key: cord-0965811-v6ki6yjh
authors: Muflih, Suhaib M.; Al‐Azzam, Sayer; Abuhammad, Sawsan; Jaradat, Sara K.; Karasneh, Reema; Shawaqfeh, Mohammad S.
title: Pharmacists’ experience, competence and perception of telepharmacy technology in response to COVID‐19
date: 2021-04-21
journal: Int J Clin Pract
DOI: 10.1111/ijcp.14209
sha: c13bf035cfa641a9857e85999fbb2c9ebf62ff02
doc_id: 965811
cord_uid: v6ki6yjh

BACKGROUND: In the telepharmacy model, the pharmacist can play a pivotal role in delivering pharmaceutical services for patients. However, evidence of pharmacists’ impact on improving patient outcomes through disease outbreak through telepharmacy is sparse. OBJECTIVES: This study aims to examine pharmacists' attitudes towards clinical benefits and identify challenges regarding the use of telepharmacy during the COVID‐19 pandemic in Jordan. METHOD: A cross‐sectional survey design was used to recruit eligible participants from both hospital and community pharmacies. RESULTS: A total of 364 pharmacists agreed to participate in the study. The majority of the participants (70.6%) expressed favourable attitudes towards telepharmacy to accurately capture and report signs and symptoms of COVID‐19. Almost 91% agreed that patients can receive immediate medical feedback while using telepharmacy services. Pharmacists (87%) emphasised their role in the monitoring of physiological parameters when entered by patients using telepharmacy technology. However, more than half of the participants reported that lack of reimbursement and evidence‐based studies might hinder the use of telemedicine technology to deliver remote clinical services. CONCLUSION: The need for implementing telepharmacy technology has been further boosted because of its noticeable benefits in promoting convenient healthcare services remotely in emergency situations.

The rapid evolution of new various communication technologies is making a tremendous impact on healthcare. Telehealth harnesses these technologies by using real-time synchronous technology to enable live interaction by using videoconference link to asynchronous interaction and transmission of data via mobile devices between healthcare providers and patients to overcome geographical disparities, distance barriers, provide equitable access, and delivery of healthcare services for both rural and urban communities. 1, 2 Furthermore, telehealth is taking a centre stage in the health sector, by paving the way for better achieving wider health coverage. 1 Originally, telehealth was designed as a technology to serve patients in remote areas with healthcare shortages. A more recent concept falls under the wider umbrella of telehealth: telepharmacy. The National Association of Boards of Pharmacy defined telepharmacy as "the provision of pharmaceutical care to patients at a distance, through the use of telecommunication and information technologies". 3, 4 This way, telepharmacy provides patients with their medications and other pharmaceutical care services where the pharmacists are not physically presented. 3, 4 Essentially, telepharmacy harnesses technology to provide services such as prescription review, medication dispensing and compounding, drug therapy monitoring and counselling. [4] [5] [6] Growing evidence suggests potential clinical benefits provided by telepharmacy and the implementation of such technology, 7 which may reduce shortage and inequalities in healthcare services provision and delivery for patients living in the rural communities or in areas where it is difficult to access healthcare or pharmaceutical services for any reason. [8] [9] [10] Telepharmacy provides an economically beneficial technology for both pharmacists and patients. 11 Moreover, telepharmacy was found to reduce travelling expenses and it saved time, which is considered a major barrier for patients in the rural and remote areas for accessing healthcare services; especially, those who are disabled and elderly people. 4, 11, 12 Furthermore, telepharmacy improves patients' adherence by increasing their satisfaction and trust with the received services. 13, 14 In addition, it has enhanced the effective clinical role of pharmacists by providing sufficient medication counselling time with better privacy. 15, 16 Generally, telehealth provides an ideal platform to address various challenges that healthcare systems around the world may face in response to global emergency situations or outbreaks. [17] [18] [19] For example, in 2014, the telemonitoring concept was adopted by many countries, such as Western Australia 20 and Guinea, 21, 22 after the Ebola Virus outbreak in Africa, which improved the disease management. 23 In addition, teleconsultation was used in Taiwan during the Severe Acute Respiratory Syndrome (SARS) epidemic for hospital quarantined infected patients, which helped to limit healthcareassociated infections and improved disease control. 24 The 2019 novel Coronavirus Disease (COVID-19) has evolved into a global emergency health situation and declared as a pandemic by the World health Organization (WHO). 25 As of July 2, 2020, over 10 million cases were confirmed globally, with about 229,780 new reported cases on that day, and the number is still increasing continuously around the world. 26 With this rapid increase in COVID-19 cases, telepharmacy can be harnessed for remote medication orders and approval, which results in reducing the time that ill patients require to get their needed medications. 8 Controlling the infection and limiting its transmission are essential strategies in the fight against this pandemic. Thus, telehealth has started to be recognised as a first-line defence strategy against COVID-19 as a solution to reduce people's exposure, and to control its spreading among both patients and healthcare workers. [27] [28] [29] Despite the widespread use of telehealth, particularly telepharmacy technology by patients and pharmacists globally, there is a lack of research that examines the attitudes and challenges regarding the use of telepharmacy during the COVID-19 pandemic. The goal of this study was to examine pharmacists' attitudes towards clinical benefits and challenges regarding the use of telepharmacy during the COVID-19 pandemic in Jordan.

A cross-sectional survey using online social media platforms was used to recruit eligible participants who were minimally holding diploma in pharmacy and currently working as full-time pharmacists either in a community or a hospital pharmacy. A Google Form was What's new 1 . The majority of participants in this study had positive views of telepharmacy services, as well as the competence to identify signs and symptoms reported by COVID-19 patients.

2. The cutting-edge telepharmacy offers numerous advantages and great promise, and should be implemented by clinical pharmacicts.

Participants should sign the online consent form attached to the first page of the online survey to confirm their agreement to participate in the study (Appendix A1: Participation Invitation Letter). While using the Google Form, the validation options "Required" and "Limit to one response" were applied to minimise missing data and prevent duplicate responses.

The survey has been developed based on an extensive review of the available literature on telepharmacy and telemedicine. The authors of this research reviewed relevant topics published in the last decade. 2, 3, 5, 7, 9, 18, 29, 30 Based on the broad outcome of the literature review, several ideas were identified to clearly formulate the survey questions used in the current study. Some items were newly developed to meet the research needs. The online survey contained 23 questions to avoid survey fatigue in respondents. Ten items were used to assess sociodemographic characteristics. Nine items were used to assess pharmacists' attitudes towards telepharmacy in response to the COVID-19 pandemic and four items were used to meas- attitudes towards telepharmacy, which indicated acceptable internal consistency. The final survey was developed and administered in the English language, which is the official language of instruction in pharmacy schools in Jordan, besides, textbooks and teaching materials for pharmacy students are only available in English.

Ethical approval was obtained from the Institutional Review Board 

Data collected on Google Forms were exported to a Microsoft Excel file, which were directly imported into IBM SPSS ® version 24.0 for statistical analysis. Assuming a number of population larger than 20,000, confidence level of 90% and 5% margin of error, the minimum recommended sample size would be 267 participants. Data were described using IBM SPSS® version 24.0.

were used to illustrate participants' characteristics and responses.

Pearson correlation analysis was performed between pharmacists' attitudes towards telepharmacy and their self-expected role competence in response to the COVID-19 pandemic. Furthermore, t-tests and analysis of variance (ANOVA) were performed to determine the effect that several independent variables have on the main dependent variable (ie pharmacists' attitudes towards telepharmacy).

In total, 364 pharmacists agreed to participate in the study and completed the questionnaire. Among them, 181 pharmacists were working in the community pharmacies and 183 were working in the hospital pharmacies. About three quarters of the respondents (73.6%) were women, and 26.4% of respondents were men. The findings showed that the "26-30" age group had the highest frequency (31.3%). Almost half of the participants attained a Bachelor degree of Pharmacy and had less than 5 years of work experience.

The results are presented in Table 1 .

The majority of pharmacists (70.6%) expressed favourable attitudes towards the online telehealth models such as telepharmacy that could be conducted frequently to accurately capture any signs and symptoms presented by COVID-19 patients. The majority of pharmacists (90.7%) agreed on the timely feedback that patients could receive using telemedicine. Almost 87% of pharmacists agreed about their role to monitor the parameters entered by patients several times a day. However, more than half of the participants reported that the lack of reimbursement might hinder the use of telepharmacy technology to deliver remote clinical services. Unexpectedly, half of the participants felt discouraged to use telepharmacy as a result of a lack of studies about its effectiveness and societal implications. Furthermore, few participants (8.8%) indicated that telepharmacy could be a time-consuming practice (see Table 2 ).

The results showed that there is a correlation pharmacists' competence and attitudes towards telepharmacy. Four competence items were significantly correlated with pharmacists' attitudes towards telepharmacy. These competences include pharmacists' ability to apply infection prevention and control measures (eg hand hygiene, social distancing), ability to expedite seeking care for patients with acute illnesses, ability to provide necessary information to patients about the level of care they should seek and how urgent it is and ability to identify epidemiological risk factors that would constitute COVID-19 (see Table 3 ).

There are many factors that are found to be predictors of attitude towards telepharmacy among pharmacists. These factors are gender (P = .006), age (P = .028), level of education (P = .005) and source of information (P = .017). All other factors did not significantly relate to attitude towards telepharmacy (P > .05). Male participants had more positive attitudes towards telepharmacy than females. Moreover, pharmacists in the age group >35 expressed more positive attitudes towards telepharmacy than their counterparts in the younger age groups. As the level of education increased, pharmacists exhibited more positive attitudes towards telepharmacy, and they depended more on scientific journals as sources of information (see Table 4 ).

To best of the authors' knowledge, this is the first study in Jordan and the Arab world that examines the attitudes of pharmacists towards telepharmacy during the time of COVID-19. A cross-sectional survey using online social media platforms was used to recruit eligible participants. The data for this study were collected from hospital The results of this study showed that many factors were predictors of the attitudes towards telepharmacy among pharmacists.

These factors were gender (P = .006), age (P = .028), level of education (P = .005) and source of information (P = .017). All of the other factors did not relate to the pharmacists' attitudes towards telepharmacy (P > .05). A study conducted to determine community pharmacists' attitudes and perceptions towards e-prescriptions found that age and gender were significantly related to the pharmacists' attitudes and adoption of e-prescribing, and similar to this study's findings, male pharmacists had positive attitudes and higher adoption of e-prescribing compared with female pharmacists. 37 However, younger pharmacists had positive attitudes and a higher adoption of this technology. 37 Conversely, another study indicated that among the characteristics of participating pharmacists, only younger participants had greater interest and positive attitudes towards using telemedicine resources. 30 In addition, a review article regarding attitudes of healthcare staff towards information technology reported that age and gender were not significant factors in explaining that attitude. 38 Supporting the findings of previous studies, 24 

Potential research participants were informed about the anonymous and voluntary nature of the study, confidentiality of information obtained in this study as well as risks and benefits associated with consenting to participate. Participants were assured that risks associated with consenting to participate in this study are no more than minimal risk ordinary encountered in daily life or during the performance of routine physical or psychological tests. As informed consent was embedded in the online survey, questions would not be viewed by potential participants unless they clicked the "I agree"

button, which indicating their voluntary participation.

This work is not under publication or consideration for publication elsewhere and all authors give the consent for the International Journal of Clinical Practice to publish their work.

I also would like to express my gratitude to the Deanship of Scientific

Research at Jordan University of Science and Technology for providing the funding for this work.

The authors of this original work declare that they have all participated in the design, execution, reviewing and analysis of the study, and that they have approved the final version. Also, there are no conflicts of interest associated with this publication and no financial support that could have influences its reported results. This work is not under publication or consideration for publication elsewhere. The purpose of the study is to measure the Pharmacists' Experience, Competence, and Perception of Telepharmacy Technology in Response to COVID-19. Your participation in this study is completely voluntary and anonymous, which does not require you to provide your name or any other identifying information.

Your participation will contribute to a better understanding of the role that pharmacists are playing during the COVID-19 pandemic. All responses will be kept confidential.

Report of the third global survey on eHealth Global Observatory for eHealth

Overview of assessments of real-time (synchronous) and asynchronous telehealth

Current practices and state regulations regarding telepharmacy in rural hospitals

Telepharmacy: time to pick up the line

Pharmacist-managed inpatient discharge medication reconciliation: a combined onsite and telepharmacy model

Telepharmacy: a new paradigm for our profession

Telepharmacy for the management of cardiovascular patients in the community

Telepharmacy-enabling technology to provide quality pharmacy services in rural and remote communities

Tele-pharmacy in remote medical practice: the Royal Flying Doctor Service Medical Chest Program. Rural Remote Heal

Rural health around the world: challenges and solutions

Telepharmacy: a pharmacist's perspective on the clinical benefits and challenges

Telepharmacy services bring new patient care opportunities

Exploring the formation of patient satisfaction in rural community telepharmacies

Clinical pharmacists connecting with patients in rural and remote towns via telehealth. 13th National Rural Health Conference

Provision of pharmacy services to underserved populations via remote dispensing and two-way videoconferencing

Telepharmacy services in an urban community health clinic system

Telepharmacy services: present status and future perspectives: a review

Telemedicine and e-health in disaster response

Telemedicine: potential applications in epidemic situations

EbolaTracks: an automated SMS system for monitoring persons potentially exposed to Ebola virus disease

International Telecommunication Union. Guinea Ebola contact tracing application

Mobile app promises to speed Ebola response in Guinea

Statement on the 1st meeting of the IHR Emergency Committee on the 2014 Ebola outbreak in West Africa

The telemedicine and teleconsultation system application in clinical medicine

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Coronavirus Preparedness and Response Supplemental Appropriations Act

Associated Press WSC. To Keep Seniors Safe at Home, Medicare Expands Telemedicine

Incorporating telemedicine as part of COVID-19 outbreak response systems

Use of telemedicine in Spainperceptions of patients

Role of pharmacists during the COVID-19 pandemic in China-Shanghai Experiences

Providing pharmacy services during the coronavirus pandemic

Impact of the COVID-19 epidemic on the provision of pharmaceutical care in community pharmacies

Role of pharmacist during the COVID-19 pandemic: a scoping review

Can telepharmacy provide pharmacy services in the bush?

Telepharmacy and access to pharmaceutical services in rural areas

E-prescribing: attitudes and perceptions of community pharmacists in Puerto Rico

The attitudes of health care staff to information technology: a comprehensive review of the research literature

e-Health. role of telehealth in the management of COVID-19: lessons learned from previous SARS, MERS, and Ebola Outbreaks

Influenza surveillance using data from a telemedicine centre

You can take this survey conveniently using your cell phone or personal computer. The survey will close on May 15, 2020.If you agree to be in this study, you will be asked to complete a brief demographic questions that will take ~1 minute to complete. Then, you will be asked to express your attitudes towards telepharmacy and your perceived competence in response to COVID-19 on a scale of 1 to 5 (Strongly Disagree = 1, Disagree = 2, Neutral = 3, Agree = 4, and Strongly Agree = 5), which will take ~5 minutes to complete.For general questions or technical issues please email the author smmuflih@just.edu.jo