Before we approach the discussion about the integration of telehealth into contemporary pharmacy practice, it is important that we discuss the terminology to understand the background and application of the various terms associated with this treatment modality. The terminology discussed in this chapter will apply to subsequent sections and chapters of this text and will be used as a framework to understand how these technologies apply to pharmacy practice. In defining the terminology, resources from several sources were considered, including payers (e.g., U.S. Centers for Medicare & Medicaid Services [CMS]);1 practitioner organizations (e.g., American Medical Association [AMA]);2 educational organizations (e.g., American Board of Telehealth);3 trade organizations (e.g., American Telemedicine Association [ATA]);4 coalitions (e.g., National Consortium of Telehealth Resource Centers [NCTRC]);5 and governmental bodies (e.g., The Office of the National Coordinator for Health Information Technology [ONC]).68 Although all resources reviewed had their own perspectives, based on the mission and purpose of the organization itself, common elements of the definitions were synthesized to develop and expand the definitions and terminology in this chapter.

As a developing modality for delivering treatment—which was propelled into increased deployment and use by the Coronavirus disease 2019 (COVID-19) pandemic—the definitions for telehealth and associated terms are somewhat dynamic and have the potential to adjust over time. As telehealth shifts from a modality deployed to address a public health crisis to a treatment delivery option widely available for patient care, education, and care coordination, the terminology will perhaps adjust to new phrases, definitions, or standardization across platforms.

TELEHEALTH

A succinct and practical definition of telehealth is the use of telecommunication technologies to deliver distanced healthcare. Another way of stating the definition is that telehealth is remote care delivered via technology. Now let's separate that definition into its components and discuss what is meant by healthcare, the concept of distanced care, and, finally, what technologies are utilized.

First, the term healthcare is used broadly to describe any aspect of patient care, whether it be administrative, population-based, or direct. Most commonly, telehealth is used in reference to direct patient care from a provider to patient and/or their caregiver(s). However, during the pandemic, telehealth has increasingly been utilized as a modality for delivery of public health initiatives, such as education of populations and coordination of immunization campaigns.

Second, a key aspect of telehealth is that it is delivered remotely, over a distance. That distance may vary with need. For example, a pharmacist located at an academic medical center may be counseling a patient who lives close by, such as in a suburban area of the same city. Another example, frequently cited for telehealth prior to the pandemic, is to extend care to rural and underserved areas in which the patient could be hundreds of miles away from the practitioner delivering the care. The essential element is that the practitioner and the patient, or audience, are in dissimilar locations, thus necessitating remote care.

Lastly, healthcare providers utilize various telecommunications technologies to deliver remote or distanced care. Telecommunications refers to the electronic exchange of information over a distance. From a technical standpoint, a telecommunications arrangement is made up of two or more stations with transmitter and receiver devices.9,10 Modern telecommunications devices include telephones, radio, fiber optics, satellites, and the Internet. For the purposes of this textbook, we will focus on telehealth being delivered via telephone and via the Internet because those are the two most common modalities in contemporary practice.11 Additionally, the term telehealth pharmacy practice (or service) will be used to separate focused remote activities from the other similar terminology to be discussed in this chapter and allow for breadth of practice variations from pharmacists provided remotely.

TELEMEDICINE

If telehealth is defined as the use of telecommunication technologies to deliver distanced healthcare, what then is telemedicine? In discussions with colleagues at your practice sites, and even in podium presentations at national conferences, these terms may be used interchangeably. However, for the purpose of our discussion in this text, we define telemedicine as a service provided separately from telehealth. Similar to telehealth, telemedicine aims to address a patient's health status via interactive communication between the patient and the provider at a distant site.12 Therefore, telemedicine can be considered a subset of telehealth focusing on the delivery of medicine using telecommunication technology. In contrast to telemedicine, telehealth is a broader term encompassing not only the practice of medicine, but also public health initiatives, such as education and training. In considering the definition of telemedicine in contrast to telehealth, we can also consider the practitioners utilizing these tools. By definition, telehealth can be utilized by any healthcare practitioner, including public health professionals. In contrast, telemedicine should be considered the domain of medicine practitioners licensed to practice medicine, such as physicians, nurse practitioners, and physician assistants. Telemedicine is viewed by payers as a cost-effective alternative to the standard method of providing medical care (i.e., in-person consultations between provider and patient).12

REMOTE PATIENT MONITORING

Remote patient monitoring (RPM) refers to the collection and transmission of patient data from outside the health system (i.e., outside of an acute or ambulatory patient care setting); these data are typically collected in an asynchronous manner. Devices or applications that collect patient clinical data (e.g., weight, blood pressure, pulse oximetry, respiratory rate) or measure therapy response are utilized at the remote location. The information collected and transmitted in RPM can subsequently be used in clinical decision making and care follow-up.13 For regulatory and reimbursement purposes, remote patient monitoring is not considered telemedicine per se; however, the follow-up care delivered as a result of the clinical data collected via RPM may be conducted via telemedicine technology. For example, a home health patient on intravenous antibiotic therapy is being monitored at home utilizing devices that capture temperature, blood pressure, and pulse oximetry. The triage nurse at the health system's infectious disease clinic notes a worsening of the patient systems upon review of their clinical data from the remote monitoring devices. Due to the concerning clinical information, the triage nurse schedules a video visit between the resident infectious diseases physician and the patient, together with their caregiver. The first part of this scenario is RPM: asynchronous data are collected and transmitted to the remote care team. When the video visit takes place between physician and patient, and caregiver, this is considered telemedicine.

TELEPHARMACY

As is true of the terms telehealth and telemedicine, the terms telehealth and telepharmacy are frequently used interchangeably among colleagues in a pharmacy practice setting. However, for the purposes of this text, we consider telepharmacy a distinct term and a distinct delivery of pharmacy services. What is telepharmacy? The August 2020 Model State Pharmacy Act and Model Rules of the National Association of Boards of Pharmacy (NABP) define telepharmacy as “the practice of pharmacy by registered pharmacies and pharmacists located within US jurisdictions through the use of telepharmacy technologies between a licensee and patients or their agents at distances that are located within US jurisdictions. The practice of telepharmacy is deemed to occur within the jurisdiction in which the patient is located and the jurisdiction(s) in which the pharmacist and, if applicable, pharmacy are located; therefore, such practice will be subject to the pharmacy practice regulations of all jurisdictions’ Boards of Pharmacy.”14 The American Society of Health-System Pharmacy (ASHP) defines telepharmacy as “a method used in pharmacy practice in which a pharmacist utilizes telecommunications technology to oversee aspects of pharmacy operations or provide patient-care services.” Further, ASHP states that “telepharmacy operations and services may include, but are not limited to, drug review and monitoring, dispensing, sterile and nonsterile compounding verification, medication therapy management (MTM), patient assessment, patient counseling, clinical consultation, outcomes assessment, decision support, and drug information.”15 As we can see from these definitions, telepharmacy can be considered a subset of telehealth for the provision of pharmacy practice and services utilizing telecommunications technology. As we discussed with telehealth and telemedicine, we can also contrast telepharmacy by the healthcare practitioner utilizing this treatment modality. We can see telepharmacy as the sole provision of licensed pharmacist providers and support staff working under their supervision (e.g., pharmacy technicians).16 Lastly, ASHP's Practice Advancement Initiative (PAI) 2030 recommendations specifically addresses telepharmacy, stating that “virtual pharmacy services (e.g., telepharmacy) should be deployed to optimize operational and clinical services that extend patient care services and enhance continuity of care.”17

Other Terminology

Synchronous Telehealth

Synchronous is defined as real-time telephonic or live audio and video interaction in the delivery of telehealth. In contemporary practice, this typically involves a patient using a smartphone, tablet, or computer to connect with their provider. In an alternate method, the synchronous care is provided by two healthcare professionals. For example, a nurse who is physically with the patient utilizes peripheral medical equipment (e.g., digital stethoscopes, otoscopes, ultrasounds) while consulting with the provider conducting the remote evaluation. Synchronous telehealth services are what most patients and practitioners are familiar with in the current pandemic environment. Most frequently, these services are delivered as a telephone call or video visit (via the Internet) between a healthcare practitioner and a patient, and they may include a caregiver or guardian such as a parent.

Asynchronous Telehealth

Asynchronous communication is defined as communication between parties that is not live (i.e., real time). Asynchronous telehealth can utilize tools such as short messaging service (SMS) messaging—commonly referred to as texting; electronic mail (email); voice messages; or use of digital patient portals. The ONC defines asynchronous telehealth as “store-and-forward video-conferencing,” which is described as the transmission of a recorded health history or patient information to a provider.6 The provider then reviews the stored data and makes diagnosis, treatment, and planning recommendations that are electronically delivered to either a referring provider, the patient, or the patient's caregiver. Online digital visits or patient check-in services via asynchronous technologies may also be utilized to evaluate whether or not an office visit is warranted. For a recent example of the utility of asynchronous telehealth, the Centers for Disease Control and Prevention (CDC) deployed V-safe, a smartphone-based application that uses SMS text messaging and web surveys to provide health check-ins after receiving the COVID-19 vaccine.18

Synchronous and asynchronous delivery of telehealth both reference the timing of the provision of healthcare services. An advantage of the synchronous approach is the efficiency gained by having the opportunity to seek additional information or data during the telehealth session, as well as providing clinical decisions or advice during the session. Conversely, efficiencies may nevertheless be obtained in asynchronous services when the telehealth episode does not require to-and-from interactions, especially when it does not rely on direct interaction with the patient throughout.19

Mobile Health (mHealth)

Mobile health (mHealth) is defined as healthcare and public health information that is provided through mobile devices. The information may include general educational information, targeted text messaging campaigns, and notifications about disease outbreaks.6

How is mHealth different from telehealth? The difference between mHealth and telehealth is that telehealth refers to all instances of healthcare via the use of modern technology, whereas mHealth refers to the concept of mobile health. Often, mHealth focuses on patient (or caregiver) self-care utilizing consumer technologies such as smartphone and tablet applications to capture their own health data. In its global survey of mHealth technologies, the World Health Organization (WHO) identifies 14 categories of mHealth services: health call centers, emergency toll-free telephone services, managing emergencies and disasters, mobile telemedicine, appointment reminders, community mobilization and health promotion, treatment compliance, mobile patient records, information access, patient monitoring, health surveys and data collection, surveillance, health awareness raising, and decision support systems. The survey findings state that the predominant form of mHealth today is characterized by small-scale pilot projects that address single issues in information sharing and access.20

eConsults

Electronic consultations (eConsults), also known as interprofessional consults, are communications between healthcare providers. Providers can use eConsults to get recommendations for complicated conditions from providers in other locations with additional expertise, for example, in specialty areas such as trauma or behavioral health.21 Providers may interact with each other using a variety of telecommunications methods, such as electronic mail, SMS messaging, and phone or audio/video, and the eConsult may occur synchronously or asynchronously as warranted in the patient care scenario. Some of the benefits of eConsults in healthcare are increased care coordination, increased access to high-quality specialty care, accelerated consultation response time, reduction in unnecessary referrals, and transmission of clinical knowledge by interprofessional interactions.21

Web-Based Services

Web-based services are healthcare applications delivered via the Internet, accessed by patients via a web browser (or browser), which is application software for accessing the World Wide Web.2224 In contrast to web-based services, app-based services require a local application to be deployed and installed on a smartphone, tablet, or computer. From a deployment and availability perspective, web-based healthcare applications offer greater accessibility for both computer and mobile devices users. However, healthcare web-based services still require careful attention to local and federal regulatory requirements, as well as security. As an example of web-based services from a public health perspective, the ONC for Health Information Technology (HealthIT) maintains web-based applications that are interactive tools to visualize and analyze ONC's open-source data. For example, there is a web-based application that creates custom summaries of the latest national and state HealthIT data and statistics.25

CONCLUSION

This chapter introduced the term telehealth as the use of telecommunication technologies to deliver distanced healthcare. Additionally, we discussed the subsets of telehealth, which are telemedicine for the remote delivery of medicine and telepharmacy for the remote delivery of pharmacy services. Telehealth and the related services telemedicine and telepharmacy may be delivered synchronously, otherwise known as real time, using audio or audiovisual technologies; or delivered asynchronously using tools such as text message, email, and digital patient portals. RPM is an example of an asynchronous method of collecting remote patient clinical data for evaluation. Another example of asynchronous telecommunication between healthcare providers is eConsults, which is designed to gain rapid specialty advice and insight into patient conditions. Lastly, we also discussed how Telehealth can be deployed via application-based services (mHealth or mobile Health) and web-based services via the Internet. Both methods have the goal of addressing a patient's health status, but they are contrasted in different technological methods for delivery. Please keep these definitions in mind as you review subsequent chapters in this text and learn more about all aspects of telepharmacy.

REFERENCES