Exploring Pharmacist Roles in Telepharmacy for Chronic Disease Management in New York State: A Qualitative Inquiry into Improving Implementation, Patient Communication, and Healthcare Technology Support

Background This qualitative study aimed to collect information regarding pharmacists' roles in telepharmacy and chronic disease management (CDM). The literature review was conducted on historical overview, CDM overview, social determinants of health (SDOH), disparities, hospital readmissions, adverse drug events, best practices, and global implications of telepharmacy. Materials and methods Eleven licensed pharmacists from New York working in retail or hospital settings were interviewed using 16 questions. The interview covered topics such as CDM, hospital readmissions, adverse drug events, best practices, SDOH, and health disparities. The recordings of these interviews were transcribed and coded for each open-ended question, resulting in 136 different codes. Results According to the comprehensive review of interview transcripts, there is still an urgent need for communication between healthcare providers and patients, pharmacist training for telepharmacy services and SDOH, and healthcare technology support. CDM can be advanced by pharmacists by understanding patient barriers, SDOHs, health disparities, and pill burdens, as well as incorporating a multidisciplinary approach to patient care. Pharmacists must facilitate open communication, overcome technological barriers, seek support from stakeholders for telepharmacy training, and integrate new mobile applications to improve telepharmacy implementation and operations for providing interventions. Conclusion The research provides insights into the comprehensive impact of telepharmacy on healthcare delivery and its potential to transform CDM. With the expansion of telepharmacy, individuals living with chronic diseases can experience improved medication adherence and overall health outcomes.


Introduction
Pharmacists are an integral part of the healthcare continuum and make up a significant part of the workforce.According to the Bureau of Labor Statistics (BLS), there are 21.7 million workers in the healthcare industry.Of this, 325,480 are pharmacists, making up approximately 1.5% of the workforce [1].Pharmacists can work in different settings, including retail, hospitals, and large pharmaceutical companies, each with distinct responsibilities.In retail, they interact directly with patients, providing counseling on medication use and answering questions, while in hospitals, they collaborate with healthcare teams to ensure appropriate medication therapy and dosing.Large pharmaceutical companies focus on research and drug development, regulatory affairs, or quality control, focusing more on the manufacturing and distribution aspects of medications [2].Recognizing the crucial role of pharmacists in managing diseases highlights the need for policies that allow them to take on more responsibilities, including prescribing medications and managing therapies.This is especially important due to the high prevalence of chronic diseases, which require ongoing medical care, and emphasizes the importance of pharmacist intervention.Chronic diseases are "conditions that last one year or more and require ongoing medical attention or limit 1 2

Current trends and market influences
Telepharmacy markets are competitive and have growth potential.Several independent research organizations have been examining markets and trends for many years.Among these companies are Straits Research, Transparency Market Research, Market Research Future, and Data Bridge Market Research.These research companies have projected significant growth in the electronic health market in the United States in the coming years.In 2021, Straits Research estimated the value of the electronic health market in the United States at approximately $98 million and projected it to grow to $338.15 billion by 2030 [8,9].
Retail giants such as Amazon are joining the field with PillPack Inc., which offers 24-hour access to pharmacists and discounts on medications [10,11].At the same time, the CDM market, which is expected to reach $20.64 billion by 2029, is being driven by the increasing prevalence of chronic diseases, particularly among the elderly, and the growing demand for digital treatment solutions accelerated by COVID-19 [12].This market includes a range of technologies and services designed to help individuals manage their conditions effectively, reduce healthcare costs, and improve their quality of life.The merging of telepharmacy and CDM markets indicates significant changes in healthcare delivery, with stakeholders investing to enhance provision and drive efficiency.This trend holds the promise of positive economic outcomes and is reshaping the roles of pharmacists in the competitive healthcare industry [10,13].

Healthcare cost
An estimated 50% of American adults suffer from at least one chronic disease [14].Considering the increasing prevalence of chronic diseases, it is necessary to develop interventions that increase positive patient outcomes and reduce costs [14].The integration of telepharmacy into the healthcare system has many advantages.The benefits of doing so include a reduction in the cost of providing healthcare to the public [15].Therefore, it is likely to impact the economy over the long term significantly.Medication-related incidents per hospital contribute to $261,109 in savings [14,16].The implementation of telepharmacy leads to a reduction in the number of adverse drug events due to high-risk medications [16].
Similarly, Garrelts et al. found that more interventions resulted in $1,132,144 in savings [17].Garrelts et al. estimated that the cost savings could be as high as $6,000 if adverse drug events are prevented, errors are caught early, and hospitalizations are reduced [17].A telepharmacy model can significantly reduce hospital costs and improve healthcare economics in the long run.This has both short-and long-term benefits for the healthcare industry.

Healthcare economics
The United States allocates approximately 90% of its $4.1 trillion healthcare expenditure to address mental disorders and chronic illnesses, with a projected annual increase of 5.1% in government healthcare spending [18].However, amidst the COVID-19 pandemic, there was a significant 46% decline in government healthcare spending.In light of this, it is imperative to safeguard healthcare funding and direct it toward sustainable endeavors such as telepharmacy.Health spending is influenced by demographics, economic conditions, and specific health-related issues such as chronic conditions.Despite an estimated 4.7%-5.1% increase in prescription drug costs in 2021 due to Medicaid spending, a 4.3% decline was anticipated in 2022.However, a subsequent 5.2% increase in healthcare expenditures is expected over the next five years, largely due to new pharmaceutical programs [18,19].
The integration of telepharmacy into care delivery has the potential to mitigate adverse drug events (ADEs), which contribute to an estimated $30 billion loss in the healthcare industry.ADEs, the third leading cause of clinic and emergency department visits, affect seven million patients annually, resulting in an approximate annual cost of $300 billion to Americans, representing a significant increase from the $145 billion reported in the early 2000s [19].Notably, medical errors contribute to 22% of readmissions and 41.3% of hospital admissions, amounting to approximately $21 billion in expenditures.The implementation of telepharmacy can reduce the economic burden substantially.Notably, in large healthcare systems, the integration of telepharmacy has demonstrated annual savings exceeding $1,132,144 [20].Considering the economic implications of telepharmacy, it becomes imperative to identify and address existing gaps.

Policy regulations
Before the onset of the COVID-19 pandemic, the utilization of telehealth services was primarily confined to remote rural areas with specific eligibility prerequisites.However, in reaction to the pandemic, governmental entities such as the United States Health and Human Services (USHHS), the Center for Medicare and Medicaid Services (CMS), and the Joint Commission facilitated the streamlined implementation and operation of telepharmacy services.Policy adjustments encompassed the enactment of the Coronavirus Preparedness and Response Supplemental Appropriations Act of 2020, the accreditation for pharmacists to invoice virtual consultations for COVID-19 diagnosis and treatment, and the relaxation of Health Insurance Portability and Accountability Act (HIPAA) regulations pertaining to pharmacist-patient interactions [21].Accrediting bodies expedited the endorsement processes for telepharmacy services, rendering them more readily accessible and advantageous for patient care.
In contrast, contemporary health policy prioritizes the delivery of high-quality care using incentive structures, most notably value-based purchasing, necessitating that hospitals fulfill specific benchmarks pertaining to health outcomes and cost containment.It is proposed that the involvement of pharmacists in enhancing patient outcomes could be similarly incentivized, akin to the penalties imposed on hospitals for readmissions that could have been prevented [22].Notably, in countries such as the United Kingdom, the existing recommendations advocate for the inclusion of pharmacists in policy formation, funding allocation, and the facilitation of vaccination programs.In the wake of the COVID-19 pandemic, comparable revisions have been instituted within the United Kingdom to augment the participation of pharmacists in healthcare decision-making [23].

Study design
This qualitative study aimed to explore pharmacists' roles in CDM and to enhance the implementation and operation of telepharmacy.The study utilized a conceptual framework by Sankaranarayanan et al. [24], consisting of three levels: individual, system, and societal impacts, as identified in Table 1.Interviews were conducted to investigate pharmacists' perspectives across these levels.

Research questions
The study addressed two primary research questions: (1) How can pharmacists contribute to the advancement of CDM? (2) What improvements are needed in telepharmacy implementation and operations for pharmacists to enhance their utilization?

Sampling
Participants were recruited using nonprobability convenience sampling, targeting licensed pharmacists practicing in New York State.A total of 11 pharmacists were recruited, ensuring representation from various practice settings and specialties.

Participant demographics
A total of 11 pharmacists participated, consisting of five men (45%) and six women (55%) in the following specialties: critical care, ambulatory care, infectious disease, pharmacotherapy, geriatric, etc.Three (27%) of the participants provided services in retail, whereas the remaining eight (73%) worked in a hospital setting.

Data collection instrument
The interview questions, categorized by theme, covered topics such as CDM, readmissions and ADEs, best practices, SDOH, and health disparities.Table 3 presents a comprehensive list of interview questions and corresponding codes.

Ethical considerations
Approval was obtained from the Institutional Review Board of Franklin University before data collection (approval number: IRB-2023-39).Participants provided informed consent and were assured of confidentiality and data security throughout the study.

Individual impact: chronic disease management
The individual-level theme impacts included the role that pharmacists play in CDM.As shown in Table 3, there were 43 unique codes resulting from these four questions, with 117 responses from pharmacists.The 117 responses were received from pharmacists who identified multiple codes for a single question.The results are summarized in Table 3, along with the total number of responses per interview question.For interview question (IQ) 2, P5 identified three codes: communication and access to providers, not considering pharmacists' critical in-patient management, and creating trust in pharmacists for managing medications.According to P5, pharmacists are not accepted as part of the provider team in New York in contrast to their experiences in Florida, where pharmacists are accepted as members of the provider team.P5 stated, "New York City area is a little bit behind the times, I would say a little slower to accept and embrace the pharmacist as part of the health care team."In IQ2, 36% (8/22) of responses from pharmacists identified that communication or access to providers outside of hospital settings was challenging when interacting with their patients.Furthermore, the top two codes for IQ1 were evaluating patients' understanding of their disease (21% or 6/29) and building trust with patients (17% or 5/29), both of which are critical steps in addressing CDM with patients.With 46 responses, IQ3 identified the most significant barriers experienced by patients in managing chronic conditions: maintaining motivation to take medication (15% or 7/46), pill burden (15% or 7/46), and lack of health literacy (13% or 6/13).Lastly, when examining IQ4, pharmacists identified two of the most effective methods for monitoring their patients' medications, such as reviewing medications in charts/pillboxes during visits and using telehealth and telemedicine efficiently (15% or 3/20).

System impact: readmissions, adverse drug events, and best practices
The system-level theme impacts the included pharmacists' role in hospital readmissions, ADEs, and best practices.Tables 4

Societal impact: SDOH and health disparities
The societal level impacts included SDOH and health disparities.Among the 110 responses, the researcher found 43 distinct codes for these IQs, as shown in Tables 6, 7. The lowest number of responses was received for this level of questions.A possible explanation for this may be that the majority of the participants came from a hospital setting where social workers rather than pharmacists examine SDOH and disparities.The greatest number of responses were received from IQ16, for which 47% (8/17) of responses reported that patient interviews and building relationships were the primary ways by which pharmacists identified disparities.As a means of interacting with patients' physicians, 40% (6/15) of responses were identified using the telephone in IQ11.As identified in IQ12, pharmacists can provide culturally competent education to their patients in seven different ways.

Chronic disease management
Medication management plays a critical role in the pharmacist's responsibilities within CDM.CDM encompasses an interdisciplinary approach to healthcare, encompassing self-management, provider-patient relationships, prevention, evidence-based guidelines, health evaluation, outcome assessment, and enhancement of quality of life [25].Healthcare teams are encouraged to implement population-specific programs, evidence-based guidelines, collaboration, risk identification, and monitoring of patient progress [25].An important consideration in the development of disease management programs for specific populations is the influence of socioeconomic status [14,25].
Pharmacists should prioritize targeted therapies for high-risk patients, closely monitor prescribing patterns, educate physicians regarding new treatments, and carefully track medication management expenditures to establish sustainable CDM practices.In instances of consistent medication misuse or abuse, pharmacists should both educate the patient and consult with the patient's physician.Many of these activities can be effectively facilitated through telepharmacy.
Patients presenting with chronic conditions necessitate comprehensive management from an interdisciplinary care team.An estimated 56% of individuals with chronic diseases are concurrently prescribed a minimum of five medications [26], leading to polypharmacy [27].This, in turn, has the potential to diminish medication adherence, with only 50% of prescribed medications being consumed as directed [26].
Telepharmacy serves as a viable solution for improving medication safety and ameliorating adherence and treatment gaps within this patient population [16,26].Inadequate medication adherence presents a substantial challenge to the healthcare system.Policymakers are urged to develop effective strategies to enhance adherence [28].Telepharmacy empowers pharmacists to oversee adherence data, thereby guaranteeing that patients adhere to their prescribed medication regimens.This technology can effectively mitigate shortcomings in medication adherence by granting patients improved access to pharmacists over an extended period.
Establishing a robust patient-pharmacist rapport is imperative.Employing multiple communication touchpoints, such as phone calls and emails, is associated with an increased likelihood of patients adhering to their treatment regimens, thereby amplifying engagement and satisfaction [6].The cultivation of trust between patients and pharmacists facilitates the disclosure of lifestyle, financial barriers, and gaps in health management, which is pivotal for effective medication adherence [6,28].
Pharmacists engage with patients frequently, often surpassing the frequency of interactions with physicians.This allows pharmacists to promptly provide essential medication information.They encounter patients 1.5 to 10 times more frequently than physicians, which provides opportunities for patient education, medication counseling, and management, leading to increased medication adherence and averting therapy duplication [29].Patients often exhibit greater ease in discussing medication concerns with pharmacists, who can consequently aid in comprehending physician diagnoses and treatment plans [30].Despite the pivotal role played by pharmacists, communication barriers with physicians persist.Telepharmacy seeks to address these gaps, thereby reducing ADEs and hospitalizations, ultimately leading to a decrease in healthcare costs [31].
In summary, pharmacists play a vital role in the management of chronic diseases through the provision of crucial medication management, patient education, and adherence support.Telepharmacy serves to augment these capacities, guaranteeing ongoing patient assistance and enhanced health outcomes.This interdisciplinary method underscores the necessity of integrating pharmacists into CDM to effectively bolster patient quality of life.

Readmission, adverse drug events, and best practices
Telepharmacy plays a critical role in preventing ADEs and significantly reducing healthcare costs.ADEs are classified into six types: dose-related, non-dose-related, dose and time-related, time-related, withdrawals, and failed therapy [7].Each year, medical errors result in 7,000 deaths and 250,000 injuries, costing over $2 billion in the United States alone [32].The introduction of telepharmacy in hospitals has been proven effective in reducing medical errors and hospitalizations [32,33].
Pharmacists play a crucial role in the healthcare system by implementing strategic approaches such as regular patient follow-ups, clear labeling, and deprescribing to manage polypharmacy and minimize ADEs.These practices help address patient concerns about medication burden, improve understanding, and ultimately reduce hospital readmissions and extended stays [27].Notably, 48% of pharmacists use deprescribing to reduce pill burden, and 10% use it to eliminate medication duplication, highlighting the necessity of a multidisciplinary approach to healthcare [34].The effectiveness of pharmacist-led teams in reducing readmission rates, compared to physician-only teams, is well-documented.These teams correct drug management errors, detect duplications, ensure proper dosages, and significantly lower occurrences of ADEs [34].Additionally, telepharmacy initiatives have demonstrated cost savings of over $700,000 annually by managing medical errors that result in adverse events [32].
The healthcare industry encourages telepharmacy as part of routine care, following standardized best practices supported by organizations such as the American Society of Health-System Pharmacists (ASHP) and CMS.It involves pharmacist training, secure patient communications, and detailed documentation of patient interactions [35,36].Additionally, incorporating screenings for SDOH into pharmacist responsibilities ensures a comprehensive approach to patient care [37].Despite some patients' technological challenges, telepharmacy has been proven to improve patient retention and follow-up care.However, for its broader implementation, specialized technology and comprehensive training in telepharmacy are crucial [38].
In conclusion, telepharmacy, supported by best practices and strategic pharmacist interventions, offers a promising solution to reduce ADEs, lower healthcare costs, and improve patient outcomes.Continued emphasis on multidisciplinary approaches and deprescribing can further enhance its effectiveness in managing chronic diseases and polypharmacy.

Social determinants of health and health disparities
SDOH refers to the conditions where people live, learn, work, and play that can impact their health and quality of life.Various factors, such as social support networks and access to medical care, can affect treatment adherence and medication effectiveness.The COVID-19 pandemic heightened these issues.Telepharmacy allows pharmacists to address SDOH in patients by discussing health literacy, housing stability, employment, medication access, insurance, and transportation.
Pharmacists need to recognize their biases when working with marginalized communities to ensure that everyone receives fair and equal care.For example, different racial and ethnic groups may have varying levels of willingness to receive vaccinations [38].Additionally, people with hearing impairments or those without internet access may encounter difficulties with telepharmacy.The lack of culturally appropriate and bilingual medication information in pharmacies can widen educational gaps [18,20,38].These gaps can impact CDM by affecting patients' understanding of their medication regimen.
To overcome these barriers, pharmacists need to create an inclusive environment and establish trust with patients, as patients often visit their pharmacists more frequently than their doctors [37].Effective communication and building strong relationships are crucial, as patients are more likely to openly share social challenges with trusted pharmacists [6,37].Using translation services, providing culturally sensitive education, and addressing systemic barriers are crucial strategies for improving medication adherence and establishing rapport with the patient [38].
Health disparities refer to the differences in health outcomes linked to social, economic, or environmental disadvantages, and they significantly impact pharmacy practice [6,39].Pharmacy deserts are often found in minority communities, and they underscore these disparities as residents in these areas face multiple barriers, such as language issues, poverty, and lack of health insurance [6,37].While telepharmacy can help address some of these issues, challenges such as broadband access and health literacy still exist.Pharmacists need to provide culturally competent care, including offering translation services and patient education, to bridge the gaps in patient understanding and medication adherence [40][41][42].It is crucial to develop pharmacists' skills in addressing SDOH and health disparities as many pharmacists lack experience in these areas [37].Collaborating with social workers and other healthcare professionals can enhance patient support, ensuring comprehensive care [37].
In conclusion, telepharmacy offers a valuable tool for addressing health disparities by enhancing patientpharmacist communication and providing culturally competent care.Building strong, unbiased relationships with patients and integrating pharmacists into multidisciplinary teams can significantly improve patient outcomes and reduce health disparities.

Research limitation
Convenience sampling may introduce selection bias, and findings may not be generalizable beyond the study population.Additionally, the study's reliance on self-reported data and the potential for social desirability bias could influence participants' responses.Also, the sample size was only a snapshot of pharmacists in New York.As a large city, New York City's pharmacist population may differ greatly from other states.According to the literature, a sample size of 10-15 pharmacists was recommended to reach data saturation, but in our study, the sample size ultimately totaled 11 pharmacists.This lack of variability in the data may lead to bias, resulting in skewed data that limits the understanding of medical practices, demographics, and disease prevalence in the area where pharmacists are practicing.
Another limitation was that we did not define "telepharmacy" when contacting the pharmacists to request their research participation.A few pharmacists thought there was a software application called "Telepharmacy" and refused to participate because they were inexperienced with the software.
Lastly, coding was done twice, once by ATLAS.ti and then again manually.As ATLAS.ti established the codes, any manual entry would have biased them.In contrast to ATLAS.ti, which provided single words, the final codes were phrases that provided a more accurate representation of the responses.

Recommendations for further research
We offer several recommendations to advance the knowledge and improve the quality of patient care at the rapidly evolving intersection of telepharmacy and CDM.
Integrating telepharmacy services with CDM platforms should be the focus of future research.Pharmacists and healthcare providers could communicate in real time, improving medication management and increasing drug adherence for chronically ill patients.
Using user-friendly mobile applications tailored for pharmacists and patients can enhance the impact of telepharmacy on CDM.Through the simplification of the interface, patient access and engagement will be enhanced, ultimately resulting in improved medication adherence and patient outcomes.Healthcare delivery can be revolutionized with these patient-centric applications.
Pharmacists do not currently receive compensation for their time spent on telepharmacy.Policymakers, healthcare systems, and government agencies should collaborate to develop billing codes and incentive programs and discuss fair reimbursement for pharmacists' services.
Future researchers should examine pharmacists' role in addressing health disparities and SDOH in their communities.Additionally, pharmacy schools, industry experts, healthcare systems, and even community pharmacies might need to emphasize education surrounding disparities and SDOH.
These recommendations are based on the findings of this study.In the study, only 5% of the pharmacists received training in CDM and telepharmacy.As a result, these fields must be examined in further depth to determine their full potential.As mentioned in recommendation 2, application improvements are necessary to address gaps found during this research.Several pharmacists noted that culturally appropriate applications were lacking, particularly regarding technology literacy.In approximately 6% of pharmacy practices, pharmacists reported that patients were unable to use teleservices because they lacked electronic literacy.Per recommendation 3, prior authorizations were obstacles to many pharmacists' responsibilities.

Level 1: Individual Impacts
What steps should be taken to address chronic disease management with your patients?IQ2: What challenges do you come across when interacting with your patient's physician regarding concerns?IQ3: What barriers have your patients expressed in their care and medication to manage their chronic disease?
IQ13: Do you screen for social determinants of health?If so, in what ways have you seen positive outcomes in their health?If not, why are social determinants not accounted for?Health disparities IQ14: How have health disparities impacted how you do your work?IQ15: In what ways do you feel you lack the necessary skills to address health disparities in the community you serve?IQ16: How have you been able to identify disparities present in the community you serve?

TABLE 1 : Pharmacist interview questions
IQ: Interview question.

Table 2
provides a detailed overview of the participants.The participants were labeled Pharmacist 1 (P1) to Pharmacist 11 (P11).

TABLE 3 : Level 1: individual (chronic disease management) interview questions 1-4, with codes and response percentages
IQ: Interview question; N: Number of responses; CDM: Chronic disease management; CMRs: Comprehensive medication reviews.

TABLE 4 : Level 2: system (readmission/adverse drug events) interview questions 5-7, with codes and response percentages
, 5 demonstrate that these IQs led to 133 responses with 49 distinct codes.The questions at this level received the highest number of responses.There is a possibility that this is because 73% of participants were from a hospital setting where adverse events, readmissions, and best practices are readily applied.IQ5 received the greatest number of responses.About 48% (10/21) of the responses identified that reducing pill burden was one of the benefits of positive patient outcomes in deprescribing methods.Six responses out of 21 (29%) indicated that monitoring patients' medication and making changes as soon as possible can help them manage adverse events and side effects.IQ6 pertains to pharmacists assuring accurate medication dispensing (28% or 8/29), tracking the medication history of a patient (24% or 7/29), and preventing drug interactions (17% or 5/29).As part of IQ7, eight of the 25 total responses (32%) indicated that pharmacists agreed that open communication with their patients and regular follow-up are the best strategies for addressing their concerns and expediting care to reduce hospitalization.In addition, 20% (5/25) of responses indicated that they provided patients with the required medications, and 16% (4/25) said they counseled patients to understand their medications.In IQ8, the top four codes included the following: regularly following up with patients to ensure compliance (4/23 or 17%), setting protocols to ensure that the patient is taking the correct medication (4/23 or 17%), counseling the patient (3/23 or 13%), and being accessible to the patients (3/23 or 13%), which were the methods used to monitor patients' medications.For IQ9, pharmacists were asked how they would change their job responsibilities to accommodate telepharmacy.About 38% (6/16) of the responses indicated that understanding and overcoming technological difficulties would be the most appropriate method.In addition, the top responses for IQ10 included that pharmacists did not receive much support (32% or 6/19) and were not provided an overview of the technology from the workplace regarding telepharmacy training (26% or 5/19).

TABLE 5 : Level 2: system (best practices) interview questions 8-10, with codes and response percentages
IQ: Interview question; N: Number of responses; CDM: Chronic disease management.