the journal of Pharmacy 1
`Technology
`
`EX. 1009
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`i
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`BAXTER INTERNATIONAL INC.
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`i
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`BAXTER INTERNATIONAL INC.
`EX. 1009
`
`

`

`
`
`
`
`the journal of Pharmacy
`Technology
`
`January/February 2004
`
`Volume 20 Number I
`
`Editorial: Natural Family Planning: A Safer Alternative
`Stanley] Lloyd
`
`5
`
`11
`
`14
`
`Effectiveness of an Amiodarone Protocol and Management Clinic in Improving Adherence to
`Amiodarone Monitoring Guidelines
`-
`,
`.
`.
`Maqual R (sraham, Marc1a A Wright, and Harold J Manley
`Panic Attack Associated with Imatinib Mesylate?
`Pankaj Malhotra, Nitin Gupta, and Subhash C Varma
`Hypertension Associated with Citalopram
`Afsin Sagduyu and Vesile Sent-ink
`
`
`taste: timer Hermit Y
`lsliNiiVERSifiw ES: WECFENSKN
`.6 it y
`.t "filtitt
`,, T J
`fl
`mama“ WE Em"? its?)
`
`17 Medications and Breast-Feeding: A Guide for Pharmacists, Pharmacy Technicians, and Other
`Healthcare Professionals—Part I
`
`Frank] Nice, Deborah DeEugenio, Traci A DiMno, Ingrid C Freeny, Marissa B Rovnack, and Joseph S Gromelski
`
`28
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`The North Dakota Telepharmacy Project: Restoring and Retaining Pharmacy Services
`in Rural Communities
`Charles D Peterson and Howard C Anderson Jr
`
`68 Medical Problems: Brief Reviews — Systemic Lupus Erythematosus
`Michael J Katz
`
` 3
`
`
`
`
`
`Test Your Knowledge
`2
`Therapeutic Trends
`41
`47 What’s New
`51
`From the Literature
`._._——_———
`Harvey AK Whitney Jr MSPharm
`Eugene M Sorkin PharmD
`Stanley J Lloyd PharmD
`Jan M Keresztes PharmD
`Publisher and Editor
`Associate Editor and
`Assistant Editor and
`Consulting Editor
`Director of Operations Director of Professional Services
`
`
`52
`55
`57
`
`Pharmacy Focus
`From the States
`Calendar of Events
`
`58
`59
`63
`
`Compounding Formulations
`New Publications
`PharmaCE Test Questions
`
`Acocisrnons AND PROFESSIONAL SERVICES: Timothy E Welty PharmD BCPS, Editor at Large and Director of Continuing Education; Deborah S Hyrne, Publisher’s Assistant;
`LizAnne Sawyer-Kubicki, Author Services Manager; April Salyers, Assistant to the Editor; Maria R Guajardo, Author Services Assistant; EDITORIAL AND PUBLISHING SERVICES:
`Jerome P Rosenthal PhD, Executive Director; Donna I Thordsen, Editorial Coordinator; Stephanie M Lang, Senior Production Editor; AnnElise Makin, Manuscripts
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`TABLE OF CONTENTS is available through F-mail. Log on to our Web site at www.jpharmtechnolrcom or Email us at toc@jpharmtechnoI.com,
`the journal of Pharmacy Technology is abstracted, indexed, and/or listed in the following reference sources: Biological Abstracts, Chemical Abstracts, CIiirA/ert, Cui
`mu/ative Index to Nursing & Allied I Iealth Literature, Excerpta Medica and its database EM BASE, Inpharma, International Pharmaceutical Abstracts, Iowa Drug Infor—
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`thejournal ofPharmacy Technology (ISSN 8755»1225;CodenJPT[[B) is published bimonthly by Harvey Whitney Books Company, 8044 Montgomery Rd, Ste. 415,
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`WWW.JPHARMTECHNOL.COM
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`JANUARY/FEBRUARY 2004 I VOLUME 20 I
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`JPHARM TECHNOL
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`The North Dakota Telepharmacy Project:
`Restoring and Retaining Pharmacy Services
`in Rural Communities
`
`CHARLES D PETERSON AND HOWARD C ANDERSON JR
`
`This material may be protected by Copyright law (Title 17 U.S. Code)
`
`
`
`Objective: To provide a detailed description of the North Dakota Telepharmacy Project including its overall
`purpose, goals, and how it works, and provide valuable information and guidelines for pharmacists and
`rural communities on how to successfully implement a telepharmacy program designed to serve small rural
`communities. that have lost their pharmacy services, are about to lose their pharmacy services, or have had
`no pharmacy services.
`Discussion: Ten rural communities in western, northern, and central frontier counties of North Dakota
`including 4 central pharmacy hub sites serving 6 remote rural telepharmacy spoke sites are described.
`Through use of audio, video, and computer links, North Dakota has developed a successful statewide
`telepharmacy program to restore and retain pharmacy services to rural communities that have lost, are about
`to lose, or have no pharmacy services. North Dakota currently has full—service telepharmacy sites established
`in the communities of Beach, New England, Maddock, Rolette, and New Town. These remote telepharmacy
`sites are served by licensed pharmacists in central pharmacies located in Killdeer, Rugby, and Watford City.
`The distance from the central pharmacy site to the remote telepharmacy site ranges from 31 to 95 miles
`(average ~57). The size of the remote telepharmacies ranges from 1,200 to 2,500 square feet (average ~1,660).
`The remote telepharmacies are staffed by 2—3 personnel (1 pharmacy technician, 1—2 store clerks). The remote
`telepharmacy sites dispense 15—55 prescriptions per day (average ~35). Hours of service of the remote
`telepharmacy sites are generally 9:00 am to 5:00 pm, Monday through Friday. The remote telepharmacy
`communities have populations ranging from 498 to 1,367 people (average ~799). The remote communities
`have a medical clinic staffed 5 days a week by either a physician, physician’s assistant, or nurse practitioner.
`Conclusions: Through use of telepharmacy technology, pharmacy services can be restored and retained in
`remote rural communities satisfying all rules and regulations of the state board of pharmacy using the same
`processes and procedures as traditional pharmacy practice including pharmacist drug utilization review,
`verification before dispensing, and patient counseling. Telepharmacy services produce. the same quality of
`pharmacy services as the traditional mode Of delivery and provide additional value—added features that are
`not found with traditional pharmacy practice.
`] Pharm Technol 2004;20:28—39.
`
`North Dakota, through the support of a federal grant
`from the Office for the Advancement of Telehealth, is
`currently implementing a statewide telepharmacy pro—
`gram in an effort to restore and retain pharmacy services
`in smaller rural communities within the state. The North
`
`telepharmacy services involving 10 rural communities in
`North Dakota since September l, 2002, when the project
`funding initially began. An additional 8 communities are
`being targeted for 2003. The purpose Of this article is to
`describe the North Dakota Telepharmacy Project includ—
`ing its overall goals, purpose, and how it works. In addi-
`tion, this article will provide valuable information and
`guidelines for pharmacists and rural communities on
`how to successfully implement a telepharmacy program
`
`
`Dakota Telepharmacy Project was established through a
`unique partnership of the “ABCS” of North Dakota phar—
`macy (Association, Board, College) working cooperative—
`ly and collaboratively, which has resulted in establishing
`
`CHARLES D PETERSON PharmD, Professor and Dean, College of Pharmacy, North Dakota State. University, Fargo, ND; and HOWARD
`C ANDERSON JR RPh, Executive Director, North Dakota State Board of Pharmacy, Bismarck, ND. Reprints: Charles D Peterson
`PharmD, College of Pharmacy; NDSU, 123 Sudro Hall, Fargo, ND, 58105—5055, fax 701 / 231—7606, Charles.Peterson@ndsu.nodakedu.
`The project described herein was supported by grant number lDlB TM 00051—01 from the Office for the Advancement of Tele—
`health, Health Resources and Services Administration, Department of Health and Human Services.
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`designed to serve small rural communities that have lost
`their pharmacy services, are about to lose their pharmacy
`services, or have had no pharmacy services.
`
`plore new ways to deliver quality pharmacy services to
`remote communities. The state’s solution was telephar—
`macy.
`
`The Problem of Rural Pharmacy Closings
`
`A
`
`One of the biggest challenges facing the profession of
`pharmacy today is closure of rural community pharma—
`cies. Recently, the North Dakota State Board of Phannacy
`reported that 26 rural communities in North Dakota
`have lost their community pharmacies and an additional
`212 communities are considered at risk of losing their
`pharmacies if something is not done soon. Most of these
`smaller rural communities have only one pharmacy and
`one pharmacist who has been serving the public’s health—
`care needs for decades. The pharmacist owners in these
`communities are at the age when they want to retire and
`sell their stores, but they are having great difficulty doing
`so.
`
`Rural communities have always had difficulty recruit-
`ing healthcare professionals. These difficulties are now
`being compounded by a nationwide pharmacist short-
`age. The current pharmacist shortage has driven phar-
`macists’ salaries beyond what rural communities can af-
`ford; thus, the current pharmacists have little or no
`chance of recruiting a replacement and are being forced
`to close flieir stores. For these rural communities, this is a
`
`great loss because, in many of these areas, the pharmacist
`is one of the only healthcare providers. By losing their
`pharmacies, these communities are essentially losing ac—
`cess to health care. Over time, this will have a major nega—
`tive impact on the health and welhiess of rural America.
`
`A
`
`One of the biggest challenges
`
`facing the profession of
`
`pharmacy today is closure of
`
`rural community pharmacies.
`
`V
`
`North Dakota is a rural state with a population of only
`634,110 people. Over 50% (27 of 53) of the counties are
`categorized by the Health Resources and Services Ad-
`ministration as frontier counties (go people per square
`mile). Obviously, with the state being this sparsely popu-
`lated, it presents some unique challenges in access and
`delivery of healthcare services, including pharmacy ser—
`vices, to many remote locations. For this reason, North
`Dakota believed it needed to address this crisis and ex—
`
`The pharmacist is able to
`
`communicate live to the
`
`technician and patient through
`
`computer links at the remote site.
`
`V
`
`North Dakota’s plans to explore telepharmacy as a
`possible solution to this problem was initiated through
`the leadership and support of the North Dakota State
`Board of Pharmacy. Previously, a pharmacy could not
`open or operate without a licensed pharmacist being
`physically present. Pharmacies are allowed to use phar-
`macy technicians to assist in the process of filling pre-
`scriptions as long as they are directly supervised by a li—
`censed pharmacist. North Dakota felt there was no reason
`that this supervision could not occur at a distance using
`modern technology links. They took action on this
`premise, resulting in North Dakota being one of the first
`states to pass administrative rules that allow pharmacies
`to operate in certain remote areas without requiring a
`pharmacist to be present. The North Dakota State Board
`of Pharmacy has established ”Telepharmacy Rules" to
`define guidelines for practitioners on how telepharmacy
`can be safely practiced.1
`
`What Is Telepharmacy?
`
`Telepharmacy uses state—of—the—art technology allow-
`ing a licensed pharmacist at a central location to super-
`vise a phamiacy technician in the dispensing of pharma-
`ceuticals at a remote site through audio and video
`computer links?8 The pharmacist is able to communicate
`live to the technician and patient through computer links
`at the remote site. Using telepharmacy connections, the
`pharmacist can Visually check the technician’s work to
`ensure that the prescriptions have been properly filled
`with the right medication and can counsel patients di-
`rectly to ensure that they understand the proper direc-
`tions for use.
`
`In North Dakota, the telepharmacy sites are full-ser-
`vice pharmacies that have complete drug inventories in-
`cluding over-the-counter and prescription drugs, health
`and beauty aids, as well as other up—front general mer-
`chandise (Figure l). The telepharmacy stores therefore
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`provide the same services as traditional pharmacies in-
`cluding filling prescriptions and providing both drug uti-
`lization review and patient counseling. The telepharma-
`cy sites satisfy all board of pharmacy requirements for
`pharmacy practice in the state. The services provided
`and processes used for filling a prescription at the remote
`sites are the same as traditional pharmacy services except
`that the pharmacist, technician, and patient are not pres—
`ent in the same store.
`
`What Is Happening in Other States
`
`Nebraska has a dispensing model that delegates pre—
`scripu'on processing to non-pharmacist healthcare profes-
`sionals. Washington has a rule allowing remote dispens—
`ing devices. Arizona has approved off—site verification of
`prescriptions, which should make telepharmacy easy to
`implement. Other states, such as Minnesota and Iowa,
`approve telepharmacy requests on a case-by-case basis.
`Texas is conducting a pilot program at Texas Tech Uni-
`versity in implementing telepharmacy services to the
`western portion of the state. Alaska is conducting a
`demonstration project supported through the Depart—
`ment of Health and Human Services to bring medication
`to 2 remote, previously underserved communities through
`the use of drug-dispensing machines.
`North Dakota’s telepharmacy approach is much dif-
`ferent than those used by the other states. Telepharmacy
`has been delivered in other states using a remote vend-
`ing machine model where a limited supply of prepack-
`aged medications is stocked in a vending device. The
`prescriber’s order is entered into the dispensing system
`and verified by the pharmacist; the pharmacist then di—
`rects the release of the medication by the vending device.
`In this model, patient counseling has been generally the
`responsibility of the prescriber. This vending model is of—
`ten used when a pharmacy is serving a medical clinic not
`located in the same building or community.
`
`
`PRESCRIPTIONS
`
`
`
`Figure 1. Remote telepharmacy site in Beach, ND.
`
`How Do I Start a Telepharmacy Program?
`
`LAWS AND RULES
`
`Pharmacy probably has more laws and rules in every
`state than any other area of health care. A careful analysis
`of existing state and federal laws and rules related to op-
`erating a pharmacy is necessary. The state must have
`laws and rules in place for allowing telepharmacy ser-
`vices to operate, and the remote site must be licensed by
`the state board of pharmacy.
`The state board of pharmacy should be the first point
`of contact when considering establishing telepharmacy
`services to ensure that the current rules and regulations
`allow this practice and that any future plans for establish—
`ing telepharmacy services are in full compliance with
`state law. The state board of pharmacy will provide infor-
`mation on the proper process for applying for a telephar-
`macy permit.
`
`LICENSE APPLICATION
`
`The application for a telepharmacy permit must be
`processed by the licensed pharmacist owning the busi—
`nesses of both the central pharmacy and remote telephar-
`macy sites. In addition to the state license, the applicant
`must also Obtain registration numbers from the National
`Council for Prescription Drug Programs (NCPDP) and
`Drug Enforcement Administration (DEA). It is important
`that the licensed pharmacist obtain state board of phar-
`macy, NCPDP, and DEA registration numbers for each
`telepharmacy site that are separate from the central phar-
`macy site registration numbers. The state board of phar-
`macy, NCPDP, and DEA registration numbers for both
`the central pharmacy and remote telepharmacy sites are
`also needed for obtaining reimbursement from third—par—
`ty payers for telepharmacy services. The regulatory ap—
`proval process may vary depending upon each state’s
`rules and regulations, and it may take 2—3 months or
`longer for approval of the telepharmacy operating per-
`mits.
`
`THIRD-PARTY REIMBURSEMENT
`
`What makes this telepharmacy model unique is that,
`while other telehealth/ telemedicine programs are look-
`ing for ways to obtain reimbursement from third—party
`payers for services offered, this approach is ”business as
`usual:” featuring the same full-service pharmacy opera-
`tion as traditional pharmacies; supervised by a licensed
`pharmacist; approved and licensed by the state board of
`pharmacy, NCPDP, and DEA; and satisfying all state board
`of pharmacy requirements. In North Dakota, the remote
`telepharmacy sites are currently receiving reimburse-
`ment by third-party payers. Once the registration permits
`are obtained, the site is eligible for third—party reimburse—
`ment claims.
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`
`ASSESS THE NEED
`
`Generally, rural communities being considered for
`telepharmacy services should be assessed for the need of
`such services. The following questions need to be ad—
`dressed: Are pharmacy (and pharmacist) services cur-
`rently available in the community? Are there healthcare
`personnel in the community authorized to prescribe
`medications (ie, medical clinic or other health facility) to
`support a telepharmacy operation? Is there a convenient
`cost-effective location in which to establish telepharmacy
`services? Is there support for establishing telepharmacy
`services from the community, medical personnel, state
`board of pharmacy, local government and businesses, pa—
`tients, telecommunications company, and pharmacists? Is
`there a licensed pharmacist willing to establish and deliv-
`er telepharmacy services to the targeted rural communi—
`ty? Has a business plan been developed to assess via pro-
`jected expenses versus revenue whether the proposed
`telepharmacy services can be profitable and sustainable?
`Are there sufficient resources available from private, lo—
`cal, and state support to establish such services?
`Access to quality pharmacy services is very important
`to the proper use of medications and to the reduction of
`medication errors As drugs become increasingly potent
`and capable of curing and mitigating disease, pharmacy
`(and involvement of the pharmacist) becomes more im-
`portant in ensuring rational, safe, and cost—effective use
`of medications.
`
`Rural communities across the country are struggling
`with declining and aging populations, shortages of health
`professionals, declining access to health care, and loss of
`local businesses. In many cases, mail order is the only
`pharmacy service available to the public unless they are
`willing to travel great distances to obtain their prescrip—
`tion medications. Often the poor and elderly in these
`communities are the least able to use mail—order pharma-
`cy services. Patients obtaining their prescriptions in this
`manner who have questions regarding their drugs find
`no pharmacist to ask. Loss of access to local services
`sometimes necessitates that people move to other com-
`munities to be close to services. This upsets both their
`family and community life and causes negative econom-
`ic consequences for the community they must leave. The
`resulting out-migration is one of the most serious prob—
`lems affecting many rural areas. Rural health clinics have
`done an excellent job of providing basic primary care to
`patients living in rural areas, but often the pharmacy ser-
`vices have not followed.
`
`BENEFITS OF TELEPHARMACY SERVICES
`
`Telepharmacy is a unique and innovative way to de—
`liver a full—service pharmacy operation that incorporates
`all the safe practices offered by the traditional mode of
`delivery. Potential benefits to the rural communities in—
`clude restoring access to health care, pharmacy services,
`
`NORTH DAKOTA TELEPHARMACY Pkoircr
`
`and pharmacists; improving economic development by
`building new businesses and adding new jobs; improv-
`ing the chances of recruiting or retaining pharmacists in
`rural communities; and providing new clinical training
`sites for pharmacy students for teaching them how to de—
`liver pharmacy services to rural communities in a unique
`way. As North Dakota establishes telepharmacy sites
`across the state, the College of Pharmacy at North Dako-
`ta State University plans to use these locations as experi-
`ential training sites for pharmacy students. This will ex—
`pose the students to innovative practices and the latest
`advances in pharmacy technology. This will help North
`Dakota in its recruitment efforts to attract and retain
`
`more pharmacy graduates to stay in North Dakota.
`North Dakota State University College of Pharmacy
`has installed the telepharmacy technology in its new
`state-of—the-art Concept Pharmacy instructional laborato-
`ry on campus so that students in the professional pro-
`gram can become involved in the project. Students can
`connect to both the central pharmacy and telepharmacy
`sites from the university to provide drug and disease
`state information to the pharmacist and assist in patient
`counseling. Students are licensed interns, and a Business
`Associate Agreement will be in place to satisfy Health In—
`surance Portability and Accountability Act (HIPAA) re-
`quirements.
`Developing these types of innovative practices will
`also make life better for the rural pharmacists who are
`struggling to succeed by giving them an opportunity to
`expand the professional and financial sides of their busi-
`ness. Adding a satellite to their central pharmacy opera-
`tion will potentially help make their business more vi—
`able, profitable, and sustainable.
`
`IMPORTANCE OF PHARMACIST IN VOL VEMENT
`
`The North Dakota model of providing telepharmacy
`services is different from others being proposed in that it
`includes and retains the active role of the pharmacist as
`the primary healthcare provider in the delivery of phar-
`macy services. This is done to achieve the highest quality
`for delivering pharmacy services to rural communities
`and for the protection, safety, and welfare of the public
`related to ensuring the proper use of pharmaceuticals.
`This is a value-added quality assurance feature that is of-
`ten lacking in other telepharmacy models that exclude
`pharmacist involvement, resulting in no formal drug uti-
`lization review or patient counseling. Pharmacist involve-
`ment is essential. Exclusion of the pharmacist could po—
`tentially increase risks to the patient leading to a higher
`incidence of medication errors, adverse effects, excessive
`
`drug costs, and uncontrolled disease. Examples of mod-
`els that often exclude pharmacists, particularly in provid-
`ing patient counseling, include Internet pharmacies,
`mail—order pharmacies, models that delegate the phar—
`macist’s duties to another health professional, and vend-
`ing machine models.
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`Types of Telepharmacy Services
`
`TRADITIONAL FULL-SERVICE PHARMACY
`
`Most rural communities want a full—service pharmacy
`that supplies a complete line of health—related goods and
`services. Full—service telepharmacies provide a complete
`inventory of prescription and nonprescription drugs sim-
`ilar to that of traditional pharmacies including other up—
`front merchandise. Most full-service pharmacies in rural
`areas have an inventory of approximately 2300 prescrip-
`tion drugs. Prescriptions are prepared on location, with
`the patients picking up their medications at the same
`store they were prepared. Pharmacists provide drug uti-
`lization review and patient counseling at the point of
`sale.
`
`North Dakota currently has full-service telepharmacy
`sites in the communities of Beach and New England,
`Maddock and Rolette, and New Town (Figure 2). These
`sites are served by central pharmacies located in Killdeer,
`Rugby, and Watford City, respectively. The distance from
`the central pharmacy site to the telepharmacy site ranges
`from 31 to 95 miles (average ~57). The size of the remote
`telepharmacies ranges from 1,200 to 2,500 square feet (av—
`erage ~l,660). They are staffed by 2—3 personnel (1 tech-
`nician, 1—2 store clerks). The remote sites dispense 15—55
`prescriptions per day (average ~35). Hours of service are
`generally 9:00 am to 5:00 pm, Monday through Friday.
`The remote telepharmacy communities have populations
`ranging from 498 to 1,367 people (average ~799). Medical
`clinics in the communities are staffed 5 days a week by
`either a physician, physician’s assistant, or nurse practi—
`tioner.
`
`REMOTE CONSULTATION SITES
`
`In remote consultation sites, there is no prescription
`drug inventory and no requirement for a registered phar—
`
`
`o Rolelte
`
` *Rugby
`
`0 New Town
`0 Maddock
`
`
`*Watford City
`
`1%
`
`*Bismarck
`
`0 New England
`
`
`
`Figure 2. 2002 North Dakota telepharmacy sites. Central sites: Killdeer,
`Walford City, Rugby, and Forman. Remote sites: Beach, New England,
`New Town, Maddock, Rolette, and Gwinner.
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`JPHARM TECHNOL I VOLUME 20 I
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`032
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`macy technician. Prescriptions are prepared at the central
`pharmacy and delivered to the remote site that is a short
`distance away twice daily by a courier, and patient coun-
`seling is then provided by the pharmacist via an audio
`and video computer link. This model is used by a phar—
`macist who does not wish to manage 2 prescription drug
`inventories at both sites.
`
`North Dakota currently has one remote consultation
`site established in Gwinner that is being served by a cen-
`tral pharmacy located in Forman. The consultation site is
`a general merchandise store of approximately 575 square
`feet. A second consultation site is being planned and will
`be located in Lidgerwood, served via a central pharmacy
`in Hankinson.
`
`HOSPITAL/INSTITUTIONAL SETTING
`
`In these locations, a registered pharmacy technician
`prepares the medication for final dispensing to the floor
`or swing bed patient. The medication is checked by the
`pharmacist via the telepharmacy links and is dispensed
`to the floor or patient.
`
`Automated Dispensing Machines
`
`Some rural health clinics may have need for an auto-
`mated dispensing machine. The prescriber’s order is pro-
`vided to the pharmacist at a central pharmacy site elec-
`tronically or by fax. The pharmacist checks the patient
`profile, performs drug utilization review, and instructs
`the dispensing machine to release the medication. The
`patient is then counseled by the pharmacist via the audio
`and video computer links. Automated dispensing ma—
`chines have limited drug inventory (generally 20 of the
`most frequently used medications) and are usually de—
`signed to provide an urgent dose or the first dose of ther-
`apy (eg, antibiotics). Patients still require the services of a
`traditional pharmacy to obtain their maintenance doses
`to complete their treatment course. Telepharmacy Solu-
`tions, lnc., is one vendor that supplies automated dis-
`pensing units.
`
`Important Elements in Creating a Successful
`Program
`
`DEVELOP COMMUNITY PARTNERS
`
`Several community partners are needed to effectively
`implement telepharmacy services in rural areas. In select—
`ing prospective communities, it is important to consider
`the following issues: community need, interest, and in—
`vestment in the project; availability of a pharmacist at a
`central pharmacy site in a nearby community willing to
`deliver telepharmacy services; and support from the
`state board of pharmacy. Priority should be given to rural
`communities that have no pharmacy services or are
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`032
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`

`

`NORTH DAKOTA lELEPHARMACY PROJECT
`
`Fixtures
`
`Drug store fixtures are available through most drug
`wholesalers or through companies specializing in these
`areas. Prices can be bid or previous projects can be con-
`sulted to determine reasonable prices. Used fixtures can
`sometimes be obtained through the sale or renovation of
`a local pharmacy store. Drug fixtures for an average—size
`pharmacy may cost $20,000 or more.
`
`Inventory
`
`Up-front store merchandise can be stocked and order-
`ing done as demand is assessed. Because prescription
`drug inventory can be expensive, purchases should ini-
`tially be conservative and based on expected demand.
`Generally, for a rural community pharmacy, prescription
`drug inventory may cost between $60,000 and $80,000
`depending on the brands that are stocked. Factors such
`as frequent deliveries from the wholesaler, the ability to
`move merchandise between the central and remote sites,
`
`and limiting inventory/ potential losses can help control
`costs. The pharmacist at the central pharmacy, in consul—
`tation with area drug wholesalers, will be able to assist
`with initial setup and management of the telepharmacy
`store merchandise and prescription drug inventory.
`
`Telecommunications
`
`Telepharmacy technology is new, so prices are gener-
`ally high at first and then decline as demand increases.
`Telephone companies in rural areas seem the most reluc-
`tant to lower transmission costs. Telepharmacy transmis—
`sion costs are often higher when the central pharmacy
`and the remote site are located in areas not being served
`by the same telephone company. The digital subscriber
`lines (DSLs) may cost approximately $250 per month
`(512-K bandwidth); T—l lines are considerably more ex-
`pensive and may cost up to $800 per month (768-K band—
`width). Prices will vary depending on location, competi—
`tion, demand, and vendor.
`
`
`
`about to lose their pharmacy services. This will maximize
`the benefit of telepharmacy services to these areas and
`minimize potential conflict in local pharmacies compet-
`ing for business.
`
`A
`
`Some rural health clinics may
`
`have need for an automated
`
`dispensing machine.
`
`V
`
`In determining the level of support for telepharmacy
`services and defining the scope of services needed in the
`targeted community, feedback from key stake holders or
`project partners may be beneficial (Table 1).
`
`SECUREA PHYSICAL LOCATION
`
`State board of pharmacy rules and regulations per—
`taining to building, security, sanitary standards, and pri-
`vate consultation rooms must be considered in plans for
`physical location of the pharmacy. Many pharmacy whole-
`salers have departments to assist in pharmacy layout and
`designs. The area wholesaler generally keeps up with the
`current rules and requirements of the state board of phar-
`macy and can be an excellent resource for developing
`construction plans for the faci