To describe the impact of a Specialized Pharmaceutical Care model that includes pharmacotherapeutic monitoring of patients through an Telepharmacy platform and home medication dispensing.
MethodA descriptive and retrospective study conducted in the Pharmacy Service of a tertiary hospital, between 23 March 2020 and 31 December 2021. A new pharmaceutical care model for chronic ambulatory patients was developed, including: (i) definition of criteria for selecting Telepharmacy candidate patients; (ii) stratification of patients by risk level; (iii) definition of individualized pharmacotherapeutic monitoring; (iv) adaptation of the Pharmacy Service app platform to ensure continuous pharmacotherapeutic monitoring and patient monitoring (e-Oncohealth, e-Midcare and farMcuida), (v) implementation of an appointment system; and (vi) development of a software module for the management of home medication delivery. The impact of this pharmaceutical care model was assessed by analyzing indicators of activity, safety, adherence and perceived quality. Moreover, an additional study on the impact of COVID-19 was developed in order to assess the accessibility of medical care and continuity of treatment through a survey conducted on a random sample of 100 patients.
ResultsDuring the study period, 2,737 patients benefited from the new remote pharmaceutical care model. A total of 7,758 Telepharmacy consultations were performed. Pharmacotherapeutic monitoring prevented 1,043 adverse drug reactions, which affected 10.4% of patients (3.6 adverse drug reactions/patient). Mean adherence to treatment was 95.2%. Overall satisfaction with the new model was 9.8/10. All patients would recommend this model to other patients.
ConclusionsThe new Pharmaceutical care model increases patient safety and improves treatment adherence, with a high perceived quality. Patient stratification and individualized follow-up via an Telepharmacy platform were crucial to the development of this model.
Describir el impacto de un modelo de atención farmacéutica especializada que incluye el seguimiento farmacoterapéutico de los pacientes mediante una plataforma de Telefarmacia y la dispensación de la medicación en el domicilio.
MétodoEstudio descriptivo, retrospectivo, llevado a cabo en un servicio de farmacia de un hospital terciario entre el 23 marzo de 2020 y el 31 de diciembre de 2021. Se desarrolló un nuevo modelo de atención farmacéutica para la atención de los pacientes crónicos ambulatorios, que incluye: i) definición de los criterios de selección de los pacientes candidatos a Telefarmacia, ii) estratificación de los pacientes según el nivel de riesgo, iii) definición del seguimiento farmacoterapéutico individualizado, iv) adaptación de la plataforma de apps del servicio de farmacia para garantizar el seguimiento farmacoterapéutico continuo y la monitorización de los pacientes (e-Oncosalud, e-Midcare y farMcuida), v) implantación de un sistema de citación, y vi) el desarrollo de un módulo informático para la gestión de la dispensación y entrega de la medicación en el domicilio. El impacto de este modelo de atención se evaluó mediante el análisis de indicadores de actividad, seguridad, adherencia y calidad percibida. Asimismo, se incluyó un estudio adicional sobre el impacto de la COVID-19 en la accesibilidad de la atención médica y la continuidad de los tratamientos, mediante una encuesta a una muestra aleatoria de 100 pacientes.
ResultadosDurante el periodo de estudio, 2.737 pacientes se han beneficiado del nuevo modelo de atención farmacéutica a distancia. El número de consultas de Telefarmacia realizadas fue 7.758. El seguimiento farmacoterapéutico evitó 1.043 eventos adversos asociados a la medicación, que afectaron al 10,4% de los pacientes atendidos (3,6 eventos adversos asociados a la medicación/paciente). La adherencia media al tratamiento de los pacientes fue del 95,2%. La satisfacción global con el nuevo modelo de atención farmacéutica fue de 9,8/10. El 100% de los pacientes lo recomendaría a otros pacientes.
ConclusionesEste nuevo modelo de atención farmacéutica aumenta la seguridad del paciente y mejora su adherencia al tratamiento, con unos índices de calidad percibida elevados. La estratificación de pacientes y el seguimiento personalizado mediante la plataforma Telefarmacia resultaron clave en su desarrollo.
The COVID-19 pandemic caused by the SARS-CoV-2 coronavirus has thrown the world into an unprecedented health crisis in our recent history. The protection measures established, along with fear of infection and the risk of developing severe complications led chronic patients to a situation of vulnerability. Thus, the pandemic has limited chronic patients’ access to therapeutic care and adherence to treatment1.
COVID-19 has posed a challenge to Hospital Pharmacy Services, forcing them to rapidly adapt their operating procedures in order to meet the therapeutic needs of their patients. Telepharmacy emerged as an effective strategy for the dispensation of medicines at patient's home, while the pharmacist provides information and tailored follow-up of the administration, adherence, effectiveness, and safety of their treatment2.
Telepharmacy is defined as “remote pharmaceutical practice based on the use of information and communication technologies (ICTs)”. Telepharmacy may involve activities such as informed dispensing of medication; health team coordination to ensure continuity of care; remote pharmacotherapeutic monitoring according to patients’ needs and resources available3.
However, although numerous professional associations recommend Telepharmacy, including the American Society of Health-System Pharmacists (ASHP)4 and the Spanish Society of Hospital Pharmacy (SEFH)3, among others5,6, its implementation posed an organizational challenge to hospitals7–9.
The purpose of this study is to describe the implementation and impact of an innovative remote Pharmaceutical Care (PC) model that includes an e-Health platform and home dispensing of medicines.
MethodsAn observational, descriptive study was carried out to assess the impact of a new model of personalized remote PC from March 23, 2020 to December 31, 2021. This project was developed by the Pharmacy Service (PS) of Hospital General Universitario Gregorio Marañón, a center that provides pharmaceutical care services, involving the preparation and delivery of drug therapies for more than 11,800 ambulatory patients.
In March 2020, the Management Board of the PS of the Hospital General Universitario Gregorio Marañón, in collaboration with the pharmacists involved in patient care, developed a new PC model to provide PC and deliver medicines to patients at home. This new model includes:
Definition of selection criteria for patient inclusionBased on the individual, clinical, pharmacotherapeutic and sociocultural needs (autonomy, risk of social exclusion, presence of a caregiver, technological skills and preferences of the patient), all in accordance with the principle of equity. The criteria established included:
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Patients in quarantine for a positive COVID-19 test or close contact with an infected person.
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Patients living alone who cannot travel.
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At-risk patients due to advanced age, plurimorbidity and immunosuppression.
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Nursing home residents.
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Patients who, for whatever reason, are candidate patients who can benefit from this procedure.
Patients were stratified by level of risk. Then, a pharmacotherapeutic monitoring model, and periodicity, were tailored to the characteristics of each patient. A set of stratification criteria was established for each condition. In the case of immune mediated diseases, HIV, onco-hematological diseases and multiple sclerosis, the SEFH Ambulatory Patient Stratification Models were adapted10 (Table 1).
Patient stratification for pharmaceutical care and periodicity of telematic follow-up
| AREA | STRATIFICATION | CRITERIA | Every 2 months | Every 3 months | Every 4 months | Every 5 months | Every 6 months | Every 7 months | Every 8 months | Every 9 months | Every 10 months | Every 11 months | Every 12 months |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| High risk |
| FC | IPR | ||||||||||
| Allergy | Low risk |
| FC | IPR | |||||||||
| Arthropaties | High risk | Adaptation of the stratification model for SEFH patients with immune mediated diseases. Score >25/63: indicates high risk. | FC | IPR | |||||||||
| Low risk | Score <25/63: indicates low risk. | FC | IPR | ||||||||||
| High risk |
| FC | IPR | ||||||||||
| Cardiology |
| ||||||||||||
| Low risk | The remainder of patients not meeting the criteria above. | FC | IPR | ||||||||||
| Dermatology | High risk | Adaptation of the stratification model for SEFH patients with immune mediated diseases. Score >25/63: will indicate high risk. | FC | IPR | |||||||||
| Low risk | Score <25/63: indicates low risk. | FC | IPR | ||||||||||
| High risk |
| FC | IPR | ||||||||||
| Gastroenterology |
| ||||||||||||
| Low risk | The remainder of patients not meeting the criteria above. | FC | IPR | ||||||||||
| High risk |
| FC | IPR | ||||||||||
| Endocrinology | – Lack of adherence and/or tolerance problems Patients in their first year of treatment. | ||||||||||||
| Low risk | The remainder of patients not meeting the criteria above. | FC | IPR | ||||||||||
| Inflammatory Bowel Disease | High risk | Adaptation of the stratification model for SEFH patients with immune mediated diseases. Score >25/63: will indicate high risk. | FC | IPR | |||||||||
| Low risk | Score <25/63: indicates low risk. | FC | IPR | ||||||||||
| Rare diseases | High risk | All patients with rare diseases will be considered high risk patients. | FC | IPR | |||||||||
| Microbiology | High risk | Adaptation of the stratification model for SEFH patients with HIV. Score >7/37: will indicate high risk. | FC | IPR | |||||||||
| Low risk | Score <7/37: indicates low risk. | FC | IPR | ||||||||||
| High risk |
| ||||||||||||
| Nephrology |
| FC | IPR | ||||||||||
| Low risk | Patients not meeting high-risk criteria | FC | IPR | ||||||||||
| High risk | All patients with pulmonary fibrosis will be considered high-risk patients. Patients who meet some of the following criteria: | ||||||||||||
| Pneumology |
| FC | IPR | ||||||||||
| High risk | Adaptation of the selection and | ||||||||||||
| Neurology | pharmaceutical care model for chronic patients Score >6/38: will indicate high risk. | FC | IPR | ||||||||||
| Low risk | Score <6/38: indicates low risk. | FC | IPR | ||||||||||
| High risk |
| FC | IPR | ||||||||||
| Ophthalmology |
| ||||||||||||
| Low risk | The remainder of patients not meeting the criteria above. | IPR | |||||||||||
| Oncohematology | High risk | Adaptation of the stratification model for SEFH cancer patients. Score >15/96: will indicate high risk. | FC | IPR | |||||||||
| Low risk | Score <15/96: indicates low risk. | FC | IPR | ||||||||||
| Pediatrics | High risk |
| FC | IPR | |||||||||
| Low risk | The remainder of patients not meeting the criteria above. | FC | IPR |
CF: Functional class; FC: Follow-up consultations; PH: Pulmonary Hypertension; WHO: World Health Organization; SEFH: Spanish Society of Hospital Pharmacy; I PR: Integral pharmacotherapy review; HIV: human immunodeficiency virus.
Additional pharmaceutical care consultations can be scheduled as needed. For instance, in case of changes of treatment, patients with Lack of disease control/tolerance, patients receiving novel drug therapies requiring a closer follow-up, etc. Likewise, pharmacotherapy monitoring will be complemented at home via the appropriate app (e-Oncosalud, eMidCare, FarMcuida).
Two types of remote PC consultations were available, which involved:
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Integral medication review (IMR): information on key aspects of patient's medication and review of the medical history of interest, comorbidities, effectiveness, safety, drug-interactions, quality of life, and patient's satisfaction with the Service of Telepharmacy. Figure 1 displays the model for recording this activity on the medical history of the patient.
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Dispensing follow-up consultation (FC): full medication review, assessment of treatment adherence and tolerance.
To guarantee continuous communication and follow-up of patients, FC was complemented with the use of an e-Health platform available at the Pharmacy Service: the app e-Oncosalud for the management of onco-hematologic patients, and eMidCare for patients with immunity-mediated inflammatory diseases (rheumatoid arthritis, spondyloarthropathies, psoriasis, psoriatic arthritis, Crohn's disease and ulcerative colitis, among others). The FarMcuid app was developed for the management and follow-up of other complex chronic patients, such as patients with HIV and pulmonary hypertension. These apps enable continuous two-way communication with the patient and improve treatment adherence, minimize adverse events and promote self care.
AppointmentsFor a more effective management of this new pathway, new appointment books were created for PC consultations and medication dispensing. The patient receives an SMS and a letter with the date of appointment for PC and the delivery of medication.
DispensingA robot prepares the medication the day before the scheduled date of home dispensing. Along with medication, individualized information about the treatment and procedures of the PS are provided.
Quality controlAfter the dispensing process has been completed, the pharmacist carries out a quality control. The operator seals the bag that contains the medication to guarantee confidentiality and stores it in optimal storage conditions.
Shipping and home deliveryShipping is performed by a company with experience in the dispensing of medicines that complies with the highest quality standards. Medicines are delivered at the home of patients in working days. Traceability is recorded electronically.
The PS developed a delivery programme called Farhos® for the management of home delivery and their integration into the appointment book of the hospital. This new application developed during the pandemic contains four modules:
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Patient search: module for the identification of candidate patients to home dispensing. The module shows the patients with a home dispensing appointment. This application enables the edition of the actual date of dispensing. Once patients have been selected, they are transferred to the following module (selected patients).
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Selected patients: the module displays the selected patients. The application allows multiple-patient selection to massively print prescriptions and ID labels for shipping, which facilitates the process.
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Patients which medicines has been dispensed: this module performs a shipping traceability analysis. It contains a section to record events, such as cancelled shippings or a color-based visual alert system based.
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Scoreboard: this module makes it possible to monitor the development and performance of the Telepharmacy Service.
A scoreboard of indicators of activity, safety, adherence and perceived quality was developed to evaluate the development and performance of the model.
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Activity was measured according to the number of teleconsultations performed by the patients via telephone, electronic mail or apps.
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The impact of treatment safety was assesses based on the number of adverse drug reactions (ADRs) prevented through remote PM and monitoring via apps. The severity of prevented ADRs was categorized according to the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP)11.
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Treatment adherence was assessed on the basis of delivery records and Morisky-Green tests delivered in each clinical (remote/face-to-face) interview.
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Perceived quality was assessed (anonymously and voluntarily) using a telematic survey (using a QR code created on Google Form) that was sent to patients, along with their medicines. The ad hoc survey consisted of an additive rating scale including ten closed questions, which includes factors such as easiness to communicate with the pharmacist, satisfaction with the integrated care model, and level of recommendation. (supplementary material).
To complement these indicators, an observational study was conducted to assess the impact of COVID-19 on access to pharmaceutical care and continuity of treatments in this population of patients. For that purpose, a survey was carried out in a random sample of 100 patients during the 01/04/2021-31/05/2021 period. The interview consisted of 14 questions that assessed the employment status of patients, the presence and severity of previous COVID-19 infection, access to medical consultations, and hospital medication. Likewise, treatment adherence was assessed using the Morisky-Green test and delivery records.
ResultsDuring the study period, 2,737 patients benefited from the new remote PC model. A total of 7,758 telematic consultations were performed, including 1,230 consultations performed via apps (Table 2).
Results for activity and perceived quality indicators
| INDICATORS OF ACTIVITY | |
|---|---|
| Number of patients included in the Telepharmacy program including home delivery of medicines (% respect to the total of ambulatory patients attended) | 2,737 (23.1%) |
| Patient distribution by clinical area (%) | |
| Immune mediated diseases | 27.6% |
| Oncohematology | 16.8% |
| Neurology | 13.5% |
| Infectious | 8.7% |
| Gastroenterology | 6.7% |
| Cardiology | 6.1% |
| Pediatrics | 5.5% |
| Ophthalmology | 5.5% |
| Nephrology | 4.6% |
| Other | 4.9% |
| % of patients included in the program living > 30 km from the hospital | 29.5% |
| No. teleconsultations performed | 7,758 |
| No. of consultations received via app | 1,230 |
| No. of face-to-face pharmaceutical care consultations | 1,921 |
| Total of pharmaceutical care consultations (teleconsultations and face-to-face) | 9,679 |
| % of teleconsultations with respect to total | 75.2% |
| No. of dipensations performed | 10,049 |
| INDICATORS OF SAFETY | |
| No. of prevented adverse drug reactions (ADRs) | 1,043 |
| No. of prevented ADRs that may potentially cause temporary damage or require intervention (NCC MERP = E category) | 501 |
| No. of prevented ADRs that may potentially cause temporary damage or require hospital admission (NCC MERP = F category) | 141 |
| No. of prevented ADRs that may potentially cause permanent damage (NCC MERP = G category) | 51 |
| No. of prevented ADRs that do not cause any damage (NCC MERP = C/D category) | 350 |
| INDICATORS OF THERAPEUTIC ADHERENCE | |
| % Overall adherence | 95.2% |
| % Adherence by disease | |
| Patients with ophthalmological diseases | 98.8% |
| Patients with infectious diseases | 96.7% |
| Patients with gastroenterological diseases | 96.5% |
| Patients with immune mediated diseases | 96.4% |
| Patients with multiple sclerosis and amyotrophic lateral sclerosis | 95.9% |
| Onco-hematologic patients | 95.2% |
| Patients with heart diseases | 92.4% |
| Pediatric patients | 90.2% |
| Patients with chronic kidney disease/transplant recipients | 90.0% |
| INDICATORS OF PERCEIVED QUALITY | |
| % of patients satisfied with the integral telehealth model | 98.4% |
| % of patients satisfied with the apps | 97.9% |
| % patients who would recommend the service to other patients | 100% |
| Overall rate of satisfaction with the Telepharmacy service | 9.8 |
The most frequently consultations via apps were mostly related to the management of AEDs (21.2%) and compatibility of the treatment with concomitant medication (13.6%). Consultations directly linked to COVID-19 account for 11.5%, and time distribution was directly related to the waves of the pandemic. The most frequent reasons of consultation were doubts about the prevention and management of COVID-19 (7.1%) and the indication and compatibility of COVID-19 vaccines with the treatment (3.4%).
Remote PM prevented 1,043 ADRs, which affected 27.9% of patients. In total, 18.4% of ADRs could have had severe effects on the patient (NCC MERP ≥ F categories). Mean adherence to treatment was 95.2%.
The overall satisfaction rate in relation to this model, as reported by 417 patients, was 9.8/10. In total, 98.4% of patients were satisfied with this new service, and 97.9% with the use of the apps. All patients would recommend this integral Telepharmacy service to other patients. The aspects most appreciated by patients included the 7/365 availability of pharmaceutical care and PM and the rapidity of response by the pharmacist to answer questions.
Figure 2 displays the specific results of the study on the impact of COVID-19 on the health services provided to these patients. According to this study, no patients had any problems to receive their medication as a result of the COVID-19 pandemic, and only 25 of patients had stopped taking their medication for fear of having a higher risk for infection. Ninety-six percent of the patients surveyed showed an optimal treatment adherence, which is confirmed by delivery records and the Morisky-Green test.
Discussion
This article describes the implementation of a Telepharmacy model developed to ensure pharmacotherapeutic monitoring and access to treatment by more than 2,500 patients. This model prevented over 1,000 ADRs in a period of 20 months, and was effective in maintaining high treatment adherence rates in most of patients.
According to the national survey conducted by the Platform of Patient Organizations in 529 patients with chronic diseases during the first months of the pandemic, 69% of the patients cancelled, at least once, a medical consultation due to the COVID-19 pandemic. Near 25% of patients missed a dose, and 8.5% reported having been out of medication during the state of alarm12. According to our study, no patients found any difficulty in continuing their treatment, and only 2% stopped taking their medication for fear of having a higher risk for infection.
In our case, patient stratification and tailored PM through an e-Health platform were key to guaranteeing the continuity of pharmaceutical care and treatment adherence. Patient stratification enables the Pharmacy Service to intensify PC in vulnerable patients needing close PM. App-based monitoring facilitated follow-up and communication. Patients could consult their pharmacist at any time of the day, who provided recommendations and simple tools to improve tolerance and adherence to treatment. Specifically, this project prevented 1,043 ADRs in 10.4% of patients, with 18% being severe.
With respect to the use of ICTs, the pandemic has been a turning point in the use of these tools, which offer a broad variety of advantages for patient monitoring. A recent research demonstrated a 64% increase in the demand for home health services due to the pandemic. It is estimated that this percentage will be seven times higher by 202513. In the field of Hospital Pharmacy, experiences with Telepharmacy are growing in number. According to the survey on the situation of Telepharmacy in PS in Spain during the pandemic14, 87.6% of hospitals performed teleconsultations prior to the dispensing of their medication. Several studies confirm that teleconsultations improve health outcomes. Margusino-Framiñán et al. observed that medication dispensing together with PC consultation improves health outcomes in patients with HIV15. Likewise, Megías-Vericat et al. observed that 95% of patients with hemophilia perceived that the PC and home delivery program improved adherence to treatment16.
Finally, this model received a satisfaction rate of 9.8 points out of 10 on the survey. User satisfaction with the app and home dispensing service exceeded 97% in the two cases, which is consistent with the literature2,14,16,17. The ENOPEX study conducted by the SEFH in 9,442 patients revealed that 91% preferred continuing with the service of Telepharmacy after the suspension of the state of alarm16. According to the 'Stada Health Report’, 82% of Spaniards is in favor of using teleconsultations for clinical follow-up18.
The development of this project has been a challenge for this PS from an organizational and resource point of view. In this sense, the collaboration of the Managing Board of the hospital, technology suppliers of the PH, health professionals and patients were crucial for its implementation.
The new model of Telepharmacy and automatization of PC increases patient safety and improves treatment adherence, with high perceived quality. Patient stratification and individualized follow-up via an e-health platform were crucial to the development of this model.
FundingNo funding.
AcknowledgementsThanks to SEFH, Fundación Once and GastoMove for their unvaluable and generous support.
Conflict of interestsNo conflicts of interest.
Contribution to the scientific literature
This paper describes an innovative model of remote pharmaceutical care that includes patient stratification, personalized pharmacotherapeutic monitoring via an e-health platform, and medication dispensing. The new Telepharmacy care model increases patient safety and improves treatment adherence, with high perceived quality.
Satisfaction survey for the new pharmaceutical care model.
