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

North Dakota Rural Health Care Crisis: Community Pharmacy Closings 26 rural community pharmacy closings 12 additional pharmacies at risk of closing pharmacist retirements - no replacement national pharmacist shortage negative impact on rural health

Exploring Solutions: Telepharmacy Rules telepharmacy rules established by NDBDPH Pilot project in 2001  permanent rules established in June 2003 allow pharmacists to supervise a technician at remote site within 50 miles dispense prescriptions pharmacist - patient consultation

Telepharmacy Grant Awarded NDSU College of Pharmacy Congressionally mandated federal grant via the assistance and support of Senator Byron Dorgan Office for Advancement of TeleHealth, Health Resources and Services Administration of HHS First Initiated: September 1, 2002 $1,671,621 federal support to date

Goals of Telepharmacy Grant: RESTORATION - restore pharmacy services in rural communities which have lost their services RETENTION - retain pharmacy services in rural communities which are at risk of losing their services

Lost: 20 Risk: 6 Telepharmacies: 11 Central: 7

Telepharmacy Grant Budget Assist in the telepharmacy start-up costs 50% OAT Grant/50% North Dakota Technology: Hardware, Software, Connectivity Registered Pharmacy Technician Pharmacy Fixtures Drug Inventory Travel

Pharmacy Technician Responsibilities: Remote Telepharmacy Site Maintains drug inventory at remote site Processes all prescriptions orders including controlled substances Computer order entry, filling, billing, labeling Takes original prescription orders by phone Prepares prescription for dispensing by pharmacist Connects patient to the pharmacist for private consultation via audio and video link

Technician Training Requirements: Telepharmacy Sites Registered with Board of Pharmacy ASHP accredited program or equivalent Minimum of one year experience in dispensing prescriptions Salaries are $13-15/hour or more Reciprocity from other states requires PTCB certification

Pharmacist Responsibilities Final check of technician Rx preparation Dispenses drug to the patient Drug utilization review Patient education counseling

Telepharmacy Sites March 2004

FY 2002 North Dakota Telepharmacy Sites Rolette Rugby New Town Maddock Watford City Killdeer Fargo Beach Bismarck New England Gwinner Forman

FY 2003 North Dakota Telepharmacy Sites

Benefits to North Dakota with the Telepharmacy Program Improved access to health care for rural citizens Rural economic development Improved quality of care/pharmacist consults Increased patient & pharmacist satisfaction Increase financial viability of rural pharmacies Increased educational opportunities for students Increased retention of pharmacy graduates

Economic Impact of Telepharmacy Has added a $500,000 per year business to the rural community Thus far, has added an estimated total of $4.5 million annually to the North Dakota rural economy Has added an estimated 25-30 new jobs to the North Dakota rural marketplace Has added 40-50% increase in prescription sales to combined pharmacy operation

Future Goals of Telepharmacy in North Dakota 5 - 10 new community sites each year 50 telepharmacy sites in five years develop a model for serving rural hospitals assist other states in implementing telepharmacy services in rural areas establish a state-wide data & video network establish equipment standards

From the technical side …. Project parameters Independent, privately owned businesses Keep costs down Keep prescription processing separate from consultation 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

Concerns HIPAA Authentication Secure connections Reliability Internet1 Network management Troubleshooting Standardization Growth Flexibility

Multiple Hardware Solutions Yikes!! Prescription processing: PC, Printer, Logitech Quickcam or Live Imaging w Audio, NetMeeting, pharmacy software Consultation: Polycom, Logitech Network: VPN encrypt Rx & video Firewall: (Sonicwall Tele3, Cisco PIX, D-Link, None (ATM switch) Data: 56K frame relay or 56K modem (POTS) Video: 512K SDSL At the beginning consultants were hired to put together these pharmacy clusters. They were expensive and didn’t have a good solution, so I was brought into the project. The pharmacy clusters don’t have the same pharmacy software. The Logitech for consultation was a mistake Not all the same firewalls were purchased Dedicated POTS line as well Result,

Independent Pharmacy Clusters 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

Thrifty White has provided this slide – shows the setup at 2 of their sites

No central coordination Consultation station (Polycom, Logitech) Dispensing station (Pharmacy soft, doc cam, NetMeeting Firewalls (Sonicwall Tele3, Cisco PIX, D-Link, None (ATM switch) VPN Network ( 56K frame relay, 56K POTS, 512K SDSL) Not involved initially

Lessons learned Not all pharmacies the same, unique components Customers prefer talking to a “TV” Separate prescription processing - consultation Standards needed (except pharmacy software) Polycom units need flexibility (speakers, mics) Video works – VPN, firewall, 512K SDSL, 256K Different local phone companies Different pricing, solutions I1 & quality problem beginning at 3pm Need video links to all

Possible solution Statewide Private IP Network

DCN IP Core Public Internet NDSU Killdeer Pharmacy Managed VPN. Radius Authentication Server Access Device With integrated VPN Access Device With integrated VPN VPN Accelerator 512X512 DSL DCN Core Router DCN Core Router DCN T1 Internet Access ISP Connected to DCN IP Core DCN IP Core Managed VPN. 2 Core routers – redundancy 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 ISP Connected to DCN IP Core DSLAM Public Internet 512X512 DSL Access Device With integrated VPN Beach Pharmacy

DCN IP Core NDSU Killdeer Pharmacy Radius Authentication Server Access Device With integrated VPN IP Tunnel IP Tunnels Pharmacist Access Device With integrated VPN VPN Headend Student or Instructor DCN IP Core 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 IP Tunnel IP Tunnel Pharmacy Tech Access Device With integrated VPN Access Device With integrated VPN New England Pharmacy Beach Pharmacy Pharmacy Tech

Features Data encryption, authentication & security provisions – HIPAA Secure videoconference between pharmacies – patient consultation Secure data connection with document camera, database – dispensing Management, growth, redundancy, reliability, QoS (video) Internet access

Thank you Dr. Charles Peterson charles.peterson@ndsu.nodak.edu Sandy Sprafka sandy.sprafka@ndsu.nodak.edu (701) 231-8688