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 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

3. Exploring Solutions: Telepharmacy Rules
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

4. 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

5. 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

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

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

8. 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

9. 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

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

19. Telepharmacy Sites March 2004

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

21. FY 2003 North Dakota Telepharmacy Sites

22. 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

23. 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 new jobs to the North Dakota rural marketplace
Has added 40-50% increase in prescription sales to combined pharmacy operation

24. Future Goals of Telepharmacy in North Dakota
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

25. 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

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

27. 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,

28. 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

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

30. 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

31. 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

32. Possible solution
Statewide Private IP Network

33. 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

34. 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

35. 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

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