A systematic scoping review of implementation of telepharmacy during COVID-19

This systematic scoping review aimed to examine the literature on expanding role of telepharmacy services during the ongoing COVID-19 pandemic. Four electronic databases, PubMed, Scopus, ProQuest, and Cochrane, were searched to identify published studies that reported implementation of telepharmacy services since the start of pandemic (31st December 2019 to 31st May 2022). Twenty-eight studies met the inclusion criteria comprising 15 cross-sectional studies, 12 studies sharing experience and practice related to telepharmacy services, and one pre-post intervention study. Studies reported establishment and implementation of various novel telepharmacy models in different settings; primary, secondary, tertiary, and quaternary care hospitals, hospital and community pharmacies, and specialized care centers. Telepharmacy provided pharmaceutical care to patients with COVID-19, chronic diseases, HIV infection, cancer, cystic fibrosis, and patients on anticoagulants. Pharmaceutical care services like patient counseling services (19 studies), medication order review and medication reconciliation (15 studies), drug therapy optimization (11 studies), adverse drug reaction monitoring and management (7 studies), medication adherence assessment (5 studies), and drug-related problem monitoring (4 studies) were delivered using telepharmacy. Based on the identified evidence, telepharmacy proved beneficial in delivering a range of pharmaceutical care services to the patients during the current pandemic. However, there is a need for more rigorous evidence on the reliability, safety, and effectiveness of telepharmacy in comparison to the traditional face-to-face healthcare delivery model.


INTRODUCTION
The implementation of telepharmacy models began in early 2000s in United States, Australia, and Canada with the aim of providing telehealth services to patients situated at remote locations (Clifton et al., 2003;McDonald, 2009;Nissen and Tett, 2003). Telepharmacy, which falls under the telemedicine umbrella, refers to the provision of pharmaceutical care services through information and communication technologies to the patients in remote areas without direct contact with the pharmacist (Alexander et al., 2017). Over the years, telepharmacy has been useful in delivering medication-use activities when pharmacists may not be present physically or in situations where there may be limitations of pharmacy resources (Baldoni et al., 2019). Furthermore, it provides an alternative for delivering care services in specialty areas where staffing is limited Peterson and Anderson, 2004;Poulson et al., 2010;Win, 2017).
Adoption of telepharmacy services has proved beneficial in many aspects. It has improved accessibility of pharmaceutical care services to patients in rural and far-flung areas (Kimber and Peterson, 2006). It has reduced cost and saved time for the patients (Littauer et al., 2017;Traynor, 2013). Furthermore, telepharmacy improved medication adherence (Fensterheim et al., 2015) among patients by enhancing their trust and contentment with the provided services. Telepharmacy has expanded the role of pharmacists by providing an ideal medium for improving the medication management in patients with chronic diseases (Margolis et al., 2013;McFarland et al., 2012), for identifying and resolving the drug-related problems (McNamara et al., 2021;Wang et al., 2021), for medication monitoring and optimization (Mohiuddin et al., 2021;Surapat et al., 2021), for efficient patient education with enhanced privacy (Hudd and Tataronis, 2011;Lam and Rose, 2009), for adverse drug reaction monitoring (Bindler, 2020;, and for dealing the social determinants of health (Livet et al., 2021).
The COVID-19 pandemic has changed the way how information technology is utilized in healthcare services (Budd et al., 2020). During the ongoing pandemic, telepharmacy received increased attention and being widely employed all around the world (Killeen et al., 2020). It has emerged as a viable substitute for the provision of face-to-face pharmaceutical care services during the pandemic, especially at a time when people are required to practice social distancing and limit the in-person visits to the healthcare facilities (Ameri et al., 2020;Unni et al., 2021). Therefore, this systematic scoping review aimed at summarizing the expanding role of telepharmacy services in the pandemic era which emerged as a useful tool in delivering the best telehealth services to patients and rebooted the role of clinical and community pharmacists in healthcare system. Unni et al. (2021) conducted a similar scoping review of telepharmacy during COVID-19. However, their literature search was limited to only two databases with different study inclusion criteria. This systematic review employed a comprehensive search of four large databases and included all types of studies that reported implementation of telepharmacy services since the beginning of COVID-19 pandemic.
The objectives of this systematic review were to: 1. Identify the different types of studies that reported implementation of telepharmacy services during the COVID-19. 2. Characterize the pharmaceutical care services provided through telepharmacy during COVID-19. 3. Recognize the different means and tools employed for telepharmacy. 4. Examine the impact or outcomes of telepharmacy services on the study populations.

METHODS
This systematic scoping review was carried out as per the guidance by Joanna Briggs Institute (Peters et al., 2015) and is reported following the Preferred Reporting Items for Systematic Reviews and Meta-analyses Extension for Scoping Reviews (PRISMA-ScR) guidelines (Tricco et al., 2018).

Search strategy
Four electronic databases, PubMed, Scopus, ProQuest, and Cochrane, were searched from 31 st December 2019 to 31 st May 2022, utilizing recognized search methods for scoping reviews (Peters et al., 2015) to identify relevant published studies. On each of these databases, preliminary searches were carried out to identify relevant search terms. A combination of keywords was used: Coronavirus disease, COVID-19, SARSCoV-2, telepharmacy, tele-pharmacy, telemedicine, tele-medicine, telehealth, tele-health, pharmacist, clinical pharmacist, hospital pharmacist, and community pharmacist. The search terms were combined using Boolean operators; AND, OR, and NOT. The search strategy was developed in consultation with the university librarian. Furthermore, to identify additional studies the reference lists of all the selected studies were screened.

Inclusion criteria
All articles, research, practice innovation, and experience, which reported implementation, application, establishment, modification, and expansion of telepharmacy services, involving pharmacists since the beginning of COVID-19 pandemic, were included in the review. Furthermore, articles only in English language were included. The start of the pandemic was taken as 31 st December 2019, when the health authorities in Wuhan confirmed first cases of COVID-19.

Exclusion criteria
Review articles, opinions, letters, articles describing opportunities and challenges, articles related to other healthcare professions (other than pharmacists), knowledge, attitude, and perception articles, and technology-related articles were excluded from the review.

Study selection
Two reviewers Syed Arman Rabbani (SAR) and Shrestha Sharma (SS) performed the screening of the articles (title and abstract screening along with full-text screening for eligibility) based on the eligibility criteria. Other two reviewers Asiya Mahtab (AM) and Faheem Hyder Pottoo (FHP) independently confirmed this screening exercise. In case of any conflict or disagreement during the screening process, opinion of the fifth reviewer Sathvik B. Sridhar (SBS) was sought. Conflict or disagreement was resolved through consensus discussion.

Charting and synthesis of data
Two reviewers (SAR and SS) independently carried out the data extraction or charting. The following information was recorded: authors, country, type of study, study setting, type of pharmaceutical care service offered through telepharmacy, tools/ means of telepharmacy, and description and impact of the study.
Methodological quality assessment of the studies included in this review was not carried out as the review aimed to summarize and disseminate the current evidence on telepharmacy implementation during COVID-19. A narrative synthesis of the evidence was completed and presented in the review.

Search results
The literature search generated 270 articles. Following deduplication, screening titles, and abstracts of the articles, 68 full-text articles were reviewed for eligibility. Out of these, 40 articles did not meet the eligibility criteria and were excluded. Reasons for exclusion were: studies related to other healthcare professionals, studies related to knowledge, attitude, perception of telepharmacy, opinions, recommendations, advice, statements, patient experiences, and technology-related studies. In total, 28 studies, which met the inclusion criteria, were included in the review. Figure 1 depicts the details of the literature search and the screening processes.

Characteristics of the studies
The key characteristics of the studies included in the review are outlined in Table 1.
Telepharmacy services were implemented in different settings including primary, secondary, tertiary, and quaternary care hospitals, hospital and community pharmacies, and specialized care centers like cancer, stroke, anticoagulation, cystic fibrosis, and pediatric. In addition, rural and remote areas were also served by telepharmacy during the COVID-19.

Participants
Out of the 28 studies, 17 studies reported the different numbers and types of participants. Telepharmacy services were offered to varied populations including COVID-19 patients, cancer patients, patients with cystic fibrosis, patient with HIV infection, patients with other chronic diseases, and patients on anticoagulation therapy, patients with hospital, community pharmacy visits, and general population.

Pharmaceutical care services delivered through telepharmacy during COVID-19
The details of pharmaceutical care services provided using telepharmacy during the ongoing pandemic are summarized in Table 1 and illustrated in Figure 2. In majority of the studies (19 out of 28), patient counseling or education services were provided virtually employing telepharmacy. In 15 studies medication order review or verification and medication reconciliation were delivered remotely through telepharmacy. Drug therapy optimization and medication management services were also offered during COVID-19 with the help of telepharmacy in 11 of the 28 reviewed studies. Moreover, adverse drug reaction monitoring  • The team tele-monitored the patients using the hospital's computerized physician order entry system.
• Tele-monitoring helped in detection of drug-related problems and adverse drug reactions in COVID-19 patients.
• Different pharmaceutical care services were provided through telepharmacy including drug dosage regimen design for COVID-19 patients.
• Telepharmacy was found to be viable and effective method for clinical pharmacists to provide pharmaceutical care services.
Tortajada-Goitia et al. and management were carried out remotely in seven studies. Five studies reported medication adherence assessment and in four of the studies, drug-related problem monitoring and management were done using telepharmacy mode. Other pharmaceutical care services included medication history interview, chronic disease management, therapeutic drug monitoring, antibiotic stewardship, and psychological counseling.

Means and tools for telepharmacy
Different tools and means like telephones, smartphones, online platforms/portals, social media apps, and dedicated telepharmacy software were employed for the implementation and execution of telepharmacy services (Fig. 3). Table 1 describes the impact or outcomes of implementation of telepharmacy services during COVID-19. Studies reported that telepharmacy model provided efficient and effective pharmaceutical care services to the patients during the ongoing pandemic (n = 5). Telepharmacy services facilitated riskfree virtual patient education and counseling (n = 17), helped in resolution and minimization of different drug-related problems (n = 5), resulted in improved medication adherence among the patients (n = 3), identification and prevention of medication errors (n = 3), better medication management (n = 3), symptom assessment (n = 1), and giving out COVID-19 related recommendations to the patients (n = 5).

DISCUSSION
This systemic review mainly focused upon the implementation of telepharmacy in response to COVID-19 for providing pharmaceutical care services all around the world. The sudden onset of COVID-19 demanded swift restructuring of healthcare systems for ensuring delivery of pharmaceutical care and forced to revamp the roles of clinical and community pharmacists in the healthcare system. With a series of COVID-19 waves, frequent lockdowns and mobility restrictions have become a norm and with this new normal telepharmacy emerged as a valuable tool for providing healthcare services at home. Telepharmacy was used for delivering pharmaceutical care services within the purview of pharmacist's responsibilities while maintaining the temporal and spatial distance between the patients and the healthcare providers.
This review describes the different types of pharmaceutical care services that are being offered through telepharmacy in the ongoing pandemic worldwide and their impact. These tele-pharmaceutical care services were well received by both the patients and other healthcare professionals as they ensured uninterrupted patient care, accessibility to medicines, and proved their significance in these testing times.
A myriad of pharmaceutical care services were provided using telepharmacy including medication order review, medication dispensing, medication reconciliation, medication management and optimization, medication adherence assessment, medication query resolution, therapeutic drug monitoring, adverse drug reaction monitoring, drug-drug interaction monitoring, chronic disease management, medication-related problem resolution, patient education, psychological support, and drug information services. Telepharmacists employed different means and tools for discharging these services including smartphones, telephones, online platforms and portals, and different applications and software. Telepharmacy provided pharmaceutical care to COVID-19 patients, patients with HIV, cancer, cystic fibrosis, and other chronic diseases, patients on anticoagulants, and patients presenting to hospital and community pharmacies and general population.
Studies reported the establishment and implementation of various novel telepharmacy models during COVID-19. A study conducted in Pakistan reported a novel multi-stakeholder collaboration telepharmacy model called "Guddi-baji" (Bukhari et al., 2021). The model effectively connected the rural community patients to real time healthcare professionals including doctors and telepharmacists through female-healthcare workers. The pharmacists performed virtual prescription verification, dispensing, and counseling for the patients. The model resulted in better health awareness and medication adherence in the community. Furthermore, it resulted in prevention of medication errors.
A number of studies conducted in United States described different telepharmacy and remote pharmacy services. Kjerengtroen et al. (2020) shared implementation of a remote pharmacy services plan as part of COVID-19 preparedness in a quaternary referral medical trauma and stroke center. Clinical pharmacists were equipped with different software applications like "TeleHealth AV", "Connect Care Pro TeleHealth", and devices like "Vocera Badge" to provide remote pharmaceutical care services to the patients. Virtual clinical pharmacy services were established in pediatric and neonatal intensive care units where during virtual rounds clinical pharmacists provided real time recommendations to medical team using video conferencing and provided discharge counseling to the patients. Efficient and effective pharmaceutical care was provided to the patients remotely using these virtual clinical pharmacy services (Allison et al., 2021).
In China, a well-timed and interactive telepharmacy service model, "Cloud Pharmacy Care" utilizing social software "WeChat app," model facilitated medication therapy management in chronic patients. In addition, the model effectively provided patient education and addressed medication-related problems of the patients (Li et al., 2021). Furthermore, with the help of radio and telephone, clinical pharmacists provided pharmaceutical care interventions including resolution of drug-related problems, psychological support, and relieved patients' COVID-19associated fears and concerns (Wang et al., 2021).
In United Arab Emirates, telepharmacy services augmented patient's accessibility to pharmaceutical care and reduced medication-dispensing errors (Al Mazrouei et al., 2021;Ibrahim et al., 2020). Pharmacies with telepharmacy services provided significantly higher number of COVID-19related recommendations as compared to pharmacies without telepharmacy services. In addition, pharmacies with telepharmacy services had lower incidence of medication dispensing errors than pharmacies without telepharmacy services. Furthermore, implementation of telepharmacy services potentiated the clinical significance of pharmacist interventions related to over the counter medicine abuse. Older and vulnerable patients accessed telepharmacy services more compared to younger patients (Al Mazrouei et al., 2021;Ibrahim et al., 2020).
Telepharmacy services were also extended to support patients on anticoagulant (Al Ammari et al., 2021), antineoplastic (Marchese et al., 2021), and antiretroviral (Quirós-González et al., 2021) agents in Saudi Arabia, Canada, and Spain, respectively. Clinical pharmacists provided different pharmaceutical care services to these patients including remote medication history interview, care plan development, telephone-based dose adjustments, telephonic medication counseling, medication adherence assessment, and medication delivery.
Studies included in this review reported either implementation of telepharmacy services or assessed established telepharmacy services. These studies advocated that telepharmacy models enhanced the provision of different pharmaceutical care services with augmented patient access and minimized pharmacist-patient direct contact. The telepharmacy models were found to be efficient, cost-effective, and met patient satisfaction. These advantages and benefits are consistent with the previous literature reviews on telehealth and telepharmacy (Monaghesh and Hajizadeh, 2020;Shafiee Hanjani et al., 2020;Unni et al., 2021). In addition to these advantages and benefits, the studies identified many barriers and challenges to the implementation of telepharmacy. The major barriers to the successful application of telepharmacy services included poor technological and network connectivity in remote areas (Allison et al., 2021;, lack of technology familiarity, and knowledge and resources among the patients (Al Marchese et al., 2021). Other barriers included legal issues, confidentiality, privacy, and security concerns Hedima and Okoro, 2020), insurance payments and reimbursement, government licensing issues, and lack of coordination among the different healthcare providers (Tortajada-Goitia et al., 2020). Execution and implementation of extensive and uniform telepharmacy laws and regulations remain a challenge to the future of telepharmacy (Hedima and Okoro, 2020; Kovačević et al., 2021).
The main strength of this scoping review is that it has examined the emerging evidence on telepharmacy services in the current ongoing pandemic. Furthermore, this review employed a comprehensive search of large databases and included all types of studies related to telepharmacy services. The methods and search strategies employed in this review might help in the protocol development for future systematic reviews on this subject. However, this review had some limitations. First, we followed scoping review approach instead of systematic review approach, as the purpose was first to determine the scope and coverage of existing body of literature on telepharmacy services during COVID-19, investigate the telepharmacy evidence rapidly emerging during this pandemic and identify the types of studies conducted on the topic. This approach, however, lacked critical appraisal. Second, the review did not take into account the studies published in languages other than English. Third, majority of the studies were descriptive and were not consistent in outcomes reported, which preluded any conclusive take on intervention effectiveness. Fourth, existing telepharmacy models that are being used in practice but not published were not captured.

CONCLUSION
This scoping review reports increased use of telepharmacy for delivering pharmaceutical care services during the ongoing COVID-19 pandemic. The review gathered evidence on the implementation of telepharmacy services during COVID-19 and selected 28 studies describing the establishment, implementation, modification, and expansion of telepharmacy services. Based on the identified evidence, telepharmacy proved beneficial in delivery of a myriad of pharmaceutical care services to the patients, including medication order review, medication dispensing, medication reconciliation, medication optimization, medication adherence assessment, medication query resolution, therapeutic drug monitoring, adverse drug reaction monitoring, drug-drug interaction monitoring, chronic disease management, medication-related problem resolution, patient education, psychological support, and drug information services.
The review highlights the scope and coverage of emerging evidence on telepharmacy services in light of COVID-19, paving the way for future systematic reviews and meta-analyses. Telepharmacy has the potential to revolutionize pharmaceutical care in the future. However, there is an urgent need for development and adoption of unified telepharmacy laws and regulations; development of robust telepharmacy platforms; mechanisms for monitoring and evaluation of these services; provision for continuing professional development programs and integration of telepharmacy consultations into the health insurance plans. Furthermore, there is a need for more rigorous evidence on the reliability, safety, and effectiveness of telepharmacy in comparison to the traditional face-to-face healthcare delivery model.