key: cord-0721803-y4pl2sp6 authors: McNamara, Anusha; Zhao, Milly; Lee, Shin‐Yu title: Evaluating the primary care clinical pharmacist visit transition to telehealth during the COVID‐19 pandemic by comparing medication related problems from telehealth visits and in‐person visits date: 2021-06-29 journal: J Am Coll Clin Pharm DOI: 10.1002/jac5.1487 sha: e9d99a0de6fb78de17c574b79bdd78664aa5f673 doc_id: 721803 cord_uid: y4pl2sp6 BACKGROUND: The coronavirus disease 2019 (COVID‐19) pandemic forced healthcare systems to rethink healthcare delivery, and forced primary care pharmacists in our healthcare system to switch all visits that were previously face to face (FTF) to telehealth. METHODS: We conducted a retrospective observational cohort study to examine the association between medication related problems (MRPs) resolved in telehealth vs FTF primary care clinical pharmacist visits. The telehealth visits took place in the context of the COVID‐19 pandemic, which forced health care systems to rethink care delivery. Data was collected for patient visits for 2 weeks in January before the pandemic and 2 weeks in June during the pandemic. RESULTS: There was significantly more average MRPs resolved per patient encounter in FTF visits compared with telehealth visits, particularly in patient encounters that were previously seen by the pharmacist, who were under 65 years old, identified as Black/African American, had chronic kidney disease but not on dialysis, diabetes with end organ damage, and had uncontrolled blood pressure and uncontrolled A1c. CONCLUSION: These results provide a start to establish criteria for which patients should be seen by a clinical pharmacist in person vs over the phone. The coronavirus disease 2019 (COVID-19) pandemic has forced health care systems to rethink care delivery. The Centers for Disease Control and Prevention 1 and Health Resources and Services Administration 2 have established guidance and a list of toolkits for telehealth in order to protect the safety of health care workers and patients. Telehealth has been shown to satisfy the quadruple aim, with evidence in patient satisfaction, 3 outcomes, 4-6 cost, 6, 7 and provider experience. 8 Potential problems with telehealth include limited ability to perform physical assessments or vitals, potential privacy issues, reimbursement, and failures in technical equipment. 9, 10 Many primary care clinical pharmacy practices are inherently set up using telehealth, such as Kaiser, the Veterans Health Administration, and rural health outreach. These systems have provided providers and patients access to adequate technology to conduct video visits. 6 The benefit of pharmacists in telehealth primary care management of chronic disease has been documented in improving hypertension, 11, 12 diabetes, [13] [14] [15] asthma, 16 anticoagulation, 17 human immunodeficiency virus (HIV), and hepatitis C. [18] [19] [20] An American College of Clinical Pharmacy White Paper published in 2018 outlines guidance on implementing comprehensive medication management (CMM) virtually. Telehealth is defined as using technology to deliver health care, health information, or health education at a distance. Telehealth visit formats must take into account maintaining patient safety and privacy, protecting the patientpharmacist relationship, and enhancing communication and coordination. Additionally, the patient and the pharmacists have several technology requirements. 21 There are no studies comparing the number of medication related problems (MRPs) resolved by pharmacist services between telehealth and in-person visits within the same practice, when a pandemic created the need to switch all visits that were previously face to face (FTF) to telehealth. MRPs are well-established measurements for pharmacists' unique impact on patient care within a team-based model. 22 This study evaluates the impact of clinical pharmacist care via in-person and telehealth by comparing the average MRPs resolved during the visits. San Francisco Health Network (SFHN) is the city's only integrated safety net delivery system (federally qualified health center) operating under the city's department of public health (DPH). All DPH staff are considered disaster service workers that can be deployed to essential services in emergency situations such as pandemics and other natural disasters. SFHN consists of ambulatory care clinics, mental health facilities, and two hospitals. The 12 adult primary care clinics treat 90 000 publicly insured or uninsured individuals. Fourteen primary care pharmacists practicing in all of these clinics provide medication management under a collaborative practice agreement that allows them to prescribe medications, order labs, and make referrals. Prior to the pandemic, over 4500 patients were seen each year in FTF visits by the primary care clinical pharmacists. As with other health care professionals, the COVID-19 pandemic has required the clinical pharmacists with SFHN to provide care to patients largely virtually. CMM services are the professional activities needed to meet the standard of care. 22 Patients are seen by the primary care clinical pharmacist, MRPs are identified and resolved, and then scheduled for follow up with the pharmacist for on-going monitoring and medication titration, with the objective of meeting chronic disease patientcentered goals. All patients seen by primary care pharmacists are over the age of 18 and are referred to primary care pharmacist visits generally because they have one or more uncontrolled chronic conditions, are on treatments that require close monitoring, have complicated medication regimens, or have difficulty understanding or taking their medications. 23 This is a retrospective observational cohort study designed to examine the association between MRPs resolved in telehealth vs FTF primary care clinical pharmacist visits. Patient encounters included in our study were those seen by primary care pharmacists within 9 primary care clinics in the San Francisco Health Network over the course of 2 weeks in January 2020 and 2 weeks in June 2020. Only 9 out of the 12 clinics were included in this evaluation because they have the most consistent CMM primary care practices, whereas other clinics may have more specialty or disease-specific practices (anticoagulation, infectious disease, etc.). January 2020 was chosen because it was a pre-pandemic month with fully staffed clinical coverage. June 2020 was selected because it was the first full month that telehealth was fully rolled out network-wide. Visits in January 2020 were all FTF encounters, and visits in June 2020 included both telehealth and FTF encounters. The primary predictor was telehealth or FTF encounter, and the outcome was the average number of MRPs per encounter. MRPs were collected by a researcher outside of our practice through a retrospective manual chart review using the data collection form (see key in Supporting Information). Patient characteristics were collected as well as number and types of MRPs resolved. All telehealth encounters were done as scheduled telephone visits, as access to video technology was not available. Although the determination criteria for telehealth vs in-person visits was not clearly defined because of the abrupt switch to telehealth visits, the general guiding principle was patients would be seen via telehealth if no physical assessment or vitals or labs was absolutely needed. All components of CMM were done virtually including gathering home health data such as home blood sugar and blood pressure (BP) readings, but physical exams and vitals were not able to be done. MRPs were categorized by type 22 (needs additional drug therapy, unnecessary drug therapy, different drug needed, dose too low, adverse drug reaction, drug interaction, dose too high, non-adherence, lab monitoring needed). In order to identify the unique role that clinical pharmacists play in the primary care team, education MRPs were not included. MRPs were all identified by retrospective review of pharmacist chart notes, and only MRPs that were completed in that encounter were entered into the data collection form. For example, a lab ordered in the encounter was included but a consideration for a lab in 3 months was not included. MRPs were collected by encounter as opposed to aggregated per patient because a patient may have been seen FTF or telehealth between the two time periods. This analysis aims to consider the specific encounter. Of note, MRPs are not routinely tracked in current practice, but discussions are in place to implement measures to do so. Additional data points collected include clinic location, follow up vs initial visit, age, gender, ethnicity/race, history of hospitalizations or emergency department (ED) visits in the past year, homelessness, number of medications, presence of high risk medications, 25 A total of 537 encounters were evaluated between January and June (173 as telehealth and 364 as FTF). All of the visits in January were FTF. In June, 172 visits were telehealth and 79 visits were FTF. The subgroup analysis found that a majority of the factors analyzed had more average MRPs for FTF visits. Please see Table 3 for Center for Disease Control and Prevention website Getting Started with Telehealth. U.S. Department of Health and Human Services website Patient perceptions of telehealth primary care video visits Outcomes of a home telehealth intervention for patients with diabetes and hypertension Impact of telehealth on clinical outcomes in patients with heart failure Pharmacists providing care in the outpatient setting through telemedicine models: A narrative review Home telehealth reduces healthcare costs. Telemed e-Health Telemedicine may support flexible work-life balance, survey finds Success factors for telehealth -A case study Board on Health Care Services; Institute of Medicine. The role of telehealth in an evolving health care environment: Workshop summary Effectiveness of home blood pressure monitoring, web communication, and pharmacist care on hypertension control: A randomized controlled trial Effect of home blood pressure telemonitoring and pharmacist management on blood pressure control: A cluster randomized clinical trial Use of home telehealth monitoring with active medication therapy management by clinical pharmacists in veterans with poorly controlled type 2 diabetes mellitus Integrating telehealth technology into a clinical pharmacy telephonic diabetes management program Pharmacistprovided diabetes management and education via a telemonitoring program The effect of telepharmacy counseling on metered-dose inhaler technique among adolescents with asthma in rural Arkansas Implementation and outcomes of a pharmacist-managed clinical video telehealth anticoagulation clinic Improved virologic suppression with HIV subspecialty care in a large prison system using telemedicine: An observational study with historical controls Establishing a telemedicine clinic for HIV patients in a correctional facility Sustained virologic response with peginterferon plus ribavirin in the Illinois prison population infected with hepatitis C virus through telemedicine: A retrospective chart review Providing comprehensive medication management in telehealth Pharmaceutical care practice: The patient centered approach to medication management Primary care provider perceptions of pharmacist services in an urban, safety net health system Validation of a combined comorbidity index Institute of Safe Medication Practices website Patient characteristics associated with choosing a telemedicine visits vs office visit with the same primary care clinicians Addressing equity in telemedicine for chronic disease management during the Covid-19 pandemic. NEJM Catal The authors declare no conflicts of interest. https://orcid.org/0000-0002-9032-7562