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  • Difficult to know what people have (they sometimes not know) Pharmacies hired consultants to design & implement their cluster – different solutions No consistency throughout Dealing w local phone companies Not know about SDSL (would video even work?) Know nothing about pharmacies No central connecting network - isolated groups
  • This project was conceived as completely separate pharmacy clusters that couldn’t connect to each other. Currently it has 21 sites (w NDSU) and 8 clusters May want to: recertification, take vacation & have another pharmacist able to oversee pharm tech, meetings
  • Managed VPN. 2 Core routers – redundancy VPN Accelerator – the “brains.” A router that establishes the tunnels, prioritizes the video NDSU – T1 link Other sites SDSL 512K going through their local ISP (phone co) Secure connection through VPN tunnel to core router Access to Internet
  • VPN tunnel between members of the cluster – separate video connection & data connection Separate tunnel connects all sites – video only. No access to pharmacy software Two levels of authentication – key & user. Key auth no user intervention 2 classes of service – video (highest priority), data
  • North Dakota is the first state that has changed its laws to allow telepharmacies. Other states like South Dakota, and Hawaii are looking to ND for guidance and assistance. I2 will enable the expansion of this program to other states.
  • 20040601-Sprafka.ppt

    1. 1. The North Dakota Telepharmacy Project Restoring and Retaining Pharmacy Services in Rural Communities Charles D. Peterson, Pharm.D. Dean & Professor College of Pharmacy Sandy Sprafka, Information Tech Services North Dakota State University Fargo, North Dakota
    2. 2. North Dakota Demographics 2000 Census Highlights <ul><li>642,200 population, ranks 47 th in nation </li></ul><ul><li>Population growth 0.5% (1990-2000) </li></ul><ul><li>Population shift from rural to urban </li></ul><ul><li>Only 6 of 53 counties gained population </li></ul><ul><li>50% of ND counties lost at least 10% </li></ul><ul><li>27 of 53 counties classified as frontier </li></ul><ul><li>14.7% over 65, vs 12.4% nationally </li></ul>
    3. 3. Pharmacy Services in ND <ul><li>Of the 373 cities, 73 have pharmacies </li></ul><ul><li>Of the 53 counties, 9 do not have a pharmacy and 11 have only one Rx </li></ul><ul><li>North Dakota 51% ownership law </li></ul>
    4. 4. North Dakota Rural Health Care Crisis: Community Pharmacy Closings <ul><li>26 rural community pharmacy closings </li></ul><ul><li>12 additional pharmacies at risk of closing </li></ul><ul><li>Pharmacist retirements - no replacement </li></ul><ul><li>National pharmacist shortage </li></ul><ul><li>Negative impact on rural health </li></ul>
    5. 5. Exploring Solutions: Telepharmacy Rules <ul><li>Required changes in pharmacy practice act </li></ul><ul><li>Telepharmacy rules established by NDBDPh </li></ul><ul><li>Pilot project in 2001  permanent rules established in June 2003 </li></ul><ul><li>Allow pharmacists to supervise a technician at remote site within 50 miles </li></ul><ul><li>Dispense prescriptions </li></ul><ul><li>Pharmacist - patient consultation </li></ul>
    6. 6. Telepharmacy Grant Awarded NDSU College of Pharmacy <ul><li>Congressionally mandated federal grant via the support of Senator Byron Dorgan </li></ul><ul><li>Office for Advancement of TeleHealth, Health Resources and Services Administration of HHS </li></ul><ul><li>First Initiated: September 1, 2002 </li></ul><ul><li>$1,671,621 federal support to date </li></ul>
    7. 7. Goals of Telepharmacy Grant: <ul><li>RESTORATION - restore pharmacy services in rural communities which have lost their services </li></ul><ul><li>RETENTION - retain pharmacy services in rural communities which are at risk of losing their services </li></ul>
    8. 9. Telepharmacy Project Partners <ul><li>NDSU College of Pharmacy </li></ul><ul><li>North Dakota State Board of Pharmacy </li></ul><ul><li>ND State Pharmaceutical Association </li></ul><ul><li>Licensed rural community pharmacies </li></ul><ul><li>Targeted rural communities </li></ul>
    9. 10. Telepharmacy Grant Budget <ul><li>Assist in the telepharmacy start-up costs </li></ul><ul><li>50% OAT Grant/50% North Dakota </li></ul><ul><li>Technology: Hardware, Software, Connectivity </li></ul><ul><li>Registered Pharmacy Technician </li></ul><ul><li>Pharmacy Fixtures </li></ul><ul><li>Drug Inventory </li></ul><ul><li>Travel </li></ul><ul><li> </li></ul>
    10. 11. Pharmacy Technician Responsibilities: Remote Telepharmacy Site <ul><li>Maintains drug inventory at remote site </li></ul><ul><li>Processes all prescriptions orders including controlled substances </li></ul><ul><li>Computer order entry, filling, billing, labeling </li></ul><ul><li>Takes original prescription orders by phone </li></ul><ul><li>Prepares prescription for dispensing by pharmacist </li></ul><ul><li>Connects patient to the pharmacist for private consultation via audio and video link </li></ul>
    11. 12. Technician Training Requirements: Telepharmacy Sites <ul><li>Registered with Board of Pharmacy </li></ul><ul><li>ASHP accredited program or equivalent </li></ul><ul><li>Minimum of one year experience in dispensing prescriptions </li></ul><ul><li>Salaries are $15/hour or more </li></ul><ul><li>Reciprocity from other states requires PTCB certification </li></ul>
    12. 13. Pharmacist Responsibilities <ul><li>Final check of technician Rx preparation </li></ul><ul><li>Dispenses drug to the patient </li></ul><ul><li>Drug utilization review </li></ul><ul><li>Patient education counseling </li></ul>
    13. 22. Demographics: Remote Telepharmacy Sites yes 2,500 sq. ft. May 21, 2003 48 miles 498 Maddock no 575 sq. ft. June 18, 2003 10 miles 717 Gwinner yes 2,000 sq. ft. Nov. 2, 2002 32 miles 538 Rolette 60 miles 95 miles Distance -Central Rx yes yes Full Service Pharmacy 1,200 sq. ft. 1,400 sq. ft. Size of Pharmacy Nov. 26, 2002 Sept. 18, 2002 Date Operational 555 1,116 Population New England Beach Site
    14. 23. Demographics: Remote Telepharmacy Sites Clinic 5d /wk PA/MD 3 FTE’s with 4 people 9:00-5:30 pm, M-F 50-55 Maddock Clinic 5d/wk MD 2 FTE’s with 3 people 8:30 – 5:00 pm, M-F 25-30 New England 9:00 – 5:00 pm, M-F 9:00 – 5:30 pm, M-F 8:30 – 5:00 pm, M-F Hours of service Clinic 5d/ wk PA/MD Clinic 3-4d /wk PA/MD Clinic 5d/wk PA Medical Coverage 1.5 FTE’s tech/clerk 3 FTE’s with 3 people 1.5 FTE’s tech/clerk # People employed 13-15 10-15 35-40 Rx ‘s dispensed per day Gwinner Rolette Beach Site
    15. 24. Benefits to North Dakota with the Telepharmacy Program <ul><li>Improved access to health care for rural citizens </li></ul><ul><li>Provides rural economic development </li></ul><ul><li>Improved quality of care/pharmacist consults </li></ul><ul><li>Increased patient & pharmacist satisfaction </li></ul><ul><li>Increased financial viability of rural pharmacies </li></ul><ul><li>Provides relief for pharmacists for vacations, etc. </li></ul><ul><li>Increased educational opportunities for students </li></ul><ul><li>Increased retention of pharmacy graduates </li></ul>
    16. 25. Economic Impact of Telepharmacy <ul><li>Has added a $500,000 per year business to the rural community </li></ul><ul><li>Thus far, has added an estimated total of $7.5 million annually to the North Dakota rural economy </li></ul><ul><li>Has added an estimated 30-40 new jobs to the North Dakota rural marketplace </li></ul><ul><li>Has added 50% increase in prescription sales to combined pharmacy operation </li></ul>
    17. 26. Economic Development Add’l Benefits of Telepharmacy <ul><li>Helps attract other businesses and families to community because basic health care infrastructure is present </li></ul><ul><li>Pharmacy can be used for other business retailing not currently available within the community </li></ul>
    18. 27. Pharmacy Student Involvement <ul><li>Incorporate telepharmacy technology in NDSU’s new Concept Pharmacy Lab </li></ul><ul><li>Trains students on the latest advances in pharmacy technology </li></ul><ul><li>Teaches students how to deliver pharmacy services in a unique and innovative way to smaller rural communities </li></ul>
    19. 28. Student Activities <ul><li>Provide pharmacists at the Central Pharmacy with drug information and disease state management assistance </li></ul><ul><li>Provide patient education counseling to remote telepharmacy sites </li></ul>
    20. 29. Future Goals of Telepharmacy in North Dakota <ul><li>5-10 new community sites each year </li></ul><ul><li>50 telepharmacy sites in five years </li></ul><ul><li>Develop a model for serving rural hospitals </li></ul><ul><li>Assist other states in implementing telepharmacy services in rural areas </li></ul><ul><li>Establish a state-wide data & video network </li></ul><ul><li>Establish equipment standards </li></ul>
    21. 30. Recent Publication <ul><li>If you would like more information: </li></ul><ul><li>Peterson, CD and Anderson HC. The North </li></ul><ul><li>Dakota Telepharmacy Project: Restoring and </li></ul><ul><li>Retaining Pharmacy Services in Rural </li></ul><ul><li>Communities </li></ul><ul><li>J. Pharm. Tech 2004:20:28-39 </li></ul>
    22. 31. From the technical side …. Project parameters <ul><li>Independent, privately owned businesses </li></ul><ul><li>Keep costs down </li></ul><ul><li>Keep prescription processing separate from consultation </li></ul>
    23. 32. Independent Pharmacy Clusters
    24. 33. Issues to Address <ul><li>HIPAA </li></ul><ul><li>Authentication </li></ul><ul><li>Secure connections </li></ul><ul><li>Reliability </li></ul><ul><li>Internet1 </li></ul><ul><li>Costs </li></ul><ul><li>Network management </li></ul><ul><li>Troubleshooting </li></ul><ul><li>Standardization </li></ul><ul><li>Growth </li></ul><ul><li>Flexibility </li></ul>
    25. 34. Telepharmacy Technology Hardware <ul><li>Polycom Viewstation (VSX7000 </li></ul><ul><li>Second camera </li></ul><ul><li>Document camera </li></ul><ul><li>2 mics (mute separately) </li></ul><ul><li>PC & printer </li></ul><ul><li>2 TV monitors </li></ul><ul><li>VPN – for encrypting Rx and video </li></ul>
    26. 35. Telepharmacy Technology – cont’d <ul><li>Prescription Processing </li></ul><ul><li>Standard Pharmacy Operations Software </li></ul><ul><li>Patient Consultation </li></ul><ul><li>Polycom ViewStation </li></ul><ul><li>Prescription Verification </li></ul><ul><li>Polycom Viewstation </li></ul><ul><li>HIPAA/Privacy </li></ul><ul><li>Virtual Private Network (VPN) – Sonic Firewall </li></ul>
    27. 36. Telepharmacy Technology Connectivity <ul><li>Local telephone company </li></ul><ul><li>Prescription Processing </li></ul><ul><li>Dedicated POTS with 56K modem </li></ul><ul><li>Patient Consultation </li></ul><ul><li>Symmetric DSL at 512K bandwidth </li></ul>
    28. 37. Lessons learned <ul><li>Not all pharmacies the same, unique components </li></ul><ul><li>Customers prefer talking to a “TV” </li></ul><ul><li>Separate prescription processing - consultation </li></ul><ul><li>Polycom units need flexibility (speakers, mics) </li></ul><ul><li>Video works – VPN, firewall, 512K SDSL, 256K </li></ul><ul><li>Different local phone companies </li></ul><ul><ul><li>Different pricing, solutions </li></ul></ul><ul><ul><li>Internet1 a quality problem beginning at 3pm </li></ul></ul>
    29. 38. Identified Needs <ul><li>Standards (except pharmacy software) </li></ul><ul><li>Video links to all </li></ul>
    30. 39. Network solutions <ul><li>Statewide Private IP Network </li></ul><ul><li>Connection to Internet2 for out-of-state </li></ul>
    31. 40. Public Internet DCN IP Core DCN T1 Internet Access DCN Core Router DCN Core Router VPN Accelerator Killdeer Pharmacy NDSU Beach Pharmacy Access Device With integrated VPN ISP Connected to DCN IP Core Access Device With integrated VPN Access Device With integrated VPN DSLAM ISP Connected to DCN IP Core 512X512 DSL 512X512 DSL Radius Authentication Server
    32. 41. DCN IP Core Radius Authentication Server VPN Headend Killdeer Pharmacy NDSU Beach Pharmacy IP Tunnel Access Device With integrated VPN Access Device With integrated VPN Access Device With integrated VPN IP Tunnel New England Pharmacy Access Device With integrated VPN IP Tunnels IP Tunnel Student or Instructor Pharmacy Tech Pharmacy Tech Pharmacist
    33. 42. Features <ul><li>Data encryption, authentication & security provisions – HIPAA </li></ul><ul><li>Secure videoconference between pharmacies – patient consultation </li></ul><ul><li>Secure data connection with document camera, database – dispensing </li></ul><ul><li>Management, growth, redundancy, reliability, QoS (video) </li></ul><ul><li>Internet access </li></ul>
    34. 43. Future Directions <ul><li>Connect to other states </li></ul><ul><ul><li>Collaboration </li></ul></ul><ul><ul><li>Instruction </li></ul></ul><ul><ul><li>Services </li></ul></ul><ul><li>Internet2 – enabling technology </li></ul><ul><li>Research Universities </li></ul><ul><li>SEGP participants </li></ul>
    35. 44. High Speed Networks <ul><li>Attract researchers, faculty, students </li></ul><ul><li>Provide increased grant opportunities </li></ul><ul><li>Provide greater access to resources </li></ul><ul><li>Fuel economic development </li></ul><ul><li>Facilitates innovative & progressive projects </li></ul>
    36. 45. Thank you <ul><li>Dr. Charles Peterson </li></ul><ul><li>[email_address] </li></ul><ul><li>Sandy Sprafka </li></ul><ul><li>[email_address] </li></ul><ul><li>(701) 231-8688 </li></ul>