What do pharmacists need to know about the recent ‘telepharmacy’ changes?
The COVID-19 pandemic has changed the face of healthcare – and indeed pharmacy – as we know it.
Since 21 April, pharmacists have been able to undertake a range of medication reviews via telehealth, including MedsChecks, Diabetes MedsChecks, Home Medicines Reviews and Residential Medication Management Reviews for eligible patients, according to changes enacted by the Federal government.
The ‘telepharmacy’ measures were announced following the rollout of telehealth for GPs in response to the pandemic, as people have enacted social distancing to reduce exposure to the virus.
These temporary changes are particularly important for those most vulnerable to COVID-19 – the elderly and those with underlying health conditions – as they are also more likely to be on a number of medications and in need of review by a pharmacist.
For a medication review to be conducted via telehealth, i.e. video or telephone, the patient must meet the following eligibility criteria, in addition to the eligibility criteria for the relevant program):
- Meets the current national triage protocol criteria for suspected COVID-19 infection after consultation with either the national COVID-19 hotline, state COVID-19 hotlines, a registered medical or nursing practitioner or COVID-19 trained health clinic triage staff;
- people aged over 70;
- people who identify as Aboriginal and Torres Strait Islander people aged over 50;
- people with chronic health conditions or who are immunocompromised; or
- parents with new babies and people who are pregnant.
Meanwhile further changes announced at the same time allow accredited pharmacists to provide two additional follow-ups for HMRs and RMMRs within nine months but not earlier than one month following the initial review.
The Pharmaceutical Society of Australia welcomed the new measures.
“Allowing medicine reviews via telehealth, whether it be on videoconference or teleconference, is a common-sense decision made by the Government to ensure Australians continue to receive the support and medicine safety information they need without the risk of contracting COVID-19,” said PSA national president, Associate Professor Chris Freeman.
“This announcement also helps reduce the risk to pharmacists … of getting contracting COVID-19 themselves.”
Society of Hospital Pharmacists of Australia chief executive Kristin Michaels said the introduction of telehealth to ensure continuation of medication reviews is “essential to supporting optimal use of limited hospital beds, while removing risk of asymptomatic COVID-19 transmission between health practitioners and Australians managing their medicines at home.”
Pharmacists on the frontline
The changes have been welcomed by many consultant pharmacists who noticed medication reviews dropping off as the pandemic took hold.
Katja Naunton-Boom, a Canberra-based consultant pharmacist working within a general practice, told AJP she noticed a decline in HMRs immediately after the COVID outbreak.
“I conduct approximately five HMRs a week. [However] less referrals were coming from the doctors because they were worried about sending a pharmacist to an elderly person’s home – often with chronic health conditions,” she said.
“I also had several patients cancelling their HMR because they were worried about a pharmacist coming to their house. For these patients a telehealth is a great alternative.
“I am still conducting HMRs at the patients’ houses if I can, but I have used the telehealth option in a couple of occasions.”
Nevertheless, she points out that there are some obstacles. For example, if the patient doesn’t have great hearing and doesn’t have access to videocall.
South Australian consultant pharmacist Dr Manya Angley conducted her first HMR interview by telehealth on 23 April – just a few days after the telehealth measures were passed.
It was a “complex” case, she told AJP, involving a man with dementia and swallowing difficulties.
“The telehealth was great. The daughter took a photo of the blister pack medications and texted it to me; we had a lot of dialogue over the phone,” she said.
However there were issues because his carers wouldn’t crush his medicines.
“The daughters would come in and crush the medicines,” said Dr Angley. “I provided crushing info and identified deprescribing opportunities. The GP and family are very happy – in fact, one of the daughters who is a health professional has been really positive about my input.”
Dr Angely also applauded the addition of follow-up appointments, and said she will “absolutely” be taking advantage of them.
Karalyn Huxhagen, a consultant pharmacist based in Mackay, Queensland, agreed the changes were needed and said she plans to utilise telehealth herself.
“In this time of COVID-19 crisis, I welcome the ability to perform medication reviews during telehealth services where appropriate,” Ms Huxhagen said.
“Since the March lockdown started we’ve had patients who have had refused to have their HMR – not because they don’t want one but because they’ve self-isolated due to their age and medical conditions and do not want anyone in their homes.
“Now the procedure is in place we will now be re-visiting with those patients to see if we can initiate telehealth.”
In the past few weeks, Ms Huxhagen has completed a telephone HMR with a “very elderly and frail” man.
“It took a good 45 minutes as I needed to go slowly so he absorbed everything over the phone,” she said.
“He has excellent support from his local pharmacists so it was easy to coordinate. His community pharmacist made sure he had a list of his medications and good knowledge of what we were going to talk about.”
However the telehealth measures may be viewed as less of a boon for community pharmacists, who primarily conduct MedsChecks and Diabetes MedsChecks face to face in the pharmacy setting as opposed to in the home.
Victorian community pharmacist and proprietor Angelo Pricolo told AJP he doesn’t see the new measures as a huge game changer for himself or his business.
“We do heaps of MedsChecks and Diabetes MedsChecks, several a week,” he said.
“I’ve got to be honest, at this stage I don’t see a huge need for [telehealth]. It’s not something that will impact my practice in a sizeable way.
“I don’t have any philosophical objection to telehealth consults, but haven’t really had any need to do them yet. And with things loosening up now, I feel there will be even less need going forward,” said Mr Pricolo.
“It’s not a huge game changer for me, but I can see it has some impact on some pharmacists, and I think it has some benefits for some patients.
“There’s no doubt, for example where you have a patient that is getting their medicine via a carer or not coming in to pick up their meds as often, that there are some positive implications for this new allowance.”
‘Not the default option.’
While consultant pharmacists have hailed telehealth measures as beneficial during the current crisis, they have also pointed out the importance of conducting HMRs in the home.
Brisbane-based consultant pharmacist Debbie Rigby applauded the rapid implementation and acceptance of telehealth services, but was quick to add that medication reviews by telehealth should not be considered the default option.
“The optimal format for the HMR consultation is in the person’s home,” Ms Rigby argued.
“For HMRs there is a benefit in seeing the patient in their home, and accessing all the medicines they have.
“I’d like to see telehealth consultations for HMRs and RMMRs continue post-COVID in rural and remote areas, under specified conditions.”
Ms Huxhagen agreed that HMRs are, in general, best performed in person.
“My viewpoint is that the HMR service should where possible be performed in the home, because that is the most appropriate method to determine many issues that are seen by the HMR pharmacist,” she said.
“Going forward there may be a role to perform the new services such as the two follow ups as telehealth services, because the initial HMR would have been performed in the home. Especially for rural areas (PhARIA 4-6) the follow-ups could be done in a telehealth format.
“I would like telehealth to stay for exceptional cases [following COVID-19] and definitely for the follow–up stages in the future.”
Consultant pharmacists and University of Canberra academics Mark Naunton and Sam Kosari meanwhile told AJP the addition of telehealth has been a “fantastic” addition during the COVID-19 crisis for people who are unable to be interviewed or reviewed face-to-face.
“Of course, in many cases the initial interview is best done in the patients home, but this is not always feasible,” said Associate Professor Naunton.
“At this point of time I am aware of some patients not wishing to have a pharmacist come to their house to conduct the interview, so it is great that there is a telehealth option,” he said.
“But I don’t think we want to see a situation where the default position is to do telehealth medication reviews, as there is a lot of information that can be gathered when visiting the patient in their home.
“I have been to houses where I have seen several bags of medicines unopened from previous hospitalisations, indicating non-adherence. It is also helpful to conduct these reviews in the home as you can help the patient with setting up reminder systems in the house to help them take their medicine (e.g. notes on fridge doors), and you can also identify other things such as trip hazards,” said Associate Professor Naunton.
Despite this, telehealth is valuable during the current crisis as many people may be at urgent need of a medication review, but unable to visit their GPs or community pharmacies in person as often as they used to before, said Assistant Professor Kosari.
“Pharmacists can fill in the gap to ensure that there are continued efforts to maintain medication safety for their clients. Introducing the two follow–ups has also offered a better opportunity for pharmacists to be more involved in patients’ care,” he said.
“Conducting HMRs using telehealth is fairly new for pharmacists, so it will perhaps take some time for pharmacists to develop their routine to work in the new setting.”
Telepharmacy: what you need to know
In late April, the PSA conducted a webinar on telehealth hosted by Chris Freeman, PSA lead 7CPA negotiator Shane Jackson and pharmacist Nicolette Ellis.
Here are five top pieces of advice from the broadcast:
1. Discuss the appropriateness of a telehealth consult.
It’s really important to have contact with the patient beforehand to discuss and establish the appropriateness of a telehealth consult, said Ms Ellis.
“There is an eligibility criteria for medications reviews that is outlined for those most at risk,” she said.
Dr Jackson added: “It shouldn’t be the default.”
Professional indemnity insurance provider PDL told AJP: “Each opportunity to undertake a telehealth service needs to have a risk-benefit assessment to ensure that the means of consultation is suitable for the client and pharmacy and the risk of oversight, omission or miscommunication is minimised.
“Documentation supporting the decision to undertake the service via telehealth should be saved. If there is an inability to communicate clearly and professionally with a client, then the telehealth option should not be used and the reasons for this decision documented.”
2. Remember to gain and document informed consent.
Ms Ellis warned that pharmacists who don’t have documented patient consent for a government-funded service may need to pay back the money.
“I always email my patients with the consent form so I have it in writing,” she said.
Associate Professor Freeman reminded pharmacists that there is an up-to-date consent form on the Pharmacy Programs Administrator website.
3. Familiarise yourself with the program rules, and the professional guidelines for service delivery.
Dr Jackson called on pharmacists to familiarise themselves with two documents:
“One being the program rules, which are around claiming and eligibility – so you’re not delivering the service to somebody you shouldn’t have or outside of the payment rules,” he said. “Secondly is from a professional perspective, familiarise yourself with the professional guidelines for service delivery.”
He said the HMR and RMMR guidelines have now been brought together into one comprehensive document on medication review, released in April 2020.
“I encourage people to look at that as well because that’s the ‘how’ – the step-by-step guideline around how you do a medication review from a professional practice point of view,” said Dr Jackson.
4. Be aware of privacy considerations.
“Privacy is really important, especially to health consumers,” said Ms Ellis. “I discuss with them that none of the consultation will be recorded without their consent. The patient should not be recording the consultation because you’re not sure what would happen with the recording as well – so just to protect you.”
She also highlighted the importance of using encrypted software for consultations.
PDL told AJP: “The means of telehealth communication must be considered to ensure it is undertaken in a secure and private manner to minimise the risk of a breach of privacy or confidentiality.”
They reminded pharmacists to review the security standards of any platform and preferably use secure platforms utilising high levels of protection such as encryption and invitation-only formats where control of access is visible and suitably managed.
5. Check your indemnity insurance covers telehealth consultations.
Ms Ellis reminds pharmacists that it’s important to check your professional indemnity insurance covers telehealth, as there is potential for some providers not to cover these forms of consultation.
“The take–home message is to double check,” said Associate Professor Freeman. “If you’re going to get that advice, please get it in writing … in the event that you might need to draw upon that.”
PDL informed AJP that its Non-Proprietor Pharmacists Liabilities Insurance Master Policy provides cover for HMRs, RMMRs, MedsCheck and Diabetes MedsCheck.
This policy cover extends to include telehealth medication reviews, as defined in the April 2020 Program Rules.
PDL reiterates that program rules and practice standards need to be followed at all times, with particular reference to the criteria to qualify for a telehealth service.
This article is also published in the June 2020 print issue of AJP.