key: cord-0916091-h70od8mn authors: Park, Lindsay; Kim, Ju Hee; Waldman, Georgina; Marks, Christin Rogers; Clark, Jacqueline E. title: Impact analysis of virtual ambulatory transplant pharmacists during COVID‐19 date: 2021-07-04 journal: J Am Coll Clin Pharm DOI: 10.1002/jac5.1488 sha: ffe380c4e299ae1c62c0b68f4c5d77ff3e7860a2 doc_id: 916091 cord_uid: h70od8mn INTRODUCTION: During the coronavirus disease 2019 (COVID‐19) pandemic, transplant centers were challenged to meet the demand for new telemedicine strategies. The ability of lung transplant providers (LTP) to conduct face‐to‐face clinic visits for high‐risk immunocompromised patients, such as lung transplant recipients (LTR), was limited. Through the implementation of comprehensive medication management visits, pharmacists were able to assist LTP in the transition to telemedicine. METHODS: A retrospective chart review of telephone encounters from cardiothoracic (CT) transplant pharmacists at our center from March to September 2020 was completed. LTR scheduled for clinic visits with LTP were called prior to the visit by CT transplant pharmacists who conducted medication list reviews, adherence assessments, and medication access assistance. Clinical recommendations were communicated directly to the LTP and documented in patient electronic medical records. The primary outcome was the number of pharmacist‐driven clinical interventions. Secondary endpoints included the clinical severity and value of service of each intervention, percentage of accepted recommendations, patient cost savings interventions, prevention of adverse events, and avoidance of inappropriate doses. RESULTS: From March to September 2020, the CT transplant pharmacists conducted 385 virtual visits on 157 LTR with a median of 20 minutes spent per visit. There were 891 total interventions made by CT transplant pharmacists, including 778 medication discrepancies identified. Over 60% of encounters demonstrated some form of medication error and over 55% of encounters exhibited value of pharmacy services. CONCLUSION: Implementation of CT transplant pharmacist telehealth visits has potential for increased patient access to pharmacy care and improved accuracy of medication lists. When focusing on the severity of errors and value of services, most demonstrated a level of significance. Further investigation is needed to analyze the impact of this service on patient outcomes as well as cost‐effectiveness. A retrospective chart review was completed of telephone encounters conducted primarily by two CT transplant pharmacists at our center from March to September 2020. Each CT transplant pharmacist had 2 years of residency training, including a specialty year in solid organ transplant. In addition, they work with the CT transplant population daily, rotating through inpatient and ambulatory care services. Telephone visits were conducted 1 to 3 days prior to scheduled patient telehealth or clinic visits with advanced practice providers or attending pulmonologists, referred to as LTP for the purposes of this paper. Calls were not conducted if patients were contacted within the past 30 days. In collaboration with the LTP, CT transplant pharmacists focused calls on high-priority patients, including but not limited to, outcomes based on evaluation of adherence rates and new clinical findings. Though patients were not scheduled at exact times for these virtual visits, they were told by schedulers and during inpatient stays to anticipate a phone call by the pharmacist prior to their clinic visit. This method ensured flexibility for pharmacists and patients due to the virtual nature of the visits. During the visit, the pharmacists utilized a standardized template to conduct lab evaluations, medication list reviews, adherence assessments, in addition to an assessment of patient tolerability of medications, cost limitations, and medication access (see Appendix A). Cost savings interventions were defined as interventions resulting in a lower cost alternative agent, use of lower tier agents per insurance formularies, enrollment in patient assistance programs, or discontinuation of high-cost agents. Adherence assessments were defined using criteria outlined in Appendix B. Prior to these clinic visits, CT transplant pharmacists reviewed individual patient's electronic medical record (EMR), including but not limited to, relevant labs, microbiology, pulmonary function tests, and consult notes. Using this objective data, CT transplant pharmacists made interventions to the team after gaining additional context from conversations with the patients and reviewing the patient medication list. CT transplant pharmacists called patients utilizing institution network phones; however, Doximity or Google Voice was utilized when requiring remote access. Virtual appointments were often conducted in conjunction with caregivers. Clinical assessments and recommendations were communicated directly to the LTP in a concise email prior to each clinic visit and subsequently documented in the patient's EMR. The baseline demographics and clinical characteristics of the study population are summarized in Table 1 . Over half of the study popula- Though there was no established comprehensive drug therapy management (CDTM) agreement with LTP, pharmacist-driven interventions were based on a combination of institutional protocol as well as professional clinical judgment. Table 2 lists the total number of inter- Table 3 ) The results from grading the interventions are shown in Table 4 8 Overhage and Lukes' scale was found to be an applicable and reliable tool to characterize CT transplant pharmacists' clinical activities. 6 The use of two different scales avoided issues that may arise when utilizing a single instrument to measure two separate elements, "since services can be identified as high value even when there are no prescribing errors." 6 A handful of patient errors and pharmacist intervention were quite notable. One "potentially lethal" patient error consisted of taking an incorrect 50% dose reduction of azathioprine for 3 weeks, which led to a "very significant" impact of preventing a possible case of organ rejection. Another This value of service was considered "extremely significant" since any further delay in identification of this error could have resulted in a potential hospitalization or fatal situation (see Table 4 ). The specific errors and interventions mentioned above resulted in more frequent follow-up with a total of five visits each, which was at and ability to utilize the technology (81% and 86%). 12 As this study's telehealth method was via telephone, there were no technologyassociated difficulties. As the future of telemedicine in transplant heads toward a favorable path, it will be essential to be aware of potential barriers such as lack of digital literacy, disparities in technology access, use by patient age, race/ethnicity, and socioeconomic status. To overcome these barriers, lasting telehealth services must be validated from a financial and regulatory perspective. 13 This study should be interpreted by considering several limitations. First, the small sample size within a single institution could pose lack of patient heterogeneity, race, and even socioeconomic status. Another limitation is possible misinterpretation of patient cost-savings Table 4 ). The authors declare no conflicts of interest. Lindsay Park contributed to the conception and design, participated in analyzing and interpreting data, participated in writing of the paper, Who is responsible for filling pill box: {***, self, self with assistance from partner, patients' partner, visiting nurse, nursing facility, other support ***}. The patient's medication list {WAS/WAS NOT} correct. • Medications added to the home medication list:*** • Medications stopped on the home medication list:*** • Medications edited on the Epic medication list:*** The patient uses the following tools as reminders to take medications: {***, alarms on phone, reminder app on phone ***, follows consistent routine}. The patient takes their medications regularly at ***am/***pm. Spent approximately *** minutes reviewing medications and providing medication education via telephone counseling. All questions/concerns were addressed to the patient's satisfaction. During this visit, the following activities were completed: [medication reconciliation, adherence assessment and counseling, posttransplant medication counseling, HCV medication counseling, blood pressure log review, blood sugar log review, medication access counseling]. Pharmacist assessment and recommendations Impact of clinical pharmacist services delivered via telemedicine in the outpatient or ambulatory care setting: A systematic review Impact of pharmacist involvement on Telehealth transitional care management (TCM) for high medication risk patients. Pharmacy (Basel) Telemedically supported case management of living-donor renal transplant recipients to optimize routine evidence-based aftercare: A single-center randomized controlled trial A randomized controlled trial of a Mobile medical app for kidney transplant recipients: Effect on use of sun protection. Transplant Direct Text messaging improves participation in laboratory testing in adolescent liver transplant patients Practical, reliable, comprehensive method for characterizing pharmacists' clinical activities Necessity is the mother of invention: Rapid implementation of virtual health care in response to the COVID-19 pandemic in a lung transplant clinic Effects of pharmaceutical care intervention by clinical pharmacists in renal transplant clinics Impact of a pharmaceutical care program on liver transplant patients' compliance with immunosuppressive medication: A prospective, randomized, controlled trial using electronic monitoring Telemedicine based remote home monitoring after liver transplantation: Results of a randomized prospective trial Outcomes of telehealth care for lung transplant recipients Evolving impact of COVID-19 on transplant center practices and policies in the United States In-person outreach and telemedicine in liver and intestinal transplant: A survey of National Practices, impact of coronavirus disease 2019, and areas of opportunity Opportunistic Infections: a. Viral: *** b. PCP: *** c. Fungal: *** 3. ID: a. Vaccines: Patient has *** received their high dose flu shot for 2021on *** CLAD prevention: Patient is taking azithromycin *** and ***statin per protocol for CLAD prevention 5. Hypertension: 6. Blood sugar management: 7. GI: 8. Renal: SCr at last lab draw ***, CrCl ***. Medications adjusted: *** Bone health: 11. Medication adherence-Patient endorses *** adherence to the current regimen and has *** missed ***doses of their medications Assess the inappropriateness of the order or its deviation from the standard of practice. Assess the potential impact of the pharmacists' recommendations on patient care.