ASHP InterSections ASHP InterSections

May 6, 2021

Pharmacy Teams Lead Telehealth Expansion Efforts

Caroline Pitney, Pharm.D, BCACP

WHEN THE COVID-19 PANDEMIC erupted last March, clinicians with the University of Washington (UW Medicine), the Seattle Cancer Care Alliance and their four medical centers, and many other health systems across the country quickly amped up their provision of telehealth services to continue meeting patient needs. Pharmacists were key players in this activity, said ASHP member Caroline Pitney, Pharm.D., BCACP, a clinical pharmacist with UW Harborview Medical Center.

Telehealth Growth

Prior to the pandemic, federal regulations had limited the scope of telehealth pharmacist services, leaving it mainly for patients in rural areas far from clinics or who had limited access to healthcare. However, the Coronavirus Preparedness and Response Supplemental Appropriations Act enacted on March 6, 2020, loosened restrictions on telehealth services. Then, on March 17, 2020, CMS announced its telehealth waiver had been expanded to cover diagnosis and treatment of COVID-19 and other conditions.

With UW pharmacists already embedded in ambulatory care settings as providers seeing their own patients with various disease states, it only made sense for them to jump on the telehealth bandwagon as well, Dr. Pitney said. The organization credentialed 69 pharmacists to offer comprehensive medication management via telehealth to patients in their primary care and specialty clinics. Pharmacists and other clinicians then completed learning modules on obtaining informed consent, videoconferencing etiquette, documentation, billing, adverse event reporting, and risk management. The health system selected Zoom as its secure telehealth platform, integrating it within the electronic medical record system.

Typically, at Dr. Pitney’s medical specialties clinic, doctors refer patients to pharmacists to help initiate new therapies or monitor ongoing treatment and chronic diseases. Dr. Pitney and her colleagues offered telehealth, along with in-person or telephone visits, to their patients as soon as it was available.

One benefit to video has been in face-to-face demonstrations of proper use of injectable medications, Dr. Pitney said. “It’s really challenging to try to do that over the telephone,” she said. “Before the pandemic, we would always recommend the person come in for an in-person teaching visit.”

Overall, she said, telehealth has provided a modality for pharmacists to see patients and their medications. We can ascertain patients’ ability to administer and take those medications. “Having this option in the future will only allow us to reach more patients. Not just for pharmacists but for all providers, it’s a step in the right direction,” Dr. Pitney added.   

Technology Bridges Barriers

Some health systems using telehealth found themselves upgrading technology as time went on. In the very early stages of the pandemic, pharmacists with Tampa General Hospital in Florida first moved some patients’ in-person visits to telephone calls, later shifting everyone to telehealth during April, May, and June while pharmacists worked from home, said ASHP member Jessica Bianco, Pharm.D., C.Ph., BCACP, CACP, a pharmacotherapy specialist in ambulatory care for the medical center. Their patient caseload includes people with diabetes and other chronic diseases, in addition to those taking anticoagulant medications.

By summer 2020, the hospital adopted a new platform with better video quality and the option to use translation services, Dr. Bianco said. Through a collaborative practice agreement there, pharmacists change or start medications and adjust doses between physician visits.

“Interestingly, I think some patients like it more,” Dr. Bianco said of telehealth. “It’s really bridged the barriers that there are for patients being able to make it to the clinic, such as transportation or parking issues.”

Streamlining Care     

Baptist Health South Florida, in the Miami area, sees many patients in their 70s, 80s, and 90s, so when the pandemic hit, clinicians and pharmacists were worried about putting them at risk. Fortunately, many patients were tech-savvy, or had family to support their adoption of telehealth, said ASHP member Jennifer Miles, Pharm.D., C.Ph., BCACP, BCMTMS, a clinical coordinator in ambulatory pharmacy there.

Jennifer Miles, Pharm.D., C.Ph., BCACP, BCMTMS

“Our patients were really happy there were minimal interruptions in their care because a lot of folks were really worried about offices shutting down and concerned with their safety and being able to get care,” Dr. Miles said. “We didn’t want to delay that.”

Dr. Miles and her colleague Faaria Quadri, Pharm.D., BCPS, work with the health system’s lipid clinic and congestive heart failure clinic. In their model, pharmacists see patients in tandem with advanced practice providers such as physician assistants or advanced practice registered nurses. Under telehealth, the provider sees a patient over telehealth for the medical portion of the visit and explains a pharmacist will call them next to go over medications and how they work, explain any potential drug interactions, help establish medication schedules, and talk about covering the medications, Dr. Miles explained.

Pharmacists also follow up with patients on a regular basis if they don’t have clinic visits scheduled to ensure they are adherent to medications. The heart failure clinic even provided bathroom scales to patients so they could continue to record their weights and blood pressures at home, Dr. Quadri noted.         

“Some patients, despite their age and risks, adamantly want to be seen in a clinic because they like that comfort of knowing they’re checked out physically,” Dr. Quadri said. “But another set is so nervous to come in, and so grateful for the opportunity to have a telemedicine visit.”

Overcoming Challenges        

Even as clinics nationwide have slowly resumed seeing patients in person, many have continued their telehealth appointments. About a third of patients at UW are still seen that way, Dr. Pitney said. At Tampa General, it’s more than half, said Dr. Bianco.

Jessica Bianco, Pharm.D., C.Ph., BCACP, CACP

There are some limitations to telehealth that clinicians still need to work through, Dr. Pitney cautioned. Not every patient has access to a computer or secure video device. Some patients, depending on their disease states, still need periodic, in-person physical exams. And while pharmacists are considered providers in Washington and many other states, CMS currently does not reimburse for pharmacist visits, whether telehealth or in-person.

Pharmacists should look at telehealth as an opportunity to highlight their clinical skills and knowledge to the general population, Dr. Quadri said.

“It’s a great opportunity to show what we’re capable of,” she said. “In the past, I think patients did not see our contributions to their medication regimens because we were making those to the providers and patients would assume it was from them. Now, they see firsthand that pharmacists can do this.”

The pharmacists offered the following tips for optimizing telehealth:

  • Know your audience. Telehealth should not be a one-size-fits-all option, Dr. Bianco said. Some patients are not comfortable with video and prefer a phone call, while others will appreciate telehealth for more of a face-to-face visit. Be aware that some patients may not have access to a computer or a secure location to do a telehealth visit, added Dr. Pitney. In those cases, a telephone visit is a good alternative to an in-person one.
  • Shed your fears. There has been some trepidation among pharmacists that this will be a big change and patients won’t like it, Dr. Miles said. Find a secure platform to continue your visits and set up infrastructure for training.

“We live in a society where our patients really want this to close the gap on the care they need, and limitations they have with their busy lives and now a pandemic keeping us all separate,” she said. “We can find creative ways to still be connected to one another…I don’t think anything will ever fully replace that human touch and being there face-to-face in the examination room with our patients, but it helps provide our presence in a way that is still supportive.”

Telehealth pharmacy practice is one of five areas of focus in ASHP’s Innovation Center. For more information, visit ASHP’s Telehealth Resource Center or listen to ASHP’s telehealth management pearls webinar. Be on the lookout for a special telehealth theme issue of AJHP later this year and a report summarizing the outcomes from the ASHP Pharmacy Executive Leadership Alliance’s virtual conference on Telehealth Innovations.

By Karen Blum

November 13, 2020

Pharmacists Take the Lead in Providing Vaping Interventions

Kimberly Novak, Pharm.D., BCPS, BCPPS, FPPA, with PGY2 residents Becca Wytiaz and Mara Rubin.

AN INCREASE IN THE USE OF E-CIGARETTES AMONG adolescents in the U.S. is erasing recent progress in reducing overall tobacco use in this population, according to alarming statistics from the Centers for Disease Control. Some 27.5% of high schoolers and 10.5% of middle schoolers reported current use of e-cigarettes, the CDC reported in a recent issue of the Morbidity and Mortality Weekly Report, creating an immense opportunity for pharmacists to get involved.

Vaping and COVID-19

In 2019, there was a surge in E-cigarette or vaping product use-associate lung injury (EVALI) which was particularly noted in adolescents and young adults. Interestingly, there was an observed decrease in EVALI cases early in 2020, explained Kimberly Novak, Pharm.D., BCPS, BCPPS, FPPA, an advanced patient care pharmacist in pediatric and adult cystic fibrosis at Nationwide Children’s Hospital in Columbus, Ohio. “This was originally attributed to increased public awareness of vaping and strategies aimed at reducing marketing and access of flavored vaping products of preferred by this population,” said Dr. Novak. “However, this decrease also corresponded with the initial surge in COVID-19 cases and many state-mandated stay-at-home rules as well as increased implementation of work-from-home and virtual school policies.”

As many of these policies were loosened in the summer months, health care practitioners have noted an increase again in EVALI cases, perhaps due to less supervision as parents returned to onsite work, she added.

Pharmacist roles

In general, e-cigarette usage in adolescents “has blown up among this population way more than people suspected, particularly because it’s so easy to hide, and it doesn’t smell,” said Dr. Novak. “This snuck up on us as a society with very little regulation, and now we’re working backward, trying to catch up to this epidemic that got out of the bag before we got a hold on it.”

Kyle Mays, Pharm.D., BCPPS, discusses cessation options with a teenage patient.

Pharmacists can play several important roles in patient care regarding e-cigarette usage and related lung injuries, said Dr. Novak, an ASHP member since 1998. In teaching hospitals like hers, pharmacists provide continuity where attending physicians and residents may change over. They also can monitor trends in nicotine usage, and, because patients view pharmacists differently than their physicians, they may share more information about medication histories with them.

Typical agents prescribed to help curb nicotine cravings, like varenicline (Chantix) and bupropion (Zyban, Wellbutrin), are not indicated for people under the age of 18, noted Justin Reinert, Pharm.D., BCCCP, a clinical assistant professor at the Ben and Maytee Fisch College of Pharmacy at the University of Texas at Tyler. This doesn’t mean physicians aren’t prescribing them for this population, he said, but pharmacists can employ motivational interviewing techniques and assess patients’ readiness to change.

Interventions to reduce usage

In addition, pharmacists can use their medication expert hat to advise primary care teams on different vaping products used by teens, said Kyle Mays, Pharm.D., BCPPS, a critical care pharmacist with SSM Health Cardinal Glennon Children’s Hospital in St. Louis. When his hospital saw a recent surge in illnesses among patients using THC-related vaping compounds, some of his colleagues weren’t aware these products were linked to lung injuries because of the solvents and vitamin E they contained. If patients are admitted with severe lung illnesses and are intubated and can’t speak, Dr. Mays and colleagues play detective, eliminating potential causes or ordering urine toxicology screens.

Justin Reinert, Pharm.D., BCCCP

In an effort to address e-cigarette usage in his area, Dr. Reinert is directing a two-fold intervention. Pharmacists and doctoral pharmacy students are providing educational in-services and assemblies in local schools, as well as surveying high school students about their use of nicotine products. Then, beginning this fall, pharmacy students will provide nicotine cessation programs in schools, targeted to high schoolers who may have violated a tobacco or nicotine use policy.

Among over 100 students they surveyed so far, about 78% reported using these products, said Dr. Reinert, an ASHP member since 2013. “Students are primarily into vaping, but it’s important to be cognizant of other things out there,” he noted. “Kids are still smoking cigarettes, they’re still using cigar wrappers for marijuana. The addictive component of the devices remains nicotine.”

Dr. Reinert tries to use shock value to educate the students, asking how many of them who drive and pump gas would stick the gas nozzle into their mouths and inhale. “There are components in these vaping cartridges that are identical to components of unleaded gasoline—lead, mercury, nickel, cadmium and heavy metals, etc.,” he said. “The students have no idea, which is terrible, but it also highlights the need for targeted education at this age group, which I think pharmacists are uniquely positioned to accomplish.”

Strategies for pharmacists    

The pharmacists offered advice on working with adolescent patients and their families:

  • Take an objective yet compassionate stance. “Don’t tell them they’re [doing something] wrong,” Dr. Novak said, as that can cause the patient to shut down and not disclose information. Instead, acknowledge that they may have made an unhealthy choice but keep the lines of communication open. “Your job is to treat the patient and make them better, not ridicule what they were doing that brought them in,” added Dr. Mays, an ASHP member for the past 10 years.
  • Put your message in terms relative to adolescents. Dr. Reinert’s cessation curriculum discusses the financial, health and psychosocial ramifications of nicotine use at a level appropriate for adolescents, not adults or younger children.
  • Offer resources for quitting. Educate adolescents that, similar to cigarettes, it’s hard to quit cold turkey, Dr. Mays noted. Encourage them to seek appropriate help through their pediatrician or another primary care provider, and work with them to develop a plan.
  • Try to talk to the patients without their parents. Patients may not want to fully admit to using these products, especially if their parents are present, Dr. Mays said.
  • Keep current on your knowledge. People tend to think JUUL devices are the e-cigarette of choice for teens, but new ones are popping up all the time, said Dr. Mays. “You have to stay trendy with what’s going on in a teenager’s mind,” he added.

Patient impact

Vaping devices essentially are nebulizers that deliver a drug, Dr. Novak said. But they haven’t yet been adequately studied to determine what products should go in them, what the safety margins are, or if chemicals put into them are altered by heat that the devices generate. Hopefully, with time, she said, the medical community will learn better safety information about these devices and their related products.

Meanwhile, pharmacists should stay involved, such as working with ASHP to advocate for more regulation around vaping and nicotine products. “The more we can do this on an individual level, whether in our own institutions, providing education or working with poison centers, we can make a pretty positive impact wherever our patients are,” said Dr. Novak.

 

By Karen Blum

 

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