As telehealth pharmacy practice becomes more integrated into clinical care models, it is important to consider how this medium may impact pharmacy learning experiences. The rigor of the learning experience and the teaching of essential skill sets must be maintained in the telehealth practice model. This new care approach can allow for creative methods to learning, whether creating a new experience or adapting an existing one. Successful preparation of sites, preceptors, and learners is imperative for successful integration of learners into telehealth pharmacy practice models.
General steps to preparing telehealth pharmacy practice sites for learners include:
Patient care experience preparation
PREPARING THE CLINICAL SITE FOR TELEHEALTH PHARMACY PRACTICE LEARNERS
Although site preparations will vary depending on the type of telehealth provided, evaluating the experiential learning environment and meeting site requirements for learner participation remains constant. A well-developed site integrates both the patient care environment and the environment in which teaching and learning occur1 where the structure of the telehealth learning environment should enhance and complement the patient care environment (see Figure 16.1). When preparing different clinical and learning environments that will be provided via telehealth, initial evaluations should consider necessary resources. Resident and student preparation will differ. Residents have the ability to practice independently of their preceptor, as they are licensed pharmacists, and as such they do not require direct supervision. However, students will be licensed pharmacy interns, thus requiring additional space for preceptor oversight or direct supervision for certain activities (varying based on state pharmacy legislation). The physical space must be large enough to accommodate the number of pharmacy learners adherent to site and experience requirements for group interactions, preceptor oversight, distancing, and the like, while also offering private space as needed for HIPAA-compliant patient care, individual projects, and preceptor feedback. Access to the electronic health record and/or patient charts may require authorization for distance accessibility if the physical space onsite is inadequate and a remote location is needed. The site's technical support should be evaluated and a plan developed in anticipation of technical failures. In addition to computer access, a phone that allows three-way calling can be useful for preceptor use in modeling patient care and learner oversight, as well as enabling interpreter services. Learners will also benefit from access to drug information and primary literature resources either online or onsite.
Site-related learner requirements may come from the pharmacy program, institution, and state and/or local government, and will require the preceptor to navigate and resolve any conflicting or ambiguous requirements of the learner. Examples include clarifying any needed immunizations and testing (e.g., PPD, influenza, COVID-19), as well as defining the frequency of testing if the experience is ongoing or longitudinal. If learners are remote and interacting via distance experiential learning, the plan will need to consider how to obtain confidentiality agreements, background checks, drug testing, and any other requirements. In addition to site preferences, individual states likely differ in terms of required preceptor oversight and student supervision and may need clarification for telehealth purposes.
Beyond physical resources, it is important to ensure that the telehealth pharmacy practice experiences offer the same number and variety of patient encounters as a traditional face-to-face experience to ensure attainment of course goals and objectives. Sites that offer the addition of support staff to provide assistance with nonclinical activities such as scheduling, verifying patient eligibility, confirming patient accessibility to connective resources, and calling for appointment reminders can allow more time for clinical services and provide a more efficient teaching experience.2,3
Tool for Telehealth Pharmacy Practice Experiences
Site Preparation Checklist
1. SITE-SPECIFIC REQUIREMENTS
Immunization, physicals, background checks
Confidentiality agreements, method to obtain agreements
Drug information resources: availability and accessibility
Primary literature resources: availability and accessibility
2. SPACE/PHYSICAL CAPACITY
5. QUALITY EXPERIENCES
Group working space with appropriate distancing or ventilation
Private space to conduct remote pharmacy visits
Confidential patient space (if visit occurs from office setting)
Site offers number and variety of patients with technology literacy/resources
Site offers staff support to ensure quality time with patients and students
6. STATE-SPECIFIC REQUIREMENTS
Electronic health record access (onsite and remote)
Telephone access (remote routing)
Preceptor oversight requirements
Telehealth care is fully and legally compliant
Software Considerations for Pharmacy Telehealth Practice
As part of site preparation for clinical rotations that will be using telehealth as a care platform, significant thought should be given to selection of the software that will be used. Medical institutions and/or pharmacy programs may have specific software already selected. However, if the reader has the opportunity to select such software, ideal attributes include the following:
Health Insurance Portability and Accountability Act (HIPAA) compliant
Family Educational Rights and Privacy Act (FERPA) compliant
Applicable to a variety of devices, including computers, smartphones, and tablets as well as operating systems (iOS, Android)
HIPAA compliance. The U.S. Department of Health and Human Services (HHS) stresses the importance of maintaining HIPAA when providing telehealth services. When selecting a telehealth software, HHS recommends choosing vendors that will enter into a HIPAA business-associated agreement.4 As telehealth continues to grow and evolve, HIPAA-compliant software will be developed and updated. The HIPAA Journal is a useful resource when searching for the most up-to-date HIPAA-related information, and it provides a checklist for HIPAA compliance.5
Cost effectiveness. When selecting telehealth software, the reader may consider the initial cost of the application, as well as additional costs associated with distributing to providers, pharmacists, residents, and students. It may also be worth verifying patient costs to access and utilization of software. Ideally, the selected software will be easily distributed to rotating learners and free for patients to use.
Ease of use. Selected software should be easy for providers, patients, residents, and students to use. In addition, if the software supplies training videos for its users, this may significantly increase the benefit users derive from it.
Video/telephone capabilities. Ideally, software will give users the capability of conducting patient encounters via video or telephone conferencing. Video and telephone capabilities are important for patient populations with barriers to either communication mechanism. Known barriers include minimal/no access to the Internet/video cameras, lack of proficiency in using technology, and patient preferences to avoid video communications. However, the nature of the visit may require video communication (e.g., evaluation of bruising from an anticoagulant, peripheral edema), and this should be considered when scheduling the visit with the patient and discussing the method of telehealth pharmacy practice care delivery.
Highlighting Essential Components of Telehealth Software for Learners
The development of communication skills is essential for learners. According to the Accreditation Council for Pharmacy Education, Standard 3.6 identifies communication as a key component for student learners.7 In addition, communication is highlighted throughout PGY1 and PGY2 ASHP Accreditation Standards.8–10 As new forms of communication continue to be developed, it will be important for learners to master technological forms of communication such as video and telephone.
Screen-sharing capabilities. In order for students and residents to counsel patients safely and effectively, telehealth software should have the ability to screen share. Screen sharing allows students or residents to effectively display information on their screen for the patient, and it also allows preceptors to model chart reviews. With this feature, it is easier to counsel patients. For example, when starting insulin, it is important to ensure that the patient has a good understanding of how to administer the medication. A student or resident could pull up a video of administration steps for insulin to share with the patient.
Screen-sharing capabilities give preceptors the ability to mirror on-the-spot teaching and topic discussions in a virtual environment. Some software has the ability to not only screen share but also mimic a whiteboard as an additional tool to assist comprehension for visual learners.
Chat feature. In the same way that screen sharing assists students and residents with counseling patients, a chat feature can be utilized for counseling. For example, students and residents can type out instructions that the patient can save for later reference. The chat feature can also be used to supply website links to the patient regarding other counseling points. A good example might be inclusion of a hyperlink to the plate method for patients with diabetes. If the platform allows for private chat, this feature could also be used during live educational sessions to coach the learner for specific tasks or areas to cover without having the observing preceptor interrupt.
Simultaneous multi-user capabilities. This function allows preceptors to accompany students or check in on residents during a patient visit, as well as allowing more than one person to complete the appointment. For example, when appointments are scheduled in advance and a specific learner is not assigned to the appointment, it is useful to have a versatile link that any student, resident, or pharmacist can access to complete the appointment. The link can also be used by preceptors to check in on learners.
The ability of preceptors to view learners in a virtual setting is important for both evaluation and feedback and ensures that the learner is appropriately communicating accurate information to the patient. In instances where learners encounter a problem and require assistance, the ability to have multiple users simultaneously engage in the visit may allow preceptors to step in and assist the learner and solve any issues that develop.
Applicability to a variety of devices. Patients will have different preferences for how to communicate with their healthcare team in terms of telehealth delivery route (phone vs. video) or device, which may include a computer, smartphone, or tablet. These devices may run different operating systems such as iOS or Android. The ideal program will not only be applicable to a variety of devices but also to operating systems to give patients and providers the ability to use their preferred device for the telehealth pharmacy practice visit.
Evaluating and Selecting Multimedia for Learning
Anstey and Watson recently released a Rubric for E-Learning Tool Evaluation, which may offer pharmacy educators and preceptors a way to assess the capabilities of different e-learning tools to meet the needs of pharmacy students.11,12 This rubric may prove useful in evaluating various multimedia platforms as sites prepare for their students and residents.
Functionality: Does the tool serve its intended purpose well?
Can be scaled to accommodate any size class and allow creation of smaller subgroups
Ease of Use
Has a user-friendly interface, allowing students and preceptors to become easily proficient
Tech Support / Availability of Help
Campus-based technical support or documentation is easily accessible, robust support platform for troubleshooting
Allows user to communicate via different channels (audio, visual, textual); allows flexible/adaptive engagement with material
Accessibility: Does it support multiple learning approaches and engagement for all students?
Does it, at a minimum, adhere to mandated requirements for accessibility?
Addresses the needs of different users with different literacies and capabilities
Use of tool does not require equipment beyond normal capabilities of educators, preceptors, or students
Cost of Use
All aspects of tool can be used free of charge or at minimal cost
Technical: Does the technology have integral Internet access, software, hardware, and computer availability?
Integration/Embedding within Learning Management System (LMS)
Can the tool be embedded into a LMS (.html), yet retain full functionality?
Desktop/Laptop Operating Systems
Can be utilized with any standard, up-to-date operating system
Can be utilized with any standard, up-to-date browser
Students or users do not need to download any additional software or extensions
Mobile Design: Can it deliver content using current and expanding mobile technology?
Can be downloaded as either an app or mobile browser; takes into account use of smaller-sized screen
Little or no difference between mobile and desktop version
Offers offline mode, including continued access to core features/functions
Privacy, Data Protection, and Rights: Does it adequately protect personal information and intellectual property?
Sign Up / Sign In
Use of tool does not require external account or additional login
Data Privacy and Ownership
User can keep data private and decide if or how data are shared
Archiving, Saving, and Exporting Data
Can archive, save, import, and export content or data as needed
Social Presence: Does it allow participants to project their personal characteristics into the community, creating a safe, trusting environment for collaboration and teamwork?
Able to support a community of users through synchronous and asynchronous opportunities
Has technical solutions to hold users accountable for their actions
Tool is widely known and popular; likely, nearly everyone has basic technical competence to use it
Teaching Presence: Does it enable instructors to establish and maintain their teaching presence through facilitation, customization, and feedback?
Easy-to-use features allowing instructors/preceptors to actively engage, monitor, and provide feedback to students
Adaptable to the learning environment, easily customized to fit different contexts and learning outcomes
Instructors/preceptors can monitor student performance via a variety of measures and provide feedback via user-friendly dashboard
Cognitive Presence: Does it support students’ cognitive engagement in learning tasks?
Enhancement of Cognitive Tasks
Enhances engagement in tasks once thought overly complex or inconceivable via other means
Allows users to exercise higher-order thinking skills
Learners can regularly receive formative feedback on learning (track performance, monitor improvement, regularly test knowledge)
FURTHER PREPARING THE SITE: OBTAINING NECESSARY PERMISSIONS
Clinical Care: Obtaining Consents
Telehealth visits being conducted remotely require patient consent for insurance reimbursement. Additionally, it may be prudent to obtain patient consent if multiple parties participate in the visit such as students, residents, the primary clinical pharmacist, physicians, and nurses. Based on the nature of the visit and/or the patient's personal preferences, the patient may wish to limit the number of people involved in the visit, including those passively observing, making it important to address this issue at the very start of the visit. Outlining who will be conducting which element(s) of the visit establishes transparency with the patient and provides an opportunity to express patient preferences or concerns. In addition, by using remote means to complete the appointment, patients may be more willing to have observers as physical space limitations have been eliminated.
Methods to Communicate with Patients before, during, and after Telehealth Visits
Depending on the delivery mechanism of the telehealth pharmacy practice visit (telephone vs. video), patient-specific information may have to be delivered to the patient. For example, a link for a video visit will be patient-, date-, and time-specific, and may also need to be specific for the pharmacist or learner completing the telehealth pharmacy practice visit (see the earlier section in this chapter titled Software Considerations for Pharmacy Telehealth Practice). The clinic will have to determine how to communicate this information to the patient. Based on the type of visit and resources available, information may be transmitted via secure messaging within the electronic health record (EHR), directly emailing the patient, mailing information through traditional mail, or providing the information to the patient over the phone prior to the visit. The patient's preferred mechanism of communication should be determined, although the method of communication may depend largely on the route of telehealth delivery. Furthermore, if email is the preferred route, the clinic should consider who will be sending the patient the message, as it may be through an email of the clinic staff or pharmacist who may not wish to provide a personal email to patients. Use of institutional email sent to outside addresses may also compromise security. It is reasonable to consider including additional information in the email message concerning simple steps on how to use the telehealth software, to reply to that email for technical help, to ask clinical questions, or to provide emergency issues and specific instructions regarding whom the patient should contact if questions arise.
Lastly, preceptors will have to determine who will send information to the patient. Based on the type of information, the sender may include clinic staff (most likely for logistical information related to the visit, who to contact for technical support, etc.), the pharmacist preceptor, or the learner. If the learner is to be responsible for sending information, they should not have to use their personal, school, or residency email address to communicate with the patient. Ideally, the electronic medical record would be used to send information to the patient, with the additional advantage of being available to other members of the healthcare team for continuity. The preceptor should be able to review the information first for accuracy and completeness before it is sent to the patient. The preceptor may also have to implement a process to educate learners on the appropriate strategies to communicate information and appropriate verbiage to utilize, and also to vet the learner's ability to communicate via this mechanism prior to allowing the learner to send information to the patient. However, this will be highly dependent on the learner (IPPE, APPE, resident) and practice setting, and the process will have to be adjusted accordingly. The preceptor may consider separate training in this area, developing a “Best Practices Guide” or having patient cases to work through ahead of time to provide practice opportunities for the learners and clarifying questions. This practice approach will also allow the preceptor to gauge learner skillset, identify areas that require additional coaching, and provide feedback.
Defining Plans for Research or Quality Assessment Projects Regarding Learner Involvement in Pharmacy Telehealth Practice
Given the novelty of providing medication management services via telehealth, as well as creating, re-designing, and/or implementing telehealth-based learning experiences for a variety of learners, pharmacists may perform practice-based research, quality improvement projects, or education-based research evaluating the new or different models they are working within.13 Student learners may be interested in completing research projects, while residents will likely be required to complete a project. While the novelty of delivering healthcare and education via telehealth provides unique opportunities for research, it also introduces additional challenges that must be identified and addressed.
Based on the nature of a clinical project, the local Institutional Review Board (IRB) may require informed consent from the patient, depending on the focus of the research. It is important for the pharmacist to consult with their local IRB to determine whether telehealth-focused projects require IRB approval or if approval can be granted as a continuous quality improvement (CQI) project. These determinations would then guide the pharmacist with respect to what kind of patient consent, if any, would be required to collect and share data from these visits. If the IRB requires informed consent, it is important to ensure that the personnel obtaining informed consent are listed as researchers on the project. Students and/or residents rotating through the practice site on a short-term basis may not be listed on the project and therefore should not be the ones obtaining informed consent from the patient for the research-related aspects of the visit.
For education-based projects, informed consent may be required from the learners who will be the study participants. Given that students may be considered a vulnerable population, special attention will have to be given to the IRB and consenting process. Furthermore, if the nature of the research is behavioral or survey-based, the local IRB may have different and/or additional requirements than are required for traditional clinical projects. If the project is describing changes made to an experience or discussing high-level considerations for restructuring or delivering learning experiences through telehealth, it may not require formal IRB approval, but it may be prudent to check with the local IRB before starting the project.14
QUALITY AND OUTCOME ASSESSMENTS FOR LEARNERS ENGAGED IN PHARMACY TELEHEALTH PRACTICE
Developing a quality assessment program is instrumental in ensuring that the experience is delivering both high-quality patient care and student/resident learning opportunities. Hard metrics used to assess the patient care environment, such as number of patients seen and number of clinical interventions, can also be used to evaluate the quality and variety of the student/resident learning environment and see that learners are provided an appropriate number of opportunities to make clinical interventions.
In addition to utilizing student site evaluations after the experience, assessment of qualitative measures throughout the experience is important. Input from staff, clinicians, students, and patients should be solicited to track satisfaction metrics on both the patient and student/resident experiences. Possible survey questions could include the following:
How has the telehealth pharmacy practice experience impacted student/resident satisfaction?
How has student/resident integration impacted patient satisfaction?
How has student/resident integration affected provider satisfaction?
How has student/resident integration influenced patient outcomes?
Workflow quality assessments should also be included, noting time of student engagement at each step, as well as technology benefits and limitations. Preceptors should look for opportunities to restructure and improve the processes and learning experiences if problems are identified. Given the novelty of providing both patient care and education functions in a telehealth environment, it is expected that adjustments will be required. In addition, routine assessment of the service, both clinically and from an educational perspective, will be needed to ensure changes are made in a timely manner.
As society demands improved teaching and awareness of cultural competency, other areas for focused consideration include tracking for diversity of patient encounters during the telehealth platforms, social determinants that create barriers for telehealth use, or disabilities that may influence care quality if not considered. Learners need to have skills ranging across various social determinants of health. Thus, it is important to comprehensively introduce students to a wide diversity of patients so that they may be exposed to varied approaches necessary to improve the patient care outcome. Another often overlooked consideration is the healthcare worker's implicit bias, which may offer interesting discussions with learners trying to implement care with telehealth modalities.15
PREPARING THE LEARNING EXPERIENCE TO HIGHLIGHT PHARMACY TELEHEALTH PRACTICES
In traditional experiential teaching, consistency and standardization are essential for effective teaching, and the same remains true for integrating students and residents into a telehealth pharmacy practice experience.16 To provide a learning environment that supplements the clinical environment, the preceptor should be prepared to evaluate the learning objectives, structure and workflow of the experience, preceptor and learner training, the quality of patient encounters, and clinical and educational outcomes.
Establishing Goals and Objectives
Preparation for the telehealth pharmacy practice experience starts with determining how goals and objectives will be practiced and assessed for student/resident ambulatory learning. Experiential requirements may need to be adjusted to account for the delivery of services via telehealth, though the extent may depend on a variety of factors including:
The route(s) of delivery of telehealth pharmacy practice services
The proportion of clinical services provided in-person versus telehealth
The location of the learner (clinic site only, home only, or a hybrid)
Scope and types of services offered including, but not limited to, medication management, medication reconciliation, patient counseling and education, or vaccine administration
Opportunities (or lack thereof) for collaboration with other healthcare providers
Opportunities (or lack thereof) for physical assessment skills such as blood pressure, point-of-care blood glucose, HbA1c, or INR testing, foot exams
Opportunities for documentation regarding patient interactions and care plan development
If objectives are not met or are not adequately evaluated, alternative options should be explored. While simply delaying assessment of these skills until a later rotation may seem reasonable, the schedule of the learner and the number and type of rotations remaining may not allow for assessment of certain skills.
If certain objectives cannot be met during the course of the rotation due to lack of access to direct patient care or lack of remote access to the electronic health record, creativity in achieving the objectives is required. Identified gaps in the experience can be supplemented with self-directed learning such as journal clubs, topic discussions, drug information questions, and case studies. Asking the residents or students to present the next clinical step after independently researching the topic can challenge learners efficiently and complement the telehealth encounter.17
Tool for Meeting Objectives in the Virtual Environment13,19,20
Supplementary Asynchronous Ambulatory Care Activities in the Telehealth Pharmacy Experience
Medication therapy management (MTM) reviews
Prior authorization processing
Medication assistance program enrollment coordination
Educational session (in-services, grand rounds, etc.)
In cases where the assessment of certain objectives is not feasible (e.g., vaccine administration, physical assessment skills) due to services being provided exclusively via telehealth, the preceptor may have to evaluate these skills outside of a patient care episode. It may be possible for certain learners to demonstrate some of these skills on a consenting person living in their household/co-learner on the same rotation while the preceptor observes remotely in real time or a recording of the learner performing the assessment skills. Some skills, such as vaccine administration, may necessitate assessment through a discussion with the learner who would verbally walk through the required elements or through a written assessment created by the preceptor to evaluate specific techniques and skills. While these routes of assessment are not preferred to assessment completed on a live patient, they may be required if in-person clinical services cannot be provided. Alternative options may also include instructing the learner to develop their own training video and record themselves performing the steps in a simulation-type setting with the use of training aids or on another student.
Outlining the Workflow for Learning Engagement in Pharmacy Telehealth Practice
After determining the goals and objectives of the experience, preceptors should develop a workflow plan for learner integration into telehealth pharmacy practice visits that take into account both patient care and student learning or teaching environment. Successful integration of students into the telehealth process is a team effort, and engagement of clinic staff, clinicians, and IT personnel is necessary to provide input on workflow design and identify areas in the patient care environment where the student experience will fit. Different models will need to be created for students and residents, assuming the resident acquires licensure in the state. While oversight is still necessary, the intensity is different than with a student learner.
Opportunity #1: The pharmacy clinician schedules patients rather than having support staff, leaving less time for student interaction.
Solution #1: If support staff are not available, students can be involved in patient scheduling and preparation, particularly if clinical baseline questions are incorporated at this stage.
Opportunity #2: Patients are unfamiliar with telehealth procedures, which makes the experience less efficient.
Solution #2: Patients may need an orientation to the telehealth procedure and tips to facilitate the visit. The student can be included in assessing patients’ health literacy and barriers to care and can be asked to reflect on the early contact points of the encounter.
Establishing a Technology Orientation Process for Learners
Many student/resident experiences are blocked rather than longitudinal. Establish a plan to train preceptors, students, and residents on the telehealth platform that will be used. In addition to training information concerning the platform, incorporation of training specific to telehealth communication strategies is essential. Training resources and expectations for self-study should be communicated to learners before the experience in addition to onsite training and reinforcement.
Tools for Establishing a Technology Orientation Process
Check with vendor about the availability of training support resources.
Develop or obtain from your vendor written and/or training materials that learners and preceptors can use.
Develop or obtain from your vendor patient educational materials that learners can be taught to use to support different patient learning styles.
Provide resources ahead of the rotation for prep work and training.
Set clear expectations of learners’ self-directed learning and timeframe to complete.
Schedule time for preceptor-directed learner training and reinforcement.
CONDUCTING EVALUATIONS DURING OR VIA TELEHEALTH
Telehealth integration into learning models highlights the need for optimized evaluation. Evaluations can be broken into two major types: formative and formal.
Remote rotations may offer fewer in-person interactions, and it may become difficult for preceptors to give on-the-spot, formative feedback to learners. This problem can be alleviated by setting up “pulse checks” with learners. Pulse checks can be defined as a quick tool for formative feedback. Preceptors may set up pulse checks on a weekly or daily basis, and they consist of on-the-spot feedback dependent on the learners’ progress at that time. The goal of pulse checks is similar to that of in-person or on-sight rotations. However, with remote rotations, it may be more important to have frequent check-ins with learners to maintain the flow of communication and preceptor–learner relationships. “Remote Coffee Hour” and “Remote Lunch Breaks,” which encourage providing feedback during an informal virtual social setting, have been utilized in the professional arena and can be useful to help coworkers feel less isolated when working from remote locations.20 This concept can be applied to learners on remote rotations. These daily or weekly pulse checks can have a designated time determined at the start of the rotation and can be incorporated during breaks or mealtimes. Formative evaluations can also be spur-of-the-moment efforts to give the learner feedback in real time. In some cases, preceptors may find it is important to have both designated times set aside as well as opportunities for feedback in real time.
Tool for Pulse Checks
Pulse checks should encompass the following:
Feedback on learner’s performance from a patient care and professionalism standpoint
Feedback from learners to address concerns they may have, to discuss their learning experience so far, and to ensure the learner feels supported by the preceptor
Mental health check-ins to discuss feelings of inclusivity versus isolation due to less in-person interaction
Knowledge checks to ensure learners’ progression should be expected throughout the rotation
Formal evaluation may be less affected by remote learning environments than formative evaluations. Formal evaluation is data-driven, occurs after a particular learning cycle has ended, compares one student to expected outcome threshold for performance (e.g., exam scores), and may not be immediately actionable. Examples of such evaluations include writing assignments and formal exams.21
It is still imperative for preceptors to have clear-cut expectations and objectives for IPPE and APPE students and residents when conducting formal evaluations. A recent work by Boyle and colleagues22 examined student perceptions of IPPE rotations. Overall, students had less favorable expectations of their preceptors to develop site-specific goals and objectives, and they were less confident in creating and sharing their own personal and professional goals with those preceptors following their IPPEs.22 To provide greater focus on the development of pharmacy curricula and student rotational experiences, the Center for the Advancement of Pharmacy Education (CAPE)23 developed specific educational outcomes intended to highlight the unique role pharmacists played on the healthcare team and expand the clinical roles and responsibilities of future pharmacists. The reader is encouraged to access a complete listing of outcomes on the AACP website. Comprising 4 domains and 15 subdomains, many of the 2013 CAPE Educational Outcomes link directly to telehealth. Two examples are immediately apparent. First, the domain “Essentials for Practice and Care” discusses collecting and interpreting evidence, formulating assessments, and monitoring and adjusting plans. Second, the domain “Approach to Patient Care” highlights recognizing social determinants of health (like economic stability and access to certain technologies) to eliminate disparities in patient access to care. All of these skills can be drawn upon in a telehealth environment and should be encouraged by preceptors and residency directors.23
The American Association of Colleges of Pharmacy (AACP) designed Entrustable Professional Activities (or EPAs), which are essential activities or tasks that all new pharmacy graduates—whether entering the workforce or pursuing residency training—must be able to perform without supervision. AACP suggests that graduates should be “independently executable, observable, and measurable in their process and outcome.” The following EPAs serve as bare minimum competencies for newly minted pharmacists.24 The reader is encouraged, once again, to access a more comprehensive listing of EPAs on the AACP website. Of the 15 listed activities, at least one-third tie directly to telehealth and its opportunities for patient care, notably:
Collect information to identify a patient's medication-related problems and health-related needs.
Analyze information to determine the effects of medication therapy, identify medication-related problems, and prioritize health-related needs.
Follow up and monitor a care plan.
Identify patients at risk for prevalent diseases in a population.
Educate patients and professional colleagues regarding the appropriate use of medications.
Since such a high level of importance is placed on these activities in real-life practice—and they are witnessed in nearly every sector of pharmacy practice—it is essential that preceptors and other evaluators instill and cultivate these skill sets within their students’ pharmacists. While on rotation, telehealth pharmacy practice encounters could help students to further develop their ability to quickly assess a patient and their individualized needs, educate that patient about their therapy and potential side effects, and then successfully follow that patient longitudinally. No matter where a student pharmacist eventually practices, these foundational principles are essential.
When rotations are transitioned to remote learning settings, formal evaluation may not be directly impacted by this transition. However, to ensure all accreditation standards and residency standards are met, additional emphasis may be placed on key pieces of formal evaluations.
Formal elements of evaluation for rotational students:
Teaching, education, and dissemination of knowledge*
Special consideration may be placed on certain aspects of formal evaluations. When learners are completing patient interactions via telehealth, unforeseen challenges may be encountered when presenting patients to preceptors, interviewing patients, and providing education or counseling to patients. While the specific criteria used to evaluate learners will not change, as quality patient care still needs to occur regardless of the setting, the means to meet these standards have changed and may require more coaching from preceptors. While remote rotations and experiences will provide unique challenges, formal evaluations remain important benchmarks for learners as well as preceptors and should cover all aspects of the learning experience.
PREPARING THE LEARNER FOR PHARMACY TELEHEALTH PRACTICE
To provide the foundation for a successful experience whether remotely or in person, it is ideal to create a well-organized orientation that occurs at the beginning of each learning experience. While a well-structured orientation will likely create an increased workload upfront, it will also ensure a smoother experience for the learner during the rotation.
Part of the orientation may include a checklist for essential tools required of the learner for the experience.
Tool for Essential Resources Required for Learner Experience
Sample Resource Checklist
Computer/hardware (i.e., widescreen monitor, working computer, quality headphones/microphones)
Quiet work area that ensures clinical activities (i.e., phone calls) can be completed in private
Resources for drug information requests
Capability for contacting patients via phone (i.e., HIPAA-compliant phone app)
Resources for communicating with preceptor real-time during clinical activities
Once orientation is under way, preceptors must embrace innovation and creativity to optimize the learning experience, as this can make for a better experience for both the learner and the preceptor. Early in the experience, topic discussions could be batched remotely to gauge the learner's baseline knowledge and to prepare the learner for patients seen either in person or as telehealth pharmacy practice. Nondirect patient care activities can occur via a remote platform without jeopardizing the learning experience.13,25 For instance, with learning experiences in which learners are onsite for some of the time and remote for the remainder of the time, a half-day per week may be devoted to completing topic discussions and journal clubs via a remote platform.
Discussion of expectations and scheduled check-ins with learners are vital for remote-based experiences. Learners may feel apprehensive that the experience may not be able to provide them with direct patient care opportunities (especially those interested in ambulatory care) or that they will not have enough opportunity to develop crucial relationships with preceptors that may benefit them as future career opportunities arise.26 In addition, anecdotal evidence suggests that learning experiences, which are 100% remote or hybridized, can feel isolating. While preceptors are in charge of precepting the clinical experience, they are also responsible for fostering both personal and professional growth during the rotation. The key to success for such growth is to promote personal resilience and care for the learner's well-being. The following may be considered in order to promote resilience and well-being in our learners during times of change:
Upfront and clear expectations
Assurance that learning objectives will be met regardless of direct patient care opportunities
Regular check-ins with the learner to ensure progression on rotation activities
Regular check-ins with learners to gauge how things are going personally
Emergency and backup contact information so that the preceptor is readily accessible
WORKING THROUGH BARRIERS WHILE PREPARING A TELEHEALTH PHARMACY PRACTICE LEARNING EXPERIENCE
Barrier 1: Transition to Remote-Based Learning Environments (Students and Residents)
The majority of teaching prior to rotations happens live within the classroom setting for students and within the clinical setting for residents. The majority of students and residents have had minimal learning experiences/encounters remotely. Also, students and residents are commonly prepared to complete rotations in person with preceptors and patients. These common practices do not prepare students for the transition to remote patient care experiences.
Solution 1: Incorporate Brief Training in Student and Resident Orientation to a Clinical Experience
Orientation for students and residents typically consists of familiarizing learners with the physical practice site, workflow, and expectations/responsibilities. For remote rotations, the focus of orientation may shift. Instead of familiarizing learners with the physical practice site, preceptors can spend time reviewing how to use the telehealth software and the electronic health record. This can be done with the preceptor or on the learners’ own time with training videos or modules provided by the telehealth software and/or the institution. Orientation to workflow and setting expectations/responsibilities will also shift to focus on remote interactions. Differences will occur in how and when learners will need to report to preceptors, whether in reference to patients, projects, questions, and so on. In addition, clearly defined expectations will need to be set, with emphasis on telehealth/remote encounters.
Barrier 2: Possible Reduction to Patient Access/Patient Encounters
Because of the inherent challenges of telehealth related to technological literacy and to limited access to technology/Internet, remote rotations may have a smaller number of available patients to be seen during a rotation dependent on population.
Solution 2: Alternative Projects Focused on Clinical Knowledge and Patient Care
According to Standard 13 of the Accreditation Council for Pharmacy Education, APPE students are not required to see a certain number of patients; however, they” should be exposed to a minimum of 160 hours in each required APPE area.”7 This concept holds true for residents as well. According to ASHP Duty Hour Requirements, pharmacy residents must complete a specific number of hours on each rotation.27 With a decrease in patient touch points, preceptors will need to have prepared projects/assessments to replace the time learners would usually spend with patients. These projects/assessments should be focused on clinical knowledge or patient care, providing the learners with experiences analogous to patient care.
Patient Case Development: Have learners create a patient case focusing on a specific disease state. Along with this case, have learners develop questions to go along with it. Learners will have to review the disease state in depth in order to create a complex case with thought-provoking questions.
Note Template Development: Have learners create a note template they would want to use to help guide themselves through patient interviews. This gives learners the opportunity to work through what information is important to gather on a subjective level and what information is needed to make clinical decisions. Further, it creates opportunities to have learners justify the importance and relevance of the interview questions to encourage a deeper understanding behind the structure and focus of an interview for a particular disease state.
Barrier 3: Patient Resistance to Telehealth Pharmacy Practice Appointment Types Coupled with Learners Providing Care
In some instances, patients may express concern about the accuracy or efficacy of completing an appointment over telehealth. This worry may be amplified when a learner is completing the encounter, regardless of preceptor presence.
Solution 3: Empowering Learners to Explain the Details of Telehealth
Patient resistance in this setting gives learners the opportunity to flex their communication skills. Throughout the rotation, learners will have the opportunity to observe their preceptors in order to see how to best alleviate a patient's fear. Preceptors can empower learners to explain what telehealth pharmacy practice is, what it will look like for the patient over the next several months, and what to expect from healthcare professionals. It will be important for preceptors to prepare learners for these conversations with patients, and opportunities to practice via role-playing scenarios may be necessary prior to learners engaging in conversations with patients. This is a vitally important skill for residents as they will be evaluating patients more autonomously as opposed to the supervised student interactions.
Barrier 4: Time Management
Given the increased utilization of web-based platforms for telehealth, time spent on such applications as well as integrating other essential activities may be increased when compared to 100% face-to-face activities. Therefore, it might prove difficult to find enough time to complete the required patient care activities in addition to these other essential activities in remote learning environments.
Solution 4: Set Priorities and Remember Boundaries
Integrate learners into practice early on to help with both clinical and nonclinical activities.
See workflow incorporation suggestions under Outlining the Workflow for Learning Engagement in Pharmacy Telehealth Practice.
Evaluate points in the workflow where students can be integrated and design learning activities to complement the work function. Example: Learners can participate in scheduling, but add a clinical component such as a health literacy assessment that the learner can provide and reflect upon.
Barrier 5: Communication
Learners should be prepped on best practices related to communicating via video or telephonic routes, as most didactic teaching is focused on in-person communication where body language and other nonverbal cues are able to be ascertained and communicated. However, some of these cues may not be received at all, such as when communicating exclusively over the phone, or they may be reduced when using video mechanisms of communication. The importance of speaking slowly and clearly should be emphasized, but learners should also be prepared to pause the conversation frequently to ensure the patient is appropriately following along, has understood what has been communicated, and has no additional questions. Utilization of the “teach back” method following counseling will likely be prudent to ensure the information conveyed by the learner was accurately received and internalized by the patient. If possible, it may also be important to send written instructions to the patient following the visit to ensure pertinent information is available to the patient after the visit has concluded.
Solution 5: Additional Practice with the Preceptor or Other Learners Will Likely Be Needed Prior to the Learner Completing Direct Patient Care Activities
Ideally, these practice sessions should occur via the same delivery mechanism of the planned patient care services (telephonic, video) in order to more accurately simulate the expected environment in which the care will be provided.
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