Description of Operational Telehealth Pharmacy Practice Workflow in Comprehensive Medication Management

in Telehealth: Strategies for Establishing Pharmacy Practice Models in Ambulatory Care Settings
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Comprehensive medication management (CMM) is a patient-centered approach to optimizing medication use and improving patient health outcomes that is delivered by a clinical pharmacist working in collaboration with the patient and other healthcare providers. This care process ensures each patient's medications (whether prescription, nonprescription, alternative, traditional, vitamins, or nutritional supplements) are individually assessed to determine that each medication has an appropriate indication, is effective for the medical condition and achieving defined patient and/or clinical goals, and is safe given the comorbidities and other medications being taken. The care process ensures that the patient is able to take the medication as intended and adhere to the prescribed regimen.1 Three core components of CMM exist for you to consider: a shared philosophy of practice, a patient care process, and a practice management system.2 These components frame implementation of CMM to your practice regardless of modality.

A shared philosophy of practice serves as a foundation and incorporates the values and beliefs that guide the decisions and actions you will make as part of the interprofessional patient-centered care team.3 It is critical for you to establish a relationship with both the patient and the provider. This relationship is based on trust and is an essential part of the CMM philosophy. Five core tenets inform the philosophy of practice for CMM. You should embrace these tenets as you integrate CMM into practice.

  1. Meeting a social need

  2. Assuming responsibility for optimizing medication use

  3. Embracing a patient-centered approach

  4. Fostering an ongoing patient-pharmacist relationship

  5. Working as a collaborative member of the healthcare team

The CMM patient care process occurs when you, working in collaboration with the patient and the healthcare team, provide care to an individual patient with the goal of optimizing medication use and improving the quality of their healthcare.4 Establishing a common language for the patient care process is essential to ensure that CMM is understood and is valued as distinct from the other care delivered by the team. A standard patient care process also allows the interdisciplinary team of healthcare providers and staff to understand how the ways in which you provide CMM contribute to the patient care process for optimizing medication use. Although the core elements of a patient care process for pharmacists had previously been developed and standards of practice for CMM were published, the CMM in primary care research team sought to apply the principles of implementation science to validate these essential functions of CMM and explicitly describe how to carry out each function.5 The essential functions of the CMM patient care process include:

  1. Collecting and analyzing subjective and objective information

  2. Developing and assessing the information to formulate a medication therapy problem list

  3. Developing the care plan

  4. Implementing the care plan

  5. Following up and monitoring, with the goal of ongoing medication optimization and improved care

The operational definitions of each of these essential functions can be found in The Patient Care Process: A Common Language for Delivering Comprehensive Medication Management.4 You are encouraged to review these functions as you provide CMM to ensure fidelity to the true CMM process.

It is important to have a practical assessment of your performance as you deliver CMM. This helps to ensure that the CMM is being implemented as intended.6 Fidelity to the patient care process when providing CMM is necessary for you to produce optimal patient outcomes; it requires you to take responsibility for optimizing a patient's medications in a manner that is congruent with the work of, and done in collaboration with, the patient's other healthcare providers. Establishing a common language for the provision of CMM has been the key to ensuring that the care provided is consistent and that it is understood by patient, healthcare team, and payers alike.

Finally, you need to consider another component of CMM: the CMM practice management system, which includes regular assessment of the structural and system-level supports needed to effectively implement and sustain a CMM practice.7 The essential components of practice management are grouped into five domains: organizational support, care delivery processes, care team engagement, evaluation of CMM services, and guarantee of consistent quality care. Organizational support includes having the support of leadership, adequate space for patient care, and financial procedures such as billing. Necessary care delivery processes include methods for identifying those patients needing CMM, patient scheduling, and a system for appropriate documentation. Assessment of care team engagement involves reviewing the presence of a scope of practice or collaborative practice agreement and the extent of interprofessional collaboration, as well as the availability and use of support staff. Evaluation should also include the program's ability to measure and assess data to document that intended outcomes are being achieved. Lastly, guaranteeing consistency and quality of care requires putting quality assurance and improvement processes in place, as well as ongoing CMM practitioner training.

This chapter describes the implementation of CMM using telehealth services. As the philosophy of CMM practice should not change based on the modality of care, we will focus on the intricacies and need for telehealth clinical pharmacy services under the construct of needs related to practice management as well as considerations in the patient care process.


At its foundation, implementing CMM telehealth pharmacy practice starts with organizational support. This includes having the financial means to support the technology platform; having available adequate clinic space for pharmacists to practice; and ensuring services are reimbursed through billing and revenue. Telehealth platforms offer both direct and indirect means for the clinical pharmacist to interact with the patient. A direct relationship includes video, phone, or remote wireless monitoring of a patient. An indirect relationship, however, includes monitoring patients through wearable monitors, mobile apps, and/or web portals.8 While both relationships offer patients access to 24/7/365 care, the financial means of supporting varies. For some telehealth platforms, the costs of configuration and system setup are included in the institution's license agreement within their EMR. These costs are often associated with a system upgrade. Platforms outside an EMR, however, can be costly for an institution to support and include; there are considerations of security, legality, interface, and quality control. Additionally, having the tech support as well as the personnel to maintain the platform needs to be factored in. While there are many benefits to adopting a platform, the upfront start-up fees can be a deterrent. In contrast, the financial responsibility of indirect relationship telehealth services often falls on the patient, thereby creating a barrier.

Even when direct and indirect telehealth can be financially supported, it is essential that you have adequate space to practice. Fortunately, only minimal space is needed, and typically a clinic room and/or office will suffice. Additionally, adequate light, sound, and privacy are necessary. If one is providing direct patient care through video/phone, a pretest prior to an appointment can be beneficial as part of the steps in pre-visit workflow, as highlighted in Chapter 4. This allows the patient to feel comfortable using the technology prior to the beginning of the appointment. It also helps you as the clinician to troubleshoot any connection or environmental barriers the patient may be experiencing. One of the few studies available—Hatton et al.—studied the correlation between direct telehealth services and patient satisfaction.9 Through a 30- to 45-minute face-to-face video-conference, patients interacted with a pharmacist to review their medication therapies. Post-interaction, patients were asked to complete a Likert Scale questionnaire. Results showed a positive correlation between telehealth pharmacy practice services and patient satisfaction. Once patients felt comfortable using the video device, patient-centered communication scored just as high as or higher than direct face-to-face visits.

Even if patient satisfaction is positive and an institution can provide financial support, billing and revenue associated with services is key. Payers have proposed different models for payment, including fee-for-service as well as capitated. Some payers differentiate between services such as telehealth phone versus video-conferencing. However, as the marketplace continues to shift and the need for minimal exposure increases, some payers may begin to favor or even mandate such service. This development would certainly shift the reimbursement on many levels. (Refer to Section 3, Exploring Revenue Opportunities with Telehealth for Pharmacists.)


Developing the care delivery process of CMM telehealth pharmacy practice services involves many considerations and stakeholders. Once a service is selected, a team involving implementation experts, IT support, and end users needs to be created. Often, super users are identified who aid in testing and training colleagues once live. At University of Wisconsin (UW) Health, virtual telehealth appointments were quickly launched to support COVID-driven needs. Super users—providers in specialty ambulatory clinics—were identified and taken offline for several days to train and be the first to support their patient panels on telehealth video-conferencing. Within the Carbone Cancer Center, caregivers, including pharmacists who worked directly with providers involved with telehealth, were also trained. During implementation, workflows were created to determine which oncology patients were eligible for telehealth and how each visit would be scheduled. Patients considered for telehealth oncology services included those who (1) had established care with the provider; (2) were not initiating therapy; and (3) were active in their electronic medical record. Prior to go-live, “test runs” were performed with mock patients to ensure that connectivity and interfacing worked properly. The marketing team at UW Health also created end-user guides and videos for patients to reference prior to their appointments. These guides were automatically sent through email and/or EMR once a video conference had been scheduled. Those who were not active on their EMR had more difficulty connecting with telehealth services. This clear barrier was highlighted during this process.

Prior to a patient tele-video conference beginning, a medical assistant logged into the remote video room to test connectivity with the patient. Providers, nurses, and pharmacists were then able to join in/out of the remote room during the visit. In total, patient visits were 30–40 minutes in length. Afterward, patients would log out of the remote room, and providers would document the encounter in the patient's EMR. The encounter was then signed, closed, and billed to the payer as a telehealth visit. Since pharmacists cannot bill for services directly in Wisconsin, their time spent with the patient was accounted for in the overall visit.

To date, CMM telehealth pharmacy practice services continue to increase. Within the next five years, some institutions are projecting that telehealth services will account for 30–50% of ambulatory clinic encounters. While this projection may seem encouraging, many barriers remain and need to be considered. For one, a quality control plan for how to operate during downtime needs to be created and tested. In the event of a network or EMR outage, institutions must know if video-conferencing would still be available “offline.” Additionally, from a security standpoint, third-party platforms need to be continually monitored for quality assurance to verify patient information remains confidential. Despite challenges, telehealth will remain a viable care modality for the future. Influenced by key market trends, telehealth aligns with (1) continuing innovation in a consumer-driven technology market, (2) supporting advancement in EMR and clinical decision support, and (3) improving care delivery and access.8


As mentioned above, the entire care team is involved in CMM telehealth pharmacy practice services. While this will be expanded upon in the next section, interprofessional collaboration and appropriate training are necessary to support such services. Sharma et al.10 suggest the need for provider training in a virtual communication and website manner. Mannerisms such as hand gestures or body positioning can distract a patient from their appointment. Additionally, communicating too quickly may cause more confusion and be difficult to follow in a remote platform. Suggestions to incorporate CMM telehealth training during medical school and residency are now widely endorsed.10 This training is essential not only for providers, but for pharmacists, nurses, and medical assistants as well.


CMM Provided by Telehealth

The evaluation of CMM services via telehealth pharmacy practice offers many similarities compared to the evaluation of any CMM service.7 Evaluation of CMM provided by telehealth allows you to focus on continual improvement and refinement of the overall program. As discussed earlier, CMM evaluation can be broken down into activities that assess the program management components to include organizational support, care delivery processes, care team engagement, evaluating CMM services, and ensuring consistent quality care. This evaluation will span different stages to include the implementation and sustainment phases ranging from pre-implementation, implementation to stabilization, and following a normal plan, do, study, and act (PDSA) process.6

Traditionally, much focus has been placed on the evaluation of CMM telehealth services related to the achievement of only specific clinical biomarkers with pharmacist care. There are more components of evaluation of a CMM telehealth practice other than clinical biomarkers alone that include different perspectives to include the patient, the provider, and the payer.

Source: Used with permission from the CMM in Primary Care Research Team.

Evaluation of the Practice Management Components of CMM Telehealth

The practice management components of CMM are those components that support the ability for you to provide CMM in an effective, efficient, and productive manner. In a study intended to identify the core components of CMM practices, the CMM primary care study team evaluated 35 mature CMM practices with embedded clinical pharmacists across the country.6 As part of the completion of this work, the team created a practice management assessment tool (PMAT), which allows assessment and prioritization for improvement in the practice management areas of CMM. The assessment includes the core practice management components related to CMM and sets the standard for evaluation of the practice management components related to CMM regardless of modality. Additionally, in 2018, the team released the Patient Care Process for Delivering CMM. This publication, modeled on the Joint Commission on Pharmacy Practice Patient Care Process, was developed after looking at common themes in the 35 practices.5 The practice management components of CMM for telehealth must be evaluated at some level as they set the foundation for the pharmacist to achieve positive results in any of the other outcomes measured.

Evaluation of Process Measures of CMM Telehealth

Process measures are those metrics that evaluate what any provider does to maintain or improve health.11 For you and CMM telehealth services, collecting baseline process data is required in order to maintain a longitudinal, prospective evaluation. Given that CMM telehealth pharmacy practice services have the ability to increase access to care, process measures evaluating access should be at the forefront. In a study conducted by the Department of Veterans Affairs, clinical pharmacist services provided by clinical video telehealth (CVT) were compared to face-to-face services provided in a single outpatient clinic.12 The study evaluated the potential benefits of telehealth pharmacy practice to include an increase in access, which took in the time from request of visit to appointment, and average travel distance and average travel time averted. The average time in days from consult placement to initial visit decreased from 106.3 ± 24.5 to 46 ± 35.3 (p <0.0001). The average travel distance in miles averted per patient was 99.5 ± 20.3, and the average travel time in hours averted was 1.6 ± 0.3. In addition, no-show rates with telehealth services were 4% as compared to 10% with face-to-face care.12

Suggested access process metrics for CMM telehealth pharmacy practice services are as follows:

  • Time to completion of an appointment from requested date (i.e., new patient and established patient wait times)

  • No-show rates

  • Clinic utilization of telehealth CMM appointments

  • Number of visits per individual patient

  • Supply versus demand for CMM telehealth appointments

Evaluation of the above access process measures allow pharmacy leadership to evaluate and proactively improve and/or anticipate opportunities. For example, if new patient wait times for a CMM telehealth pharmacy practice appointment are extended, evaluation of the supply of appointments and no-show rates could be considered in order to target and possibly generate additional care opportunities or project the need for additional telehealth appointments. Evaluation of access processes may reveal foundational programmatic practice management deficiencies. For example, if clinic utilization of telehealth appointments is low while no-show rates for appointments are high, it could uncover issues related to appointment scheduling and/or appointment reminders for patients (i.e., pre-visit appointment workflow). Process measures for access and foundational components of practice management are directly proportional. Strategies could then be implemented to decrease no-show rates to increase clinic utilization and subsequently access availability.

Additional process measures for CMM telehealth pharmacy practice services include pharmacist productivity related to CMM. Your productivity can include total time spent in patient care, number of patient care encounters in relation to time spent in patient care, number of medication therapy problems (MTP) identified, and the interventions provided during the patient care encounter. Pharmacist productivity should be individualized to the direct patient time of the pharmacist, which may include preparatory activities. Evaluation of interventions can include specific activities related to disease states, types and acceptance for interventions, and ordering activities, including laboratories, medication, or referrals. For example, if a need of care is identified for substance use disorder and an evaluation of practice reveals most telehealth services provided are focused on diabetes, a reeducation or pivot in care focus to more comprehensive management should be pursed. Individual healthcare system or facility evaluation will differ based on the resources available to evaluate. However, processes to evaluate productivity of pharmacists providing telehealth should be integrated into evaluation of CMM processes. Lastly, modality of telehealth care in regard to pharmacist productivity may also be considered. Some pharmacists may participate more in traditional telephonic care, while other pharmacists may provide telehealth pharmacy practice through a video modality. Given the complexities of video technology (e.g., bandwidth) efficiency, providing a telehealth visit may vary. Individual healthcare systems or practices must decide and individualize productivity based on these considerations.

Fiscal components of a telehealth CMM program must be evaluated and include such measures as generated revenue and/or cost savings from a CMM program. A thorough discussion of fiscal measures is provided in Section 3.


Creation of strategies related to the clinical outcomes of care and its monitoring are highly recommended. Evaluation of clinical outcomes allows for quantification if the process for patient care delivery has already achieved, or is achieving, the intended outcome for patient care. Evaluation of clinical care goes far beyond developing randomized controlled trials or retrospective analysis for publication. Evaluation of clinical outcomes answers the question, “Is the patient receiving the benefit intended from the services I am providing?”

Developing clinical outcomes for CMM should be individualized and if possible be specific to the care you are providing. Outcomes should be comprehensive, scientifically sound, and usable for improvement. Many clinical outcomes may be either completely or partially influenced by you or must be surrogate metrics for care. For example, in a true team-based model, you will not be the only person contributing to the care of the patient, which at times may provide heterogeneity to evaluation of a quality metric. Regardless, whenever possible, it is important to provide granularity to the care you are providing when possible. Several organizations have created metrics that, while not specific to CMM and telehealth, can be utilized to evaluate CMM.1319

Multiple meta-analysis and systematic reviews have highlighted the benefits of pharmacy provider care.20,21 Specific to telehealth pharmacy practice, a telehealth-based chronic disease management program evaluated the impact on specific primary care outcomes.22 Patients were targeted for diabetes, hypertension, and tobacco cessation. Patients in the diabetes and hypertension groups had a mean absolute HbA1c reduction of 1.61% (95% confidence interval [CI], 1.39–1.83%; p <0.0001) and a mean systolic blood pressure reduction of 26.00 mm Hg (95% CI, 22.99-28.50 mm Hg; p <0.001), respectively. Tobacco cessation was achieved in 42% of targeted patients. Similarly, blood pressure control was evaluated in 156 patients in a home-based-digital-medicine blood pressure program compared to 400 patients in a usual care group. Mean decrease in systolic/diastolic blood pressure was 14/5 mm Hg in digital medicine versus 4/2 mm Hg in usual care (p <0.001).23

Although a comprehensive list of quality metrics for telehealth and CMM does not currently exist, utilization of currently published metrics for evaluation of quality of care can be extrapolated to CMM in telehealth. A complete list of metrics evaluated should be individualized at the healthcare system level, but these can include but not be limited to measures that report adherence to medications, appropriate use of medications, medication safety, and overall clinical measures. Examples of metrics that could be considered include but are not limited to:

  • Medication possession ratios for specific classes of medications

  • Statin use in patients with diabetes or cardiovascular disease

  • Percent of patients on high-dose opioids

  • Blood pressure control <140/90 mmHg

  • HbA1c testing done annually

  • Diabetes control with HbA1c <8%

  • Disease state specific 30-day readmission rates postdischarge

  • Beta blocker use post-myocardial infarct

  • ACE-I/ARB use in heart failure


Evaluation of patient experience with CMM is a relatively new offering. The Consumer Assessment of Healthcare Providers and Systems (CAHPS) has been used as the measure to evaluate a patient's experience, both inpatient and outpatient, related to access, provider responsiveness and satisfaction, and overall patient satisfaction. A study specific to evaluation of satisfaction using CAHPS for pediatric patients seen by an advanced practice nurse showed that telehealth improved overall ratings of caregiver experience with healthcare providers.24 Although these data are useful for an overall viewpoint related to patient satisfaction, this information is not specific to a clinical pharmacist providing CMM. A study published in 2015 evaluated the impact of a pharmacist-led telehealth clinic on diabetes-related goals of therapy.12 As part of this study, the investigators evaluated the level of patient satisfaction with pharmacist care and with the telehealth modality using a modified version of the Satisfaction with Pharmacists (SWiP) scale. Patient satisfaction scores were very high overall, with a median score of 39.5 (Interquartile range [IQR] 36–40) out of a maximum score of 40. In addition, Barr and colleagues revealed higher patient engagement in hypertension management with a clinical pharmacist and a health coach using a home-based blood pressure program.25

Continued research related to patient satisfaction and CMM specific with telehealth is needed. However, evaluation of patient satisfaction is a must in relation not only to access of care but also to the modality of care provider.

Provider satisfaction with CMM services, specifically telehealth, is lacking. However, studies regarding CMM integration have shown positive effects on provider well-being by decreasing workload.26 Funk and colleagues conducted a series of structured interviews with 16 primary care providers where CMM was implemented. Providers reported a decrease in mental exhaustion resulting from the reassurance of having a clinical pharmacy colleague to consult and to provide enhanced opportunities for professional learning. McFarland and colleagues evaluated provider perceptions after integrating a clinical pharmacist providing CMM into practice. Using a Likert Scale of 1 being poor perception and 5 being significant contribution on evaluation of whether integration of pharmacists into the PACT model “improve(s) your job satisfaction,” the overall rating was 4.29 with nurse practitioners, physicians, and nurses rating pharmacists at 4.67, 4.59, and 4.43, respectively.26 Provider satisfaction with CMM telehealth services should be highly considered as part of a CMM telehealth evaluation.


Extracting CMM data in an efficient and reproducible manner is crucial. As outlined above, metrics can be classified as clinical, access, patient, and provider satisfaction. Extracting data will vary depending on the healthcare system or individual practice. Regardless of practice, it is highly recommended, when possible, that data be accumulated in a proficient and reproducible manner. The use of manual chart extraction for clinical metrics, when possible, should be streamlined, with the hopes that electronic processes can be in place through automated reports for you to use. The data generated should be evaluated for the CMM program as a whole, but they should be able to be evaluated down to the patient level.

Once outcome data have been chosen and evaluated, use of the data is crucial to ensure that improvements and/or demonstration of benefit are provided. You and the team should have plans in place to evaluate the overall outcomes garnered and either used to demonstrate the value of CMM and telehealth or areas of improvement. These data, once gathered, can be presented internally to the team where the patient is seeking care, facility, or healthcare leadership, or you may present externally to payers and/or at professional meetings/publication. Pharmacy leaders should have scheduled times (i.e., quarterly, monthly) when this information is reported.

Ensuring Consistent Quality Care

Establishing evaluation components to ensure quality of care for telehealth CMM is important. Basic activities that you provide related to CMM via telehealth (e.g., the patient care process) should not differ from face-to-face care. However, training processes should be in place to ensure that new staff or current staff entering into the telehealth arena or exploring new technology should be in place. This could include a mentoring program where a high-functioning pharmacist with telehealth mentors a new or struggling pharmacist. In addition, ongoing developments related to telehealth could be considered during staff meetings, journal clubs, or other group settings. Facility or healthcare system policies should be routinely updated to address changes in facility, state, and/or federal regulations related to telehealth management. These changes should be routinely relayed to the provider practicing CMM in the telehealth environment. Lastly, data generated from CMM telehealth outcomes should be incorporated into a quality assessment process. This could include pharmacy-specific activities or activities addressed by a facility quality assurance team.


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Scenario 1

You recently started a position as clinical pharmacist at a physician-based clinic located in a rural area. Since starting, you have implemented chronic disease management services for diabetes, hypertension, and dyslipidemia. To date, you have a no-show rate of approximately 45%, and many patients state it is simply too far to travel from their home for monthly appointments. Given this significant no-show rate and identified barrier, you would like to explore establishing telehealth pharmacy services. Who could you reach out to as a first step to discuss this opportunity?

Response 1

The clinic manager would be a great resource for you when considering starting telehealth pharmacy services. The clinic manager will likely know about any current telehealth services and workflows that could be extended to include telehealth pharmacy services. If there are no existing telehealth services or workflows, the clinic manager would be a necessary partner for helping to establish telehealth pharmacy services. For example, the clinic manager will be able to engage key staff members in needed workflows such as patient check-in or registration, enrolling patients in the telehealth platform or providing support or education on a telehealth platform, scheduling, and so on. It can also be beneficial to have a physician champion involved in the process to help advocate for the importance of pharmacy services to have access and resources to provide telehealth pharmacy services.

Scenario 2

While working through developing workflows for telehealth pharmacy services, you become concerned about the ability to have your patient share any blood sugar or home blood pressure monitoring data in a meaningful way. You are concerned about having to work through a month's worth of data with patients either over the phone or virtually to get the information you need to make adjustments to medication regimens. Plus, you are worried that getting all that information during the visit may take up a significant portion of the visit time.

Response 2

Review what options you could build into your workflow to capture patient-reported data prior to the telehealth visit. Some electronic health records may capture patient-reported data. This could occur through asynchronous modalities such as patient messaging or flowsheets that have prespecified fields for patient responses. If there are no options to leverage within the electronic health record to obtain these data pre-visit, consider what other options may be available: for example, leveraging clinical staff to call patients ahead of their telehealth pharmacy appointment to gather pertinent information, including the data needed for clinical decision making during the visit.