For a long time, all the National Health System services were divided into two levels: Primary Care (PC) and Hospital Care (HC), which developed in parallel with each other. The coordination between both levels of care is the current priority for health services, organizations, and European Development programs1–3.

Life expectancy in Spain exceeds 80-years of age, with an expected increase by two years for 2020 in Europe. The economic development and advances in medicine are changing the expectations in conditions such as cardiovascular or cancer. All this is creating a new epidemiological pattern, characterized by ageing and chronicity, which generates an increasing healthcare demand4.

The European Union is developing a strategic line of priority research on “Active and Healthy Ageing”, which intends to address such important problems as polypharmacy and comorbidity5. Chronicity is another essential line of research, as shown by the investment in the HORIZONTE 2020 projects, targeted to the optimization in health care plans and pharmacotherapy6.

Addressing polypharmacy in chronic patients is one of the main challenges. Different studies show that a high number of drug-related adverse events can be avoided, and these problems can lead to hospitalizations or prolonged hospital stays7,8. In different autonomous communities, strategies such as Polymedicated Patient Programs have been implemented, in order to optimize and simplify the drug therapy for chronic patients, given that these are the most vulnerable during transitions of care9.

The creation of healthcare structures with integrated management and technological development (electronic prescription, electronic patient record, etc.) have laid the foundations for building a cross-sectional healthcare model focused on patients; this has been moving forward with tools for remote patient monitoring or teleconsultation between professionals.

Teleconsultation (or e-consultation) is an emergent Information and Telecommunications Technology (ITT) tool which allows synchronous electronic communication between professionals (typically from PC to HC) on general or patient-specific matters. E-mail is the most basic form of e-consultation, though web platforms or computer applications have been developed, which combine the shared electronic medical record and instant messaging. Different medical specialties (Dermatology, Rheumatology or Cardiology) have been pioneers in the use of the most advanced teleconsultation models, integrating them in their daily practice, and in the performance indicators for the healthcare managers in their centers. However, there are limited experiences showing a similar development between Hospital Pharmacy and Primary Care10.

The main objective of this study is to describe the stages for the implementation and escalation of a Hospital Pharmacy teleconsultation (or e-consultation) model between professionals, from its most basic form to its development integrated within the electronic clinical record of the patient.

The teleconsultation project in Pharmacy was developed in a healthcare area managing > 500,000 inhabitants. This healthcare area is structured with integrated management, with a common management team for HC and PC. It includes 52 PC centers, a chronic psychiatric center, two hospitals (with 1,275 beds in total), and > 1,500 beds in social and health care centers with agreement with the hospital regarding pharmaceutical care. There are 23 Hospital Pharmacists and 13 Primary Care Pharmacists in charge of pharmaceutical management and care in all these centers.

The Health System has a single and joint electronic clinical record for HC-PC, electronic prescription and, since 2012, there is enough support for the development of teleconsultation (between professionals or with patients), and telemonitoring at patient homes.

The creation of Pharmacy Teleconsultation between professionals was initiated by mid-2014 and developed in three stages, differentiated by the level of development of the electronic tool used and the professionals involved.

In total, 470 consultations were registered in the three stages of the study; 353 of them were conducted from PC to HC (see Table 1).

The reasons for consultation were: to solve problems associated with medications with sanitary approval (32.8%), evaluations of artificial home nutrition (20.6%), patient inclusion in the Primary Care Polymedicated Program (18.2%), information about medications (off-label use, depot antipsychotics, cytostatic agents, etc.) (10%), inadequate dosing (9.8%), drug duplications (6.4%), and others (2.2%).

Consultations were solved in > 90% of cases. With teleconsultation, the average time to response was < 48 hours (with 4 hours as minimum and 144 hours as maximum); and approximately 40% of patients were referred for a second personal consultation in the Hospital Pharmacy in order to obtain home nutritional support or medications used off-label.

The visualization of teleconsultation is shown in figures 1 and 2.

Figure 1

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Figure 1

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The benefits of e-consultation have been widely described, both for patients and professionals. For patients, it represents an improvement in access in terms of time and space, as well as regarding the communication and information received. In terms of professionals, it improves the communication between levels, and this translates into a higher quality of care and patient safety11.

The innovation of this article lies in the description of how to start a Pharmacy Continuity Program, and how to create and implement a Pharmacy Teleconsultation at the same level than the other medical specialties. This leads to positioning this activity (internally for the Pharmacy Unit and externally for managers and patients) as a highly problem-solving process that can provide visibility, safety, and savings in costs and time.

Regarding the results achieved, we can observe that the number of consultations has increased since the start of the program, and mostly with the incorporation of Primary Care Physicians to the circuit. However, we consider that these data will increase as the new communication tool gets established, and higher electronic involvement of professionals is encouraged.

Publications about care coordination experiences are frequent among medical specialties. Thus, in 1996 Friedman et al. had already published a study on telemedicine to monitor blood pressure and treatment adherence among patients with hypertension12. Another example is the publication in 2010 by Eron et al. for the follow-up of infections at hospital discharge13. And there is a more recent telemedicine experience published, targeted to improving treatment adherence in schizophrenic patients14.

There are limited experiences described in Pharmacy, and the majority present descriptive results which are difficult to compare from a quantitative point of view; however, there are comparable data regarding the main reasons for consultation (the need for follow-up and healthcare approval)10.

The incorporation of teleconsultation between PC and medical specialties is a healthcare activity conducted habitually in the corporative information systems of many Regional Health Ministries for different autonomous communities, such as Galicia, Andalucía, etc.11. However, this is an unresolved matter for Pharmacy Units; so far we have presented the first coordination program to achieve an e-consultation with the same visibility than any other specialty. But this has some limitations, because so far computer tools have allowed to develop and integrate into the electronic record the referral of patients in one direction (from PC to HC), and it has been necessary to use other communication platforms (collaborative websites, etc.) in order to do it in the other direction10. It is also necessary to extend the period of analysis in order to achieve a higher volume of results that show that this activity offers health outcomes that can be measured, which will allow to strengthen and encourage the use of this type of strategies. In this sense, we intend to extend the study and go deeper into the objectives of efficiency and patient satisfaction.

However, the study presented here represents a chance for improvement in coordination of care in any healthcare area with electronic record and prescription, thus giving an answer to the suggestions published in other studies associated with the follow-up of chronic patients with multiple conditions15.

As a conclusion, teleconsultation allows to coordinate pharmaceutical care between levels, in a fast and simple manner, it increases the visibility and access for professionals, and any discrepancies can be solved without travels or time delays for patients; therefore, it would be expected to have a reduction in expenses and an improvement in the perception of healthcare quality by the users.

No funding.

To all professionals from Primary Care, Pharmacy, Admissions, Quality and Management of the EOXI Vigo who are actively involved in the Pharmacy Teleconsultation program.

No conflict of interests.

This study has been presented at the 61st National Congress of the Spanish Society of Hospital Pharmacy, within the round table “Humanizing Pharmacy Services”, on October 20th, 2017.