Telehealth Comes Calling


As the healthcare landscape shifts during the pandemic, telehealth may experience a surge in pharmacy settings.

By Joseph A. Cantlupe

While the COVID-19 pandemic disrupted people’s lives this year, it also exposed a need for a crucial emerging tool of academic pharmaceutical instruction: telehealth. The University of the Pacific (UOP) Thomas J. Long School of Pharmacy began implementing telehealth years earlier as a key part of the interprofessional education (IPE) track to connect student pharmacists with students from other academic institutions miles away.

Through telehealth, student pharmacists are evaluating care and diving into the ins and outs of not only what it means to be a pharmacist, but also pushing themselves into multidisciplinary lessons, learning from and with nursing and medical students about clinical work and empathy and seeing patients as human beings. They are doing it not by sitting in the classroom with their peers but over videoconferencing, making true connections in remote learning spaces.

“With COVID and the shift to remote learning, we appreciate that we can still have the same experience with a person via videoconferencing technology. You can find ways of connecting without being in the same physical space,” said Dr. Deepti Vyas, associate professor at the University of the Pacific’s School of Pharmacy.

The school is home to an undergraduate Pre-Pharmacy Advantage Program, an accelerated three-year doctor of pharmacy program, a graduate pharmaceutical and chemical sciences program and several fellowship programs. The school is using telehealth through different levels of pharmaceutical training and various aspects of patient care, beginning with a telehealth IPE track, said Vyas. These telehealth programs, which are being used to prepare for future and professional collaboration, are growing.

Connecting With Providers and Patients

For the UOP School of Pharmacy, it was simply a matter of practicality that made it become an earnest driver of telehealth, as the school tried to link different campuses spread out many miles apart. “We had to think of a modality linking medical and nursing students with our pharmacy students,” Vyas said. “That’s why the telehealth track was born here. We use a real-life practice model so students can have a better understanding of telehealth and what they can offer in the future to connect with patients in remote locations.”

The school has a range of telehealth programs including IPE collaborations, introductory pharmacy practice experiences and outreach events using telehealth principles, Vyas said. The telehealth IPE track includes relationships between UOP and other academic institutions, including the University of Missouri-Kansas City (UMKC) School of Nursing, the Arkansas College of Osteopathic Medicine (ARCOM) and the West Virginia School of Osteopathic Medicine (WVSOM). They use a wide swath of simulations, each with a different focus of instruction, preparing students to address myriad patient health issues, such as drug interactions, cardiac concerns or psychiatric illness. They work with nurse practitioner and medical students to learn about various therapeutic plans. The programs reach deep into different areas of healthcare to expose students to richer and more advanced clinical experiences, Vyas said.

The collaboration with UMKC includes pairing second-year student pharmacists with UMKC’s psychiatric mental health/family practice nurse practitioner students, focusing on the management of complex psychiatric disorders including schizophrenia, substance use disorders, bipolar disease, Alzheimer’s disease and other chronic conditions. “[The University of Missouri-Kansas City] was very interested in using telehealth principles to link their students with ours. This was our third go-around and it was very successful,” she said.

Being paired with the nurse practitioner students was a tremendous boost in the instruction process, she added. “The nurse practitioner students provided a much-needed experience for our students. A major learning tool emerged, which was empathy development.” Not only did students focus on the clinical management of the patient, they also discussed the social barriers faced by the patient. This helped highlight the human aspect of healthcare.

According to an abstract on the UOP-UMKC relationship that Vyas co-authored, the telehealth program developed with different kinds of diagnoses and patient assessments, as well as aspects of care. Student team leaders were responsible for giving point-by-point instructions during the telehealth programs and scheduling videoconferencing. During one academic year, 140 teams were created with 28 psychiatric mental health nurse teams paired up with more than 200 student pharmacists. Students reported improved attitudes toward interprofessional collaboration.

In a similar telehealth program involving the WVSOM, second-year UOP student pharmacists were paired with medical students on their clinical clerkships. Students received a patient’s chart in a simulated electronic health record program and a video depicting a physical assessment to obtain patient information. Students then used the SBAR tool to collaborate on the care of an acutely ill patient.

The UOP telehealth program is detailed and complex, said Vyas, including simulated patients’ lab reports, medical histories, allergies and imaging, notes and records of previous doctor visits—the full scope of what would typically appear in a patient’s chart, she said. The team used YouTube video physical assessments to analyze each patient’s condition. As students worked toward resolving each patient case, the groups leaned on each other, the medical students relying on the student pharmacists and vice versa.

The Post-Pandemic Outlook for Telehealth

As the University of the Pacific continues to expand its telehealth programs, it comes at a time when the potential for such programs seems limitless. Across the healthcare landscape, telehealth is being widely adopted. The marketing firm Frost & Sullivan reports a projected growth in telehealth of 64.3 percent by the end of 2020 and an estimated sevenfold increase by 2025.

Other studies confirm the growth potential. In July, the U.S. Department of Health and Human Services released a report showing “dramatic utilization trends of healthcare services in primary care delivery in fee-for-service Medicare in the early days of the COVID-19 pandemic.” HHS noted that an internal Centers for Medicare & Medicaid Services (CMS) analysis found that before the public health emergency, only 14,000 beneficiaries received telehealth services, but during the pandemic from mid-March to early July, more than 10.1 million beneficiaries received telehealth services.

I think telehealth is here to stay and the demand is only going to grow. The COVID-19 pandemic didn’t start telehealth but it definitely served as a catalyst. I think we’re going to see patients demanding that those services stick around because they like the convenience.

Dr. Allie Jo Shipman

That growth is spilling into pharmacy practices of telehealth, known as telepharmacy. The Global Telepharmacy Market Research Forecast of 2020–2025 bluntly projects a “boom.” A report noted: “There is no doubting the exponential surge of telemedicine and telehealth markets; the market is poised to expand at a significant rate in the next few years.”

“Access for patients and access to patients are the biggest lures for initiating telehealth programs, especially amid a pandemic when patients may not be able to come to a separate physical location,” said Dr. Allie Jo Shipman, director of state policy for the National Alliance of State Pharmacy Associations. “I think telehealth is here to stay and the demand is only going to grow. The COVID-19 pandemic didn’t start telehealth but it definitely served as a catalyst. I think we’re going to see patients demanding that those services stick around because they like the convenience.”

Typically, telemedicine services are administered by physicians while telehealth can be provided by a wide range of healthcare professionals, such as pharmacists, nurses and others, according to the World Health Organization. Telehealth allows for the delivery of pharmacy care via telecommunications to patients in locations where they may have not direct contact with pharmacists. As patients were forced to stay at home instead of having direct contact with physicians, pharmacists and other healthcare providers, telehealth allowed them to continue to access healthcare.

During the COVID-19 pandemic, HHS also made it easier to provide telehealth services through commonly used apps such as FaceTime, Facebook Messenger, Google Hangouts, Zoom or Skype. CMS has issued temporary measures to make it easier for people enrolled in Medicare, Medicaid and the Children’s Health Insurance Program to use telehealth. Pharmacy kept apace. “With speeds seldom seen by states board of pharmacy, regulations governing pharmacy operations have been rewritten in response to the pandemic and waivers have proliferated and new guidelines issued daily to open the door to telehealth,” Shipman added.

Telehealth has been extremely helpful for pharmacists, providing ongoing monitoring and management of patients with chronic conditions, medication therapy management, chronic disease management, transitions of care, remote dispensing and ambulatory care. While telehealth may be the wave of the future, that doesn’t mean it won’t be without hiccups, especially in terms of billing, regulatory procedures and even patient response, according to Dr. Mary Ann Kliethermes, director of medication quality and safety at the American Society of Health-System Pharmacists.

In June, ASHP surveyed its members about their attitudes regarding telehealth medicine management services. Their responses were decidedly mixed, Kliethermes said. About 38 percent of respondents said they preferred telehealth to healthcare visits, while another 25 percent wanted face-to-face appointments. At least 15 percent “didn’t care either way” and 20 percent didn’t have an opinion or neglected to share one, said Kliethermes. “We are finding in the industry patients who prefer telehealth but many who still want face-to-face visits. As we move forward that’s going to be in the mix.” In her experience in ambulatory practice, Kliethermes observed that some patients would come early for appointments, “coming for socialization because they were mainly alone.”

Telehealth also has been the focus of a lack of reimbursement for pharmacists. About 60 percent of pharmacists surveyed said they didn’t bill for telehealth “because it was hard and confusing and there were so many barriers” to reimbursement, Kliethermes said. “It’s been that way for a long time because pharmacists aren’t considered healthcare providers.” Despite the obstacles, Kliethermes believes telehealth will be “what the population needs. I think it will be part of practices. Enough patients will like it.”

Aside from the technology aspect, personal relationships overall will be important for student pharmacists as they pursue telehealth studies, said Kliethermes. Generally, younger people “don’t have to learn the technology,” she said. “Students know the technology. It’s just really about the connections. How do you conduct the visit [over Zoom or phone]? This is among the things to think about. How does the patient know you are authentic, someone whom they’ve never met before?”

While clinical instruction is important, Vyas agrees that interprofessional collaboration regarding social issues related to health is equally vital. That’s why UOP’s School of Pharmacy entered into a telehealth partnership with the Arkansas College of Osteopathic Medicine. They worked to examine social determinants of health, particularly in cases where studies have shown that minorities receive less equitable treatment than whites. Using telehealth, the students can discuss “global issues that face our communities, examining the research in the literature to see the reason for disparities and identify strategies to pull together those social determinants of health,” Vyas said.

The idea, she continued, was to foster more research and have consensus building. As telehealth evolves, it must go deeper into conditions of care as well as help healthcare leaders understand relationships that can play pivotal roles in broadening its response to patients. In that way, telehealth becomes more than just another voice or image. It’s that human connection, and that can begin with academic pharmacy instruction, Vyas indicated. “We’re looking at professional collaboration and improving peer perceptions of interprofessional collaboration. There are so many things we have yet to discover. The biggest value is leaning on each other in the future.”

Joseph A. Cantlupe is a freelance writer based in Washington, D.C.