ABSTRACT: Telehealth has gained significant traction in recent years, enabling healthcare providers, including pharmacists, to enhance continuity of care. Findings indicate that technology-based interventions and monitoring can improve outcomes such as time within the therapeutic range and adherence while reducing adverse events such as thromboembolic incidents or bleeding. Emerging technologies, including artificial intelligence, personal coagulometers, and chatbots, further support improved patient adherence and clinical outcomes. These innovations highlight the potential for optimizing the management of complex conditions and therapies. As digital health evolves, telehealth is poised to become an indispensable tool, advancing the role of pharmacists in positively influencing patient outcomes and driving innovations in chronic disease management.
In the past several years, telehealth services have grown significantly, partly due to the adaptation of telehealth practices during and after the COVID-19 pandemic. Telehealth enables medical professionals, including pharmacists, to improve access to patients and preserve continuity of care while reducing in-person visits. Morever, it is a valuable tool that allows the profession of pharmacy to extend its reach to patients.
Telehealth Terminology
There are variations within the terminology used to describe telehealth; many refer to telehealth, telemedicine, and/or telepharmacy interchangeably. The American Society of Health-System Pharmacists considers telehealth to be the overarching term for the remote delivery of patient care services, as the terms “telemedicine” and “telepharmacy” are less broad.1
The Center for Connected Health Policy (CCHP)is a nonprofit, nonpartisan organization that works to improve outcomes, care delivery, and cost effectiveness of telehealth. It was federally designated as a National Telehealth Policy Resource Center in 2012. Per the CCHP, there is no single definition for telehealth, and federal and state agencies may differ in their definitions. These distinctions were further complicated by the COVID-19 pandemic, when many jurisdictions temporarily adopted broader definitions of the term “telehealth” that superseded existing laws and policies.2
The CCHP states that telehealth encompasses four distinct applications, commonly known as live video, store-and-forward, remote patient monitoring (RPM), and mobile health.2
Live Video
Live video, also referred to as “real-time” video, is defined as “live, two-way interaction between a person and a provider using audiovisual telecommunications technology.” It is historically the most common application of telehealth care and is an effective healthcare and consultation tool. Some areas of benefit include remote consultation with specialists who are not available locally, the use of live language translators who provide video interpretation services to multiple locations, and improved healthcare access for several groups of patients, including those with limited mobility, those in areas with limited access to healthcare, and patients who are reluctant to keep in-person appointments.
Store-and-Forward
Store-and-forward is defined as the “electronic transmission of medical information, such as digital images, documents, and prerecorded videos, to a practitioner, usually a specialist, who uses the information to evaluate the case or render a service outside of a real-time or live interaction.” This communication often takes place among medical professionals to aid in consultations when live video or face-to-face contact is not necessary; the efficiency of the healthcare services is increased because these consultations do not require all parties to be available simultaneously, and therefore, the need to coordinate schedules is removed.
Additional benefits include the provision of specialty care for patients without the need to travel or have an additional visit outside of their primary care provider, decreased wait time for specialists, the potential to overcome language and cultural barriers, and ease of access for specialists who can review cases when it is convenient for them. Store-and-forward can also be used for electronic consultations (eConsults), which allow a primary care physician and a specialist to securely share health information and discuss patient care.
Remote Patient Monitoring
RPM is defined as “personal health and medical data collection from an individual in one location, which is transmitted via electronic communication technologies to a provider in a different location for use in care and related support.” Data such as vital signs, weight, blood pressure, heart rate, and blood oxygen levels can be collected by monitoring programs and transmitted to health professionals. This allows a provider to track healthcare data for a patient who is released from the inpatient setting to home or a care facility, which can help reduce readmission rates. RPM may help improve quality of life and lower costs by helping to keep people healthy, allowing older and disabled individuals to remain at home longer rather than moving into facilities, preventing hospitalizations and readmissions, and decreasing lengths of stay.
Mobile Health
Mobile health is defined as “healthcare and public health practice and education supported by mobile communication devices such as cell phones, tablet computers, and PDAs.” Examples of mobile health include targeted text messages that promote healthy behaviors, wide-scale alerts about disease outbreaks, and dedicated application software (apps) which are downloaded onto devices.2
COVID-19 Impact on Telemedicine Use
Telemedicine use in the United States was steadily increasing before March 2020, but logistics were complex, and its absolute integration remained low. Barriers to integration included inconsistent reimbursement for services, restrictions on the location of participating parties, and regulations that necessitated investments in secure telecommunication technology.3 Patients who accessed telemedicine before March 2020 had overall positive impressions, noting the benefits of improved outcomes, decreased travel time, preference over face-to-face visits, ease of use, and lower cost. Patients expressed some concerns about telemedicine, however, including data security.3
Clinicians had more variable opinions, with those using telehealth citing concerns about visit quality and liability potential. Those who were not yet using telehealth expressed barriers to implement telehealth including lack of training, equipment costs, liability concerns, and inadequate reimbursement.3
Once the COVID-19 pandemic was recognized as a public health emergency in the U.S. in March 2020, many prior barriers to telemedicine were upended. In early March 2020, Congress made major alterations to Medicare restrictions. It changed rules regarding telemedicine origination locations, reimbursement, and platforms that could be used, which paved the way for similar relaxations of interstate practice and privacy regulations and led to dramatic improvements in reimbursement rates. State and private payors followed Medicare’s lead to allow for continued healthcare access and solvency for practices.3
A systematic review by Garfan et al discussed obstacles to telehealth that emerged during the COVID-19 pandemic, including technology challenges, lack of clear guidelines, and concerns about data privacy and security. The literature revealed motivations found during the pandemic to improve healthcare and telehealth, however, including to improve safety, conserve resources, improve health access, provide guidance, and evaluate telehealth’s effectiveness.4
Oral Anticoagulation and Telehealth
Medications used for oral anticoagulation (OAC) are prescribed to millions worldwide, and they are the cornerstone of treatment for several diseases, the most common of which are atrial fibrillation and venous thromboembolism.5
Warfarin is a member of the vitamin K antagonist (VKA) medication class, which has been used in humans for over 60 years.6 Warfarin dose adjustment is guided by serial testing for the international normalized ratio (INR). The quality of OAC therapy is often expressed as time in therapeutic range (TTR); TTR correlates with the incidence of bleeding and thromboembolic events.
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