The North Dakota Telepharmacy Project Restoring and Retaining Pharmacy Services in Rural Communities

1. The North Dakota Telepharmacy ProjectRestoring and Retaining Pharmacy Services in Rural Communities Charles D. Peterson, Pharm.D. Dean & Professor College of Pharmacy Sandy Sprafka, Information Tech Services North Dakota State University Fargo, North Dakota

2. North Dakota Demographics2000 Census Highlights • 642,200 population, ranks 47th in nation • Population growth 0.5% (1990-2000) • Population shift from rural to urban • Only 6 of 53 counties gained population • 50% of ND counties lost at least 10% • 27 of 53 counties classified as frontier • 14.7% over 65, vs 12.4% nationally

3. Pharmacy Services in ND • Of the 373 cities, 73 have pharmacies • Of the 53 counties, 9 do not have a pharmacy and 11 have only one Rx • North Dakota 51% ownership law

4. North Dakota Rural Health Care Crisis:Community Pharmacy Closings • 26 rural community pharmacy closings • 12 additional pharmacies at risk of closing • Pharmacist retirements - no replacement • National pharmacist shortage • Negative impact on rural health

5. Exploring Solutions:Telepharmacy Rules • Required changes in pharmacy practice act • Telepharmacy rules established by NDBDPh • Pilot project in 2001  permanent rules established in June 2003 • Allow pharmacists to supervise a technician at remote site within 50 miles • Dispense prescriptions • Pharmacist - patient consultation

6. Telepharmacy Grant Awarded NDSU College of Pharmacy • Congressionally mandated federal grant via the support of Senator Byron Dorgan • Office for Advancement of TeleHealth, Health Resources and Services Administration of HHS • First Initiated: September 1, 2002 • $1,671,621 federal support to date

7. Goals of Telepharmacy Grant: • RESTORATION - restore pharmacy services in rural communities which have lost their services • RETENTION - retain pharmacy services in rural communities which are at risk of losing their services

9. Telepharmacy Project Partners • NDSU College of Pharmacy • North Dakota State Board of Pharmacy • ND State Pharmaceutical Association • Licensed rural community pharmacies • Targeted rural communities

10. Telepharmacy Grant Budget • Assist in the telepharmacy start-up costs • 50% OAT Grant/50% North Dakota • Technology: Hardware, Software, Connectivity • Registered Pharmacy Technician • Pharmacy Fixtures • Drug Inventory • Travel

11. Pharmacy Technician Responsibilities: Remote Telepharmacy Site • Maintains drug inventory at remote site • Processes all prescriptions orders including controlled substances • Computer order entry, filling, billing, labeling • Takes original prescription orders by phone • Prepares prescription for dispensing by pharmacist • Connects patient to the pharmacist for private consultation via audio and video link

12. Technician Training Requirements: Telepharmacy Sites • Registered with Board of Pharmacy • ASHP accredited program or equivalent • Minimum of one year experience in dispensing prescriptions • Salaries are $15/hour or more • Reciprocity from other states requires PTCB certification

13. Pharmacist Responsibilities • Final check of technician Rx preparation • Dispenses drug to the patient • Drug utilization review • Patient education counseling

22. Demographics:Remote Telepharmacy Sites

23. Demographics:Remote Telepharmacy Sites

24. Benefits to North Dakota with the Telepharmacy Program • Improved access to health care for rural citizens • Provides rural economic development • Improved quality of care/pharmacist consults • Increased patient & pharmacist satisfaction • Increased financial viability of rural pharmacies • Provides relief for pharmacists for vacations, etc. • Increased educational opportunities for students • Increased retention of pharmacy graduates

25. Economic Impact of Telepharmacy • Has added a $500,000 per year business to the rural community • Thus far, has added an estimated total of $7.5 million annually to the North Dakota rural economy • Has added an estimated 30-40 new jobs to the North Dakota rural marketplace • Has added 50% increase in prescription sales to combined pharmacy operation

26. Economic Development Add’l Benefits of Telepharmacy • Helps attract other businesses and families to community because basic health care infrastructure is present • Pharmacy can be used for other business retailing not currently available within the community

27. Pharmacy Student Involvement • Incorporate telepharmacy technology in NDSU’s new Concept Pharmacy Lab • Trains students on the latest advances in pharmacy technology • Teaches students how to deliver pharmacy services in a unique and innovative way to smaller rural communities

28. Student Activities • Provide pharmacists at the Central Pharmacy with drug information and disease state management assistance • Provide patient education counseling to remote telepharmacy sites

29. Future Goals of Telepharmacy in North Dakota • 5-10 new community sites each year • 50 telepharmacy sites in five years • Develop a model for serving rural hospitals • Assist other states in implementing telepharmacy services in rural areas • Establish a state-wide data & video network • Establish equipment standards

30. Recent Publication If you would like more information: Peterson, CD and Anderson HC. The North Dakota Telepharmacy Project: Restoring and Retaining Pharmacy Services in Rural Communities J. Pharm. Tech 2004:20:28-39

31. From the technical side …. Project parameters • Independent, privately owned businesses • Keep costs down • Keep prescription processing separate from consultation

32. Independent Pharmacy Clusters

33. HIPAA Authentication Secure connections Reliability Internet1 Costs Network management Troubleshooting Standardization Growth Flexibility Issues to Address

34. Telepharmacy TechnologyHardware Polycom Viewstation (VSX7000 Second camera Document camera 2 mics (mute separately) PC & printer 2 TV monitors VPN – for encrypting Rx and video

35. Telepharmacy Technology – cont’d Prescription Processing Standard Pharmacy Operations Software Patient Consultation Polycom ViewStation Prescription Verification Polycom Viewstation HIPAA/Privacy Virtual Private Network (VPN) – Sonic Firewall

36. Telepharmacy TechnologyConnectivity Local telephone company Prescription Processing Dedicated POTS with 56K modem Patient Consultation Symmetric DSL at 512K bandwidth

37. Lessons learned • Not all pharmacies the same, unique components • Customers prefer talking to a “TV” • Separate prescription processing - consultation • Polycom units need flexibility (speakers, mics) • Video works – VPN, firewall, 512K SDSL, 256K • Different local phone companies • Different pricing, solutions • Internet1 a quality problem beginning at 3pm

38. Identified Needs • Standards (except pharmacy software) • Video links to all

39. Network solutions • Statewide Private IP Network • Connection to Internet2 for out-of-state

40. NDSU Killdeer Pharmacy Radius Authentication Server Access Device With integrated VPN Access Device With integrated VPN VPN Accelerator 512X512 DSL DCN Core Router DCN Core Router DCN T1 Internet Access ISP Connected to DCN IP Core DCN IP Core ISP Connected to DCN IP Core DSLAM Public Internet 512X512 DSL Access Device With integrated VPN Beach Pharmacy

41. NDSU Killdeer Pharmacy Radius Authentication Server Access Device With integrated VPN IP Tunnel IP Tunnels Pharmacist Access Device With integrated VPN VPNHeadend Student or Instructor DCN IP Core IP Tunnel IP Tunnel Pharmacy Tech Access Device With integrated VPN Access Device With integrated VPN New England Pharmacy Beach Pharmacy Pharmacy Tech

42. Features • Data encryption, authentication & security provisions – HIPAA • Secure videoconference between pharmacies – patient consultation • Secure data connection with document camera, database – dispensing • Management, growth, redundancy, reliability, QoS (video) • Internet access

43. Future Directions • Connect to other states • Collaboration • Instruction • Services • Internet2 – enabling technology • Research Universities • SEGP participants

44. High Speed Networks • Attract researchers, faculty, students • Provide increased grant opportunities • Provide greater access to resources • Fuel economic development • Facilitates innovative & progressive projects

45. Thank you Dr. Charles Peterson charles.peterson@ndsu.nodak.edu Sandy Sprafka sandy.sprafka@ndsu.nodak.edu (701) 231-8688