One of the greatest challenges facing the profession of pharmacy today is delivery of pharmacy services to small rural hospitals.  Of North Dakota's 47 general acute care hospitals, 39 are small rural hospitals.  Thirty-one of these facilities are critical access hospitals with a maximum of 25 beds.  Most of the state's rural hospitals are staffed by one full-time pharmacist providing services for 8 hours a day, 5 days a week, or they contract for pharmacy services with a local community pharmacist.  National pharmacist shortages have made it difficult for small rural hospitals to find pharmacist relief help in covering routine hours, evenings, nights, weekends, vacations, sick time, and professional meetings.  Furthermore, new and anticipated requirements on hospitals, instituted by national accreditation groups and federal agencies, are targeting efforts to improve patient safety and asking hospitals to provide 24-hour pharmacist review of all medication orders, which also present challenges to small rural hospitals.

The North Dakota Telepharmacy Project was established in 2002 for the purpose of restoring, retaining, or establishing pharmacy services in medically underserved rural communities through the use of telepharmacy technology.   The project is currently funded by a congressionally mandated grant through the Office for the Advancement of Telehealth (OAT) in the U.S. Department of Health and Human Services.  Initially, the focus of the project was rural retail pharmacies, which had seen numerous closings due to pharmacist retirements.  With the success of telepharmacy in a community pharmacy setting, hospitals began requesting information regarding whether or not telepharmacy could work in a hospital setting to address the challenges of pharmacist staffing and pharmacy services.  As a result, the decision was made to explore telepharmacy as a solution for small rural hospitals in addressing the challenges of delivering pharmacy services.  In 2003, the North Dakota Board of Pharmacy established administrative rules for telepharmacy in hospitals, opening the door to telepharmacy for rural hospitals in North Dakota.   The following year the North Dakota Telepharmacy Project added its first hospital telepharmacy sites (3 rural hospitals initiated a telepharmacy program).   In September 1, 2006, a total of 13 rural hospitals were participating in the project; beginning September 2008, this number will expand to 23 rural hospitals exploring telepharmacy solutions for their pharmacist staffing and pharmacy services.

With additional OAT funding granted in 2008, the North Dakota Telepharmacy Project is further expanding hospital telepharmacy.  The goal of this initiative is to establish a pharmacist-staffed central order entry (COE) site in Fargo, which will ultimately deliver 24-hour pharmacy services via telepharmacy technology to any rural hospital in the state choosing to contract for these services.  Project funding will also be used to install and implement telepharmacy technology at a pilot group of nine small rural hospitals (remote telepharmacy sites).  In addition to the North Dakota Board of Pharmacy and the North Dakota Pharmacists Association, the project is partnering with Catholic Health Initiatives (CHI) to expand hospital telepharmacy.  CHI is a national nonprofit health system based in Denver, which includes 70 hospitals, including 19 with the critical access designation; 43 long-term care facilities, assisted-living facilities and residential units; and two community-based health organizations.  

The COE site will provide supervisory pharmacist oversight to remote rural hospital pharmacies via telepharmacy technology, including audio, video, and computer links and scanned electronic images.  Using this telepharmacy technology, a pharmacist supervises a pharmacy technician at remote telepharmacy site in processing medication orders for patients.  The pharmacy technician obtains the medication order from the nursing station or physician, enters the order into the computer, prepares the product for dispensing by the pharmacist (product selection, labeling, billing), and then the pharmacist performs a final check of the product and releases the medication to the nursing station and provides professional consultation to the patient, nurse, or physician, if needed.  Through use of a wireless telepharmacy cart, access to a pharmacist and pharmacy services can be potentially available to any rural hospital 24 hours a day, 7 days per week, at any location within the hospital, ER, nursing station, patient bedside, pharmacy. Real time pharmacy oversight to the medication order entry and use process in hospitalized patients is recognized as a key component of high quality medication safety practices, and there is an opportunity in North Dakota to extend this level of coverage to all critical access hospitals that are willing to participate. The project also provides quality assurance monitoring to ensure optimum patient safety through medication error tracking and other quality assurance measures.