The Spanish Society of Hospital Pharmacy Position Paper on Telepharmacy states that the inclusion of patients should take into account ethical considerations and, therefore, be based on the concept of equity. Thus, it establishes that Telepharmacy should not be limited to specific pathologies or medicines, but should be based on the individual needs of each patient: it also highlights the need to rely on selection or prioritisation models to help identify patients who can benefit from Telepharmacy. The aim of this article is to present the Spanish Society of Hospital Pharmacy Telepharmacy Patient Prioritisation Model, which establishes key recommendations and a reference prioritisation model to guide hospital pharmacists in the identification and prioritisation of patients who are candidates for inclusion in Telepharmacy programmes. This model was developed based on the experience of a group of experts in their clinical practice as well as on a review of the main reference documents available in this field. It comprises 25 criteria, grouped into 8 minimum inclusion criteria, 5 continuity criteria, and 12 recommended criteria. The latter criteria are divided into high, medium, and low priority criteria. Patients are prioritised according to their scores on meeting the recommended criteria, such that those with the highest scores are given the highest priority. As stated in the Spanish Society of Hospital Pharmacy Position Paper on Telepharmacy, pharmacotherapeutic monitoring can be conducted via remote consultation without sending medication, but not vice versa; thus, the 25 criteria defined apply to Telepharmacy programmes in the area of the remote dispensing and informed delivery of medicines, but only 19 of them apply to pharmacotherapeutic monitoring programmes. The model presented is intended to be a reference guide and should be adapted to the particular characteristics and circumstances of each pharmacy service, depending on demand and available resources.
La Sociedad Española de Farmacia Hospitalaria, en su Documento de Posicionamiento sobre Telefarmacia, establece que la inclusión de pacientes debe tener en cuenta consideraciones éticas y, por tanto, estar basada en el concepto de equidad. Por ello, establece que la Telefarmacia no debe restringirse por patologías ni medicamentos, sino en función de las necesidades individuales de cada paciente, y destaca la necesidad de apoyarse en modelos de selección o priorización que ayuden en la identificación de los pacientes que puedan beneficiarse de la Telefarmacia. El objetivo de este artículo es presentar el “Modelo de priorización de pacientes en Telefarmacia de la Sociedad Española de Farmacia Hospitalaria”, que pretende establecer recomendaciones clave y un modelo de priorización de referencia que sirva de orientación a los farmacéuticos especialistas en farmacia hospitalaria para la identificación y priorización de pacientes candidatos a ser incluidos en programas de Telefarmacia. El modelo ha sido desarrollado en base a la experiencia de un grupo de expertos en su práctica clínica y a la revisión de los principales documentos de referencia disponibles en este ámbito y está conformado por un total de 25 criterios, agrupados en 8 criterios mínimos de inclusión, 5 criterios de continuidad y 12 criterios recomendables. Estos últimos se dividen en criterios de alta, media y baja prioridad. En función de las puntuaciones obtenidas del cumplimiento de los criterios recomendables, se establece el orden de prioridad de pacientes, de modo que aquellos que mayor puntuación obtengan serán los más prioritarios. Tal como recoge el “Documento de Posicionamiento sobre Telefarmacia de la Sociedad Española de Farmacia Hospitalaria”, puede haber seguimiento farmacoterapéutico por teleconsulta sin envío de medicación, pero no al contrario, por lo que los 25 criterios definidos aplican a programas de Telefarmacia en el ámbito de la dispensación y entrega informada de medicamentos a distancia, pero solamente 19 de ellos aplican para los programas de seguimiento farmacoterapéutico. El modelo que se presenta ha sido concebido como un marco de referencia y deberá adaptarse a las características y circunstancias particulares de cada servicio de farmacia, en función de la demanda y de los recursos disponibles.
The Spanish Society of Hospital Pharmacy (SEFH) Position Paper on Telepharmacy defines Telepharmacy as “remote pharmacy practice through the use of information and communication technologies”. It identifies four main areas of application: pharmacotherapeutic monitoring, patient training and information, coordination with the healthcare team, and the remote dispensing and informed delivery of medicines. It also establishes that the inclusion of patients who are candidate for a Telepharmacy programme must take into account ethical considerations and, therefore, be based on the concept of equity. Thus, it states that Telepharmacy should not be restricted by pathologies or medicines, but should be based on the individual needs of each patient according to clinical, pharmacotherapeutic, and personal and social aspects1,2.
In Spain, prior to the COVID-19 pandemic, there were few examples of Telepharmacy programmes in hospital pharmacy services (HPS). However, during the COVID-19 state-of-emergency, most HPSs promoted them in order to respond to patients’ needs, although, in most cases, no protocols or models for patient selection or prioritisation were established3–6. Following these experiences, some HPSs developed their own patient selection models based on the fulfilment of selection criteria (inclusion/non-inclusion), but without prioritising patients. These selection models do not differentiate between pathologies or treatments, and are typically not protocolised to establish an order of priority. Currently, increasing numbers of HPSs are promoting and demanding the use of protocolised models for the selection and prioritisation of patients for their inclusion in Telepharmacy programmes.
Aware of the need for the appropriate implementation of Telepharmacy in Spanish hospitals, SEFH launched the Strategy for the Development and Expansion of Telepharmacy in Spain, which has four fundamental objectives: to cover the methodological requirements for the implementation of Telepharmacy initiatives; to create an institutional support structure for their development; to encourage the achievement of outcomes and continuous improvement in their use; and to identify needs and provide appropriate technological resources. To this end, a series of lines of action have been proposed, the first being the developement of a set of methodological support documents, including the Telepharmacy Patient Prioritisation Model7.
In fact, one of the key points in the development of Telepharmacy is to determine which patients should be targeted for interventions. The SEFH Position Paper on Telepharmacy establishes that its use should not be limited to specific pathologies, but that Telepharmacy interventions should be assessed and targeted according to the individual needs of each patient from the clinical and pharmacotherapeutic point of view and their personal and social situation (autonomy, technological capacity, risk of social exclusion, technological gap, socioeconomic gap, family or professional dependence, and patient preferences). The need for selection or prioritisation models that help identify patients who can benefit from Telepharmacy has been highlighted in relation to facilitating this activity2,8–11.
In this setting, the purpose is to establish key recommendations and a reference prioritisation model to help hospital pharmacists identify and prioritise patients candidates for inclusion in Telepharmacy programmes.
The objective of this article is to present the SEFH Telepharmacy Patient Prioritisation Model, so that it can be used as a reference guide for its development in HPSs.
Methodology for the development of the prioritisation modelThe model was developed by a working group comprising hospital pharmacists with experience in the development of Telepharmacy initiatives in several Spanish hospitals. This group participated in the review and analysis of the literature, semi-structured interviews and workshops, and in the final validation of the article. The methodology for the development of the model also included a prioritisation exercise with a sample of patients from several hospitals in Spain in order to assess the accuracy of the criteria. The development and validation of the document was conducted between May and November 2021.
The prioritisation model was developed by taking as a reference some key aspects that were established based on the experience of the experts in their clinical practice and the review of the main reference documents in this field1,2,8–13. Thus, the model had to incorporate the following characteristics:
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Be practical to be used during pharmaceutical care consultations.
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Be dynamic and adaptable to use in any HPS.
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Be applicable in pharmacotherapeutic monitoring programmes and remote dispensing and informed delivery of medicines.
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Be adaptable to different telematic communication tools.
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Should not discriminate according to specific pathologies or treatments.
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Should distinguish between the following criteria:
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Minimum inclusion criteria; to select patients.
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Continuity criteria; mandatory to assess the continuity of patients in the Telepharmacy programme.
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Recommended criteria; to prioritise patients.
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Should make it possible to establish an order of priority for the inclusion of patients in a Telepharmacy programme, without replacing the individual assessment of patients by hospital pharmacists.
The model comprises 25 criteria, grouped into 8 minimum inclusion criteria, 5 continuity criteria, and 12 recommended criteria.
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The minimum inclusion criteria are mandatory criteria for the inclusion of patients in a Telepharmacy programme. Failure to meet them would justify the patients’ non-inclusion in a Telepharmacy programme.
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The continuity criteria are mandatory criteria for the continuity of patients in a Telepharmacy programme. If patients meet al.l these criteria, they continue in the programme. If patients do not meet these criteria, they do not continue in the programme.
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Recommended criteria are criteria to prioritise patients in a Telepharmacy programme.
The recommended criteria are classified into 3 groups according to the level of priority: thus, 3 criteria were included in Group A (highest priority, assigned a score of 5 points), 6 criteria in Group B (intermediate priority, assigned a score of 3 points), and 3 criteria in Group C (lowest priority, assigned a score of 1 point).
The order of patients priority is established according to the sum of the scores on meeting the recommended criteria, such that those with the highest scores are given the highest priority.
The classification of the recommended criteria and the scores assigned for their weighting were established as indicative references based on previous experience in the framework of the Mapex project11–14 and on the judgement of the working group. These aspects can be modified by each HPS to adapt them to their particular situation.
It should be borne in mind that, as stated in the SEFH Position Paper on Telepharmacy, pharmacotherapeutic monitoring can be conducted via tele-consultation without sending medication, but not vice versa. This is because it is mandatory that, together with sending medications, hospital pharmacists conduct a teleconsultation according to the objectives established for the individual pharmacotherapeutic monitoring of each patient. This teleconsultation has to be recorded in the patient clinical history2. This is the reason why the 25 criteria defined apply to Telepharmacy programmes in the area of the remote dispensing and informed delivery of medicines, but only 19 of them apply to pharmacotherapeutic monitoring programmes.
Based on the working group judgement, no specific criteria were defined for the scope of application of training and information for patients because it was considered that such training can be achieved through Telepharmacy programmes for most patients or carers/families, and no restrictions are needed. Similarly, no criteria were defined regarding coordination with the care team, as it was considered that this aspect does not apply directly to patients.
Criteria of the Telepharmacy Patient Prioritisation ModelTable 1 summarizes the panel of criteria of the SEFH Telepharmacy Patient Prioritisation Model. These criteria are grouped into minimum inclusion criteria, continuity criteria, and recommended criteria. The table indicates their scope of application in Telepharmacy (remote dispensing and informed delivery of medicines and/or pharmacotherapeutic monitoring), and priority group (A, B, or C) in the case of recommended criteria.
Summary of the prioritisation model criteria
| DD | PTM | PG | |
|---|---|---|---|
| MINIMUM INCLUSION CRITERIA | |||
| 1. Autonomy and/or social and family support | Yes | Yes | − |
| 2. Communicative competence (linguistic, sensory limitations, language) | Yes | Yes | − |
| 3. Technological competence (access to technology and skills) | Yes | Yes | − |
| 4. Patient preferences and consent | Yes | Yes | − |
| 5. Face-to-face consultation at start or change of treatment | Yes | Yes | − |
| 6. Patient in stable clinical condition | Yes | No | − |
| 7. Fixed home and official address in the Autonomous Community | Yes | No | − |
| 8. Medication suitable for remote delivery | Yes | No | − |
| CONTINUITY CRITERIA | |||
| 9. Adherent with face-to-face appointments with physicians and/or hospital pharmacy | Yes | Yes | − |
| 10. Adherence with scheduled teleconsultations | Yes | Yes | − |
| 11. Adherence with scheduled medication delivery and/or collection appointments | Yes | No | − |
| 12. Achievement of pharmacotherapeutic goals and/or absence of significant change in clinical status | Yes | Yes | − |
| 13. Continuation of usual treatment regimen | Yes | Yes | − |
| RECOMMENDED CRITERIA | |||
| 14. Limited physical mobility or dependency | Yes | Yes | A |
| 15. Inclusion in a Telemedicine Programme | Yes | Yes | A |
| 16. Age ≥ 80 years | Yes | Yes | A |
| 17. Age ≥ 70 and < 80 years | Yes | Yes | B |
| 18. Inadequate adherence to treatment or non-adherence to face-to-face appointments due to difficulty in accessing hospital | Yes | Yes | B |
| 19. Difficult access to hospital due to distance or geographical location of home and/or workplace | Yes | Yes | B |
| 20. No possibility of reconciliation with working life and/or studies | Yes | Yes | B |
| 21. No possibility of access using own vehicle or public transport | Yes | Yes | B |
| 22. Difficulties in access due to social and/or economic reasons | Yes | Yes | B |
| 23. Adherence with appointments and/or face-to-face consultations | Yes | Yes | C |
| 24. Good treatment adherence | Yes | Yes | C |
| 25. Good hospital attendance | Yes | Yes | C |
DD: remote dispensing and informed delivery of medicines; PG: prioritisation group; PTM: pharmacotherapeutic monitoring.
Tables 2, 3, and 4 provide further details of the criteria, including an explanation of each one, specific recommendations for their assessment, and a standard question to facilitate their evaluation in clinical practice.
Minimum inclusion criteria
| No. | Criteria | Definition and recommendations |
|---|---|---|
| 1 |
| The patient must be autonomous or have the social and/or family support needed to take responsibility for inclusion in the Telepharmacy programme. |
| 2 |
|
|
| 3 |
|
|
| 4 |
| The patient or the responsible person (family, caregiver, nurse), if delegated, having received all the information on the Telepharmacy programme, must state that he/she understands the commitments to be assumed, expresses his/her motivation for being included in the programme, and conveys his/her agreement to it verbally or by means of written informed consent, which will be recorded in the clinical record. |
| 5 |
|
|
| 6 |
| The patient must be in a stable clinical condition, according to clinical, medical, and pharmaceutical criteria, not limiting inclusion in a Telepharmacy programme by specific pathology or treatment. |
| 7 |
|
|
| 8 |
|
|
Continuity criteria
| No. | Criteria | Definition and recommendations |
|---|---|---|
| 9 |
| The patient must keep appointments or face-to-face consultations with physicians and/or hospital pharmacy related to the assessment of his/her process and hospital dispensing treatment. |
| In the event of non-adherence with the scheduled face-to-face consultations without justification, at the pharmacist's discretion, the patient's non-continuation in the Telepharmacy programme will be assessed. | ||
| 10 |
|
|
| 11 |
| Patient must keep scheduled medication delivery and/or collection appointments. |
| In the event of non-adherence with the scheduled medication delivery or collection appointments without justification, at the pharmacist's discretion, the patient will not be considered for continuation in the Telepharmacy programme. | ||
| 12 | Achievement of the pharmacotherapeutic objectives and/or absence of significant change in the clinical situation | Patients included in the Telepharmacy programme must achieve the established pharmacotherapeutic objectives and/or not have significant changes in his/her clinical condition that require a face-to-face medical or pharmaceutical assessment. |
| Is the patient achieving the therapeutic objectives or has there been a significant change in his/her clinical condition? [Yes/No] | According to the SEFH Strategic Framework for Telepharmacy, pharmacotherapeutic objectives should at least include the detection of drug interactions, the detection of adverse effects, therapeutic adherence, a review of pharmacotherapy, and assessment of health outcomes. | |
| In the event of incidents related to some of these objectives, or a significant change in the patients' clinical situation, at the pharmacist's discretion, the following aspects should be considered: referral to the responsible physician, and/or scheduling the next appointment or face-to-face consultation at the pharmacy service, and/or assessing the patients' continuity in the Telepharmacy programme. | ||
| 13 |
| The patient should maintain his/her usual treatment regimen. |
| In case of significant changes in the treatment regimen, at the pharmacist's discretion, the patient's non-continuation in the Telepharmacy programme will be assessed. |
SEFH: Spanish Society of Hospital Pharmacy.
Recommended criteria
| No. | Criteria | Definition and recommendations |
|---|---|---|
| 14 |
| The patient or responsible person (family, caregiver, etc) has difficulty in moving or accessing the hospital due to limitations in physical mobility or dependency situation. |
| 15 |
|
|
| 16 |
| Patient is 80 years of age or older. |
| 17 |
| Patient is between 70 and 79 years of age. |
| 18 | Inadequate adherence to treatment or non-adherence with face-to-face appointments due to difficulty in accessing the hospital | Patient who, at the pharmacist's discretion, demonstrates inadequate adherence to treatment or is unable to keep appointments due to difficulties in accessing the hospital. |
| Does the patient demonstrate inadequate adherence or non-adherence with face-to-face appointments due to difficulties in accessing the hospital? [Yes/No] | ||
| 19 |
|
|
| 20 |
| The patient or person designated as responsible (family, carer, etc) has difficulty in travelling or accessing the hospital due to difficulties in reconciling work and/or studies. |
| 21 |
| The patient or person designated as responsible (family, carer, etc) has difficulty in travelling or accessing the hospital within a reasonable time because he/she does not have his/her own vehicle or public transport. |
| 22 |
| The patient or person designated as responsible (family, carer, etc) has difficulty in travelling or accessing the hospital due to social and/or economic reasons (e.g. difficulty in meeting travel costs, institutionalised patient). |
| 23 |
|
|
| 24 |
| The patient, at the pharmacist's discretion, demonstrates adequate treatment adherence. |
| 25 |
|
|
Next, we present general recommendations for the implementation of the prioritisation model, as well as specific guidelines for the inclusion, prioritisation, and follow-up of patients in a Telepharmacy programme, based on the inclusion, continuity, and recommended criteria included in the proposed prioritisation model.
These recommendations and guidelines are applicable to Telepharmacy programmes that only include pharmacotherapeutic monitoring and to those that also include the remote dispensing and informed delivery of medicines. These programmes were defined according to the experience of the hospital pharmacists who participated in the working group that developed the prioritisation model and conducted a literature review of the main reference documents1,11–14.
- 1.
General recommendations:
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Hospital pharmacists should inform patients that Telepharmacy is a complementary modality rather than a substitute of face-to-face care, and that it enables, among other things, remote pharmaceutical care to be conducted with the aim of continuous and close monitoring, and to bring medication closer to the patients.
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All patients treated at an HPS may be candidate for inclusion in Telepharmacy programmes—subject to approval by hospital pharmacists—while taking into account the criteria of the prioritisation model defined, the individual situation of each patient, and the available resources.
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The HPS is responsible of defining the criteria of the prioritisation model applicable in its area to select patients for inclusion in a Telepharmacy programme, so that they can be applied as consistently and equitably as possible. In order to reach a consensus on the definition of the criteria, the collaboration of other care units, management, or hospital advisory committees (e.g. health care ethics committees or patient advisory committees) is recommended.
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It is also recommended that HPSs include the criteria defined in its prioritisation model and the indications for its use in clinical practice in the Standard Operating Procedures for pharmacotherapeutic monitoring and remote dispensing and informed delivery of medicines.
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Hospital pharmacists are the health care professionals responsible for identifying and selecting patients who are candidate for Telepharmacy services and for offering these services to such patients on an individual basis.
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In order to guarantee the long-term and continuous character of the pharmacist-patient relationship, it is recommended that the hospital pharmacists who offer and conduct Telepharmacy interventions should also be the ones who perform face-to-face care.
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Hospital pharmacists are responsible for making the health care professionals involved aware of the prioritisation model.
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It is recommended that hospital pharmacists act in coordination with other hospital services to facilitate decision-making in relation to the patients’ health care and thus optimally assess the inclusion of patients in a Telepharmacy programme.
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Hospital pharmacists must inform patients about the prioritisation model criteria and the commitments that they must agree to, in order to participate in a Telepharmacy programme.
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Hospital pharmacists must inform patients, in a clear and concise manner, that their inclusion in a Telepharmacy programme is subject to the discretion of the responsible hospital pharmacist, and, if deemed necessary, includes the possibility of a temporary or permanent changeover to the face-to-face care modality.
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The HPS can use the proposed criteria and structure of the Telepharmacy prioritisation model presented as a reference, although it may be adapted to the characteristics of each HPS and health care organisation.
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Whenever needed, it is recommended to have available support tools in health care practice (e.g. Standard Operating Procedure, criteria checklist, guidelines, application) to facilitate decision-making by hospital pharmacists in the selection and prioritisation of patients for a Telepharmacy programme.
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- 2.
Inclusion and prioritisation of patients:
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It is recommended that at least the first patients assessment for inclusion in a Telepharmacy programme should be conducted in a face-to-face consultation, in which hospital pharmacists will assess whether patients meet the criteria of the prioritisation model and inform them of the conditions for their participation.
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In order to include patients in a Telepharmacy programme, hospital pharmacists must first assess whether the patients meet the minimum inclusion criteria.
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If they do not meet the minimum inclusion criteria, a priori they will not be candidate for inclusion in a Telepharmacy programme. However, when deemed necessary, hospital pharmacists can always individually assess the patients’ circumstances and the available resources.
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If patients meet the minimum inclusion criteria, they will be candidate for inclusion in a Telepharmacy programme, and, therefore, they will be assessed to determine whether they meet the recommended criteria to establish their order of priority for inclusion.
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Patients are prioritised based on the sum of the scores on their meeting the recommended criteria. Patients with the highest priority are those with the highest scores.
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The order of priority enables each HPS to determine which patients have the highest priority to receive Telepharmacy interventions.
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It is recommended that each HPS establishes priority rankings based on the number of candidate patients, the capacity of the HPS, and the available resources. It is recommended that these rankings established are periodically reviewed to adapt to changes in demand and capacity of the HPS.
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The prioritisation models are indicative, and final decisions will be taken by hospital pharmacists based on the patients’ situation and available resources.
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The patients (or, if applicable, their legal guardian and/or carers) must understand the commitments and the scope of their inclusion in a Telepharmacy programme and give their agreement verbally or by means of informed consent which, in any case, will be recorded in their clinical history.
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It is recommended to spend the necessary time and resources to inform patients about the pharmaceutical care model that will be used (i.e. pharmacotherapeutic monitoring or remote dispensing and informed delivery of medicines). It is also recommended that appropriate information support material is made available.
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- 3.
Patient follow-up and continuity:
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It is recommended to monitor patients included in Telepharmacy programmes in order to to ensure that they are adhering to the conditions of the programme and to identify any changes that may affect their position in the prioritisation model.
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In order to conduct the monitoring process, whether periodical or at the pharmacists’ discretion, it is recommended to assess the fulfilment of the continuity criteria and to reassess the minimum inclusion and recommended criteria.
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If patients do not meet the minimum inclusion and continuity criteria, they will no longer be candidate to continue in a Telepharmacy programme.
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If patients meet al.l the minimum inclusion and continuity criteria, they will be candidate to continue in a Telepharmacy programme; thus, their fulfilment of the recommended criteria can be assessed to establish their order of priority to receive these interventions.
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It is recommended that all changes in the patients’ situation regarding fulfilment with the prioritisation model criteria are recorded in the clinical history to facilitate monitoring the patients’ progress and to update their level of priority.
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All patients can choose not to participate in a Telepharmacy programme or to leave it at any time in favour of face-to-face model without this decision affecting the quality of the pharmaceutical care received.
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Figure 1 shows the algorithm for assessing the inclusion and continuity of patients in the prioritisation model.
In summary, the model presented is intended to be a practical reference framework for pharmacists in pharmaceutical care consultations to prioritise patients for their inclusion in Telepharmacy programmes. Prioritisation is based on the concept of equity and should be adapted to the particular characteristics and circumstances of each HPS, specially regarding the demand of this type of service and the available resources. Furthermore, it is important to bear in mind that the model forms part of a set of documents created within the SEFH's Strategy for the Development and Expansion of Telepharmacy in Spain, such that its implementation in practice must consider the other published documents15 in order to guarantee the optimal implementation of Telepharmacy initiatives in the HPSs of Spanish hospitals.
FundingNo funding.
AcknowledgementsTo Ascendo Consulting for its consulting and advisory services in the development of this document.
Conflict of interestsNo conflict of interest.
