are temporary additions, introduced during the public health emergency, and some are permanent inclusions.26

WHAT DOES THIS MEAN FOR PHARMACISTS?

Pharmacists can bill for telehealth services “incident-to” a Medicare-recognized provider (physician). Services that have required direct supervision in which the physician is present in the same office suite are now waived as well; this supervision can be provided remotely. For quite some time now, pharmacists have been providing and have been paid for medication therapy management (MTM), including comprehensive medication reviews (CMRs) and targeted medication reviews for patients with Medicare Part D. This is the most common method for paying pharmacists for providing telehealth services. These services are generally paid for by the pharmacy benefit manager (PBM) or a third-party company that contracts with the PBM. This system has not changed in the face of the public health emergency.27

Pharmacists have also participated as part of the interprofessional clinic team in providing transitional care management (TCM) and chronic care management (CCM) services via telehealth, and the provision of and reimbursement for these services has not changed during the pandemic. (For additional information, see Section 3: Exploring Revenue Opportunities with Telehealth for Pharmacists.)

Through familiarity with the basic terminology, history, and infrastructure of telehealth, pharmacists will be prepared to successfully incorporate this growing healthcare service into their future practices. The following chapters will explore in greater detail the specifics of clinical workflows, billing, metrics, and educational opportunities for learners, which are all essential elements in building a successful and integrated telehealth practice model.

REFERENCES