Study design

A descriptive, qualitative approach using face-to-face focus group (FG) discussions was used in this study.

Focus groups take advantage of the interaction and in-depth discussions between participants to highlight their attitudes and understanding, enable the expression of a wider range of ideas and experiences and explore various perspectives arising from the debate within the group [9,10].

The study was conducted per the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist, a guide that promotes explicit and comprehensive reporting of qualitative studies [11].

Participants

Clinical pharmacists across Hamad Medical Corporation (HMC), the principal public non-profit healthcare provider in the State of Qatar, were purposively selected to participate in the study.

Clinical pharmacy supervisors were excluded from this study to avoid the impact of power differentials, which could inhibit the participants from expressing their thoughts freely [12].

Recruitment continued until saturation was achieved and an agreement was made between the research team that no new concepts or ideas were emerging [13].

An email invite was sent to the candidates by the research team. The email included the research information sheet and a link to an electronic survey created via survey monkey to provide baseline demographics such as age, gender, and area of practice. The study was announced by emails and pharmacy leaders’ meetings across HMC.

Focus group sessions

The face-to-face (60–90 minutes) focus groups took place within HMC premises. A researcher (DK or RB) moderated the discussion with the assistance of an observer (DK or RB), who helped in facilitation, when needed, and took field notes. Both researchers are registered clinical pharmacists (Doctor of Pharmacy (PharmD) holders) practicing in HMC with experience in moderating FG discussions Only the moderator, observer and participants were present.At the start of every FG, written informed consents were obtained from the participants.

To promote an organized flow of the discussion and in-depth exploration of opinions, a semi-structured facilitation guide developed from available literature in the field of telepharmacy, telemedicine and telehealth [14–17] was used.

The sessions were audio-recorded to ensure that all participants’ views were captured accurately. Participants were asked for approval of voice recording before each session. The recordings were stored on a password-protected computer within HMC. All audio recordings were transcribed verbatim by a researcher (AO). Subsequently, two authors independently (DA or RJ and EA) verified the transcripts for accuracy. Final revised transcripts were emailed back to the participants for comment and/or correction. Participants did not provide any feedback on the findings.

Analysis

Data were analyzed by thematic content analysis. Two authors read each transcript, performed initial coding, clustered the codes, and defined emergent themes independently to increase the reliability of the data. Discrepancies between codes and themes generated by the researchers were subsequently discussed among the research team and resolved through consensus.

The study was approved by the Institutional Review Board (IRB) at HMC. (approval no: MRC-01-20-432).

Theme 1: Perceived meaning and scope of telepharmacy

The participants shared similar thoughts about the definition and scope of telepharmacy. They viewed telepharmacy as an alternative means of communication with patients and healthcare providers for the provision of pharmaceutical services when direct (face-to-face) contact is unachievable.

“Telepharmacy is caring for patients by pharmacists remotely through different methods of communication either phone or video conference or any other means of remote communication”- FG2, P4

One participant considered telepharmacy a part of telemedicine, whereas another believed that telemedicine is more advanced.

“So, for me, telepharmacy is part of telemedicine”—FG4, P1

“I think telemedicine is more advanced than telepharmacy”—FG5, P5

As they described the perceived meaning of telepharmacy, participants touched on available telepharmacy technologies, which included telephone calls, video calls (e.g., Zoom calls), text messages, and other communication platforms (e.g. Microsoft Teams). Of these, the telephone was the most commonly used modality as reported by some participants.

“The physicians in our setting were able to make video consultations, we didn’t do that in pharmacy, we just utilized the phone calls”—FG5, P5

Participants described telepharmacy activities provided during the pandemic as routine pharmaceutical services that are typically delivered through direct communications. These include remote medical chart review and subsequent communication of therapeutic recommendations to the healthcare team, medication reconciliation, patient education, and provision of drug information. One participant mentioned “It’s the same idea, counseling, drug information inquiries, pharmacotherapy suggestions, medication availability, proper administration, the same interventions but through the phone”

- FG4, P2

Theme 2: Readiness and preparedness for practicing telepharmacy

The discussants were not aware of any existing practice guidelines for telepharmacy. Few participants knew about the American Society of Health-System Pharmacists (ASHP) s’ and the American College of Clinical Pharmacy (ACCP)’s position statements on telepharmacy.

Only one pharmacist had prior telepharmacy experience and commented that:

“I worked in a clinic where I did a lot of telepharmacy… I had a list of telepharmacy patients where I would call them, and I would actually make changes to their therapy…”—FG2, P4

Apart from personal efforts and some literature searches, none of the participants received formal telepharmacy education or training.

“Truly, we did not have any education about telepharmacy”—FG3, P2

Moreover, participants reported a lack of local supporting telepharmacy guidelines or policies. One participant commented: “There was nothing in place to guide or to protocolize this process. No, not as per my information”—FG4, P2

The participants also spoke about the inadequacy of telepharmacy resources, which is an identified challenge that will be further described under theme 6. One pharmacist related this to limited crisis preparedness in general: “I think all in all, we did not have the preparedness to deal with the crisis across Qatar and the Middle East, we have no experience with such crisis…”—FG5, P4

Theme 3: Experience with applying telepharmacy in practice

Most participants reported being confident or very confident in applying telepharmacy. They expressed that their confidence increased as they acquired competence through clinical experience.

“You gain experience from different situations that you face with the patient or family members, so you get more confident by time”—FG5, P5

Many participants, however, described their experience with telepharmacy as being very difficult and challenging. They considered it an excessive burden that can lead to burnout. This was attributed to several challenges identified in theme 6. A participant remarked: “It was a huge, huge stress because there was no protocol in place to govern this process”—FG4, P2

Almost all participants favored in-person pharmaceutical services over telepharmacy.

“If in a normal situation, I don’t prefer remote coverage…no, face to face, you have to be there with patients…with the team”—FG1, P2

Theme 4: Perceived benefits of providing care through telepharmacy

Health system-related telepharmacy benefits

Limiting health care professionals’ infectious exposure risk was perceived as a major advantage of telepharmacy services.

“The first thing, it decreases the risk of infection transmission, so protect yourself and protect the patient and the team”—FG2, P2

Many participants noted that telepharmacy was more efficient than bedside rounds and led to enhanced work quality and productivity. They reported that telepharmacy provided an opportunity to stay focused, review a higher number of patients thoroughly and improve documentation as it avoided the travel time to patients’ wards and the round distractions.

“You have to go to the floor, to your unit and then come back to be called again for one more education, so doing it through telepharmacy saved time”—FG1, P1

“I felt that it was a more effective round because, during the physical rounds, you got many interruptions…”—FG5, P2

“Maybe I was better in documentation…. because there were less distractions”- FG4, P2

Participants also highlighted the role of telepharmacy in sustaining and expanding clinical pharmacy services to handle the COVID-19 patients’ surge during staff shortages. One pharmacist explained: “We were able to maintain our capabilities for a longer period of time”—FG4, P1

Another added: “If we need to cover more than one area, for example, NICU, PICU, sometimes emergency at the same time, it saves time and can give a chance to focus on the more serious patients”—FG2, P2

Some participants commented on improved communication among healthcare providers with telepharmacy, particularly in the ambulatory setting.

“I think in the outpatient, it improved the communication with physicians and nurses and even social workers…to get the best treatment plan and then to deliver it to the patient”- FG5, P5

However, most of the participants perceived telepharmacy as a threat to effective communication, particularly in acute care settings, which is addressed as a challenge in theme 6.

Theme 5: Perceived risks and drawbacks of providing care through telepharmacy

Many participants were worried about the negative impact of telepharmacy on the quality of patient care as they highlighted the value of attending bedside multidisciplinary rounds on the development and execution of well-informed, effective, and timely clinical decisions. One participant remarked: “I did an infectious disease telepharmacy, you would call the doctor and say, you know, we need to de-escalate to this antibiotic, and he says, oh my God, have you seen his leg? He has seen it and it’s horrible. I haven’t seen it. . . .”—FG2, P4

Concerns about the loss of patient confidentiality were also raised. Potential confidentiality threats identified by participants included the inadequacy of private spaces to conduct virtual consults and the lack of robust patient identity verification systems.

“I believe also the confidentiality of the patient was compromised because sometimes you are in a shared office, and you have to talk with the patient over the phone, like you do not have a private place to discuss issues with the patient”—FG5, P2

“We don’t really have a method to identify patients, so you call and ask is this patient X? They will tell you yes. But how do you make sure that this is the patient, not the patient’s son, not the patient’s brother? So patient identification was really challenging”—FG2, P3

Participants also spoke about the negative impact imposed by telepharmacy on their professional rapport with other healthcare professionals who deprecated CPs’ absence from bedside patient care rounds. One participant explained “We worked hard to build the relationship with nursing…then we disappeared, so we lost that communication, and then we came back…to try to build it again, this was a disadvantage”

- FG1, P4

“For me, it was a disadvantage, you totally lose the communication with health care professionals”—FG3, P2

Many participants perceived a preestablished trusting relationship between CPs and physicians as an important determinant for the acceptance of their therapeutic recommendations. A participant commented: “If the team knows you, I think your intervention mostly will be accepted, if the team doesn’t know you, I think the acceptance rate could be lower”—FG2, P2

Some participants described telepharmacy as an extra burden, as they highlighted the considerable time and effort required to conduct a tele-consult.

“Sometimes it will take double the time that you used to take in the face-to-face educational session”—FG5, P2

Patients’ dissatisfaction with remote clinical pharmacy services was perceived as another telepharmacy drawback. Participants explained that some patients preferred direct over virtual consults, particularly in the inpatient setting. One pharmacist commented: “It was difficult especially if the patient is demanding that you come and see him or her like other professions, like nurse, like physician…they were around the patient, but you were not there, so they were questioning “why you are not coming?”—FG1, P4

Theme 6: Barriers/Challenges in implementing telepharmacy

The sixth theme emerged from participants’ perceived challenges and barriers to the implementation of telepharmacy.

Patient-related telepharmacy challenges

Participants identified patient’ characteristics that could impede the implementation of telepharmacy and compromise health outcomes.

Low digital health literacy was perceived as a major barrier to effective telepharmacy use. A participant commented: “You are utilizing technologies to communicate and also you are talking about health topics, so if the general population health literacy and technology literacy is low you will not be able to utilize the telepharmacy… Well even simple like messaging for informing some 60 years old, I will say someone with low health literacy and low technology literacy, simply telling him I will send you a picture of this through this platform, he will not be able even to download this platform”—FG1, P2

Participants also discussed the challenge of delivering virtual care to complex, multimorbid patients and patients receiving complex medications such as inhalers and injectables, where comprehensive in-person education was believed to be necessary to ensure safety.

“If you have a complicated patient with multiple comorbidities and he has new medications started, you have to physically counsel, it will be very difficult as telepharmacy” FG1, P1

“If we have education for medications requiring explaining the technique…it is a major limitation to be honest”—FG1, P5

Several patient-related communication challenges were highlighted. Of which, language barrier was the most emphasized. Many participants rely on interpreters (e.g., nurses) to communicate with non-Arabic or English proficient patients during in-person consultations, which was impractical virtually.

“When we see the patients physically sometimes, we can use the help of a translator colleague, a nurse, or some other colleagues, but over the phone, it’s almost impossible. So, the language barrier is a huge one”—FG4, P5

As telepharmacy relied vastly on telephone calls, the lack of nonverbal communication was identified as another barrier to effective communication.

“You will lose all nonverbal communication, for example, clues for better understanding of the patient”—FG1, P4

“If you’re doing a chemotherapy education for the first time, you can express empathy in a face-to-face session, but it was very difficult over the phone”–FG5, P2

Participants also described communication challenges related to the difficulty in reaching patients, such as outdated contact information in electronic health records (EHRs), patients not responding to the calls, and family interference.

“You know, in the system… in Cerner, sometimes you can find six or seven numbers, contacting the first one, they transfer you to another number….and so on…of course, you will miss the patient”—FG2, P1

Moreover, participants indicated that financial constraints could limit some patients’ accessibility to the internet or hi-tech devices required for tele consults.

“Some patients will be kind of not privileged of having high technology, their mobiles even are very very old without advanced technologies, they will not be able to view videos or see PDFs or any kind of QR codes”—FG1, P4

Provider-related telepharmacy challenges

Participants identified a challenge in reaching some healthcare professionals to discuss patients’ updates and communicate therapeutic recommendations. This was further magnified when multiple specialties were involved in patient care.

“When you are trying to communicate to this specific patient you find yourself spending half an hour trying to reach the doctor trying to reach the nurse”–FG1, P5

Participants discussed at length the dissatisfaction and resistance expressed by other healthcare professionals toward transitioning to remote clinical pharmacy services, which negatively impacted pharmacists’ involvement in patient care. Many attributed this resistance to the lack of consistent communication about the service transition by the respective pharmacy leaders. Some participants even expressed feelings of embarrassment, stress, and self-defense as they frequently had to justify their absence from bedside rounds.

“You know, it’s a bad image…they were blaming you for not being there like them. They all have families, they all have risk factors, you know what I mean?”—FG4, P2

“The lack of communication between departments was a challenge. We had to explain to each one of the healthcare providers why we were not in the rounds”—FG1, P4

Participants also commented on the absence of telepharmacy culture, as another contributor to the encountered resistance.

“For them to accept, we have to build a culture, this is something new to everybody, including the patients and the physicians… it is not accepted because it’s something new rather than it’s not efficient”—FG2, P3

Deficiencies in patients’ electronic records due to late or incomplete documentation was another perceived major challenge. As their care plan relied mainly on chart review, CPs were worried about missing vital patient information. One pharmacist explained:

“I believe if you will get 100% full picture of the patient through face to face encounter with the team and the patient, actually through telepharmacy you will get two third or half that full picture because physicians will not have time to discuss over the phone as if they are face-to-face with you, so some of the data will be missing”—FG1, P2

System-related telepharmacy challenges

Most participants perceived insufficient operational and resource preparedness as a major challenge. Participants addressed the inadequacy of telepharmacy resources, and the lack of training, standardization, and consistent communication about the service transition as barriers toeffective telepharmacy implementation.

“We thought about having video calls but again we were not familiar with that situation, we did not have training to do that…so it was difficult"—FG1, P4

“I think also one of the major barriers from my point of view is missing the standardization, every pharmacist is performing telepharmacy according to his way”—FG1, P3

One participant commented that virtual care platforms were available, but CPs were not granted access to such platforms.

“There is a system, but the system is not open for other people to utilize it as it is needed. We don’t say there is no technology, no, there is a technology, but it is underutilized”—FG4, P4

Theme 7: Suggested facilitators of successful implementation of telepharmacy

Most participants suggested standardizing the practice of telepharmacy through well-established protocols or pathways and training staff as major facilitators of successful telepharmacy implementation.

“Have a pathway in place, this is the first thing. If you don’t have a pathway, you don’t have clear rights and the obligations for both the caller and receiver, nothing will work…things have to be standardized, it has to be very, very clear”—FG4, P2

Few participants spoke about the value of collaboration and sharing telehealth experiences with other professions across the healthcare system.

“I think collaboration is important to avoid this type of problems between different healthcare providers and to make a strategy about telemedicine, including telepharmacy, not to work in solos, working together is better I think”—FG5, P5

“First thing sharing experiences between others then we can have it standardized”—FG1, P5

Participants also voiced the need for resources required to conduct teleconsultations effectively, such as dedicated spaces, information technology support, approved communication platforms, and educational materials.

“In my opinion, the first one is building a communication platform, you cannot just depend on a phone, we need something that’s secure and efficient in communication”—FG2, P4

"Educational material approved for the patients, platforms for communication”—FG1, P5

Some participants suggested the creation of a pharmacy portal, such as a hotline or a website to improve patients’ access to pharmaceutical services. One pharmacist commented

“Can we also suggest a pharmacy website for HMC? So, patients can log in and put whatever they want. And then it is disseminated to the particular facility to provide their professional evidence-based answer”—FG5, P5

Promotion of telepharmacy services through dedicated channels was also suggested to enhance awareness and cultural acceptance.

“Informing the patients on large scale, on Facebook, HMC website, Instagram that we are having this service… the community will have expectations or that they know that this service is there”—FG1, P2

“Advertisement should be there, not only for the public, it should be actually first for the physicians and nurses and then once you fix that part, you can go for the public”—FG4, P2