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The 139-bed hospital's in-house pharmacy was only open 14 hours a day. During that time an on-staff pharmacist would review all new prescription orders. Drug orders placed during off hours, however, would be reviewed and filled by nurses, who are well-versed in potential adverse drug interactions but lack the in-depth knowledge of pharmacists, says Richard Stomackin, director of the inpatient pharmacy at Lewistown.

So when the hospital deployed the electronic medication record, Stomackin also wanted to have 24-hour pharmacist review of drug orders. His first inclination was to hire two new pharmacists, but considering each position would require a six-figure salary plus benefits, finding two new staff members wasn't an attractive financial option. He also thought it would be difficult to attract qualified candidates to Lewistown's central Pennsylvania location.

Stomackin found another option in Rxe-source, a telepharmacy service from Cardinal Health, Dublin, Ohio. The telepharmacy enables a hospital to supplement its onsite pharmacy services by connecting to telepharmacists working at remote locations.

The telepharmacists receive faxed or phone drug orders, then evaluate a patient's medication profile, review necessary lab values, enter the medication into the patient profile, check for possible interactions and authorize orders for administration.

Lewistown began using Rxe-source in September 2005. The hospital's on-site pharmacy is staffed from 7 a.m. to 9 p.m. weekdays and 8 a.m. to 6 p.m. on weekends. When the on-site pharmacists leave, all calls and faxes are routed to the telepharmacy in Ohio.

Lewistown nurses typically fax the orders to the telepharmacy. The telepharmacists then connect via a secure Internet connection to Lewistown's medication administration record to check the patient's previous medications and medical conditions. The telepharmacist reviews the current order and calls a nurse or physician at Lewistown if any revisions are necessary.

After the telepharmacist approves the order, either via fax or phone, the nurse then retrieves the medication from cabinets that are stocked during the day with drugs the caregivers will need during the night shifts. If the medication is not available in a cart and needs to be administered immediately, a staff pharmacist is asked to come to the facility and fill the order.

Cardinal Health charges Lewistown a monthly fee based on the medication order volume during Rxe-source's hours of coverage. Lewistown declined to provide details about costs.

Initial setup of the telepharmacy was challenging, Stomackin says. Staff pharmacists had to fill out a 26-page survey that asked questions about the hospitals policies and procedures, as well as what drug substitutions the hospital allows and the facility's potential order volume. Lewistown also had to standardize order sets so the telepharmacist could follow standard protocols.

In addition, Lewistown nurses have had some run-ins with the telepharmacists, Stomackin says. "Nurses complain that the telepharmacy guys are stricter than we are," he says. "If you tell the telepharmacy this is hospital policy they adhere to it. This is different when we're here during the day when we have some flexibility to work things out."

Stomackin adds that because the pharmacists know the physicians and the personalities involved it's easier for them to make exceptions to hospital policy, whereas telepharmacists will stick to the rules.

But Stomackin believes the telepharmacy service has helped increase patient safety at Lewistown. "Any time you have an additional check you improve patient safety," he says. "It's one more safeguard to make sure that the patient is getting the right drug."

Another benefit of the service: by enabling the hospital to have 24-hour pharmacy coverage, it helped Lewistown improve its score during a recent review by the Joint Commission on Accreditation of Healthcare Organizations, Stomackin adds.

Pharmacists increasingly are in demand, and it's likely the need for telepharmacy services will increase, says Paul Johnston, senior consultant at Healthia Consulting, a Minneapolis-based health care I.T. consulting firm. The U.S. Department of Labor is predicting a shortfall of 157,000 pharmacists by 2020.

Rural areas that have chronic problems hiring full-time pharmacists are turning to telepharmacies to improve safety around the medication administration process, Johnston says.

"In an inpatient setting it's critical to have a pharmacist involved," he says. "The telepharmacist can check for harmful interaction, review current medications and perform dosage correction."