What is telepharmacy?

Through the use of state-of-the-art telecommunications technology, pharmacists are able to provide
pharmaceutical care to patients at a distance. Telepharmacy expands access to quality health care to
communities nationwide, primarily in rural, medically-underserved areas. 

Through the North Dakota Telepharmacy Project, a licensed pharmacist at a central pharmacy site
supervises a registered pharmacy technician at a remote telepharmacy site through the use of video
conferencing technology.  The technician prepares the prescription drug for dispensing by the pharmacist.
The pharmacist communicates face-to-face in real time with the technician and the patient through audio
and video computer links. The North Dakota Telepharmacy Project is a collaboration of the NDSU
College of Pharmacy, Nursing, and Allied Sciences, the North Dakota Board of Pharmacy, and the North
Dakota Pharmacists Association. North Dakota was the first state to pass administrative rules allowing
retail pharmacies to operate in certain remote areas without requiring a pharmacist to be present. 

To date there are 94 pharmacies involved in the North Dakota Telepharmacy Project, 32 central pharmacy
sites and 62 remote telepharmacy sites

Approximately 80,000 rural citizens have had their pharmacy services restored, retained, or established
through the North Dakota Telepharmacy Project since its inception.  The project has restored valuable
access to health care in remote medically underserved areas of the state and has added approximately
$26.5 million in economic development to the local rural economy including adding 80-100 new jobs. 

Licensed pharmacists provide traditional pharmacy services, including drug utilization review,
prescription verification, and patient counseling to a remote site via telepharmacy technology. Retaining
the active role of the pharmacist helps assure the delivery of safe, high quality pharmacy services that can
be at risk when the pharmacist is left out as in the case of internet and mail-order pharmacies. 

Telepharmacy sites in North Dakota are full service pharmacies that have complete drug inventories,
including over-the-counter and prescription drugs as well as health and beauty aids and other general
store merchandise.

How does telepharmacy work?

A patient takes their prescription to their local telepharmacy and gives it to the registered pharmacy
technician, who prepares the prescription for dispensing by the pharmacist. The pharmacist reviews the
patient's medication profile for drug interactions and other potential problems before examining digital
pictures of the completed prescription for accuracy via videoconferencing equipment.

Once the pharmacist has approved the prepared prescription, the pharmacy technician brings the patient to
a private consultation room for counseling by the pharmacist on the proper use of their medication.
Patient education counseling is required by the North Dakota Board of Pharmacy for all patients receiving
telepharmacy services and also takes place via videoconferencing. Patient confidentiality is assured
throughout the processing of their prescription. The pharmacist is ultimately responsible for proper
preparing and dispensing of medications.

Most telepharmacies in North Dakota are full-service sites with a complete inventory of prescription and
nonprescription drugs. When a telepharmacy is a short distance from the central pharmacy, the
pharmacist may choose to develop a remote consultation site where there is no drug inventory and no
requirement for a registered pharmacy technician. The pharmacist fills prescriptions at their central
pharmacy, and a courier makes deliveries twice a day to the telepharmacy, which is a general
merchandise store.  Patient counseling by the pharmacist occurs by way of videoconferencing.

Another telepharmacy model is one in a hospital or other institutional setting. In this case, a registered
pharmacy technician prepares the medication, which is checked by a pharmacist at a different location via
audio and video computer links before it is dispensed to a patient.

History and Progress of HRSA/OAT Telepharmacy Funding 

In 2001, in response to an escalation of rural community pharmacy closings in the state, the North Dakota
State Board of Pharmacy established Pilot Telepharmacy Rules to explore the feasibility of using
telepharmacy to restore and retain pharmacy services in medically underserved remote rural communities
of North Dakota. 

In September of 2002, the NDSU College of Pharmacy received a federal grant from the Office for the
Advancement of Telehealth (OAT), Division of Health Resources and Services Administration,
Department of Health and Human Services, to implement a state-wide telepharmacy program to save
rural pharmacies from closing and to test the new telepharmacy pilot rules established by the Board of
Pharmacy. In FY'2002, a total of ten North Dakota rural communities were involved in the first year of
the federal OAT grant. Four central pharmacy sites in Killdeer, Watford City, Rugby, and Forman, North
Dakota, were established to serve six remote telepharmacy sites in Beach, New England, New Town,
Rolette, Maddock, and Gwinner, North Dakota. 

In June 2003, due to the overwhelming success of the telepharmacy pilot project, the North Dakota State
Board of Pharmacy established permanent rules allowing telepharmacy to be practiced on a broader scale
in North Dakota. These permanent rules allow a retail pharmacy to open and operate in certain remote
rural areas of the state without a licensed pharmacist being physically present in the store and allows a
pharmacist to supervise a registered pharmacy technician at a remote telepharmacy site using
telepharmacy technology for the purposes of dispensing prescriptions to patients, providing drug
utilization review, and patient education counseling.  

In September of 2003, the NDSU College of Pharmacy received a second year of federal funding from
OAT/HRSA. In FY'2003, a total of eight new North Dakota rural communities were added to the North
Dakota Telepharmacy Project. Three new central pharmacy sites in Minot, Bismarck, and LaMoure,
North Dakota, were established to serve five remote telepharmacy sites in Mohall, New Salem, Enderlin,
Lisbon, and Oakes, North Dakota. 

In September of 2004, the NDSU College of Pharmacy received a third year of federal funding from
OAT/HRSA. In FY'2004, nine new communities were added to the Telepharmacy Project and one
community, Rugby, obtained an additional site.  Four central pharmacy sites in Turtle Lake, Fargo,
Rugby, and Hankinson, North Dakota, are being established to serve six remote telepharmacy sites in
McClusky, Underwood, Harvey, Devils Lake, and Lidgerwood, North Dakota, and in Karlstad,
Minnesota.  The North Dakota Telepharmacy Project added its first hospital telepharmacy sites to the
project this year (three hospitals) and added its first interstate telepharmacy site, a remote telepharmacy
site in Minnesota.  

As of November 2004, twenty-eight pharmacies were involved in the North Dakota Telepharmacy
Project, eleven central pharmacy sites and seventeen remote telepharmacy sites. Of the twenty-eight
pharmacies involved, twenty-five were retail pharmacies and three were hospital pharmacies.  
As of January 2006, fifty-seven pharmacies are involved in the North Dakota Telepharmacy Project,
twenty-one central pharmacy sites and thirty-six remote telepharmacy sites. Of the fifty-seven pharmacies
involved, forty-four are retail pharmacies and thirteen are hospital pharmacies. Thirty-three (62%) of
North Dakota’s fifty-three counties are involved in the project and two in Minnesota. Approximately
40,000 rural citizens have had pharmacy services restored, retained or established through the North
Dakota Telepharmacy Project since its inception. The project has restored valuable access to health care
in remote medically underserved areas of the state and has added approximately $12 million in economic
development to the local rural economy. 

To date there are eighty-one pharmacies involved in the North Dakota Telepharmacy Project, twenty-five
central pharmacy sites and fifty-six remote telepharmacy sites. Of the eighty-one pharmacies involved,
fifty-three are retail pharmacies and twenty-eight are hospital pharmacies. Thirty-eight (73%) of North
Dakota's fifty-three counties are involved in the project and two in Minnesota. Approximately 80,000
rural citizens have had pharmacy services restored, retained or established through the North Dakota
Telepharmacy Project since its inception. The project has restored valuable access to health care in
remote medically underserved areas of the state and has added approximately $26.5 million in economic
development to the local rural economy

What can telepharmacy do for my community?

The goal of the North Dakota Telepharmacy Project is to restore and retain pharmacy services in
communities that have lost or are at risk of losing their pharmacy services. 

For rural communities, a telepharmacy means: 

 local access to a pharmacist and pharmacy services 

 safe, timely delivery of medications 
 enhanced economic development through new businesses and added jobs 
 better climate for recruiting and retaining health care providers 
 increased potential for attracting new businesses and families to the community 

To date, the North Dakota Telepharmacy Project has added: 

 a $500,000 per year business to the rural community 

 an estimated total of $12 million to the state's rural economy 
 an estimated 40 to 50 new jobs in the rural marketplace

What can telepharmacy do for me as a pharmacist/business owner?

Telepharmacy offers a pharmacist/business owner the opportunity to expand the professional and
financial sides to their operation. 

For licensed pharmacists, a telepharmacy means: 

 Potential for more business and greater revenue 

 More opportunity for relief help for personal and professional reasons 
 Greater viability, sustainability, and salability of business 
 Increased pharmacist and patient satisfaction 
 What does telepharmacy offer rural hospitals?

One of the greatest challenges facing the profession of pharmacy today is delivery of pharmacy services
to small rural hospitals.  Of North Dakota's 47 general acute care hospitals, 39 are small rural hospitals.
Thirty-one of these facilities are critical access hospitals with a maximum of 25 beds.  Most of the state's
rural hospitals are staffed by one full-time pharmacist providing services for 8 hours a day, 5 days a week,
or they contract for pharmacy services with a local community pharmacist.  National pharmacist
shortages have made it difficult for small rural hospitals to find pharmacist relief help in covering routine
hours, evenings, nights, weekends, vacations, sick time, and professional meetings.  Furthermore, new
and anticipated requirements on hospitals, instituted by national accreditation groups and federal
agencies, are targeting efforts to improve patient safety and asking hospitals to provide 24-hour
pharmacist review of all medication orders, which also present challenges to small rural hospitals.

The North Dakota Telepharmacy Project was established in 2002 for the purpose of restoring, retaining,
or establishing pharmacy services in medically underserved rural communities through the use of
telepharmacy technology.   The project is currently funded by a congressionally mandated grant through
the Office for the Advancement of Telehealth (OAT) in the U.S. Department of Health and Human
Services.  Initially, the focus of the project was rural retail pharmacies, which had seen numerous closings
due to pharmacist retirements.  With the success of telepharmacy in a community pharmacy setting,
hospitals began requesting information regarding whether or not telepharmacy could work in a hospital
setting to address the challenges of pharmacist staffing and pharmacy services.  As a result, the decision
was made to explore telepharmacy as a solution for small rural hospitals in addressing the challenges of
delivering pharmacy services.  In 2003, the North Dakota Board of Pharmacy established administrative
rules for telepharmacy in hospitals, opening the door to telepharmacy for rural hospitals in North
Dakota.   The following year the North Dakota Telepharmacy Project added its first hospital
telepharmacy sites (3 rural hospitals initiated a telepharmacy program).   In September 1, 2006, a total of
13 rural hospitals were participating in the project; beginning September 2008, this number will expand to
23 rural hospitals exploring telepharmacy solutions for their pharmacist staffing and pharmacy services.

With additional OAT funding granted in 2008, the North Dakota Telepharmacy Project is further
expanding hospital telepharmacy.  The goal of this initiative is to establish a pharmacist-staffed central
order entry (COE) site in Fargo, which will ultimately deliver 24-hour pharmacy services via
telepharmacy technology to any rural hospital in the state choosing to contract for these services.  Project
funding will also be used to install and implement telepharmacy technology at a pilot group of nine small
rural hospitals (remote telepharmacy sites).  In addition to the North Dakota Board of Pharmacy and the
North Dakota Pharmacists Association, the project is partnering with Catholic Health Initiatives (CHI) to
expand hospital telepharmacy.  CHI is a national nonprofit health system based in Denver, which includes
70 hospitals, including 19 with the critical access designation; 43 long-term care facilities, assisted-living
facilities and residential units; and two community-based health organizations.  

The COE site will provide supervisory pharmacist oversight to remote rural hospital pharmacies via
telepharmacy technology, including audio, video, and computer links and scanned electronic images. 
Using this telepharmacy technology, a pharmacist supervises a pharmacy technician at remote
telepharmacy site in processing medication orders for patients.  The pharmacy technician obtains the
medication order from the nursing station or physician, enters the order into the computer, prepares the
product for dispensing by the pharmacist (product selection, labeling, billing), and then the pharmacist
performs a final check of the product and releases the medication to the nursing station and provides
professional consultation to the patient, nurse, or physician, if needed.  Through use of a wireless
telepharmacy cart, access to a pharmacist and pharmacy services can be potentially available to any rural
hospital 24 hours a day, 7 days per week, at any location within the hospital, ER, nursing station, patient
bedside, pharmacy. Real time pharmacy oversight to the medication order entry and use process in
hospitalized patients is recognized as a key component of high quality medication safety practices, and
there is an opportunity in North Dakota to extend this level of coverage to all critical access hospitals that
are willing to participate. The project also provides quality assurance monitoring to ensure optimum
patient safety through medication error tracking and other quality assurance measures.