Frontline Pharmacist
F rontline Pharmacist
Clinical video telehealth in a cardiology pharmacotherapy clinic
A
dvances in technology have provided health care systems with the opportunity to establish new modes of providing clinical services that may afford various benefits to patients, providers, and health care systems alike. One such delivery system is telehealth. “Telehealth” refers to the provision of health-related services or medical information via various types of telecommunication technologies. Modes of telecommunication can range from telephones to multinational video teleconferences.1 The use of telehealth in the management of chronic diseases appears beneficial, but due to the large variety of interventions and populations being studied, it is difficult to make broad conclusions regarding its use across all clinical settings.2-4 The value of adding a pharmacist care component to telehealth services appears promising.5-7 Clinical video telehealth (CVT) is a subset of telehealth that uses a secure connection to transfer both video and sound in real-time to connect a health care practitioner and a patient when one is located at a remote site.8 The goals of CVT implementation within the Veterans Affairs system are to reduce travel time, improve patient satisfaction, increase access to providers, and improve the health of veterans.8 The cardiology pharmacotherapy clinic at the West Palm Beach Veterans
Affairs Medical Center (VAMC) provides medication management to patients with a broad spectrum of chronic cardiovascular diseases by a residency-trained clinical pharmacy specialist who specializes in cardiology and practices under an independent scope of practice. The cardiology pharmacotherapy service is currently only provided at the parent medical center campus and requires that patients travel (sometimes at great distances) to the medical center to be seen. The integration of CVT into the cardiology pharmacotherapy clinic allows patients who live closer to an affiliated, remote community-based outpatient clinic (CBOC) than to the VAMC itself to have their medication management appointments closer to home. This also allows the clinical pharmacy specialist, who remains at the West Palm Beach VAMC, to see patients at multiple CBOCs within the same day. Program design and implementation. Clinical pharmacy specialists, CVT specialists, cardiologists, nurses, and administrative staff at both the West Palm
The Frontline Pharmacist column gives staff pharmacists an opportunity to share their experiences and pertinent lessons related to day-to-day practice. Topics include workplace innovations, cooperating with peers, communicating with other professionals, dealing with management, handling technical issues related to pharmacy practice, and supervising technicians. Readers are invited to submit manuscripts, ideas, and comments to AJHP, 7272 Wisconsin Avenue, Bethesda, MD 20814 (301-664-8601 or [email protected]).
1974
Am J Health-Syst Pharm—Vol 70 Nov 15, 2013
Beach VAMC and associated CBOCs were consulted before implementation of this new service. All members involved played an integral role in the design and implementation of the service. The goal was to improve patient access to the cardiology pharmacotherapy clinic and medication management services while reducing time, costs, and risks associated with patient travel to the medical center. An electronic consultation process was developed to allow all cardiology providers to refer patients to the CVT service. The CVT medication management service was offered to patients who (1) preferred visits at select CBOC locations rather than at the West Palm Beach VAMC, (2) had no substantial hearing or visual deficits, (3) were generally clinically stable and required only mild, if any, physical assessment, and (4) had a basic understanding of their medication regimen. Once enrolled in the CVT cardiology pharmacotherapy program, visits were conducted utilizing existing CVT technology at the CBOC nearest the patient’s residence. The process for the pharmacotherapy appointment was modified to efficiently provide care through CVT. The patient reports to the CBOC two to seven days before the CVT appointment for any required laboratory tests (e.g., basic metabolic profile, lipid panel, thyroid function panel). On the day of the appointment, the patient checks in with the receptionist at the CBOC and has his or her vital signs measured by nursing staff
Frontline Pharmacist
and receives the most recent copy of his or her medication list. At this point, any home logs (e.g., blood pressure logs) are faxed by CBOC staff to the West Palm Beach VAMC. Once the patients’ vital signs are entered into the electronic medical chart, the patient is brought to a location where the CVT technology (webcam and television screen) is set up. The clinical pharmacy specialist then conducts the patient interview. The clinical pharmacy specialist can control the camera on the patient’s side to move or zoom to help assist with mild physical assessment (e.g., assessment of pedal edema) or can secure the assistance of a CBOC telehealth nurse if needed. Once the interview is completed, the clinical pharmacy specialist types all instructions and medication changes and remotely prints that document to a printer at the CBOC for the patient. Other documents, such as patient education sheets and blank homemonitoring logs, can also be printed to CBOC printers for the patient. The patient instructions also indicate when the patient should return to the clinic. The CBOC receptionist makes note of this when retrieving the document for the patient and makes follow-up appointments accordingly. Experience with the program. CVT services were integrated into the West Palm Beach VAMC cardiology pharmacotherapy clinic on December 20, 2010. Initial availability was limited to two appointments one day a week but has since expanded to five appointments one day a week. To date, 236 patients have been seen via CVT. The no-show rate for CVT appointments is currently 4%. The noshow rate of the face-to-face pharmacotherapy clinic since CVT integration is 10%. For the 2012 fiscal year, 26,784 miles were averted by patients in travel to and from the medical center. These miles are equivalent to 670 hours of travel and represent 8.9% of the total miles averted by all CVT programs at West Palm Beach VAMC. Miles averted were calculated by multiplying the number of miles for one round trip from the CBOC to West
Palm Beach VAMC by the total appointments held at that CBOC for that year. In total, CVT programs at our facility averted 300,904 miles in the 2012 fiscal year, equivalent to 19,928 travel hours. Patient satisfaction for telehealth overall has been between 90% and 95% in our network. Technical aspects of the CVT interface have been adequate in allowing for basic physical assessment and have not hindered communication with patients taking part in cardiology pharmacotherapy management through CVT. Administrative assistance at the CBOCs has allowed for the successful provision of printed materials (updated medication lists, patient instructions, and informational materials) to the patient via remote printing. This teambased approach to patient management is essential for providing patients with high-quality care from a remote site. The initial positive responses have led to plans for the expansion of CVTenabled appointment slots within the cardiology pharmacotherapy clinic. Plans to further expand this clinic to additional times or days are currently in progress. Other clinical pharmacy specialists have initiated CVT provider training to allow for expanded clinician participation in CVT at the cardiology pharmacotherapy clinic. West Palm Beach VAMC has also initiated clinical pharmacy services via video telehealth in the diabetes and pain management pharmacotherapy clinics. Future areas for expansion under consideration include primary care, anticoagulation, and mental health pharmacotherapy clinics. Conclusion. The CVT pharmacotherapy management service in cardiology has improved access to clinical pharmacy specialist care for patients who live a distance from the medical center. This manner of delivery of clinical pharmacy services is exportable to other medical facilities, in addition to other pharmacy specialty areas such as pain management, anticoagulation, primary care, endocrinology, and follow-up after discharge from the hospital.
1. American Telemedicine Association. What is telemedicine? www.americantelemed. org/learn/what-is-telemedicine (accessed 2013 Sep 23). 2. Izquierdo RE, Knudson PE, Meyer S et al. A comparison of diabetes education administered through telemedicine versus in person. Diabetes Care. 2003; 26:1002-7. 3. Stone RA, Rao RH, Sevick MA et al. Active care management supported by home telemonitoring in veterans with type 2 diabetes. Diabetes Care. 2010; 33:478-84. 4. Wootton R. Twenty years of telemedicine in chronic disease management—an evidence synthesis. J Telemed Telecare. 2012; 18:211-20. 5. Green BB, Cook AJ, Ralston JD et al. Effectiveness of home blood pressure monitoring, web communication, and pharmacist care on hypertension control. JAMA. 2008; 299:2857-67. 6. Thompson CA. Pharmacists run telehealth clinic to keep veterans independent. Am J Health-Syst Pharm. 2008; 65:1310-1. News. 7. McFarland M, Davis K, Wallace J et al. Use of home telehealth monitoring with active medication therapy management by clinical pharmacists in veterans with poorly controlled type 2 diabetes mellitus. Pharmacotherapy. 2012; 32:420-6. 8. Department of Veterans Affairs. VA Telehealth Services. www.telehealth.va.gov/ index.asp (accessed 2012 Nov 9).
Christina Coakley, Pharm.D., Clinical Pharmacist [email protected] Augustus Hough, Pharm.D., BCPS, Clinical Pharmacy Specialist Daniel Dwyer, R.N., Facility Telehealth Coordinator David Parra, Pharm.D., FCCP, BCPS, Clinical Pharmacy Specialist in Cardiology West Palm Beach Veterans Affairs Medical Center 7305 North Military Trail West Palm Beach, FL 33410
At the time of writing, Dr. Coakley was Postgraduate Year 2 Cardiology Pharmacy Resident, West Palm Beach Veterans Affairs Medical Center. The authors have declared no potential conflicts of interest. DOI 10.2146/ajhp120731
Am J Health-Syst Pharm—Vol 70 Nov 15, 2013
1975
Copyright of American Journal of Health-System Pharmacy is the property of American Society of Health System Pharmacists and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
F rontline Pharmacist
Clinical video telehealth in a cardiology pharmacotherapy clinic
A
dvances in technology have provided health care systems with the opportunity to establish new modes of providing clinical services that may afford various benefits to patients, providers, and health care systems alike. One such delivery system is telehealth. “Telehealth” refers to the provision of health-related services or medical information via various types of telecommunication technologies. Modes of telecommunication can range from telephones to multinational video teleconferences.1 The use of telehealth in the management of chronic diseases appears beneficial, but due to the large variety of interventions and populations being studied, it is difficult to make broad conclusions regarding its use across all clinical settings.2-4 The value of adding a pharmacist care component to telehealth services appears promising.5-7 Clinical video telehealth (CVT) is a subset of telehealth that uses a secure connection to transfer both video and sound in real-time to connect a health care practitioner and a patient when one is located at a remote site.8 The goals of CVT implementation within the Veterans Affairs system are to reduce travel time, improve patient satisfaction, increase access to providers, and improve the health of veterans.8 The cardiology pharmacotherapy clinic at the West Palm Beach Veterans
Affairs Medical Center (VAMC) provides medication management to patients with a broad spectrum of chronic cardiovascular diseases by a residency-trained clinical pharmacy specialist who specializes in cardiology and practices under an independent scope of practice. The cardiology pharmacotherapy service is currently only provided at the parent medical center campus and requires that patients travel (sometimes at great distances) to the medical center to be seen. The integration of CVT into the cardiology pharmacotherapy clinic allows patients who live closer to an affiliated, remote community-based outpatient clinic (CBOC) than to the VAMC itself to have their medication management appointments closer to home. This also allows the clinical pharmacy specialist, who remains at the West Palm Beach VAMC, to see patients at multiple CBOCs within the same day. Program design and implementation. Clinical pharmacy specialists, CVT specialists, cardiologists, nurses, and administrative staff at both the West Palm
The Frontline Pharmacist column gives staff pharmacists an opportunity to share their experiences and pertinent lessons related to day-to-day practice. Topics include workplace innovations, cooperating with peers, communicating with other professionals, dealing with management, handling technical issues related to pharmacy practice, and supervising technicians. Readers are invited to submit manuscripts, ideas, and comments to AJHP, 7272 Wisconsin Avenue, Bethesda, MD 20814 (301-664-8601 or [email protected]).
1974
Am J Health-Syst Pharm—Vol 70 Nov 15, 2013
Beach VAMC and associated CBOCs were consulted before implementation of this new service. All members involved played an integral role in the design and implementation of the service. The goal was to improve patient access to the cardiology pharmacotherapy clinic and medication management services while reducing time, costs, and risks associated with patient travel to the medical center. An electronic consultation process was developed to allow all cardiology providers to refer patients to the CVT service. The CVT medication management service was offered to patients who (1) preferred visits at select CBOC locations rather than at the West Palm Beach VAMC, (2) had no substantial hearing or visual deficits, (3) were generally clinically stable and required only mild, if any, physical assessment, and (4) had a basic understanding of their medication regimen. Once enrolled in the CVT cardiology pharmacotherapy program, visits were conducted utilizing existing CVT technology at the CBOC nearest the patient’s residence. The process for the pharmacotherapy appointment was modified to efficiently provide care through CVT. The patient reports to the CBOC two to seven days before the CVT appointment for any required laboratory tests (e.g., basic metabolic profile, lipid panel, thyroid function panel). On the day of the appointment, the patient checks in with the receptionist at the CBOC and has his or her vital signs measured by nursing staff
Frontline Pharmacist
and receives the most recent copy of his or her medication list. At this point, any home logs (e.g., blood pressure logs) are faxed by CBOC staff to the West Palm Beach VAMC. Once the patients’ vital signs are entered into the electronic medical chart, the patient is brought to a location where the CVT technology (webcam and television screen) is set up. The clinical pharmacy specialist then conducts the patient interview. The clinical pharmacy specialist can control the camera on the patient’s side to move or zoom to help assist with mild physical assessment (e.g., assessment of pedal edema) or can secure the assistance of a CBOC telehealth nurse if needed. Once the interview is completed, the clinical pharmacy specialist types all instructions and medication changes and remotely prints that document to a printer at the CBOC for the patient. Other documents, such as patient education sheets and blank homemonitoring logs, can also be printed to CBOC printers for the patient. The patient instructions also indicate when the patient should return to the clinic. The CBOC receptionist makes note of this when retrieving the document for the patient and makes follow-up appointments accordingly. Experience with the program. CVT services were integrated into the West Palm Beach VAMC cardiology pharmacotherapy clinic on December 20, 2010. Initial availability was limited to two appointments one day a week but has since expanded to five appointments one day a week. To date, 236 patients have been seen via CVT. The no-show rate for CVT appointments is currently 4%. The noshow rate of the face-to-face pharmacotherapy clinic since CVT integration is 10%. For the 2012 fiscal year, 26,784 miles were averted by patients in travel to and from the medical center. These miles are equivalent to 670 hours of travel and represent 8.9% of the total miles averted by all CVT programs at West Palm Beach VAMC. Miles averted were calculated by multiplying the number of miles for one round trip from the CBOC to West
Palm Beach VAMC by the total appointments held at that CBOC for that year. In total, CVT programs at our facility averted 300,904 miles in the 2012 fiscal year, equivalent to 19,928 travel hours. Patient satisfaction for telehealth overall has been between 90% and 95% in our network. Technical aspects of the CVT interface have been adequate in allowing for basic physical assessment and have not hindered communication with patients taking part in cardiology pharmacotherapy management through CVT. Administrative assistance at the CBOCs has allowed for the successful provision of printed materials (updated medication lists, patient instructions, and informational materials) to the patient via remote printing. This teambased approach to patient management is essential for providing patients with high-quality care from a remote site. The initial positive responses have led to plans for the expansion of CVTenabled appointment slots within the cardiology pharmacotherapy clinic. Plans to further expand this clinic to additional times or days are currently in progress. Other clinical pharmacy specialists have initiated CVT provider training to allow for expanded clinician participation in CVT at the cardiology pharmacotherapy clinic. West Palm Beach VAMC has also initiated clinical pharmacy services via video telehealth in the diabetes and pain management pharmacotherapy clinics. Future areas for expansion under consideration include primary care, anticoagulation, and mental health pharmacotherapy clinics. Conclusion. The CVT pharmacotherapy management service in cardiology has improved access to clinical pharmacy specialist care for patients who live a distance from the medical center. This manner of delivery of clinical pharmacy services is exportable to other medical facilities, in addition to other pharmacy specialty areas such as pain management, anticoagulation, primary care, endocrinology, and follow-up after discharge from the hospital.
1. American Telemedicine Association. What is telemedicine? www.americantelemed. org/learn/what-is-telemedicine (accessed 2013 Sep 23). 2. Izquierdo RE, Knudson PE, Meyer S et al. A comparison of diabetes education administered through telemedicine versus in person. Diabetes Care. 2003; 26:1002-7. 3. Stone RA, Rao RH, Sevick MA et al. Active care management supported by home telemonitoring in veterans with type 2 diabetes. Diabetes Care. 2010; 33:478-84. 4. Wootton R. Twenty years of telemedicine in chronic disease management—an evidence synthesis. J Telemed Telecare. 2012; 18:211-20. 5. Green BB, Cook AJ, Ralston JD et al. Effectiveness of home blood pressure monitoring, web communication, and pharmacist care on hypertension control. JAMA. 2008; 299:2857-67. 6. Thompson CA. Pharmacists run telehealth clinic to keep veterans independent. Am J Health-Syst Pharm. 2008; 65:1310-1. News. 7. McFarland M, Davis K, Wallace J et al. Use of home telehealth monitoring with active medication therapy management by clinical pharmacists in veterans with poorly controlled type 2 diabetes mellitus. Pharmacotherapy. 2012; 32:420-6. 8. Department of Veterans Affairs. VA Telehealth Services. www.telehealth.va.gov/ index.asp (accessed 2012 Nov 9).
Christina Coakley, Pharm.D., Clinical Pharmacist [email protected] Augustus Hough, Pharm.D., BCPS, Clinical Pharmacy Specialist Daniel Dwyer, R.N., Facility Telehealth Coordinator David Parra, Pharm.D., FCCP, BCPS, Clinical Pharmacy Specialist in Cardiology West Palm Beach Veterans Affairs Medical Center 7305 North Military Trail West Palm Beach, FL 33410
At the time of writing, Dr. Coakley was Postgraduate Year 2 Cardiology Pharmacy Resident, West Palm Beach Veterans Affairs Medical Center. The authors have declared no potential conflicts of interest. DOI 10.2146/ajhp120731
Am J Health-Syst Pharm—Vol 70 Nov 15, 2013
1975
Copyright of American Journal of Health-System Pharmacy is the property of American Society of Health System Pharmacists and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
