Telepharmacy: A Systematic Review of Field Application,Benefits,Limitations,and Applicability During the COVID-19 Pandemic

Abstract

Introduction:

Telepharmacy is widely known as the delivery of pharmacy care offered by registered pharmacists and pharmacies using telecommunication technologies to patients at a distance. We conducted a systematic review of the reported usages, benefits, and limitations of telepharmacy models worldwide to further clarify the pros and cons of a telepharmacy model.

Methods:

A total of 39 relevant articles was included after searching for articles with a fixed term on four databases, including PubMed, Virtual Health Library (VHL), Global Health Library (GHL), and Google Scholar, as of April 2021.

Results:

Our review suggested that telepharmacy has played an essential role in addressing pharmacist shortages and helping patients both safely and effectively administer medications in underserved areas. During the COVID-19 pandemic, remote dispensing and counseling are effective measures to avoid infection.

Conclusion:

Telepharmacy could potentially replace or complement pharmaceutical-related activities, facilitating future innovation in the health care industry.

Introduction

The application of information and communication technology can open new prospects in providing telemedicine services to help reduce the burden of the health sector. Telemedicine deals with many spheres of health care, consisting of telepharmacy. Telepharmacy is well known for the delivery of pharmaceutical-related services by registered pharmacists and pharmacies using telecommunications technology to patients at a distance.¹ Some telepharmacy services include clinical pharmacy services, patient consultation and monitoring, drug selection counseling, prescription check, dispensing, and intravenous drug preparation.^1,2

Telepharmacy has been seen as a potential alternative method in drug-related problem assessment for hospitals, pharmacy care for patients in underserved areas due to economic or geographic problems, and discomposure to risks related to patient data privacy and integrity.³ We conducted a systematic review of the reported usages, benefits, and limitations of telepharmacy models to further clarify the pros and cons of a telepharmacy model.

Materials and Methods

SEARCH METHODS

The review followed the preferred reporting items for systematic reviews and meta-analyses (PRISMA) statement (Supplementary data).⁴ We did not register our review on PROSPERO.

We searched with the keyword “telepharmacy” on four databases: PubMed, Virtual Health Library (VHL), Global Health Library (GHL), and Google Scholar. All references of selected studies were used for manual search. The study selection procedure is represented in the PRISMA flow diagram (Fig. 1).

Fig. 1.

The PRISMA flow diagram of study selection. PRISMA, preferred reporting items for systematic reviews and meta-analyses.

SELECTION CRITERIA

We included all original studies and clinical reports published through April 2021 and selected all articles with reported data on the application, benefits, and limitations of telepharmacy models in health care practice.

We excluded irrelevant articles, which are studies in the field of telepharmacy, but the results do not evaluate the effects on the study subjects' health. Other unreliable sources were also excluded, including book chapters, abstract-only articles, conference reports, reviews, dissertations, posters, discussions, and letters.

RESEARCH SELECTION

We included articles through a two-stage process: first screening the title and abstract, and then scanning the full text. The screened articles were chosen based on inclusion and exclusion criteria; any duplicated articles were excluded. Two independent reviewers independently screened all titles and abstracts. Two senior reviewers independently evaluated the full texts of all included articles. Disagreement was solved by discussion. All relevant articles were used in qualitative data extraction. Data synthesis was conducted following textual descriptions and summarized in a Table 1.

Table 1.

Advantages and Disadvantages of Telepharmacy

AUTHOR (YEAR) COUNTRY	TYPES OF STUDY	SPECIFIC PURPOSES	SAMPLE SIZE	STRENGTH	WEAKNESS
Order review and dispensing
Scott et al. (2012), USA¹⁴	Cross-sectional pilot study	To examine differences in dispensing errors within community telepharmacy practices	24 rural community telepharmacies	Quality-related events rates were consistent with national estimates in traditional community pharmacies	Remote sites were more likely to include incorrect directions in the medication entry process
Sankaranarayanan et al. (2014), USA⁹	Retrospective cross-sectional study	To evaluate a telepharmacy service model	450,000 prescription orders	The frequency of interventions significantly increased each year	Not identified
Peláez et al. (2020), Spain³⁹	Cross-sectional study	To report a telepharmacy model during the COVID-19 epidemic	1,186 patients	Telepharmacy provided multiple benefits to patients during home quarantine	Not identified
Peláez et al. (2020), Spain³⁹	Cross-sectional study	To report a telepharmacy model during the COVID-19 epidemic	1,186 patients	Patient satisfaction	Not identified
Wakefield et al. (2010), USA⁵	Case studies	To describe the implementation of a telepharmacy service to provide round-the clock medication order review	9,163 approved orders, 2,226 new orders, 1,294 modified orders, 972 discontinued orders, and 179 voided orders	The telepharmacy model in a multihospital health system increased access to pharmacy services, allowing for round-the-clock medication order review by pharmacists	Not identified
Pathak et al. (2020), USA¹²	Cross-sectional study used retrospective data	To evaluate the relationship between telepharmacy services in rural areas and the quality of medication use	2,832 patients 4,402 observations	The quality of medication use at telepharmacies was no worse than at pharmacies	Not identified
Clifton et al. (2003), USA⁶	Reports	To describe a telepharmacy program	93 patients at remote sites	Telepharmacy was well received by most of the patients and improved their access to medications and pharmacy services	Not identified
Clifton et al. (2003), USA⁶	Reports	To describe a telepharmacy program	106 patients at the base site		Not identified
Ibrahim et al. (2020), UAE¹⁰	Cross-sectional, observational, comparative study	To examine medication dispensing errors across community pharmacies with and without telepharmacy services	19,974 patients at a telepharmacy group	Telepharmacy helped COVID-19 patients' access to pharmaceutical care and on medication dispensing safety	Not identified
Ibrahim et al. (2020), UAE¹⁰	Cross-sectional, observational, comparative study		9,151 patients at community pharmacy group		Not identified
Mohamed Ibrahim et al. (2021), UAE¹¹	Prospective observational study	To evaluate the predictors for effective telepharmacy services and dispensing errors in community pharmacies	79,253 recommendations related to COVID-19	Provide COVID-19-related recommendations to patients	Telepharmacy were more likely to include wrong patient errors
Mohamed Ibrahim et al. (2021), UAE¹¹	Prospective observational study		12,471 prescriptions	Dispensing errors in pharmacies with telepharmacy were significantly lower than the control group
Friesner et al. (2011), USA¹³	Pilot, cross-sectional, comparison study	To evaluate the differences in medication dispensing errors between telepharmacy and standard community pharmacy	47,078 prescriptions via telepharmacy	Medication dispensing errors rates of both groups were consistent with nationally reported levels	The error rates of telepharmacies were slightly higher than comparison pharmacies
Friesner et al. (2011), USA¹³	Pilot, cross-sectional, comparison study		123,346 prescriptions in a standard pharmacy
Khan et al. (2008), USA¹⁵	No mentioned	To assess the financial operation of a Single Business Unit, consisting of one central retail pharmacy and two remote retail telepharmacies	Income statements and balance sheets for three consecutive years	The rate of growth showed that it was getting close to median sales	The inventory turnover ratio remained consistently below the industry average
Khan et al. (2008), USA¹⁵	No mentioned				The net operating income percent was below the industry average
Margolis and Ypinazar (2008), Australia⁸	No mentioned	To describe the telepharmacy program	21,470 consultations	Enabling early access to medications for both emergencies and definitive care	Not identified
Margolis and Ypinazar (2008), Australia⁸	No mentioned	To describe the telepharmacy program	21,470 consultations	Minimizing the need for mail order pharmacy or patient travel	Not identified
Asseri et al. (2020), Kingdom of Saudi Arabia³⁸	No mentioned	To report a telepharmacy model during the COVID-19 epidemic	14,618 outpatient department requests	Telepharmacy significantly had an impact on the technical efficiency and health care system's effectiveness on resource utilization in this newly adopted institutional pandemic response model	Not identified
			10,030 inpatient orders
			41,242 counseling sessions
Lam and Rose (2009), USA⁷	No mentioned	To describes the operation and service outcomes of a telepharmacy service	Five network clinics without in-house pharmacies	Telepharmacy could improve patient access to pharmaceutical care beyond remote medication dispensing to include point-of-care refill authorization and medication assistance referrals	Not identified
Patient counselling and monitoring
Ho et al. (2015), Denmark¹⁹	No mentioned	To analyze the type of enquiries made by customers receiving chat-based counseling	476 enquiries	Patient satisfaction	The diverse enquiries require professional chat operators with broad experience
León et al. (2011), Spain²¹	Open-label, two-arm, prospective randomized study	To evaluate home health care by telemedicine for HIV patients, comparing with standard care	83 patients (42 via telemedicine, 41 via standard care)	Clinical parameters, evaluation of quality of life, and psychological questionnaires changed significantly between two types of care	Not identified
León et al. (2011), Spain²¹	Open-label, two-arm, prospective randomized study		83 patients (42 via telemedicine, 41 via standard care)	Patient satisfaction	Not identified
Stockton and Deas (2019), USA²⁶	Retrospective chart review	To review clinical outcomes of patients receiving the telepharmacy service versus the standard of care	67 patients	Telepharmacy service produced changes in clinical outcomes that numerically exceeded those experienced by patients receiving specialty care, in the diabetes clinic, and within primary care	Not identified
Brown et al. (2017), USA²⁵	Pilot study	To assess the feasibility of incorporating telepharmacy services within a community pharmacy to deliver asthma education services	20 patients	Telepharmacy was an effective means to engage patients to gain and maintain asthma control	Not identified
Taylor et al. (2018), USA¹⁶	Pilot, retrospective record review	To evaluate a virtual, interprofessional chronic care management	69 patients	Telepharmacy program constituted an added service for patients while simultaneously filling a gap in on-site pharmacist counseling services	Not identified
Young et al. (2012), USA⁴⁹	Randomized controlled trial	To assess the feasibility, acceptability, and preliminary impact of a telepharmacy in asthma patient	83 patients	Telepharmacy intervention was feasible and showed indicators of effectiveness	Not identified
Young et al. (2012), USA⁴⁹	Randomized controlled trial		83 patients	Helping patients manage asthma	Not identified
Johnstone (2017), Australia²⁴	No mentioned	Effectiveness of telepharmacy on managing patients with chronic diseases	82 patients	Telepharmacy services improved access and allowed for the provision of cost-effective health care management	Not identified
Bynum et al. (2001), USA¹⁷	Randomized controlled trial	To determine the effectiveness of telepharmacy in asthma patients	15 patients using telepharmacy	Interactive compressed video was an effective medium for teaching and improving the metered-dose inhaler technique	Not identified
Bynum et al. (2001), USA¹⁷	Randomized controlled trial		21 patients in control group		Not identified
Hudd and Tataronis (2011), USA²⁰	Retrospective electronic review	To measure the effect of a satellite telepharmacy on adherence of medication	26 patients	Telepharmacy resulted in a high level of satisfaction with accessibility, service, and patient counseling	Not identified
McGinnis et al. (2019), USA²⁷	Cross-sectional study	To describe the components of this innovative telepharmacy program	124 patients	The completion of medication histories via telepharmacy by a pharmacy technician was a novel approach that incorporates virtual services with limited resources	Not identified
Gordon et al. (2012), Canada¹⁸	No mentioned	To establish and evaluate a telepharmacy program	47 patients	Patient satisfaction	Each chemotherapeutic preparation took longer to manufacture and compound using telepharmacy.
Gordon et al. (2012), Canada¹⁸	No mentioned	To establish and evaluate a telepharmacy program	109 treatment visits	Oversee the compounding of intravenous chemotherapy and provide a clinical review of physician orders
Clinical interventions
Kosmisky et al. (2019), USA³⁶	Not mentioned	To provide a description of the implementation and evolution of ICU telepharmacy	More than 110,000 alerts	Telepharmacy provided critical care pharmacy expertise during nontraditional hours with documented clinical and financial benefits	Not identified
Kosmisky et al. (2019), USA³⁶	Not mentioned		13,000 interventions		Not identified
Monane et al. (1998), USA³¹	Cohort study	To evaluate a program designed to decrease the use of potentially inappropriate medications among the elderly	23,369 patients	Telepharmacy improved prescribing patterns and quality of care and thus provides a population-based approach to advance geriatric clinical pharmacology	Not identified
Amkreutz et al. (2020), Germany³⁵	Prospective observational study	To implement and evaluate an additional telepharmaceutical expert consultation as a part of tele-ICU services	103 patients	Telepharmacy provided the possibility to implement guidelines recommending pharmaceutical service in the ICU	Not identified
Poulson et al. (2010), Australia³⁴	No mentioned	Comparison of effectiveness between telepharmacy clinical intervention and hospital pharmacists	48 patients in Phase 1	No significant differences in the pharmaceutical activity rates between telepharmacy and direct intervention	Not identified
Poulson et al. (2010), Australia³⁴	No mentioned		97 patients in Phase 2		Not identified
Keeys et al. (2002), USA³²	Report	To describe the need for clinical pharmacy services at night and the telepharmacy approach	1,039 drug orders	Telepharmacy provided medication order review, resolution of drug-related problems, and drug information and clinical pharmacy services	Not identified
Patterson et al. (2014), USA²⁹	No mentioned	To describe the use of clinical telepharmacy	3,040,635 patients	Increasing the presence of clinical pharmacists in community clinics	Not identified
Cole et al. (2012), USA²⁸	Retrospective chart review	To discuss the implementation and results of a telepharmacy	70 patients	Telepharmacy represented a potential alternative to round-the-clock on-site pharmacist medication review for rural hospitals	Not identified
Cole et al. (2012), USA²⁸	Retrospective chart review	To discuss the implementation and results of a telepharmacy	302 telepharmacy patients		Not identified
Stubbings et al. (2005), USA³³	Report	To describe a telepharmacy service in a health maintenance organization	40,000 patients	Reducing costs and improving quality of care	Not identified
Rebello et al. (2017), USA⁵⁰	Retrospective study	To evaluate the efficacy of telepharmacy in rural areas	100 veterans	Telepharmacy was effective in decreasing acute care utilization within 30 days after hospital discharge	Not identified
Killeen et al. (2020), Canada⁴¹	Case report	To report on the effectiveness of telepharmacy during the COVID-19 pandemic	75-year-old man	Clinical pharmacological interventions on hypertension prescriptions	Patients experiencing low income or socioeconomic status or reduced digital literacy may have difficulty
Garrelts et al. (2010), USA³⁰	Case study	To evaluate the impact of telepharmacy in a multihospital health system	619 clinical interventions	Telepharmacy services expanded hours of service, improved the speed of processing of physician medication orders, and increased clinical pharmacy services and cost avoidance	Not identified
Garrelts et al. (2010), USA³⁰	Case study		881 clinical interventions via telepharmacy		Not identified
Scott et al. (2014), USA⁵¹	No mentioned	To measure medication quality-related events at critical access hospitals of telepharmacy	17 hospitals	The telepharmacy model was effective in identifying and resolving quality-related events	Not identified
Bindler (2020), USA²³	Retrospective study	To review the effectiveness of telepharmacy	218,000 prescriptions	Telepharmacist service provided a large cost avoidance by the prevention of potential adverse drug reactions	Not identified
Aseptic preparation
Jean et al. (2020,) USA⁵²	Double-arm, prospective study	To evaluate the impact of remote sterile product pharmacist checks	2,609 compounded sterile products	No difference in the accuracy and safety of sterile product pharmacist checks	The median pharmacist review time in the local process was significantly lower
Jean et al. (2020,) USA⁵²	Double-arm, prospective study		2,609 compounded sterile products	Workload sharing and cost savings
Emergency
Russi et al. (2019), USA³⁷	Case report	To describe the telepharmacy intervention for volatile aromatic alcohol poisoning	A patient commits suicide	Via telepharmacy, pharmacists calculated the proper amount of antagonistic ethanol	Not identified

ICU, intensive care unit.

DATA EXTRACTION

We extracted data on primary outcomes, including fields of use, benefits, and limitations of telepharmacy models. Secondary outcomes, including requirements for building an effective telepharmacy model and current regulations governing telepharmacy, were also discussed.

Results

A total of 413 articles were found. After the selection process, we used 39 articles for data extraction, all of which were written in English (Fig. 1).

Thirty-nine selected articles reported the application of telepharmacy in eight countries, including the United States, Canada, Spain, Germany, Denmark, the United Arab Emirates, the Kingdom of Saudi Arabia, and Australia. The application of telepharmacy included three main areas: (1) checking prescriptions and dispensing drugs, (2) clinical pharmacy, and (3) patient consulting and monitoring. In addition, telepharmacy was also applied for aseptic preparation and emergencies (tele-emergency) to a lesser extent (Fig. 2).

Fig. 2.

Fields for application of telepharmacy.

Based on the telepharmacy application fields shown in Figure 2, data on the actual advantages and disadvantages of telepharmacy in each area were extracted. The results are shown in Table 1.

The pharmaceutical supply chain is a crucial application of telepharmacy, especially in remote or underserved regions. The models of remote drug distribution by telepharmacy have developed widely in a lot of countries, and several randomized pilot studies have shown that these models work. Telepharmacy helps improve patient medicines availability during hospital night shifts,⁵ patients in remote areas, and creates favorable conditions to support remote drug delivery by courier companies.^6

–9 The quality of drug dispensing and medication errors of telepharmacy might be a significant concern to ensure safety and effectiveness.

Many studies have compared the quality between telepharmacy and traditional pharmacies; however, the results were inconsistent. Some suggested amelioration, but others showed no significant differences in drug dispensing safety and efficacy between the two models.^10
–12 For example, in a cross-sectional pilot study by Friesner et al., the error rate in areas using telepharmacy was even higher than that of the control.¹³ A greater level of errors reached the patient at the central sites than at the remote sites.¹⁴ However, these error rates were still lower than the average nationally reported.^13,14

Despite the near-average sales growth, telepharmacy models are expected to face the challenge of a lower-than-average inventory turnover ratio. When it comes to a reasonable number of customers, the host should focus on scaling up and expanding the telepharmacy model to be profitable.¹⁵

Consulting and managing patient treatment remotely with telepharmacy is a method to save travel costs¹⁶ and receive higher patient satisfaction.^17

–22 Telepharmacy helped enhance pharmacy service to ensure drug safety and effectiveness for patients and avoid preventable adverse reactions.²³ The management of patients with chronic diseases is one of the most crucial concerns for telepharmacy,^16,24 such as HIV infection,²¹ asthma,^17,22,25 diabetes mellitus,²⁶ and cancer.¹⁸ These models help patients monitor and improve personal clinical indicators, hence improving quality of life. Telepharmacy also allowed to effectively collect medication history to provide adequate medication reconciliation.²⁷

Clinical pharmacists have an essential role in ensuring safe and effective drug use, providing drug warnings, and improving health care quality. The health system faces a barrier in providing this service in rural or distant places. Telepharmacy helps clinical pharmacists remotely intervene and support hospitals and replace onsite clinical pharmacy services.^18,28,29 Various studies have shown that telepharmacy increases not only the number of clinical warning interventions,^30,31 but also the number of warnings about potential side effects in prescriptions,²³ especially at night,³² and improves the speed of doctors' prescribing³⁰ while optimizing cost-effectiveness.³³

A study of efficacy comparison showed no significant differences in the pharmaceutical activity rates in the two models: weekly visits or remotely reviews by pharmacists.³⁴ In the intensive care unit, telepharmacy is mandatory for providing expert consultations in pharmacovigilance and dose adjustment in special cases.^35,36

In addition, telepharmacy has proven its value in telemedicine for rural locations with limited resources. A case of volatile alcohol (ethylene glycol/methanol) ingestion in a rural critical access hospital, who was cared for by tele-emergency pharmacy and medicine, was described. The patient was diagnosed, and the remote pharmacists calculated the ethanol concentration required to neutralize poison.³⁷

Another application field for telepharmacy is the isolated inspection of sterile products. A study in the United States demonstrated the accuracy and safety of telepharmacy while checking sterile products, which showed no statistically significant differences in error levels with direct work procedures (p = 0.177). However, the mean time required for direct collecting workflow is significantly lower (p < 0.001); telepharmacy cost savings are estimated at $23,770.08/year.³⁸

During the COVID-19 pandemic, when infection control requirements are necessary, telepharmacy models have been applied to drug distribution and counseling to foster remote clinical warnings and relieve several burdens in a straightforward manner. This model has shown effectiveness in helping patients access medicine early during home isolation^39,40 and received a high level of patient satisfaction.⁴⁰ Comparative studies using parallel drug dispensing by telepharmacy and other distribution methods have shown no difference in drug error rates between the two procedures,^10,11 despite a higher number of patient information errors in the telepharmacy group, which suggested the need for a stricter operational process for telepharmacy.¹¹

Telepharmacy helps intervene in medication-related problems warnings to patients⁴¹; it also addressed concerns and questions related to COVID-19 to provide necessary recommendations.¹¹

QUALITY ASSESSMENT

The included studies were evaluated for study quality. We used Study Quality Assessment Tools (SQAT) of National Institute of Health⁴² to assess the quality of each research method separately, including (1) observation cohort/cross-sectional studies, (2) case-control studies, and (3) case report/case series.

Each item was rated as 1 for good practice or 0 for potential flaws. In addition, if the grading is ambiguous, we followed the guidance of SQAT to place “NA” (not applicable), “NR” (not reported), or “CD” (cannot determine). These categories represent potential flaws that we should be cautious of. The final score would be calculated as a percentage with an equal point for each item. The scoring threshold is those at least 75% to be assessed as “good” quality, those between 75% and 43% as “fair,” and below 43% as “poor” quality. Two reviewers independently extracted the assessment. Discrepancies were resolved by discussion and agreement.

Ten articles were designed as observation cohort and cross-sectional studies (Table 2), 12 articles were case-control studies (Table 3), and 6 were case report/case series (Table 4). Eleven articles were unable to be categorized to apply the SQAT. Those articles carried a high risk of bias. Thus, it should be interpreted with care.

Table 2.

Quality Assessment for Cohort and Cross-Sectional Studies

References			Criteria														Overall
No	Id	Article	1	2	3	4	5	6	7	8	9	10	11	12	13	14	Overall
1	9	Sankaranarayanan et al. (2014), USA	1	1	1	1	NA	1	NA	NA	1	NA	1	NA	NA	1	Fair
2	16	Taylor et al. (2018), USA	1	1	1	1	NA	1	NA	NA	1	NA	1	NA	NA	1	Fair
3	20	Hudd and Tataronis (2011), USA	1	1	1	1	NA	1	NA	NA	1	NA	1	NA	NA	NA	Fair
4	23	Bindler (2020), USA	1	1	1	1	NA	1	NA	NA	1	NA	1	NA	NA	NA	Fair
5	26	Deas and Stockton (2019), USA	1	1	1	1	NA	1	NA	NA	1	NA	1	NA	NA	1	Fair
6	27	McGinnis et al. (2019), USA	1	1	1	1	NA	0	0	NA	1	NA	1	NA	NA	NA	Poor
7	28	Cole et al. (2012), USA	1	1	1	1	NA	1	NA	NA	1	NA	1	NA	NA	NA	Fair
8	31	Monane et al. (1998), USA	1	1	1	1	NA	1	1	NA	1	NA	1	NA	NA	1	Fair
9	35	Amkreutz et al. (2020), Germany	1	1	1	1	NA	1	NA	NA	1	NA	1	NA	NA	1	Fair
10	40	Peláez et al. (2020), Spain	1	1	1	1	NA	0	0	NA	1	NA	1	NA	NA	1	Fair

NA, not applicable.

Table 3.

Quality Assessment of Case-Control Studies

REFERENCES			CRITERIA												OVERALL
NO	ID	ARTICLE	1	2	3	4	5	6	7	8	9	10	11	12	OVERALL
1	6	Clifton et al. (2003), USA	1	1	0	1	1	1	1	NA	NA	1	NA	1	Fair
2	10	Ibrahim et al. (2020), UAE	1	1	1	1	1	1	1	NA	1	1	NA	1	Good
3	11	Ibrahim et al. (2020), UAE	1	1	1	1	1	1	1	0	0	1	NA	1	Fair
4	12	Pathak et al. (2020), USA	1	1	0	1	1	1	1	NA	1	1	NA	NA	Fair
5	13	Friesner et al. (2011), USA	1	1	0	1	NA	1	1	0	0	1	NA	1	Fair
6	14	Scott et al. (2012), USA	1	1	1	1	1	1	1	0	0	1	NA	NA	Fair
7	15	Khan et al. (2008), USA	1	1	0	NA	NA	1	1	NA	1	1	NA	NA	Fair
8	17	Bynum et al. (2001), USA	1	1	0	1	1	1	1	NA	1	1	NA	1	Fair
9	21	León et al. (2011), Spain	1	1	0	NA	1	1	1	NA	1	1	NA	NA	Fair
10	22	Young et al. (2012), USA	1	1	1	1	1	1		NA	1	1	NA	1	Good
11	38	Jean et al. (2020), USA	1	1	0	0	1	1	1	NA	1	NA	NA	NA	Fair
12	42	Rebello et al. (2017), USA	1	1	0	0	1	1	1	NA	1	1	NA	1	Fair

Table 4.

Quality Assessment for Case Report and Case Series Studies

REFERENCES			CRITERIA									OVERALL
NO	ID	ARTICLE	1	2	3	4	5	6	7	8	9	OVERALL
1	5	Wakefield et al. (2010), USA	1	1	1	NA	NA	1	NA	1	1	Fair
2	25	Brown et al. (2017), USA	1	1	1	NA	NA	1	1	1	1	Good
3	32	Keeys et al. (2002), USA	1	1	NA	NA	1	1	NA	1	1	Fair
4	41	Killeen et al. (2020), Canada	1	1	1	1	1	NA	NA	1	1	Good
5	30	Garrelts et al. (2010), USA	1	1	1	1	NA	1	NA	1	1	Good
6	37	Russi et al. (2019), USA	1	1	1	1	1	1	1	1	1	Good

Among 10 observation cohort/cross-sectional studies, the overall rating indicated that none of the studies was of “good” quality. Nine studies were of “fair,” and only one was of “poor” quality. However, none of these studies was excluded from our systematic review. In the case-control group, the overall quality was “fair” in terms of bias, except two studies that were evaluated as “good.” Four out of six case reports/case series had “good” quality, indicating a potentially low bias level.

Discussion

The use of communication and information technology in pharmacy practice has attracted attention in many countries worldwide. The United States has the most experience, with the first telepharmacy service in the early 2000s.^17,22 Telepharmacy is a new approach to providing care from pharmacists in multidisciplinary health care that is becoming more and more popular.⁴³ Our review shows that telepharmacy has been widely applied in drug dispensing, patient counseling and management, clinical pharmacy, aseptic product preparation, and emergency interventions. Telepharmacy serves as a new ecosystem to communicate with patients or provide online pharmacy support to other health care workers in remote medical facilities.^29,37 The obtained results suggest the importance and enormous potential of the telepharmacy service in the future, which we will discuss next.

First, telepharmacy could be the solution to help reduce the shortage of pharmacists. Patients living in rural or separated areas may have difficulty accessing pharmacy services.⁴⁴ The uneven distribution of the industry structure causes a shortage of pharmacist care services in rural or hard-to-access areas, especially clinical pharmacy services.^45,46 A common term for these communities is pharmacy deserts.^47,48 Telepharmacy helps ensure proper pharmaceutical support in underserved areas^6

–9 or facilitates remote pharmacist intervention to support hospitals in providing inpatient clinical pharmacy care.^18,28,29 These technological advancements contribute to reducing inequalities in health care delivery.

Second, telepharmacy can help improve the quality of drug use. The quality of telepharmacy delivery was reported and compared with the control group through the quality-related events (QREs) index.^10

–14 Telepharmacy is generally considered to have no adverse effects on public health, patient safety, and quality of health care,^10
–12 and it is not inferior to pharmacies.^13,14 The Hawthorne effect (i.e., the tendency of some people to work harder and perform better when they are experimental participants) may have become a potential factor influencing the results of the studies.

Long-term studies of the Hawthorne effect will have a less pronounced impact (which cannot be wholly reduced).⁴⁹ Further, within 45 months of data collection, the study by Friesner et al. showed a decreasing trend in QRE, which suggested that error rates will decrease as pharmacists and their technicians get used to them. The regulations, protocols, and standards of practice are inherent in the telepharmacy model.¹³ In hospitals, telepharmacy has created an environment that facilitates pharmacists to remotely intervene on drug-related issues,^30,31 expand the scope of 24-h hospital pharmacies,³² help speed up prescription processing,³⁰ and reduce order processing time, freeing pharmacists for money-saving or quality-improvement initiatives.³³

Remote pharmacist interventions in the telepharmacy service model coordinate patient-centered pharmaceutical care and facilitate the meaningful use of electronic health records.⁹

Third, several studies examining the effectiveness of telepharmacy services in the era of COVID-19 have shown that telepharmacy improves drug-dispensing practices, helping to increase a patient's access to pharmaceutical care.^10,11 In response to the health crisis caused by the COVID-19 pandemic, hospitals have adapted their outpatient counseling and dispensing services to telepharmacy to reduce the risk of infection.^39,40 Telepharmacy offers a more comfortable environment for pharmacists to consult with patients without the risk of viral transmission.

Last but not least, education about telapharmacy is essential, not only for pharmacists but also for patients, to reinforce its use.⁶ Formal continuing education programs will keep pharmacists up to date with current telepharmacy practices. Today, people need greater access to medicines due to an increased proportion of the aging population and comorbidities,^7,8 leading to a higher need for pharmacists to meet these new needs.³³ However, not all patients have the exact needs. Further action is needed to determine which groups of patients need more intensive pharmaceutical care and, therefore, who can benefit most from telepathy, not just delivery. The goal is to continue to provide high-quality care.

LIMITATIONS

Our review had some limitations. Regardless of following the PRISMA statement, we did not register our review on PROSPERO. We have not yet made a comparison between the telepharmacy model in the studies and each other because of different backgrounds and the miscellaneous type of models when it comes to reality. Also, data on the limitations of telepharmacy were not fully understood. We suggest further clarification of these data in the future.

Conclusions

Telepharmacy has shown certain benefits in providing an alternative solution to the problem of lack of pharmacists and also contributing toward ensuring patient access to medicines in underserved areas. Despite the variation in models and some limitations requiring a higher capacity of the pharmacist in the application of technology and a higher concentration, telepharmacy is effective in providing clinical pharmacovigilance related to drugs and managing patients in treatment, thereby helping to increase the ability to use resources, as well as to save costs.

During the COVID-19 pandemic, some telepharmacy models have been shown to be effective in ensuring drug dispensing, in enhancing drugs' safety and effectiveness, and in coping with the disease in general. These data suggest the potential of telepharmacy to replace or complement pharmaceutical-related activities and facilitate future innovation in the health care industry.

Footnotes

Authors' Contributions

T.V.D. and V.L.T. were responsible for the idea and supervision. All authors did screening and extraction under the supervision of N.T.H. All authors extracted data, and N.T.H. contributed toward interpreting the results. T.V.D., V.L.T., and N.K.Q. took the lead in writing the article. All authors contributed to the article writing and approved the final version.

Disclosure Statement

No competing financial interests exist.

Funding Information

This study was funded by Ho Chi Minh City Department of Science and Technology (DOST HCMC to Truong Van Dat: under Decision 1362/QD-SKHCN and Grant 99/2020/HD-QPTKHCN).

Supplementary Material

Supplementary Data

References

Win

AZ.

Telepharmacy: Time to pick up the line. Res Social Adm Pharm, 2017; 13:882–883.

, Toscani

, Colaizzi

. Telepharmacy: A new paradigm for our profession. J Pharm Pract, 2020; 33:176–182.

Sherman

Telepharmacy-a promising alternative for rural communities. Pharm Times, 2009; 73:1–65.

Page

, McKenzie

, Bossuyt

, et al. The PRISMA 2020 statement: An updated guideline for reporting systematic reviews. BMJ, 2021; 372:n71.

Wakefield

, Ward

, Loes

, O'Brien

, Sperry

. Implementation of a telepharmacy service to provide round-the-clock medication order review by pharmacists. Am J Health Syst Pharm, 2010; 67:2052–2057.

Clifton

, Byer

, Heaton

, Haberman

, Gill

. Provision of pharmacy services to underserved populations via remote dispensing and two-way videoconferencing. Am J Health Syst Pharm, 2003; 60:2577–2582.

Lam

, Rose

. Telepharmacy services in an urban community health clinic system. J Am Pharm Assoc (2003), 2009; 49:652–659.

Margolis

, Ypinazar

. Tele-pharmacy in remote medical practice: The Royal Flying Doctor Service Medical Chest Program. Rural Remote Health, 2008; 8:937.

Sankaranarayanan

, Murante

, Moffett

. A retrospective evaluation of remote pharmacist interventions in a telepharmacy service model using a conceptual framework. Telemed J E Health, 2014; 20:893–901.

10.

Ibrahim

, Ibrahim RM

A Z

AM, Al Mazrouei

Role of telepharmacy in pharmacist counselling to coronavirus disease 2019 patients and medication dispensing errors. J Telemed Telecare, 2020:1357633x20964347.

11.

Mohamed Ibrahim

, Ibrahim

, Abdel-Qader

, Al Meslamani

, Al Mazrouei

. Evaluation of telepharmacy services in light of COVID-19. Telemed J E Health, 2021; 27:649–656.

12.

Pathak

, Haynes

, Qato

, Urick

. Telepharmacy and quality of medication use in rural areas, 2013–2019. Prev Chronic Dis, 2020; 17:E101.

13.

Friesner

, Scott

, Rathke

, Peterson

, Anderson

. Do remote community telepharmacies have higher medication error rates than traditional community pharmacies? Evidence from the North Dakota Telepharmacy Project. J Am Pharm Assoc (2003), 2011; 51:580–590.

14.

Scott

, Friesner

, Rathke

, Peterson

, Anderson

. Differences in medication errors between central and remote site telepharmacies . J Am Pharm Assoc (2003), 2012; 52:e97–e104.

15.

Khan

, Snyder

, Rathke

, Scott

, Peterson

. Is there a successful business case for telepharmacy?. Telemed J E Health, 2008; 14:235–244.

16.

Taylor

, Bingham

, Schussel

, Axon

, Dickman

, Boesen

, et al. Integrating innovative telehealth solutions into an interprofessional team-delivered chronic care management pilot program. J Manag Care Spec Pharm, 2018; 24:813–818.

17.

Bynum

, Hopkins

, Thomas

, Copeland

, Irwin

. The effect of telepharmacy counseling on metered-dose inhaler technique among adolescents with asthma in rural Arkansas. Telemed J E Health, 2001; 7:207–217.

18.

Gordon

, Hoeber

, Schneider

. Telepharmacy in a rural Alberta Community Cancer Network. J Oncol Pharm Pract, 2012; 18:366–376.

19.

, Nielsen

, Jacobsgaard

, Salmasi

, Pottegård

. Chat-based telepharmacy in Denmark: Design and early results. Int J Pharm Pract, 2015; 23:61–66.

20.

Hudd

, Tataronis

. The impact of an urban telepharmacy on patient medication adherence in a federally qualified health center. J Pharm Technol, 2011; 27:117–122.

21.

León

, Cáceres

, Fernández

, Chausa

, Martin

, Codina

, et al. A new multidisciplinary home care telemedicine system to monitor stable chronic human immunodeficiency virus-infected patients: A randomized study. PLoS One, 2011; 6:e14515.

22.

Young

Telepharmacy project aids North Dakota's rural communities. Am J Health Syst Pharm, 2006; 63:1776, 9–80.

23.

Bindler

RJ.

The impact of telepharmacy services on the identification of medication discrepancies, high-alert medications, and cost avoidance at rural healthcare institutions. J Int Soc Telemed E Health, 2020; 8(e5):1–6.

24.

Johnstone

Telepharmacy and chronic kidney disease—a Making Tracks investment strategy2017. Available at www.ruralhealth.org.au/14nrhc/sites/default/files/Johnstone%2C%20Laura_E10.pdf (last accessed April 2, 2022 ).

25.

Brown

, Scott

, Friesner

, Schmitz

. Impact of telepharmacy services as a way to increase access to asthma care. J Asthma, 2017; 54:961–967.

26.

Stockton

, Deas

. Evaluation of outcomes of a pharmacist-run, outpatient insulin titration telepharmacy service. Innov Pharm, 2019; 10, DOI: 10.24926/iip.v10i2.1737.

27.

McGinnis

, Padilla

, Garret

, Aziz

. Using pharmacy technicians and telepharmacy to obtain medication histories in the emergency department. J Am Pharm Assoc (2003), 2019; 59:390–397.

28.

Cole

, Grubbs

, Din

, Nesbitt

. Rural inpatient telepharmacy consultation demonstration for after-hours medication review. Telemed J E Health, 2012; 18:530–537.

29.

Patterson

, Kaboli

, Tubbs

, Alexander

, Lund

. Rural access to clinical pharmacy services. J Am Pharm Assoc (2003), 2014; 54:518–525.

30.

Garrelts

, Gagnon

, Eisenberg

, Moerer

, Carrithers

. Impact of telepharmacy in a multihospital health system. Am J Health Syst Pharm, 2010; 67:1456–1462.

31.

Monane

, Matthias

, Nagle

, Kelly

. Improving prescribing patterns for the elderly through an online drug utilization review intervention: A system linking the physician, pharmacist, and computer. JAMA, 1998; 280:1249–1252.

32.

Keeys

, Dandurand

, Harris

, Gbadamosi

, Vincent

, Jackson-Tyger

, et al. Providing nighttime pharmaceutical services through telepharmacy. Am J Health Syst Pharm, 2002; 59:716–721.

33.

Stubbings

, Miller

, Humphries

, Nelson

, Helling

. Telepharmacy in a health maintenance organization. Am J Health Syst Pharm, 2005; 62:406–410.

34.

Poulson

, Nissen

, Coombes

. Pharmaceutical review using telemedicine—a before and after feasibility study. J Telemed Telecare, 2010; 16:95–99.

35.

Amkreutz

, Lenssen

, Marx

, Deisz

, Eisert

. Medication safety in a German telemedicine centre: Implementation of a telepharmaceutical expert consultation in addition to existing tele-intensive care unit services. J Telemed Telecare, 2020; 26:105–112.

36.

Kosmisky

, Everhart

, Griffiths

. Implementation, evolution and impact of ICU telepharmacy services across a health care system. Hosp Pharm, 2019; 54:232–240.

37.

Russi

, Mattson

, Smars

, Newman

, Beuning

. Ethylene glycol and methanol ingestion cared for by tele-emergency pharmacy and tele-emergency medicine. J Telemed Telecare, 2019; 25:445–447.

38.

Asseri

, Manna

, Yasin

, Moustafa

, Roubie

, El-Anssasy

, et al. Implementation and evaluation of telepharmacy during COVID-19 pandemic in an academic medical city in the Kingdom of Saudi Arabia: Paving the way for telepharmacy. World J Adv Res Rev, 2020; 7:218–226.

39.

Peláez Bejarano

, Villar Santos

, Robustillo-Cortés

MLA

, Sánchez Gómez

, Santos Rubio

. Implementation of a novel home delivery service during pandemic. Eur J Hosp Pharm, 2021; 28(Suppl. 2):e120–e123.

40.

Killeen

, Grindrod

, Ong

. Innovations in practice: Telepharmacy's time has arrived. Can Pharm J (Ott), 2020; 153:252–255.

41.

Access to primary and community health-care services for people 16 years and over with intellectual disabilities: A mapping and targeted systematic review [Internet]. National Institute of Health, 2020. [cited March 2022]. Available at https://www.nhlbi.nih.gov/health-topics/study-quality-assessment-tools (last accessed April 2, 2022 ).

42.

Kane-Gill

, Rincon

. Expansion of telemedicine services: Telepharmacy, telestroke, teledialysis, tele-emergency medicine. Crit Care Clin, 2019; 35:519–533.

43.

Todd

, Copeland

, Husband

, Kasim

, Bambra

. Access all areas? An area-level analysis of accessibility to general practice and community pharmacy services in England by urbanity and social deprivation. BMJ Open, 2015; 5:e007328.

44.

McFarland

Telepharmacy for remote hospital inpatients in north-west Queensland. J Telemed Telecare, 2017; 23:861–865.

45.

Rita

Baeten

, Slavina

Spasova

, Bart

Vanhercke

, Coster

Inequalities in access to healthcare. A study of national policies 20182018. Available at https://op.europa.eu/en/publication-detail/-/publication/aff4d623-e7c2-11e8-b690-01aa75ed71a1/language-en (last accessed April 2, 2022 ).

46.

Howarth

, Peterson

, Jackson

. Does rural and urban community pharmacy practice differ? A narrative systematic review. Int J Pharm Pract, 2020; 28:3–12.

47.

Pednekar

, Peterson

. Mapping pharmacy deserts and determining accessibility to community pharmacy services for elderly enrolled in a State Pharmaceutical Assistance Program. PLoS One, 2018; 13:e0198173.

48.

Sedgwick

, Greenwood

. Understanding the Hawthorne effect. BMJ, 2015; 351:h4672.

49.

Young

, Havican

, Griesbach

, et al. Patient and phaRmacist telephonic encounters (PARTE) in an underserved rural patient population with asthma: Results of a pilot study. Telemed J E Health, 2012; 18:427–433.

50.

Rebello

, Gosian

, Salow

, Sweeney

, Rudolph

, Driver

. The rural PILL program: A postdischarge telepharmacy intervention for rural veterans. J Rural Health, 2017; 33:332–339.

51.

Scott

, Friesner

, Rathke

, Doherty-Johnsen

. Medication error reporting in rural critical access hospitals in the North Dakota Telepharmacy Project. Am J Health Syst Pharm, 2014; 71:58–67.

52.

Jean

, Francart

, Eckel

, et al. Evaluation of telepharmacy and the use of a gravimetric technology-assisted workflow system for remote sterile product pharmacist checks. Am J Health Syst Pharm, 2020; 77:560–567.

Supplementary Material

Please find the following supplemental material available below.

For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.

For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.

0.02 MB

0.00 MB