1. The North Dakota Telepharmacy Project Restoring and Retaining Pharmacy Services in Rural Communities Charles D. Peterson, Pharm.D. Dean and Professor College of Pharmacy North Dakota State University Fargo, North Dakota Funded by the Office for the Advancement of Telehealth, HRSA, of Health and Human Services

3. North Dakota Demographics 2000 Census Highlights  642,200 population, ranks 47 th in nation  population growth 0.5% (1990-2000)  population shift from rural to urban  only 6 of 53 counties gained population  50% of ND counties lost at least 10%  36 of 53 counties classified as frontier  14.7% over 65, vs 12.4% nationally

7. Access to Pharmacy Services in North Dakota  Of the 373 cities, 73 have pharmacies  Of the 53 counties, 9 do not have a pharmacy and 11 have only one Rx  North Dakota 51% ownership law

8. ND Rural Health Care Crisis: Community Pharmacy Closings  26 rural community pharmacy closings  12 additional pharmacies at risk of closing  pharmacist retirements - no replacement  national pharmacist shortage  negative impact on rural health

9. Exploring Solutions: Telepharmacy Rules  required changes in pharmacy practice act  telepharmacy rules established by NDBDPh  pilot project in 2001  permanent rules established in June 2003  allow pharmacists to supervise a technician at remote site  dispense prescriptions  pharmacist - patient consultation

10. Boards of Pharmacy Telepharmacy Regulations “Approximately 25 states currently either have telepharmacy regulations or are very close to adopting regulations. There is a good chance by the end of the year, there could be 30 pharmacy boards with regulations in place.” Carl Geberbauer, V.P. Carl Geberbauer, V.P. AutoMed Technologies, Inc AutoMed Technologies, Inc

11. Telepharmacy Grant Awarded NDSU College of Pharmacy  Congressionally mandated federal grant via the support of Senator Byron Dorgan  Office for Advancement of TeleHealth, Health Resources and Services Administration of HHS  First Initiated: September 1, 2002  Approximately $2.5 million federal support to date

12. Goals of Telepharmacy Grant:  RESTORATION - restore pharmacy services in rural communities which have lost their services  RETENTION - retain pharmacy services in rural communities which are at risk of losing their services  ESTABLISH – establish pharmacy services in rural communities which have previously not had services

13. North Dakota Telepharmacy Project : A Historical Look Year Sept 2002- Aug. 2003 Sept 2003- Aug. 2004 Sept 2004- Aug. 2005 Sept 2005- Aug. 2006 Total Central Sites 471121 Total Remote Sites 6111736 Total Sites 10182857 Retail Sites 10182544 Hospital Sites 00313 Interstate0012

15. Telepharmacy Project Partners  NDSU College of Pharmacy  North Dakota State Board of Pharmacy  ND State Pharmaceutical Association  Licensed rural community pharmacies  Targeted rural communities

16. Telepharmacy Grant Budget  Assist in the telepharmacy start-up costs  50% OAT Grant/50% North Dakota  Technology: Hardware, Software, Connectivity  Registered Pharmacy Technician  Pharmacy Fixtures  Drug Inventory  Travel

17. Pharmacy Technician Responsibilities: Remote Telepharmacy Site  Maintains drug inventory at remote site  Processes all prescriptions orders including controlled substances  Computer order entry, filling, billing, labeling  Takes original prescription orders by phone  Prepares prescription for dispensing by pharmacist  Connects patient to the pharmacist for private consultation via audio and video link

18. Pharmacy Technician Training Requirements: Telepharmacy Sites  Registered with Board of Pharmacy  ASHP accredited program or equivalent  Minimum of one year experience in dispensing prescriptions  Salaries are $15/hour or more  Reciprocity from other states requires PTCB certification

19. Pharmacist Responsibilities  Final check of technician Rx preparation  Dispenses drug to the patient  Drug utilization review  Patient education counseling  Remote site visits

26. Demographics: Remote Telepharmacy Sites SiteBeachRolette New England MaddockGwinner Population1,116538555498717 Distance - Central Rx 95 miles 240 miles 60 miles 196 miles 10 miles Date Operational Sept. 18, 2002 Nov. 2, 2002 Nov. 26, 2002 May 21, 2003 June 18, 2003 Size of Pharmacy 1,400 sq. ft. 2,000 1,200 2,500 575 Full Service Pharmacy yesyesyesyesno

27. Demographics: Remote Telepharmacy Sites Site New Town Mohall New Salem Karlstad, Mn Lidgerwood Population1,367812938794738 Distance - Central Rx 49 miles 316 miles 34 miles 155 miles 13 miles Date Operational November 2003 Jan. 26, 2004 March 1, 2004 Nov. 2, 2004 Dec. 6, 2004 Size of Pharmacy 1,500 sq. ft. 1,397 800 408 408 sq. ft. 1,925 Full Service Pharmacy yesyesyesyesno

28. Demographics: Remote Telepharmacy Sites SiteBeachRolette New England MaddockGwinner Rx ‘s dispensed per day (45) 35-4010-1525-3050-5513-15 Hours of service 8:30 – 5:00 pm, M-F 9:00 – 5:00 pm, M-F 8:30 – 5:00 pm, M-F 9:00-5:30 pm, M-F 9:00 – 5:00 pm, M-F # People employed 1.5 FTE’s tech/clerk 3 FTE’s with 3 people 2 FTE’s with 3 people 3 FTE’s with 4 people 1.5 FTE’s tech/clerk Medical Coverage Clinic 5d/wk PA Clinic 3-4d /wk PA/MD Clinic 5d/wk MD Clinic 5d /wk PA/MD

29. Demographics: Remote Telepharmacy Sites Site New Town Mohall New Salem Karlstad, Mn Lidgerwood Rx ‘s dispensed per day (45) 8062509430 Hours of service 9:00 – 5:30 pm, M-F 9:30 – 5:30 pm, M; & 9:30 – 5:00 pm, T-F 9:00-5:00 pm, M-F 9:00 – 5:30 pm, M-F # People employed 2 FTE’s with 2 people, 1 R.Ph. & 1 tech. 1 FTE with one person 1 tech 2.5 FTE’s with 3 people 1 clerk,1 tech & 1 R.Ph. 2.75 FTE’s with 3 people 2 techs, & 1 clerk 2 FTE’s with 4 people, 1 tech, 3 clerks Medical Coverage 3 Clinics 5d/wk, 5MD’s/4NPs Clinic 5d /wk MD/PA Clinic 5d/wk PA Clinic 5d /wk 2MD’s/2PA’s Clinic 5d/wk 1MD/ 1PA

30. Telepharmacy Technology  Standard PC’s with Pharmacy Software  Polycom – VSX 7000  Sonic Wall TZ170 or Tele 3, Cisco Firewall  AVerMedia - AVerVision 110 Document Camera  DSL over the Internet or dedicated T-1 line  Rx Software and audio video link run in parallel

31. Benefits to North Dakota from Telepharmacy  Improved access to health care for rural citizens  Rural economic development  Improved quality of care/pharmacist consults  Increased patient & pharmacist satisfaction  Increase financial viability of rural pharmacies  Provide relief for pharmacists for vacations, etc.  Increased educational opportunities for students  Increased retention of pharmacy graduates

32. Economic Impact of Telepharmacy  Has added a $500,000 per year business to the rural community  Thus far, has added an estimated total of $12.0 million annually to the North Dakota rural economy  Has added an estimated 40-50 new jobs to the North Dakota rural marketplace  Has added 50% increase in prescription sales to combined pharmacy operation

33. Add’l Economic Development Benefits of Telepharmacy  Helps build the local community & economy  Helps attract other businesses and families to community because basic health care infrastructure is present  Pharmacy can be used for other business retailing not currently available within the community

34. Student Involvement  Incorporate telepharmacy technology in NDSU’s new Concept Pharmacy Lab  Trains students on the latest advances in pharmacy technology  Teaches students how to deliver pharmacy services in a unique and innovative way to smaller rural communities  Helps attract graduates to rural practices

35. Student Activities  Provide pharmacists at the Central Pharmacy with drug information and disease state management assistance  Provide patient education counseling to remote telepharmacy sites

37. Future Goals of the ND Telepharmacy Project  50 telepharmacy sites in five years  develop a model for serving rural hospitals  assist other states in implementing telepharmacy services in rural areas  establish a state-wide data & video network  establish equipment standards  conduct a formal medication error study

39. Telemedicine Technical Assistance Document: A Guide to Getting Started in Telemedicine Includes 14 Telemedicine Areas http://muhealth.org/~telehealth/geninfo/TAD. html http://muhealth.org/~telehealth/geninfo/TAD. html 35 page chapter providing guidelines for how to implement telepharmacy services to implement telepharmacy services

40. http:// telepharmacy.ndsu.nodak.edu / For more information visit our website at: