CLINICAL VIDEO TELEHEALTH NOTES

Innovative models for providing clinical pharmacy

services to remote locations using clinical video
telehealth

Cassie Perdew, Pharm.D., BCPS,

VISN 20 V-IMPACT Hub, Boise VA Purpose. The use of videoconferencing and other telehealth technologies
Medical Center, Boise, ID.
to expand access to clinical pharmacy services at multiple Veterans Affairs
Katie Erickson, Pharm.D., BCPS, (VA) clinics in rural areas of Alaska and the northwestern United States is
BCACP, VISN 20 V-IMPACT Hub, Boise
VA Medical Center, Boise, ID. described.
Jessica Litke, Pharm.D., BCPS, VISN
20 V-IMPACT Hub, Boise VA Medical Summary. Beginning in 2014, clinical pharmacy specialists at a regional
Center, Boise, ID. VA Telehealth Hub based at Boise VA Medical Center in Idaho have pro-
vided telehealth services for 16 clinics. In one telehealth model, a phar-
macist and other remotely located primary care team members (a medical
provider, a medical support assistant, a social worker, and a psychologist)
conduct telehealth visits with veterans located at VA clinics, with support
provided by clinic-based nursing staff; this model has been used to im-
prove medication management services for veterans in sparsely populat-
ed areas. In the second VA telehealth model, a remotely located pharma-
cist uses telehealth technology to participate in clinical encounters along
with primary care team members located at the patient site; this model
allows on-demand remote coverage in the event of planned or unplanned
absences of clinic-based pharmacists. Since the Telehealth Hub was es-
tablished, pharmacists have engaged in video encounters and provided
other telehealth-based clinical services to more than 1,200 veterans with
diabetes, hyperlipidemia, hypertension, and other chronic conditions.

Conclusion. Within the VA healthcare system, telehealth technology has

been demonstrated to be a cost-effective and well-received means of pro-
viding clinical pharmacy services in rural areas.

Keywords: clinical video telehealth, disease state management, health

services accessibility, pharmacists, primary care, telemedicine

Am J Health-Syst Pharm. 2017; 74:1093-8

V eterans Affairs (VA) medical cen-

ters have implemented the use of
innovative telehealth technologies to
the right time in the right place.1 Tele-
health technologies such as face-to-
face clinical video telehealth (CVT),
provide timely access to healthcare home telehealth, and care coordina-
while maintaining quality and man- tion “store-and-forward” programs
aging costs. Former VA Deputy Under have enabled veterans to access care
Secretary for Health for Policy and from their local VA community clinic
Services Madhulika Agarwal stated, or from the privacy of their own home
“Our goal is to ensure that Veterans (Table 1).2 An additional benefit is the
have optimal health and that we deliv- minimization of travel for the patient
er the best health care with a focus on and associated travel costs to both the
Address correspondence to Dr. Perdew timely access and with an exceptional patient and the system.1
([email protected]). experience.” The role of telehealth in One of the most versatile tools to
the Veterans Health Administration deliver care by numerous professions
DOI 10.2146/ajhp160625 (VHA) is to provide the right care at is CVT: synchronous, real-time, live,

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 NOTES CLINICAL VIDEO TELEHEALTH

secure, and reliable videoconferenc- clustered in medical centers. Conse-

ing that enables patient assessment KEY POINTS quently, primary care providers in VA
and development of a treatment plan, • Innovative modalities such as community-based outpatient clinics
including care coordination with staff clinical video telehealth (CVT) are less likely to establish collabora-
located at the VA facility where in- technology can create new tive relationships with these pharma-
person care is provided (referred to opportunities to support and cists and make use of their services.7
as the patient site). It is estimated improve patient, provider, and Patterson et al.5 found that veterans re-
that 40–45% of veterans live in ru- clinic access to clinical phar- siding in urban areas were more likely
ral or highly rural areas, as defined macy services in rural areas. to have a CPS encounter than veterans
by federal Rural–Urban Commuting in rural areas (rates of CPS service use
• Through CVT and other meth-
Area codes (Figure 1), and these ar- were 24.9% and 19.7%, respectively).
ods, a clinical pharmacy spe-
eas often lack highly trained health- Nearly half of all veterans had received
cialist with prescribing author-
care specialists.1,3 CVT helps meet CPS services through a telehealth en-
ity under a scope of practice,
the needs of veterans by addressing counter, but less than 0.2% of those
working as a member of a
problems of unavailable or delayed encounters involved the use of CVT.
primary care team, can manage
care and bringing care closer to those Based on this finding, the research-
chronic disease states and pro-
who may have difficulty accessing it ers suggested organizational changes
vide real-time drug information
for multiple reasons, such as trans- to increase the presence of CPSs in VA
support.
portation difficulties and geographic community clinics. Utilization of CVT
barriers. Wennergren et al.4 described • Provision of clinical pharmacy and other telehealth modalities is a
the use of CVT at the Indianapolis VA services via telehealth technol- way to provide primary care clinical
medical center and how it allowed ogy holds great potential for im- pharmacy services to rural community
veterans to access specialists while proving healthcare access and clinics lacking routine access to a CPS.8
remaining in their community. Those quality in nonurban areas. By improving both provider and
researchers demonstrated that CVT patient access to a CPS, the CPS can
was cost-effective and well received improve primary care provider access
by veterans, with an overall satisfac- in rural clinics. Primary care CPSs pro-
tion score of 96%. The results of this vide follow-up between primary care
study support the idea of matching provider visits and initiate, adjust, or
innovative modalities like CVT with Clinical pharmacy services discontinue medications to target
the expertise of a clinical pharmacist using CVT improved outcomes in patients with
to improve patients’ access to high- Potential disparities in rural and chronic diseases such as diabetes, hy-
quality medication management, es- urban patients’ access to clinical phar- perlipidemia, and hypertension and
pecially for those residing in rural or macy specialist (CPS) services have those who need pain management.
highly rural areas. been identified.5,6 VA CPSs tend to be CPSs are highly trained specialists who
have commonly earned a doctor of
pharmacy degree, completed postgrad-
uate residencies in ambulatory care or
equivalent practice experience, and
2,a earned board certification. As integral
Table 1. Telehealth Modalities Used in the VA Healthcare System
members of teams providing health-
Modality Description
care within a patient-centered medical
Clinical video telehealth Allows patients to come to a local VA outpatient home model (organized within VHA as
clinic and see a clinical pharmacy specialist or
other primary care team member in real time; the Patient Aligned Care Teams [PACTs])
clinician may be located at a clinic or hospital CPSs practice at the top of their license
hundreds or thousands of miles away as providers with prescribing authority
Home telehealth Allows patients to connect to a clinic or hospital under a scope of practice. They provide
from their home using telephone lines, cellular intensive medication management
modems, and cell phones for monitoring of
symptoms and measurement of vital signs (with for high-risk patients through team-
the help of a care coordinator) based care and population manage-
Care coordination store-and- Involves the acquisition and storage of clinical ment, thus reducing the workloads of
forward telehealth information (e.g., data, images, sound or video providers and other team members.
recordings) that can be forwarded to (or retrieved
by) another site for clinical evaluation CPSs can often provide same-day ac-
a
VA = Veterans Affairs.
cess for medication-related needs or
medication-related adverse events.7

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Figure 1. The Veterans Affairs healthcare system uses Rural–Urban Commuting Area (RUCA) codes to define rurality. De-
veloped by the Department of Agriculture and the Department of Health and Human Services, the RUCA coding system
takes into account population density and how closely communities are linked socioeconomically to larger urban centers.
Urban areas are defined as census tracts with at least 30% of the population residing in an urbanized area, as defined by
the U.S. Census Bureau. Rural areas are defined as land areas not designated as urban or highly rural. Highly rural areas
are defined as sparsely populated areas where less than 10% of the working population commutes to any community larger
than an urbanized cluster (typically a town of no more than 2,500 residents). Map reprinted with permission of the Depart-
ment of Veterans Affairs.

CPSs provide comprehensive scribe the 2 main models used within tered nurses (RNs) are also integral
medication management services our program to deliver comprehen- members of primary care teams, but
that have shown a positive return on sive primary care services via CVT and those personnel are located at patient
investment.7 In addition, using CVT to telephone to patients and providers at sites. The clinical pharmacy services
provide pharmacy services, as stated remote locations. component of this program, initially
previously, minimizes travel costs for provided by 1 half-time CPS, has now
both the veteran and the system.1 CVT The Telehealth Hub program grown to encompass 6 full-time CPSs
is a cost-efficient and flexible means The regional VA Telehealth Hub working as team members with mul-
of providing primary care CPS support based in Boise, Idaho, is a multicenter tiple providers and sites.
to multiple sites, as described below. program whose reach spans some of Across all sites where telehealth
To our knowledge, there are no the most remote locations in the Unit- services have been implemented, the
other published reports on the imple- ed States, including locations in Alas- emphasis has been on CPSs working
mentation of telehealth technologies ka, Washington, Oregon, Idaho, and as providers in a team-based model
to provide comprehensive primary parts of western Montana. The Tele- and using population management
care CPS services to support multiple health Hub staff consists of primary tools to provide comprehensive medi-
remote locations. Previous relevant care providers (physicians, physician cation management for chronic dis-
literature has focused on CPSs pro- assistants, and nurse practitioners), ease states in the primary care setting.
viding specific disease state manage- CPSs, psychologists, psychiatrists, li- CPSs are assigned to provider panels,
ment services (e.g., anticoagulation, censed clinical social workers, and with the ideal ratio being 1 CPS as-
specialty pain services, diabetes care) medical support assistants. Licensed signed to a total of up to approximate-
at one site.9,10 In this article, we de- practical nurses (LPNs) and regis- ly 3,600 patients.11

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Most patients managed by CPSs phone appointments with the patient. One scenario involves provision of
are formally referred by primary care In rare cases, a medical support assis- services to rural clinics serving small
providers and other team members tant at the patient site calls and sched- populations—settings in which it
when patients with intensive medi- ules the patient. All clinical notes are would be difficult to recruit a qualified
cation management needs are iden- entered into the electronic medical full-time pharmacist with ambulatory
tified; examples include but are not record, which is easily accessible with- care experience and, due to cost and
limited to patients with glycosylated in the VA healthcare system. demand factors, a full-time position
hemoglobin values greater than 9%, To meet different sites’ needs for may not be justified. This model pro-
frequent hypoglycemia, hypertension primary care teams and clinical phar- vides patients with timely access to
that is uncontrolled with the use of 3 macy services, different models of CPS previously unavailable CPS services
or more medications, and intolerance support have been developed and in rural communities. In the second
to statins. Some patients are identified successfully implemented. Different scenario, the virtual CPS provides
as appropriate for clinical pharmacy combinations and variations of the 2 contingency coverage for established,
services through the use of popula- main models described below have permanent CPS positions in situa-
tion management tools that employ been used to meet the needs of mul- tions involving planned or unplanned
similar patient identification criteria. tiple providers and clinics. extended leave or position vacancies.
CVT enables face-to-face visits and Model 1: Virtual CPS on all- During times of CPS absence, the
same-day access to care by facilitating virtual team. In this model, a prima- team and system can become strained
“warm handoffs” among team mem- ry care team consisting of a medical and access may be decreased, as re-
bers, as if the CPS and the patient were provider, a medical support assistant, sponsibility for all chronic disease
at the same physical location. CVT also a psychologist, a licensed clinical so- management activities falls on prima-
allows the CPS to attend team meet- cial worker, and a CPS is located at one ry care providers, who may also be in
ings virtually. Other methods, such as facility while the patient and nursing short supply. In such situations, CPSs
secure instant messaging, e-mail, and staff are located at a different, remote from other teams or clinics (already
phone services, are integral tools for location (the patient site) (Figure 2). assigned full workloads themselves)
communicating with team members The telehealth team is analogous to an are sometimes asked to help. Unfor-
throughout the day and providing onsite PACT or primary care team. Al- tunately, as these CPSs are already
access to real-time drug information though the CPS may be located at the busy, they are often unable to provide
support. same physical location as other clini- robust and continuous CPS services.
CVT is typically used for initial cal team members, the CPS still often As this model uses CVT technology, it
1-hour face-to-face visits, utilizing uses CVT, secure instant messaging, is possible for the virtual CPS to pro-
patient-site nursing staff (LPNs and e-mail, and phone to communicate vide continuous face-to-face clinical
RNs) to “room” patients for the visit. with team members. All members of pharmacy services to bridge tempo-
Rooming a patient involves check- the primary care team rely on LPNs rary CPS absences. In both scenarios,
in, measuring vital signs on request, and RNs at the patient site for addi- veterans are provided timely access to
providing the patient with a medica- tional support, including the rooming CPS services in their community.
tion list, notifying the provider that of patients for CVT visits. Using this
the patient has arrived, escorting the model, CPSs have been able to provide Discussion
patient to a room outfitted for the clinical pharmacy services to 7 clinics Since the program was started in
CVT appointment, and ensuring that in the VHA Northwest region. 2014, 6 Telehealth Hub CPSs have pro-
the equipment is working properly Model 2: Virtual CPS working vided clinical pharmacy services to 16
before leaving the patient to engage with onsite team. In this model, a VA clinics serving significant num-
in the visit with the CPS. Most follow- CPS works remotely from the rest of bers of veterans in rural and highly
up visits are 30 minutes or less and the primary care team and uses CVT, rural areas. Within these 16 VA clinics,
are conducted via telephone due to a telephone, and secure instant messag- CPSs have provided remote care to
need for frequent follow-up or short ing technology and e-mail to provide over 1,200 unique patients receiving
appointments or as necessitated by full-time clinical pharmacy services chronic disease state management
the patient’s distance from the clinic. for VA clinics. The provider, nursing services, primarily for diabetes, hy-
On occasion, patients prefer to come staff, licensed clinical social worker, pertension, hyperlipidemia, and to-
to the clinic for face-to-face CVT visits psychologist, and medical support bacco cessation. Patients referred to
for all their follow-up appointments. assistant are all located at the patient CPSs for disease state management
In most cases, due to the complex- site (Figure 2). This model has been consultations are seen within an
ity of scheduling and a lack of ancillary implemented across 9 sites within the average of 6.4 days of the request,
support staff, CPSs take responsibil- Northwest region and has so far met and nonvisit CPS consults (i.e., those
ity for scheduling their own CVT and individual clinic needs in 2 scenarios. for medication management related

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 CLINICAL VIDEO TELEHEALTH NOTES

Figure 2. Models of clinical pharmacy specialist (CPS) support via telehealth. LPN = licensed practical nurse, RN =
registered nurse, LCSW = licensed clinical social worker, MSA = medical support assistant.

Patient side/location

CPS side/location

Model 1

Provider
Patient
LCSW
LPN
MSA
RN
Psychologist
CPS

Model 2
Patient
Provider
RN
CPS
LPN
LCSW
Psychologist
MSA

to a specific patient and not requiring care team members, other facility and preferred by the patient. However, we
a visit) are completed in less than 1 clinic personnel, and veterans with believe that either modality provides a
day on average. regard to the vision of telehealth and valuable means of bringing timely CPS
This program’s success is attrib- the benefits of CPS involvement in care to patients in or near their homes
uted to multiple factors. The Tele- the care process have been vital to the and addressing chronic disease medi-
health Hub was established at a site success of the program. Providers and cation management needs. Other bar-
with historically good recruitment teams have been quick to adopt CPSs riers to this program have included in-
and retention of highly qualified CPSs. as integral team members. creased documentation requirements
Provision of necessary staffing, space, Of course, the program has faced and complexities with scheduling due
and technology to support a CPS by some challenges. CVT appointments, to both clinic resource and pharma-
patient sites has also been crucial to especially for initial visits, have been cist availability constraints. We con-
success. We have found that initial and difficult to establish as standard at tinually work to overcome these chal-
semiannual visits by CPS personnel to all clinics. The clinics where it is most lenges and gain support to expand the
patient sites are key in establishing, challenging to conduct CVT visits tend program.
maintaining, and growing relation- to be those that serve areas where pa- Moving forward, program goals in-
ships with team members at those tients live exceptionally far distances clude measuring and reporting qual-
sites; the visits also help CPSs orient from the clinic or that lack dedicated ity outcomes and expanding services
themselves to a clinic’s physical en- staff for rooming patients for CVT vis- to more locations. It is also imperative
vironment and patient care culture. its. In addition, a phone appointment that we keep the program sustainable
We also believe that the willing atti- can be more convenient or timely by incorporating telehealth into post-
tude and optimistic view of primary than a CVT visit and is sometimes graduate year 1 and year 2 pharmacy

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residency training and also into the well-received means of providing 6. Lund BC, Charlton ME, Steinman MA
pharmacy school curriculum. Ad- clinical pharmacy services in rural et al. Regional differences in prescrib-
ing quality among elder veterans and
ditionally, we hope to explore more areas.
the impact of rural residence. J Rural
CPS involvement in innovative “tele– Health. 2012; 29:172-9.
primary care” opportunities (e.g., Disclosures 7. Weeks WB, Yano EM, Rubenstein LV.
shared medical appointments, inter- The authors have declared no potential Primary care practice management in
conflicts of interest. rural and urban Veterans Health Ad-
disciplinary care meetings) as integral
ministration settings. J Rural Health.
members of the primary care team
References 2002; 18:298-303.
working to improve patient access and 8. VA PBM field guidance: use of clinical
1. Agarwal M. The right care at the right
care. time and in the right place: the role pharmacists to improve access to
The Telehealth Hub program has of technology in the VHA. Fed Pract. ambulatory care. Washington, DC:
identified and characterized 2 models 2015; 32(7):10-3. Department of Veterans Affairs; 2014.
2. Department of Veterans Affairs. What 9. Singh LG, Accursi M, Korch Black K.
for CPS deployment to provide clinical
is telehealth? (June 3, 2014). www.tele- Implementation and outcomes of a
pharmacy services in support of pri- pharmacist-managed clinical video
health.va.gov/ (accessed 2016 Jun 1).
mary care teams in rural areas. Build- 3. Office of Rural Health, Department of telehealth anticoagulation clinic. Am
ing on the groundwork already estab- Veterans Affairs. About rural veterans J Health-Syst Pharm. 2015; 72:70-3.
lished, CPS support for primary care (June 30, 2015). www.ruralhealth. 10. Desko L, Nazario M. Evaluation of a
va.gov/rural-definition.asp (accessed clinical video telehealth pain man-
teams can be expanded to further im-
2016 Nov 4). agement clinic. J Pain Palliat Care
prove healthcare quality and access in Pharmacother. 2014; 28:359-66.
4. Wennergren J, Munshi I, Fajardo AD,
rural areas. Additional models could George VV. Implementation of clinical 11. VA PBM field guidance: access to clin-
be developed to meet the unique video telemedicine (CVT) within a VA ical pharmacy services at contracted
needs of specific rural health systems. medical center is cost effective and community based outpatient clinics
well received by veterans. Int J Clin (CBOCs) and rural locations. Wash-
Conclusion Med. 2014; 5:711-6. ington, DC: Department of Veterans
5. Patterson BJ, Kaboli PJ, Tubbs T et Affairs; 2015.
Within the VA healthcare system, al. Rural access to clinical pharmacy
telehealth technology has been dem- services. J Am Pharm Assoc. 2014;
onstrated to be a cost-effective and 54:518-25.

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