A Systematic Review of the Effect of Telepharmacy Services

in the Community Pharmacy Setting on Care Quality and

Patient Safety

Shweta Pathak, Carrie M. Blanchard, Elizabeth Moreton, Benjamin Y. Urick

Journal of Health Care for the Poor and Underserved, Volume 32, Number
2, May 2021, pp. 737-750 (Article)

Published by Johns Hopkins University Press

DOI: https://doi.org/10.1353/hpu.2021.0102

For additional information about this article

https://muse.jhu.edu/article/794645

[ Access provided at 12 Aug 2021 00:35 GMT from University of Edinburgh ]

LITERATURE REVIEW

A Systematic Review of the Effect of Telepharmacy

Services in the Community Pharmacy Setting on
Care Quality and Patient Safety
Shweta Pathak, MPH, PhD
Carrie M. Blanchard, PharmD, MPH
Elizabeth Moreton, MLS
Benjamin Y. Urick, PharmD, PhD

Abstract: While community pharmacy-based telepharmacy services can expand medication

access for underserved communities, the safety and quality of these services is uncertain.
A systematic review was conducted in August 2020 exploring the effect of community
pharmacy-based telepharmacy services on patient safety and care quality. Database searches
identified 866 studies, of which six met the inclusion and the risk of bias measurement
criteria. Medication dispensing errors, adherence, and patient satisfaction were the most
frequently evaluated outcomes. Literature suggests no overall difference in medication safety
and adherence, conflicting evidence on patient satisfaction, and insufficient evidence on
inappropriate medication use in community pharmacy-based telepharmacies compared with
traditional pharmacies. Due to the potential for high risk of bias, no definitive conclusions
could be made about telepharmacy outcomes. Research with stronger study designs and
more rigorous evaluation methodologies is needed to create conclusive evidence on the
effectiveness of community pharmacy-based telepharmacy services.
Key words: Community pharmacy services, telemedicine, quality of health care, patient
safety, patient satisfaction, medication adherence, medication errors.

M edications are essential for the treatment and management of disease, and nearly
half of all Americans take at least one prescription medication.1 With nearly
95% of prescriptions dispensed through chain, independent, or mass merchandiser
pharmacies, community pharmacies are the major source for prescription medications
in the U.S.2
However, pharmacy closings in rural areas3,4 and low-income urban areas5,6 have
increased over the past decade. As of 2018, 16% of rural independent pharmacies had
closed over the preceding 16 years, and some members of this group were the sole retail

SHWETA PATHAK, CARRIE M. BLANCHARD, and BENJAMIN Y. URICK are affiliated with
the University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC. ELIZABETH
MORETON is affiliated with the University of North Carolina Health Sciences Library, Chapel Hill, NC.
Please address all correspondence to: Shweta Pathak, UNC Eshelman School of Pharmacy, Center for
Medication Optimization, 2400 Kerr Hall | 301 Pharmacy Lane, Chapel Hill, NC 27599-7574; Email:
shpathak@email.unc.edu.

© Meharry Medical College Journal of Health Care for the Poor and Underserved 32 (2021): 737–750.
738 Telepharmacy in community settings

pharmacy in the communities in which they operated.3 Similarly, one in four pharmacies
have closed in low-income urban neighborhoods between 2009 and 2015.7 Pharmacy
closings can create geographic barriers to medication access and pharmacy services,
which can lead to non-adherence and other negative population health outcomes.8,9
Telepharmacy is a potential solution to expand access to medications in—and may
be useful for improving pharmacy service coverage in—rural or underserved com-
munities regardless of where the pharmacist is located.10,11 Telepharmacy is generally
viewed as a subset of telemedicine, as it refers to the provision of pharmacy services via
telecommunication technologies.12 The National Association of Boards of Pharmacy’s
(NABP) Model Act refers to telepharmacy as the practice of pharmacy by registered
pharmacies and pharmacists through the use of telepharmacy technologies, defined
as, “secure electronic communications, information exchange, or other methods that
meet applicable state and federal requirements.”13[p.27] Telepharmacy services can be
provided through a) automated dispensing devices or “kiosks” or b) remote dispensing
at a staffed location, within either a remote pharmacy or another institutional facility
such as a hospital or clinic.12,14 Remote pharmacies and remote dispensing sites are all
linked to coordinating pharmacies via a computer system and/or an auditory/video
communication system.
The adoption of regulations to enable telepharmacy practice has increased in recent
years.15 However, as of 2016, 16 of 50 states in the U.S. had no rules or legislations
authorizing the use of telepharmacy.15 Lack of information on the safety and quality of
telepharmacies is a potential barrier16 to regulations allowing the expansion of teleph-
armacy services in rural areas and low-income urban neighborhoods.
New contribution. Given current challenges to accessing medications and concerns
about the care quality and patient safety in telepharmacies, we sought to aggregate knowl-
edge about telepharmacy services and care quality in community pharmacy settings
as well as identify opportunities for research where gaps are present in peer-reviewed
literature. Previous reviews have either assessed the broader effect of telemedicine
models in the outpatient setting17,18 or examined the effectiveness of telepharmacies in
the inpatient setting.19 A more recent review summarized the variety of ways in which
telepharmacy has been adopted and used in recent years,20 but no evidence summarizing
the effectiveness of telepharmacy services was provided. Consequently, in accordance
with PRISMA guidelines for a systematic review,21 we identified articles that fit the
population, intervention, comparison, and outcome (PICO) question: What is the
effect of telepharmacy services provided by remote dispensing or remote pharmacies
in the community pharmacy setting on care quality and patient safety? The findings
from this review will address an important gap in current peer reviewed literature by
providing information about the safety and quality of telepharmacy services in the
community pharmacy setting. Moreover, this review highlights future research needs
for the expansion of telepharmacy services in underserved communities.
Conceptual framework. We used the Donabedian framework22 of structure-process-
outcomes to guide the development of this review. This framework theorizes that the
structure of health care delivery (e.g., telepharmacy) influences care processes (e.g.,
medication dispensing), which further influences care outcomes (e.g., patient satisfac-
tion, readmissions, health care utilization). The Donabedian framework also classifies
 Pathak, Blanchard, Moreton, and Urick 739

quality measures based on structure, process, and outcomes of care delivery.23 Since
telepharmacy services are provided through remote dispensing or remote pharmacies,
the structure of telepharmacy services is reasonably different from traditional pharmacy
services or other telemedicine models in clinical settings. For this literature review, we
focused on how structural differences in the delivery of telepharmacy services affected
process and outcome measures of quality in the community pharmacy setting.

Methods
Literature search. We conducted a systematic literature search in PubMed, Embase,
and Scopus databases to identify peer-reviewed articles with information about teleph-
armacy use in the community pharmacy setting. We undertook the search in consul-
tation with a subject librarian (author EM) and included all articles published until
August 2020. Examples of search terms used for the review were key words and subjects
related to community, independent, chain, or outpatient pharmacies or pharmacists,
mass merchandisers, or a combination of (community AND pharmacy). These terms
were used in conjunction with keywords and subjects related to telemedicine, remote
consultations, mHealth, or videoconferencing (see Supplementary Materials for the
full search; available from the authors upon request). All search terms were combined
using Boolean operators and no publication date limits were applied to the database
searches. All duplicate articles were removed before beginning article selection.
Article selection. Full-text articles were included in the study if they were written
in English and used telepharmacy services (as defined by NABP) in a community
pharmacy setting (Box 1). Publications with interventions in an inpatient or clinical
pharmacy setting were excluded. Studies were excluded if they did not assess a com-
parator, defined as previous standard of care and/or baseline measurement.
Studies were excluded if they measured only pre-implementation outcomes (e.g.,
perceived patient satisfaction with telepharmacy) or outcomes that did not meet the
criteria for patient quality of care (e.g., pharmacist satisfaction). Poster abstracts were
excluded from our results, but communication with poster-authors was attempted to
ensure that subsequent full-text manuscripts that were completed but not published
could be included. This process did not result in any additional articles for this study.
Two reviewers (authors SP, CMB) independently screened the titles and abstracts
of all retrieved articles using our inclusion criteria and identified eligible articles using
Covidence systematic review software (Melbourne, Australia). Discrepancies in each
phase of article selection were discussed amongst three team members (authors SP,
CMB, BYU) and resolved using consensus (Figure 1).
Data extraction. The following relevant data were extracted from each article selected
for review: Title, author, comparison group, study design, sample size, data collection
timeline, outcome(s) assessed, and a brief summary of study results. Additional com-
ments were made when necessary to provide context and clarity.
Risk of bias assessment and data analysis. We assessed factors at the study level
that affect the risk of bias using the valid and reliable Risk of Bias Assessment Tool for
Nonrandomized Studies (RoBANS).24 The risks were expressed as low risk, high risk,
and unclear risk for each of the following six domains: 1) selection of participants,
Box 1.
INCLUSION AND EXCLUSION CRITERIA FOR THE SYSTEMATIC REVIEW
Inclusion Criteria
Study designs Randomized controlled trials, before-and-after studies, retrospective
and prospective cohort studies.
Participants All participants, including those with different sociodemographic
characteristics or clinical co-morbidities.
Settings Intervention provided in the community pharmacy setting.
Interventions Telepharmacy services that include remote dispensing services and
may or may not include remote patient counselling by a community
pharmacist
Comparisons Baseline comparison of outcomes or outcomes compared with a
control group that received usual care.
Outcomes Reporting of quality of care and patient safety outcomes. Quality
of care outcomes: adherence to prescribed medications using
any method, clinical biomarkers (e.g. blood pressure, glycosylated
hemoglobin (HbA1c)), hospitalization rates, emergency room visits,
or any other markers of disease progress, outcomes that relate to
patient quality of life, experience (saving time, improving access),
or satisfaction. Patient safety outcomes: error rates
Exclusion Criteria
Studies without a control group.
No groups were excluded.
Hospitals, in-patient settings or mail order pharmacies
Telepharmacy services that do not include remote dispensing.
telehealth services (e.g. remote medication therapy management
services). Also, telehealth services implemented by other health
professionals in coordination with community pharmacies where
the contribution of the community pharmacies/ pharmacist
cannot be isolated from the effects of activities conducted by
other health care professionals.
Study involved neither a baseline comparison, nor a control
group that received usual care.
Studies that reported only pre-implementation outcomes of
telepharmacy services (e.g. perceived patient satisfaction with
telepharmacy) or outcomes that did not meet the criteria for
patient quality of care (e.g. pharmacist satisfaction)
 Pathak, Blanchard, Moreton, and Urick 741

Figure 1. PRISMA diagram for identification of eligible studies.

2) confounding variables, 3) measurement of exposure, 4) blinding of outcomes assess-

ment, 5) incomplete outcome data, and 6) selective outcome reporting. Articles where
more than three domains were high-risk were discussed among the authors to ensure
appropriateness of the classification and to justify their inclusion in the final review.
Meta-analysis was deemed inappropriate for this study due to heterogeneity in the
study populations, interventions, and outcomes of the included studies.

Results
Overview. A total of 866 articles were retrieved from database searches (Figure 1).
After applying the PICO question and our inclusion criteria, 18 potential studies were
742 Telepharmacy in community settings

selected for full-text review, of which seven studies met our inclusion criteria. After
assessing the studies for risk of bias (Table 1), only six studies were included in the final
review.
All included studies (n=6) had a cross-sectional study design and all originated from
the U.S. For most studies (n=4), the telepharmacies were situated in rural areas.25–28
However, one study included both urban and rural telepharmacies29 while another
included an urban telepharmacy only.30 Studies evaluated endpoints such as patient
satisfaction (n=3), medication dispensing errors (n=2) , adherence (n=2), and inap-
propriate use (n=1). The characteristics of the studies included in the final review are
summarized in Table 2.
Risk of bias assessment. The most common domains with high risk of bias were 1)
blinding of outcomes assessment and 2) confounding variables. None of the included
studies considered blinding before assessing differences in outcomes, which can lead
to potential detection biases. Similarly, only two studies27,28 provided any consideration
for potential confounders, which can substantially influence the relative effect of the
exposure variable on study outcomes. Another domain often assessed as high-risk or
unclear-risk in the studies included in this review is the domain of selection bias (Domain
1) for cases where the method of survey distribution was not reported clearly or where
data were generated through self-reporting or patient self-selection. One study31 was
omitted from the final review because it had five domains with high risk and the study
was collectively judged to be of overall poor quality by the authors.
Qualitative synthesis of included studies. The six included studies reported eight
endpoints; four studies reported process measures such as medication dispensing errors,
medication adherence, and inappropriate use, while three studies reported patient
satisfaction as an outcome measure.
Patient safety. Two studies (Table 2) examined error rates in telepharmacies and
control pharmacies by using quality-related events (QREs) to demonstrate differences
in patient safety.25,26 Both studies evaluated the number of near misses (QREs caught
before they reached the patient) and errors (QREs discovered after the patient received
the medication). The study by Friesner et  al. found slightly more errors related to
medication dispensing in telepharmacies than in the control pharmacies, but found
the overall error rates at remote and control sites to resemble nationally-reported error
rates.26 Similarly, the study by Scott et  al. found that QREs at the remote sites were
more likely to be near misses and less likely to be errors that reached the patient.25
Medication adherence and inappropriate use. Two studies examined differences in
medication adherence between tele- and traditional pharmacies.28,30 The study by Hudd
and Tataronis30 examined differences in medication adherence for telepharmacy and
a control retail chain pharmacy. Adherence was measured using refill patterns, and
no difference in adherence rates was observed in the two types of pharmacy. Another
study28 examined differences in adherence using proportion of days covered for cho-
lesterol, diabetes, and hypertension medications and found no difference in adherence
rates between tele- and traditional pharmacies.
Only one study28 evaluated inappropriate medication use by measuring use of high-
risk medications in the elderly (HRM) and statin use in persons with diabetes (SUPD)
and found that, after covariate adjustment, HRM use in telepharmacies was comparable
Table 1.
RISK OF BIAS ASSESSMENT OF STUDIES ELIGIBLE FOR INCLUSION

Risk of Bias Assessment Domains

Blinding
Author, Year, Selection of Confounding Measurement of outcome Incomplete Selective Overall
[Reference] participants variables of exposure assessments Outcomes reporting Inclusiona

Clifton, 2003,[29] Low risk High risk Low risk High risk High risk Low risk Included
Friesner, 2009, [27] Unclear risk Low risk Low risk High risk Unclear risk Low risk Included
Hudd, 2011, [30] Low risk High risk Low risk High risk High risk Low risk Included
Friesner, 2011, [26] High risk High risk Low risk High risk Low risk Low risk Included
Scott, 2012, [25] High risk High risk Low risk High risk Low risk Low risk Included
Inch, 2017, [31] High risk High risk Low risk High risk High risk High risk Excluded
Pathak, 2020 [28] Low Risk Low risk Low risk High risk Low risk Low risk Included

Note
a
Articles were included if three or more domains had low risk of bias.
Table 2.
CHARACTERISTICS OF STUDIES INCLUDED IN FINAL REVIEW

Author, Year,
Country, Comparison Outcome(s) Data collection
[Reference] groups Study design assessed Sample size timeline Brief summary of results

Clifton, 2003, 1 base pharmacy; Crossectional Patient Base site, n=106; 2 years post- Satisfaction with time required to
USA, [25] 5 remote clinics study Satisfaction Remote site, n=93 implementation of obtain medications and counseling
(rural and urban) telepharmacy in base vs. remote was 66% vs.
55.6% (p < 0.01).
Friesner, 8 rural tele Crossectional Patient n= 96 2 or more years The global satisfaction measure
2009, USA, pharmacies; study Satisfaction post-implementation does not differ based on the remote
[24] (4 remote sites; of telepharmacy site (mean=4.4) vs. central site
4 central sites) (mean=4.5; ANOVA: p=0.388).
Hudd, 2011, 1 urban Crossectional Adherence, Adherence, n=26; Adherence: Adherence: Difference in the mean
USA, [30] telepharmacy study patient Survey, n=95 before and after number of days between refills for
and 1 retail chain satisfaction implementation; those using telepharmacy vs. retail
pharmacy Satisfaction: 2 years chain was 37.1 vs. 38.8 (p = 0.610).
post-implementation Satisfaction: No comparison group.
Patient satisfaction (87%) with
the ease of prescription refills in
telepharmacy. Improvement (85%)
in understanding of medications
through pharmacist counseling via
telepharmacy.
(continued on p. 745)
Table 2. (continued)

Author, Year,
Country, Comparison Outcome(s) Data collection
[Reference] groups Study design assessed Sample size timeline Brief summary of results

Friesner, 14 remote (rural) Crossectional Quality-related Telepharmacy, 45 months Overall QRE rate was lower for the
2011, USA, telepharmacy sites study even (QRE) n=47,078; central traditional community pharmacy
[23] and 8 community rates pharmacy; n=123,346 (0.8%) than the remote group (1.3%;
pharmacies prescriptions p < 0.001).
Scott, 2012, 14 remote (rural) Crossectional Quality-related Prescriptions at 45 months QREs caught at the final pharmacist
USA, [22] sites and 10 study even (QRE) remote telepharmacy, check in remote vs. central sites
central sites rates n=47,078; central were 58.2% vs. 40.8% (p < 0.01),
pharmacy; n=62,480 and those caught by the patient were
0.17% vs. 0.28% (p< 0.01).
Pathak, 2020, 3 tele- and Crossectional Adherence, n=2,832 patients 18 months post- No statistically significant
USA[28] 3 traditional study inappropriate contributed 4,402 implementation of differences between tele- and
pharmacies in a use observations telepharmacy traditional pharmacies for adherence
rural area to cholesterol, hypertension, and
diabetes medications as well as high
risk medication use in the elderly.
However, statin use in persons with
diabetes was higher in tele- than
traditional pharmacies.
746 Telepharmacy in community settings

to use in traditional pharmacies, but telepharmacies demonstrated higher SUPD than

traditional pharmacies.
Patient satisfaction. Three of six studies included in the final review (Table 1) exam-
ined patient satisfaction with telepharmacies in a community pharmacy setting,27,29,30 of
which two had a comparison group.27,29 The study by Friesner et al. found no difference
in global patient satisfaction between telepharmacy and central sites.27 Conversely, the
Clifton et al. study found slightly lower patient satisfaction with time required to obtain
medications and counseling at telepharmacies than the coordinating base pharmacy.29
The third study by Hudd and Tataronis indicated a high level of patient satisfaction
with the ease of prescription refills (87%) and an improved understanding of medica-
tions through pharmacist counseling via telepharmacy (85%), but these results were
not compared with a control group.30

Discussion
This systematic review found six studies that examined the effect of telepharmacies
in the community pharmacy setting on patient outcomes. There was some indication
that telepharmacies performed comparably well or slightly better than traditional
pharmacies in catching medication-related errors and maintaining patient adherence
to medications. Additionally, telepharmacies seemed to perform slightly less well than
or no differently from traditional pharmacies on patient satisfaction. Only one study
examined inappropriate medication use as an outcome; therefore, a general trend for
telepharmacy effect on inappropriate medication use could not be assessed. Overall,
included studies revealed a high risk of bias for elements related to study design and
evaluation. Thus, we were unable to draw any definitive conclusions about patient safety
and quality-related outcomes for telepharmacies in the community pharmacy setting.
As rural residents and low-income urban communities continue to lose access to
pharmacy services, community-pharmacy-based telepharmacy services can be leveraged
to improve access to pharmaceutical care for people living in high-need communities.
Establishing a strong evidence base for the safety and effectiveness of community-
pharmacy-based telepharmacy services is an essential first step toward addressing some
of the practical and regulatory challenges to the adoption and expansion of telepharmacy
services in low-access areas. Consequently, more studies with stronger study designs
and rigorous evaluation methodologies are needed for building conclusive evidence
about differences in quality of care and patient safety outcomes between telepharmacy
and traditional pharmacies in the community pharmacy setting.
Limitations. Our study had a few limitations. We excluded many studies because
they failed to meet our designed PICO question. It was evident that some studies
discussed the implementation of telepharmacy services as a novel solution to address
access needs and consequently lacked a comparison group. Furthermore, we used the
technical definition of telepharmacy developed for pharmacy services in the U.S., but
for the sake of comparison, we also applied this definition to studies identified in other
jurisdictions. Finally, while every attempt was made to ensure this literature review was
comprehensive for current peer-reviewed literature, additional studies might have been
missed by excluding articles from grey literature.
 Pathak, Blanchard, Moreton, and Urick 747

Conclusion. In summary, literature on the effectiveness of telepharmacy services

in the community pharmacy setting was scarce and demonstrated a tendency toward
high risk of bias. Thus, no definitive conclusions could be made about patient safety
and quality-related outcomes for telepharmacies in the community pharmacy setting.
Research with stronger study designs and rigorous evaluation methodologies is needed
to establish a strong evidence base regarding the effectiveness of community-pharmacy-
based telepharmacy services.

Acknowledgments
The authors thank Chloe Richard from the University of North Carolina Eshelman
School of Pharmacy for reviewing the contents of this manuscript. We also thank
Emily Ruiz and Brittany Young for their contributions in scoping the literature on
telepharmacies.

Conflict of interest
Author BYU received research contributions and consulting fees from Cardinal Health
for telepharmacy-related work not connected with this manuscript. The remaining
authors declare that there are no conflicts of interest with respect to the research,
authorship, and/or publication of this article.

Funding
This research received no specific grant from any funding agency in the public, com-
mercial, or not-for-profit sectors.

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 Pathak, Blanchard, Moreton, and Urick 1

Supplementary Materials:
Search terms for Pubmed (ncbi.nlm.nih.gov)
(“community telepharmacy”[tw] OR “community pharmacy”[tw] OR “community
pharmacies”[tw] OR “community pharmacist”[tw] OR “community pharmacists”[tw]
OR “Community Pharmaceutical Services”[tw] OR “Community Pharmaceutical
Service”[tw] OR “Community Pharmacy Services”[tw] OR “community pharmacy
services”[MeSH] OR ((“Community Health Services”[Mesh] OR “Rural Health
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AND (pharmacy[tw] OR pharmacist*[tw] OR pharmaceutic*[tw] OR “Pharmacies”[Mesh]
OR “Pharmacists”[Mesh])) OR “independent pharmacy”[tw] OR “independent
pharmacies”[tw] OR “independent pharmacist”[tw] OR “independent pharmacists”[tw]
OR “retail pharmacy”[tw] OR “retail pharmacies”[tw] OR “retail pharmacist”[tw] OR
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“chain pharmacies”[tw] OR “chain pharmacists”[tw] OR “Retail chain”[tw] OR “retail
chains”[tw] OR “mass merchandiser”[tw] OR “mass merchandiser”[tw] OR “Outpatient
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AND
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OR videoconferenc*[tw] OR teleconferenc*[tw] OR “remote dispensing”[tw] OR
telepharm*[tw])
AND
English[lang]
Search terms for Embase (Embase.com)
(‘community telepharmacy’:ti,ab OR ‘community pharmacy’:ti,ab OR ‘community
pharmacies’:ti,ab OR ‘community pharmacist’:ti,ab OR ‘community pharmacists’:ti,ab
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OR ‘chain pharmacy’:ti,ab OR ‘chain pharmacies’:ti,ab OR ‘chain pharmacists’:ti,ab
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AND
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2 Supplementary material

encing’/exp OR ‘mobile health’/exp OR ‘telehealth’/exp OR ‘mhealth’/exp OR ‘ehealth’/

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AND [english]/lim
Search terms for Scopus
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OR “Community Pharmaceutical Services” OR “Community Pharmaceutical Service”
OR “Community Pharmacy Services” OR “independent pharmacy” OR “independent
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