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.
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.
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 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 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
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.
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.
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.
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.
The authors report no conflicts of interest in this work.
1. Le T, Toscani M, Colaizzi J. Telepharmacy: a new paradigm for our profession. J Pharm Pract. 2020;33(2):176–182. doi:10.1177/0897190018791060
2. Taylor AM, Bingham J, Schussel K, et al. Integrating innovative telehealth solutions into an interprofessional team-delivered chronic care management pilot program. J Manag Care Spec Pharm. 2018;24(8):813–818. doi:10.18553/jmcp.2018.24.8.813
3. Casey MM, Sorensen TD, Elias W, Knudson A, Gregg W. Current practices and state regulations regarding telepharmacy in rural hospitals. Am J Health Pharm. 2010;67:13. doi:10.2146/ajhp090531
4. Keeys C, Kalejaiye B, Skinner M, et al. Pharmacist-managed inpatient discharge medication reconciliation: a combined onsite and telepharmacy model. Am J Health Pharm. 2014;71(24). doi:10.2146/ajhp130650
5. Sankaranarayanan J, Murante LJ, Moffett LM, Retrospective A. Evaluation of remote pharmacist interventions in a telepharmacy service model using a conceptual framework. Telemed E Health. 2014;20(10). doi:10.1089/tmj.2013.0362
6. Win AZ. Telepharmacy: time to pick up the line. Res Soc Adm Pharm. 2017;13(4):882–883. doi:10.1016/j.sapharm.2015.06.002
7. Iftinan GN, Wathoni N, Lestari K. Telepharmacy: a potential alternative approach for diabetic patients during the COVID-19 pandemic. J Multidiscip Healthc. 2021;14:2261–2273. doi:10.2147/JMDH.S325645
8. Di Cerbo A, Morales-Medina JC, Palmieri B, Iannitti T. Narrative review of telemedicine consultation in medical practice. Patient Prefer Adherence. 2015;9:65–75. doi:10.2147/PPA.S61617
9. Bynum A, Hopkins D, Thomas A, Copeland N, Irwin C. The effect of telepharmacy counseling on metered-dose inhaler technique among adolescents with asthma in rural Arkansas. Telemed J E Health. 2001;7(3):3. doi:10.1089/153056201316970902
10. M Tourkmani A, J ALHarbi T, Rsheed AMB, et al. The impact of telemedicine on patients with uncontrolled type 2 diabetes mellitus during the COVID-19 pandemic in Saudi Arabia: findings and implications. J Telemed Telecare. 2021. doi:10.1177/1357633X20985763
11. Ghosh A, Gupta R, Misra A. Telemedicine for diabetes care in India during COVID19 pandemic and national lockdown period: guidelines for physicians. Diabetes Metab Syndr. 2020;14(4). doi:10.1016/j.dsx.2020.04.001
12. Lauffenburger JC, Ghazinouri R, Jan S, et al. Impact of a novel pharmacist-delivered behavioral intervention for patients with poorly-controlled diabetes: the ENhancing outcomes through Goal Assessment and Generating Engagement in Diabetes Mellitus (ENGAGE-DM) pragmatic randomized trial. PLoS One. 2019;14(4):4. doi:10.1371/journal.pone.0214754
13. Jahangard-Rafsanjani Z, Sarayani A, Nosrati M, et al. Effect of a community pharmacist–delivered diabetes support program for patients receiving specialty medical care: a randomized controlled trial. Diabetes Educ. 2015;41(1):127–135. doi:10.1177/0145721714559132
14. Erku DA, Ayele AA, Mekuria AB, Belachew SA, Hailemeskel B, Tegegn HG. The impact of pharmacist-led medication therapy management on medication adherence in patients with type 2 diabetes mellitus: a randomized controlled study. Pharm Pract. 2017;15(3):1–7. doi:10.18549/PharmPract.2017.03.1026
15. Arain MA, Ahmad A, Chiu V, Kembel L. Medication adherence support of an in-home electronic medication dispensing system for individuals living with chronic conditions: a pilot randomized controlled trial. BMC Geriatr. 2021;21(1):1–16. doi:10.1186/s12877-020-01979-w
16. Lyons I, Barber N, Raynor DK, Wei L. The Medicines Advice Service Evaluation (MASE): a randomised controlled trial of a pharmacist-led telephone based intervention designed to improve medication adherence. BMJ Qual Saf. 2016;25(10):759–769. doi:10.1136/bmjqs-2015-004670
17. Odegard PS, Christensen DB. MAP study: RCT of a medication adherence program for patients with type 2 diabetes. J Am Pharm Assoc. 2012;52(6):753–762. doi:10.1331/JAPhA.2012.11001
18. O’Connor PJ, Schmittdiel JA, Pathak RD, et al. Randomized trial of telephone outreach to improve medication adherence and metabolic control in adults with diabetes. Diabetes Care. 2014;37(12):3317–3324. doi:10.2337/dc14-0596
19. Xin C, Xia Z, Jiang C, Lin M, Li G. Effect of pharmaceutical care on medication adherence of patients newly prescribed insulin therapy: a randomized controlled study. Patient Prefer Adherence. 2015;9:797–802. doi:10.2147/PPA.S84411
20. Antoine SL, Pieper D, Mathes T, Eikermann M. Improving the adherence of type 2 diabetes mellitus patients with pharmacy care: a systematic review of randomized controlled trials. BMC Endocr Disord. 2014;14:0–7. doi:10.1186/1472-6823-14-53
21. Peláez Bejarano A, Villar Santos P, Robustillo-Cortés MDLA, Sánchez Gómez E, Santos Rubio MD. Implementation of a novel home delivery service during pandemic. Eur J Hosp Pharm. 2021;28(e1):E120–E123. doi:10.1136/ejhpharm-2020-002500
22. Killeen RM, Grindrod K, Ong SW. Innovations in practice: telepharmacy’s time has arrived. Can Pharm J. 2020;153(5):252–255. doi:10.1177/1715163520945732
23. McFarland R. Telepharmacy for remote hospital inpatients in north-west Queensland. J Telemed Telecare. 2017;23(10):861–865. doi:10.1177/1357633X17732367
24. Shane-McWhorter L, McAdam-Marx C, Lenert L, et al. Pharmacist-provided diabetes management and education via a telemonitoring program. J Am Pharm Assoc. 2015;55(5):516–526. doi:10.1331/JAPhA.2015.14285
25. Zullig LL, Peterson ED, Bosworth HB. Ingredients of successful interventions to improve medication adherence. JAMA. 2013;310(24):2611–2612. doi:10.1001/jama.2013.282818
26. Yang YT, Kozhimannil KB. Medication abortion through telemedicine. Obstet Gynecol. 2016;127(2):313–316. doi:10.1097/AOG.0000000000001251
27. Schwamm LH, Chumbler N, Brown E, et al. Recommendations for the implementation of telehealth in cardiovascular and stroke care: a policy statement from the American heart association. Circulation. 2017;135(7):e24–e44. doi:10.1161/CIR.0000000000000475
28. Abimbola S, Keelan S, Everett M, et al. The medium, the message and the measure: a theory-driven review on the value of telehealth as a patient-facing digital health innovation. Health Econ Rev. 2019;9(1). doi:10.1186/s13561-019-0239-5
29. Cohen LB, Taveira TH, Wu WC, Pirraglia PA. Pharmacist-led telehealth disease management program for patients with diabetes and depression. J Telemed Telecare. 2020;26(5). doi:10.1177/1357633X18822575
30. Clifton GD, Byer H, Heaton K, Haberman DJ, Gill H. Provision of pharmacy services to underserved populations via remote dispensing and two-way videoconferencing. Am J Health Pharm. 2003;60(24):2577–2582. doi:10.1093/ajhp/60.24.2577
31. Lam AY, Rose D. Telepharmacy services in an urban community health clinic system. J Am Pharm Assoc. 2009;49(5):652–659. doi:10.1331/JAPhA.2009.08128
32. Margolis SA, Ypinazar VA. Tele-pharmacy in remote medical practice: the royal flying doctor service medical chest program. Rural Remote Health. 2008;8(2):937. doi:10.22605/rrh937
33. Aguiar PM, da Silva CHP, Chiann C, Dórea EL, Lyra DP, Storpirtis S. Pharmacist–physician collaborative care model for patients with uncontrolled type 2 diabetes in Brazil: results from a randomized controlled trial. J Eval Clin Pract. 2018;24(1):22–30. doi:10.1111/jep.12606
34. Chen JH, Ou HT, Lin TC, Lai ECC, Yang Kao YH. Pharmaceutical care of elderly patients with poorly controlled type 2 diabetes mellitus: a randomized controlled trial. Int J Clin Pharm. 2016;38(1):88–95. doi:10.1007/s11096-015-0210-4
35. Choudhry NK, Isaac T, Lauffenburger JC, et al. Effect of a remotely delivered tailored multicomponent approach to enhance medication taking for patients with hyperlipidemia, hypertension, and diabetes the STIC2IT cluster randomized clinical trial. JAMA Intern Med. 2018;178(9):1182. doi:10.1001/jamainternmed.2018.3189
36. McConnell M, Rogers W, Simeonova E, Wilson IB. Architecting process of care: a randomized controlled study evaluating the impact of providing nonadherence information and pharmacist assistance to physicians. Health Serv Res. 2020;55(1):136–145. doi:10.1111/1475-6773.13243
37. Jarab AS, Alqudah SG, Mukattash TL, Shattat G, Al-Qirim T. Randomized controlled trial of clinical pharmacy management of patients with type 2 diabetes in an outpatient diabetes clinic in Jordan. J Manag Care Pharm. 2012;18(7):516–526. doi:10.18553/jmcp.2012.18.7.516
38. Khan YH, Alzarea AI, Alotaibi NH, et al. Evaluation of impact of a pharmacist-led educational campaign on disease knowledge, practices and medication adherence for type-2 diabetic patients: a prospective pre- and post-analysis. Int J Environ Res Public Health. 2022;19(16):10060. doi:10.3390/ijerph191610060
39. Lauffenburger JC, Lewey J, Jan S, et al. Effectiveness of targeted insulin-adherence interventions for glycemic control using predictive analytics among patients with type 2 diabetes: a randomized clinical trial. JAMA Netw open. 2019;2(3):e190657. doi:10.1001/jamanetworkopen.2019.0657
40. Lee JY, Wong CP, Tan CSS, Nasir NH, Lee SWH. Telemonitoring in fasting individuals with type 2 diabetes mellitus during ramadan: a prospective, randomised controlled study. Sci Rep. 2017;7(1). doi:10.1038/s41598-017-10564-y
41. Mcfarland M, Davis K, Wallace J, et al. Use of home telehealth monitoring with active medication therapy management by clinical pharmacists in veterans with poorly controlled type 2 diabetes mellitus. Pharmacotherapy. 2012;32(5):420–426. doi:10.1002/j.1875-9114.2011.01038.x
42. Olesen C, Harbig P, Buus KM, Barat I, Damsgaard EM. Impact of pharmaceutical care on adherence, hospitalisations and mortality in elderly patients. Int J Clin Pharm. 2014;36(1):163–171. doi:10.1007/s11096-013-9898-1
43. Peasah SK, Granitz K, Vu M, Jacob B. Effectiveness of a student pharmacist–led telephone follow-up intervention to improve hemoglobin A1C in diabetic patients. J Pharm Pract. 2020;33(6):832–837. doi:10.1177/0897190019857409
44. Sarayani A, Mashayekhi M, Nosrati M, et al. Efficacy of a telephone-based intervention among patients with type-2 diabetes; a randomized controlled trial in pharmacy practice. Int J Clin Pharm. 2018;40(2):345–353. doi:10.1007/s11096-018-0593-0
45. Siaw MYL, Ko Y, Malone DC, et al. Impact of pharmacist-involved collaborative care on the clinical, humanistic and cost outcomes of high-risk patients with type 2 diabetes (IMPACT): a randomized controlled trial. J Clin Pharm Ther. 2017;42(4):475–482. doi:10.1111/jcpt.12536