Introduction
The application of information and communication technology in the health sector is currently being widely used, especially since the COVID-19 pandemic.1 The provision of health services through information technology is proven to help ease the burden on the health sector. One of them is telepharmacy. Telepharmacy has been highlighted as an effective and innovative strategy to help overcome this problem.2 The National Association of Boards of Pharmacy in the United States defines telepharmacy as the provision of pharmacist care to patients remotely by registered pharmacists using telecommunications. Telepharmacy allows pharmacists with remote access to efficiently contribute their clinical expertise to multiple clinics and patients, while alleviating the strain on healthcare resources.3–5
Several telepharmacy services include clinical pharmacy services, patient consultation and monitoring, drug selection counseling, prescription checks, and dispensing. Telepharmacy services are very helpful for people with long-term illnesses who take medications regularly and need to see a physician.6 Telepharmacy has been shown to potentially be used as an alternative method of dealing with drug-related problems in diabetic patients because it is able to provide quality pharmaceutical services to remote areas and reach patients who are located far from hospitals, clinics, pharmacies or other health care facilities.7 Although, it has many benefits, there are still many limitations in the development and use of telepharmacy technology in society, especially in patients with diabetes mellitus. In this literature review, the authors discuss and evaluate the applications, benefits and limitations of using telepharmacy for diabetic patients so that they can become a reference and consideration in the development of telepharmacy.
Methods
We conducted a search for journals with the keywords “Diabetes Mellitus”, “Telepharmacy”, “Telephone”, and “Pharmacist” in three journal sources: PubMed, Google Scholar, and ClinicalTrials.gov. This narrative review was prepared based on studies related to the implementation of pharmaceutical services for outpatients with diabetes mellitus using communication technology. Selection Criteria: The authors use all original research and clinical reports published from 2012 to October 2022 regarding telepharmacy in diabetes mellitus outpatients and select research articles that explain the practice of pharmaceutical services by pharmacists through information technology, either via fax, email, messages, telephone, or special tools. The authors exclude irrelevant articles, which are the results of telepharmacy research, but the results do not evaluate the effect on the health of research subjects, research articles that do not clearly state the role of pharmacists in interventions, and other sources such as book chapters, article abstracts only, conference reports, reviews, posters, discussion results, and articles that only contain research designs. All of the articles identified were examined by authors G.N.I, K.M.E and S.A.R for inclusion. The findings were later discussed by the authors to reach a consensus. The procedure for selecting research articles is shown in Figure 1.
Figure 1 Flow chart of literature search.
Results
Of the total number of articles found, 23 articles passed the selection process and could be used in the analysis, all of which are written in English. Twenty-three selected articles reported on the use of telepharmacy in patients with diabetes mellitus in countries including the United States, Denmark, Saudi Arabia, Malaysia, Iran, Jordan, Taiwan, the United Kingdom, Ethiopia and Brazil. The scope of the implementation of telepharmacy includes counseling, monitoring patient therapy, prescription reviews, and dispensing.
Most of the research articles generally use the telephone as an information technology used in conducting pharmaceutical services, but some use web-based programs, special devices, and via messages or e-mail. Telepharmacy contributes to the improvement of pharmaceutical services in diabetes mellitus outpatients who require regular monitoring to avoid drug-related problems and unwanted side effects.
Of the 23 articles analyzed, 21 articles explained that telepharmacy services were in the form of counseling to monitor patient adherence and clinical outcomes. Counseling through telepharmacy is proven to be an effective form of pharmaceutical services with significant improvements in clinical outcomes and patient therapy adherence. However, the telepharmacy has many obstacles and limitations, such as, the lack of education and training for patients in telepharmacy services, especially in telepharmacy with special devices.
Data and explanations regarding the application, benefits, and limitations of using telepharmacy in diabetes mellitus outpatients are shown in Table 1.
Table 1 Application, Benefits and Limitations of Telepharmacy in Diabetes Mellitus
Discussion and Future Perspectives
The use of information and communication technology in health practice is increasing, especially after the COVID-19 pandemic took place.8 The practice of pharmacy through telepharmacy has been carried out since 2000 in the United States for asthma patients.9 Telepharmacy has proven to be an innovative new approach to providing pharmaceutical services, both independently and in multidisciplinary care, by pharmacists.10 Over time, forms of service through telepharmacy are becoming increasingly diverse and are applied to various patient conditions. Outpatients with diabetes mellitus are one of the groups that can benefit the most from telepharmacy because they need to be checked on regularly by pharmacists and other health workers.11 Patients with diabetes mellitus who use telepharmacy have shown better clinical outcomes and better adherence to therapy. Because of this, our study focuses on the benefits, advantages, and drawbacks of telepharmacy practice in outpatients with diabetes mellitus.
Our study shows that telepharmacy in patients with diabetes mellitus has been widely used in various countries with various forms of service in prescribing, drug administration, counseling, drug therapy monitoring, therapy adherence monitoring, dispensing, and patient activity management. The results of this study show that telepharmacy services have a lot of potential, especially for outpatients with diabetes mellitus.
Telepharmacy Benefits
Telepharmacy can help provide convenience while improving the quality of drug use, especially in terms of patient therapy compliance. This is due to the pharmaceutical services provided by clinical pharmacists in providing education about the drug therapy currently being used by patients,12–14 regular reminders of when to take drugs,15–18 and regular follow-up calls by pharmacists so that patients become more aware of the therapy they are currently undergoing.
Telepharmacy has also helped cut down on the number of hospitalizations and doctor visits that patients have to make.10,14 This could be because pharmacists use pharmaceutical care plans and services, which include preventing and treating problems with drug therapy that can lead to serious problems and the need to stay in the hospital.19 Several similar studies also found that pharmacist-led self-care counseling and training cut down on the number of hospitalizations and complications caused by diabetes.20
Several studies examining the effectiveness of telepharmacy services in the COVID-19 era show that telepharmacy improves drug delivery practices, helping to improve patient access to pharmaceutical services.21,22 Therefore, the fact that telepharmacy exists can help make up for the lack of pharmacists in rural or remote areas, where diabetic patients and other patients can easily get access to pharmaceutical services.23 In addition, telepharmacy also offers a more comfortable environment for pharmacists and patients to consult with patients without the risk of transmitting viruses.22
Significant improvements in dietary and physical activity behaviors were also seen with the use of telepharmacy, which is likely due to the provision of education and educational materials regarding types and proportions of healthy diets and encouraging patients to engage in regular physical activity.13,24
Telepharmacy Limitations
Telepharmacy practice, which is now widely used, still has some limitations. Consultation and counseling by pharmacists through telepharmacy focus more on improving patient adherence and clinical outcomes, not many telepharmacies provide education and information about self-management and self-activity of diabetes mellitus patients such as education about foot care, smoking, diet management, and weight reduction. There is a strong relationship between patient knowledge about the disease and medication adherence. It is hypothesized that well-informed patients have a better understanding of their disease and treatment process.25
Compared to traditional pharmaceutical services, telepharmacy is more vulnerable to privacy and security risks.26 For the broader application of telepharmacy, there are concerns about the privacy and security of the telehealth system. The telepharmacy provider must be responsible for ensuring regulatory compliance, patient confidentiality, and system security at all times. In addition to knowledge of the legal aspects of telepharmacy,27 it is important for providers to know and practice telepharmacy ethics. These ethical standards must be observed when pharmacists work remotely from home or make outpatient visits at their respective residences.28
Some of the telepharmacy services provided also require special devices that are usually used to monitor the patient’s daily blood sugar levels,15,29 telepharmacy that uses special devices also needs to provide comprehensive training to patients before using these devices, considering that diabetes mellitus patients are usually in their old age and are rarely exposed to technology, so they may experience difficulties.
With the rapid advancement of technology in the health sector, education on telepharmacy is very important, not only for pharmacists but also for patients. To get more people to use it, a formal continuing education program could keep pharmacists up to date on how telepharmacy is used today.30–32
Future Developments
Going forward, many steps need to be done to ensure the use of telepharmacy services growing and getting better. Pharmacist associations and pharmacists need to advocate for laws and regulations regarding telepharmacy that can guarantee security, privacy and legacy. Telepharmacy education not only for pharmacists but also for patients is also very important, the more telepharmacy education the more telepharmacy can be used widely. To facilitate communication between pharmacists and patients, a powerful, secure, and needs-based telepharmacy platform must be considered during creation. Additionally, there is a critical need for formal education programs to support pharmacists in maintaining their knowledge of modern telepharmacy procedures and their proficiency in offering pharmaceutical services. The general patients, and diabetes patients, feel secure during the consultation and, ultimately, can increase the existence of pharmacists as high-quality health workers.
Limitations
This literature review has limitations; maybe not all articles discuss the role of telepharmacy in patients with diabetes mellitus, because it depends on how the role of the pharmacist is described in articles. In addition, this study also focuses on discussing the benefits of telepharmacy in improving clinical outcomes and patient compliance, so that the output regarding cost and operational effectiveness is not discussed. However, the authors hoped that this literature review can become a reference in the future development of telepharmacy, especially for diabetes mellitus patients whose goal is to continue to provide high-quality pharmaceutical services.
Conclusion
Telepharmacy might be a different option for pharmaceutical services, even though there are still some restrictions on its use. It has been shown to be successful in giving interventions with notable results in clinical conditions and adherence to therapy in patients with diabetes mellitus. This literature review demonstrates the enormous potential of telepharmacy and serves as a guide for the creation of telepharmacy that can effectively assist patients, particularly those with diabetes mellitus, in receiving pharmaceutical services.
Acknowledgments
We would like to thank the Rector of Universitas Padjadjaran for funding the APC and Academic Leadership Grant 2022. In addition, we would like to thank the Minister of Education and Culture, Republic of Indonesia for the Matching Fund-Kedaireka Grant 2022.
Disclosure
The authors report no conflicts of interest in this work.
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