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School of Pharmacy Symposium 2018

Emerging Pharmacy Practice Models: Interprofessional Approach to Telehealth MCW Pharmacy School Symposium 2018

Harnessing the power of classic technologies like the telephone as well as cutting-edge innovations in communications, pharmacists can be at the forefront of the coming revolution in healthcare services. That was the message from presenters at the MCW Pharmacy School’s third annual symposium.

The symposium, Emerging Pharmacy Practice Models: Interprofessional Approach to Telehealth, was held July 12, 2018, at the Milwaukee campus of the Medical College of Wisconsin. It was attended by more than 150 students, faculty, residents, and practitioners. Presenters included Karen J. MacKinnon, BPharm, RPh; Bradley H. Crotty, MD, MPH; Carmen Kosicek, APNP, MSN, PMHNP-BC; and Cassandra Ruoff, PharmD, BCPS. The day’s discussions focused on transforming healthcare through technology while keeping the patient at the center of healthcare.

Telehealth or telemedicine is the remote provision of healthcare services and clinical information by means of telecommunications technology, including phone, video, and other electronic or “virtual” means of communication. However, the term is not always restricted to those modes. Telehealth can also be related to any distance-based or digital services, such as healthcare apps, testing technologies, monitoring implants, and more. As Dr. Ruoff defines it: Through a broad variety of technologies and tactics, it is a means to deliver virtual medical, health, and education services. Currently, about 25% of patients already use some type of virtual healthcare or healthcare-related service. Telehealth will play an increasingly major role in services such as chronic disease management, specialist visits (e.g., mental health consultation and addiction recovery), follow-up care, and patient and provider education.

“With telehealth, we can bring the best of everyone’s knowledge on the healthcare team to the table, including the physician with their diagnostic skills and the pharmacist who is the expert in treatments and optimal patient care. Working together as a team we can not only work more collectively and efficiently but also provide better care for our patients.”

-Karen J. MacKinnon, BPharm, RPh, assistant professor and director of outreach programs of the MCW Pharmacy School

Technology is also driving patient care to be more team oriented than ever before. For example, a nurse, doctor, and pharmacist can work interprofessionally in real time via distance technology better than if the patient had three separate visits with separate information to correlate. Karen MacKinnon, BPharm, RPh, MCW Pharmacy School assistant professor and director of outreach programs, notes that “MCW PharmD graduates will have the knowledge and expertise to practice at the top of their license/education and contribute to patient-centered care within a team-based model, ensuring optimal medication therapy outcomes. The creation of the School of Pharmacy centered on producing pharmacy graduates as contributors to addressing healthcare’s triple aim focusing on quality health, improved care, and cost.” Thus, the symposium offered a space to discuss “the transformation of interprofessional healthcare teams and how to utilize technology to assist in this mission.”

Throughout the day, presenters emphasized common barriers to care and ways in which telehealth can expand care, particularly into rural areas. Disruption, too, was a common theme, as the presenters discussed the ways in which traditional practices in the healthcare industry are ripe for change. Both the use of telemedicine and expanding roles for pharmacists will play a part in disrupting the industry, thus improving services for both patients and providers.

The lack of healthcare access in rural areas is one major void which telehealth services can fill. Rural locations with few primary care doctors and fewer specialists often do have a pharmacy and pharmacist present. Thus, pharmacists are poised to help rural people, who make up 21% of the US population, both directly and through telehealth. Patients’ common barriers to care include not only location, but also cost / financial burdens, language barriers, timing and schedules (no time off of work, long waits to see a specialist, etc.), and more. In addition to helping patients overcome such barriers, telehealth can be employed in remote emergency triage, continuous care as people move, reduction of hospital readmissions, the creation of greater choice and distance disaster response,.

Patients engaging with telehealth will have fast access and immediate feedback, as well as a sense of empowerment. MacKinnon noted that another important driver for telehealth and other digital care services is the desire to provide people with not only the healthcare they need, but the healthcare they want. For example, she noted that 80% of Americans say they would prefer to receive end-of-life care at home rather than in a care facility. However, currently only 20% are at home in their last days. With technologies like remote monitoring, more people will be able to manage their end-of-life care at home with their loved ones. Telehealth, MacKinnon emphasized, can empower patients by giving them more tools and greater access than in the past – in short, giving them the care they deserve.

“If you haven’t noticed, the world is changing very, very quickly...What we have going on – as good as it is – is not sustainable. We have to find different models of care and different ways of reaching patients that help meet their needs in a much more cost-effective way, and it’s going to be much more interprofessional and patient- and family-focused.”

-Bradley H. Crotty MD, MPH, assistant professor of medicine at the Medical College of Wisconsin and director of digital engagement at Inception Health

Dr. Crotty, general internist and director of digital engagement at Inception Health, opened his presentation by noting that legacy healthcare faces an unprecedented need to evolve. Telemedicine innovations can bring healthcare into pace with the changing world. Both he and other presenters noted major factors that have created a market ready for disruption, including cost pressures, consumerism and access to information, and people’s desire to use convenient devices rather than visit clinics. Importantly, the use of telemedicine is now not only desired, but possible due to factors such as widespread internet access, common ownership of devices that allow video communications, advancing voice technology, electronic health records, miniaturization of technology such as sensors, digiceuticals (e.g., healthcare apps), and direct-to-consumer testing. Telehealth now can move beyond being just an extra service and become an integrated part of medical and pharmacy practice, with benefits for patients and practitioners alike. Dr. Crotty called on all members of the healthcare community “to roll up our sleeves and get busy to make healthcare better.” Pharmacists, he noted, can be on the front end of helping to manage this change as medicine moves into a “whole team effort of reimagined virtual care.”

Carmen Kosicek, APNP, MSN, PMHNP-BC tele-psych practitioner and chief executive office of Alay Health Team, discussed the importance of innovation in the design of brick-and-mortar pharmacy facilities and also addressed the ways in which pharmacists partner with specialty providers. Locating independent pharmacies in rural areas is now an attractive prospect, as many people need healthcare services. Using telehealth, she noted, those facilities can provide care beyond their own walls, as well. In an area with few mental health care providers, a patient can see a specialist via videoconference from a telehealth room in a pharmacy close to home. Overall, with innovations such as telehealth, the ability to administer non-vaccine injections, pharmacogenomic testing, and the changing design of pharmacy spaces, pharmacists can disrupt the traditional market. Kosicek believes the pharmacy can be “the hub of where patients know that they can go” for many services related to their wellbeing – not only to pick up a filled prescription. Further, telehealth also allows for the inverse convenience: clinics can have a telepharmacy within their walls, allowing full care at the site. In these ways, pharmacists and practitioners can “fill the void” in mental health care access. Patient, provider, and pharmacist can all be remote and yet working together as never before. With these approaches, Kosicek sees a future in which more people initially seek and receive care, and more patients maintain their mental health and properly take their medications, all while costs are driven down.

In the final session of the day, Cassandra Ruoff, PharmD, BCPS, clinical pharmacy specialist in the Department of Veterans Affairs at Great Lakes Health System/Rural Health detailed the importance of telehealth programs for our nation’s veterans. In her work with the Veteran’s Administration in Green Bay, Dr. Ruoff found that for certain types of care, patients are sometimes required to drive up to five hours to reach the proper facility. To tackle this problem, the VA is integrating a number of devices and modalities, including clinical video telehealth (CVT), care coordination home telehealth (CCHT), telephone appointments, secured messaging, and VA Connect, a video conferencing tool. If patients do not have a device that allows videoconferencing, the VA provides them with an iPad.

“We’ve talked about the need, and we’ve talked about the tech, but how do we as clinical pharmacy specialists fit into this continuum of care?”

-Cassandra Ruoff, PharmD, BCPS, clinical pharmacy specialist in the Department of Veterans Affairs at Great Lakes Healthcare System/Rural Health

According to Dr. Ruoff, pharmacists play a role through the VA’s Patient Aligned Care Teams, working to “improve access to care and the overall health of patients through management of chronic disease states and medication monitoring.” As a striking example of telehealth’s role, Dr. Ruoff summarized the VA’s program to treat and cure hepatitis C in the veteran population. Part of this effort was a successful pharmacist-managed telemedicine clinic. At the end of the program, patient surveys showed that all respondents were at least equally satisfied with telehealth as with in-person visits, and 82% said they would prefer telehealth for their future Hep C appointments. Further, 78% said they would prefer telehealth for any future disease state management visit.

Students who attended the symposium were excited to consider the future of telehealth. MCW Pharmacy School student Cassandra Rucks (Class of 2020) noted that “some patients are at such a distance from healthcare providers that they just aren’t able go in to see them. Pharmacists can play a role in that, because we see patients on our own and when we interact and work with providers, we can build a relationship through technology to really help reach more patients.” Pharmacists could be “the doctor on the bench,” she said. “If we could play a bigger role on a healthcare team, it would be better for the patient. We know what medications they are taking, we know the interactions, and we can make changes that will improve their quality of care.”

Roberto Flotte (Class of 2021) also connected with the idea of reaching out to isolated patients. “That’s why I’m here today to become a pharmacist. I believe there’s a lack of pharmacists in the rural areas. . . . We don’t get into pharmacy for the money; most of the time we get into pharmacy because we notice that people need help.” The biggest takeaway from the symposium, he said, was that today’s pharmacy students should be prepared for this technological advancement. “By the time I get out of school, medication therapy management is going to be a big part [of our business], and we’ve got to prepare for that.” Both Flotte and Rucks noted that MCW’s telehealth lab is putting the Pharmacy School’s students ahead of the game, preparing them to integrate telehealth services into their future practice.