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ASHP Guidelines on Remote Medication Order Processing

Purpose

Because of the complexity of the care that pharmacists provide patients, the American Society of Health-System Pharmacists (ASHP) advocates that patients have 24-hour access to the pharmacist responsible for their care and that the pharmacist be physically accessible to the patient when feasible. ASHP recognizes that such access is not always possible and encourages the development of remotely delivered pharmacist care as a supplement to onsite care.

Medication order review is one aspect of pharmacist patient care. All health-system pharmacies have an obligation to provide a review of medication orders that ensures safe medication use.¹ When onsite pharmacist review is not available, health systems may determine that remote pharmacist review of medication orders is a suitable alternative. The purpose of these guidelines is to describe the policies and procedures that must be in place to safely employ remote medication order processing (RMOP). Health-system policies and procedures regarding RMOP should address quality assurance and safety; access to drug information and hospital policy resources; training and orientation; minimum technical standards and specifications; confidentiality, privacy, and security; regulatory and accreditation standards; and communication and problem resolution. These guidelines also describe some general considerations for RMOP implementation, and Appendix A provides a checklist for assessing implementation readiness. Appendix B contains an outline of a model agreement for RMOP. A glossary of terms used in these guidelines appears in Appendix C.

Because of the rapid pace of change, differences in practice settings and RMOP models, and the complexities of health care organizational arrangements, aspects of these guidelines may not be applicable to all settings. These guidelines are not intended to describe best practices for the operational relationships between satellite and central pharmacies in acute care settings. Readers should also note that these guidelines do not attempt to address all aspects of remotely delivered pharmacist care and should interpret them as limited to the subject of RMOP. These guidelines address remote order verification only when medication order fulfillment occurs through automated medication storage and distribution devices. Remote end verification of the dispensed drug product (e.g., visual approval of the drug product by video camera or other means) is beyond the scope of these guidelines. Health-system administrators and pharmacy managers should therefore exercise their professional judgment in assessing and adapting these guidelines to meet the needs of their particular settings and to comply with the health care organization’s policies and procedures.

Models of RMOP Services

The technologies used in RMOP are relatively new and rapidly changing, so different methods for RMOP have evolved, and further evolution should be encouraged. At least two models of RMOP are currently in use: contracted services and supplemental workload balancing, which includes network workload balancing and on-call assistance. Each of these models has unique characteristics that must be considered in planning for its use.

Contracted Services. In this model, a hospital pharmacy that is not continuously open contracts with a larger hospital or a service to provide RMOP when its pharmacy is closed. This model is typically applied when a hospital without 24-hour pharmacy services has sufficient automated dispensing cabinet capacity that RMOP allows nursing staff to keep functioning without having a pharmacist present,² although some institutions have developed models for remote verification by pharmacists of dispensing performed by pharmacy technicians at the client site.³

Supplemental Workload Balancing. Similar to the model described above, in this case a health system with a number of hospitals relies on the ones that have a 24-hour pharmacy department or on a service to provide RMOP for hospitals whose pharmacies are closed or that experience unanticipated peaks in order processing workload. For example, in an on-call model, a staff pharmacist from the client site or a contracted service is placed on call to help with managing workload. This pharmacist works remotely (sometimes from a home office, where allowed by state regulation) to help the client’s pharmacy department manage unanticipated peaks in order processing workload (often on the second or third shift). In this model, the remote pharmacist is responsible for medication order entry and/or review, and medication order fulfillment occurs through the client-site pharmacy.

Quality Assurance and Safety

Medication-use management and safety in the RMOP environment require special efforts in the coordination of quality-assurance, quality-improvement, and patient safety practices between the client site and the remote site. Differences in local practice standards and organizational cultures, combined with unique human factors issues, have the potential to magnify the risk of errors. Quality, safety, and risk management strategies should be jointly examined and agreed on and should address the procedures and communication pathways unique to RMOP systems. These include critical workflow steps and handoffs involved in medication ordering, review, and verification; communication among prescriber, pharmacist, and nurse; and assessing the patient’s response to drug therapy and achieving desired therapeutic outcomes.

Review of the Patient’s Profile. The remote pharmacist must be able to review the patient’s profile for

• Medication history and medication reconciliation reports,
  
• Diagnosis,
  
• Allergies and prior adverse drug reactions,
  
• Height, weight, age (measured versus estimated), and sex,
  
• Pregnancy status for women of childbearing potential,
  
• Duplications of drug therapies,
  
• Potential drug interactions,
  
• Pertinent laboratory data, and
  
• Other information as needed.

Clarification of Medication Orders. The remote pharmacist must have a process by which he or she can clarify the medication order with the prescriber. The remote pharmacist must alert other health care providers caring for the patient (e.g., the client nursing and pharmacy staff) of the need for additional review and clarification. There must be a mechanism for the remote pharmacist to readily communicate by phone or leave a note in the patient profile for other health care providers, including the client site pharmacy staff, to clarify the order or otherwise respond within an appropriate period of time. The remote pharmacy must have a mechanism for timely follow-up on medication orders that are pending clarification.

Quality-Assurance and Medication Error Reporting Systems. The remote pharmacy must participate in the client site’s quality-assurance and medication error reporting systems. These systems should include the collection and reporting of medication errors and process variances as described below:

• The medication error reporting system should include potential adverse events that reach the patient (with or without harm) and potential adverse events that are intercepted before reaching the patient.
  
• Medication error reports related to RMOP procedures and communications should be tracked by outcome, type, cause, severity, preventability, and source.
  
• Corrective action plans should be directed toward the system failures that contributed to or caused the error, variance, or adverse event.
  
• Policies and procedures should ensure that quality-assurance data and medication error reports are jointly reviewed in a timely manner by pharmacy leadership and safety officers (if applicable) at both the client and remote sites and that relevant information is shared with relevant frontline practitioners at both sites, including remote pharmacists and client-site nursing and pharmacy staff.

The quality-assurance program should include indicators that measure important aspects of RMOP, including measures of (1) timeliness (e.g., elapsed time to receive and verify an order), (2) system performance (e.g., percentage of time information technology systems are not available for RMOP), (3) compliance with contractual requirements, (4) employee satisfaction at the client and remote sites, and (5) unanticipated problems (e.g., breaks in privacy standards, communication and handoff problems).

Handoff Communication. The remote site should have a documented process for handoff communication that meets the requirements of Joint Commission National Patient Safety Goals.⁴

Access to Drug Information and Hospital Policy Resources

Drug Information Resources. Drug information resources are essential tools for health care organizations. Drug information resources, specific to the needs and scope of patients served, are essential for practicing evidence-based medicine in a safe and efficient manner. In health care systems that use RMOP procedures, each institution needs point-of-care access to internal and external drug information systems. Internal drug information resources include the client’s formulary, laboratory reference values, newsletters, and drug-use guidelines based on local standards. External drug information resources include commercially available electronic and print media that organize information into full-text and bibliographic retrieval systems.

Drug information resources available in the remote pharmacy should at a minimum meet the state board of pharmacy requirements for both the client and remote pharmacy sites and include the current edition of a drug information reference (hard copy or electronic). Other reference material (hard copy or electronic media) should be available, depending on the scope of care being provided. Recommended clinical and drug information reference materials available in the remote pharmacy include

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