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. North Dakota Demographics 2000 Census Highlights
642,200 population, ranks 47th in nation
Population growth 0.5% ( )
Population shift from rural to urban
Only 6 of 53 counties gained population
50% of ND counties lost at least 10%
27 of 53 counties classified as frontier
14.7% over 65, vs 12.4% nationally

3. Pharmacy Services in ND
Of the 373 cities, 73 have pharmacies
Of the 53 counties, 9 do not have a pharmacy and 11 have only one Rx
North Dakota 51% ownership law

4. 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

5. Exploring Solutions: Telepharmacy Rules
Required changes in pharmacy practice act
Telepharmacy rules established by NDBDPh
Pilot project in  permanent rules established in June 2003
Allow pharmacists to supervise a technician at remote site within 50 miles
Dispense prescriptions
Pharmacist - patient consultation

6. Telepharmacy Grant Awarded NDSU College of Pharmacy
Congressionally mandated federal grant via the 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

7. 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

9. Telepharmacy Project Partners
NDSU College of Pharmacy
North Dakota State Board of Pharmacy
ND State Pharmaceutical Association
Licensed rural community pharmacies
Targeted rural communities

10. 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

11. 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

12. 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 $15/hour or more
Reciprocity from other states requires PTCB certification

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

22. Demographics: Remote Telepharmacy Sites
Beach
Rolette
New England
Maddock
Gwinner
Population
1,116
538
555
498
717
Distance -Central Rx
95 miles
32 miles
60 miles
48 miles
10 miles
Date Operational
Sept. 18, 2002
Nov. 2, 2002
Nov. 26, 2002
May 21, 2003
June 18, 2003
Size of Pharmacy
1,400
sq. ft.
2,000
1,200
2,500
575
Full Service Pharmacy
yes no

23. Demographics: Remote Telepharmacy Sites
Beach
Rolette
New England
Maddock
Gwinner
Rx ‘s dispensed per day
35-40
10-15
25-30
50-55
13-15
Hours of service
8:30 – 5:00 pm, M-F
9:00 – 5:30 pm, M-F
9:00-5:30 pm, M-F
9:00 – 5:00 pm, M-F
# People employed
1.5 FTE’s tech/clerk
3 FTE’s with 3 people
2 FTE’s with 3 people
3 FTE’s with
4 people
1.5 FTE’s tech/clerk
Medical Coverage
Clinic 5d/wk PA
Clinic 3-4d /wk PA/MD
Clinic 5d/wk MD
Clinic 5d /wk PA/MD
Clinic 5d/ wk PA/MD

24. Benefits to North Dakota with the Telepharmacy Program
Improved access to health care for rural citizens
Provides rural economic development
Improved quality of care/pharmacist consults
Increased patient & pharmacist satisfaction
Increased financial viability of rural pharmacies
Provides relief for pharmacists for vacations, etc.
Increased educational opportunities for students
Increased retention of pharmacy graduates

25. Economic Impact of Telepharmacy
Has added a $500,000 per year business to the rural community
Thus far, has added an estimated total of $7.5 million annually to the North Dakota rural economy
Has added an estimated new jobs to the North Dakota rural marketplace
Has added 50% increase in prescription sales to combined pharmacy operation

26. Economic Development Add’l Benefits of Telepharmacy
Helps attract other businesses and families to community because basic health care infrastructure is present
Pharmacy can be used for other business retailing not currently available within the community

27. Pharmacy Student Involvement
Incorporate telepharmacy technology in NDSU’s new Concept Pharmacy Lab
Trains students on the latest advances in pharmacy technology
Teaches students how to deliver pharmacy services in a unique and innovative way to smaller rural communities

28. Student Activities
Provide pharmacists at the Central Pharmacy with drug information and disease state management assistance
Provide patient education counseling to remote telepharmacy sites

29. 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

30. Recent Publication If you would like more information:
Peterson, CD and Anderson HC. The North
Dakota Telepharmacy Project: Restoring and
Retaining Pharmacy Services in Rural
Communities
J. Pharm. Tech 2004:20:28-39

31. 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

32. 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

33. Issues to Address HIPAA Authentication Secure connections Reliability
Internet1
Costs
Network management
Troubleshooting
Standardization
Growth
Flexibility

34. Telepharmacy Technology Hardware
Polycom Viewstation (VSX7000
Second camera
Document camera
2 mics (mute separately)
PC & printer
2 TV monitors
VPN – for encrypting Rx and video

35. Telepharmacy Technology – cont’d
Prescription Processing
Standard Pharmacy Operations Software
Patient Consultation
Polycom ViewStation
Prescription Verification
Polycom Viewstation
HIPAA/Privacy
Virtual Private Network (VPN) – Sonic Firewall

36. Telepharmacy Technology Connectivity
Local telephone company
Prescription Processing
Dedicated POTS with 56K modem
Patient Consultation
Symmetric DSL at 512K bandwidth

37. Lessons learned Not all pharmacies the same, unique components
Customers prefer talking to a “TV”
Separate prescription processing - consultation
Polycom units need flexibility (speakers, mics)
Video works – VPN, firewall, 512K SDSL, 256K
Different local phone companies
Different pricing, solutions
Internet1 a quality problem beginning at 3pm

38. Identified Needs Standards (except pharmacy software)
Video links to all

39. Network solutions Statewide Private IP Network
Connection to Internet2 for out-of-state

40. 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
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
ISP Connected to
DCN IP Core
DSLAM
Public
Internet
512X512 DSL
Access Device
With integrated VPN
Beach Pharmacy

41. 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

42. 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

43. Future Directions Connect to other states
Collaboration
Instruction
Services
Internet2 – enabling technology
Research Universities
SEGP participants
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.

44. High Speed Networks Attract researchers, faculty, students
Provide increased grant opportunities
Provide greater access to resources
Fuel economic development
Facilitates innovative & progressive projects

45. Thank you Dr. Charles Peterson charles.peterson@ndsu.nodak.edu
Sandy Sprafka
(701)