PART 33               TELE-PHARMACY AND REMOTE DISPENSING             ISSUING AGENCY:  Regulation and Licensing Department - Board of Pharmacy.

[ NMAC - N, 05-14-10]             SCOPE:  This section applies to hub pharmacies and remote tele-pharmacies.  Both the hub pharmacy and remote tele-pharmacy must be located within and licensed by the New Mexico board of pharmacy. The remote tele-pharmacy must be greater than 20 miles from an existing retail pharmacy to qualify under these rules.

[ NMAC - N, 05-14-10; A, 06-09-17]             STATUTORY AUTHORITY:  Section 61-11-6.A(6) NMSA 1978 requires that the board of pharmacy provide for the licensing of retail pharmacies and nonresident pharmacies and for the inspection of their facilities and activities. Section 61-11-6.A(1) NMSA 1978 requires the board of pharmacy to adopt, regularly review and revise or repeal rules and regulations necessary to carry out the provisions of the Pharmacy Act.

[ NMAC - N, 05-14-10]             DURATION:  Permanent.

[ NMAC - N, 05-14-10]             EFFECTIVE DATE:  May 14, 2010, unless a different date is cited at the end of a section.

[ NMAC - N, 05-14-10]             OBJECTIVE:  The objective of Part 33 of Chapter 19 is to ensure the safe and competent delivery of quality pharmaceutical products and the provision of pharmaceutical care to the public by establishing standards for the operation of remote dispensing sites and tele-pharmacy, including but not limited to minimum space requirements and standards for equipment, accessories, personnel, dispensing and labeling.

[ NMAC - N, 05-14-10]             DEFINITIONS:

                A.            “Board” means the New Mexico board of pharmacy.

                B.            “Electronic link” means a real time, continuous HIPAA-compliant computer video and audio link between the hub pharmacy and the remote tele-pharmacy during all hours of the remote tele-pharmacy’s operation and in compliance with Paragraph (4) of Subsection A of NMAC.

                C.            “Indirect supervision” means continuous supervision through a constant live video link with not less than four camera views which provide for real time live monitoring by the hub pharmacy of the remote tele-pharmacy which is recorded for a minimum of 90 days.  This indirect supervision must be in compliance with Subsection B of NMAC.

                D.            “Patient-pharmacist audio visual link” means a real time HIPAA-compliant audio visual link from the private patient counseling area of the remote tele-pharmacy to the pharmacist at the hub pharmacy.

                E.            “Hub pharmacy” means a board licensed pharmacy located in New Mexico operating under the direct control of a board registered pharmacist from which computer-aided pharmacist supervision of a remote tele-pharmacy occurs.

                F.            “Hub pharmacist” means a board registered pharmacist who provides the indirect supervision of a remote tele-pharmacy via HIPAA-compliant electronic link that includes provisions for visual observations and inspection of the inside of the remote tele-pharmacy and all prescription orders prior to dispensing and is in compliance with Subsection B of NMAC.  This oversight is to include visual inspection of and patient consultation for any prescription order dispensed from the remote tele-pharmacy.

                G.            “Pharmacist-in-charge” means the pharmacist for the hub pharmacy from which the hub pharmacist oversees the day to day operation of a remote tele-pharmacy and who shall comply with NMAC.

                H.            “Pharmacist site visits” means the visitation and inspection of the tele-pharmacy by the hub pharmacist by which the hub pharmacist is physically present to assess the remote tele-pharmacy’s compliance with all laws and regulations.

                I.             “Remote dispensing site” means a pharmacy location primarily staffed by technicians and remote dispensing technology electronic link and indirect supervision with required pharmacist supervision and pharmacist site visits.

                J.             “Remote tele-pharmacy” means a board licensed pharmacy located in the state of New Mexico staffed by a remote tele-pharmacy technician who practices under the direct, computer aided and supervision of a hub pharmacist working from the hub pharmacy by electronic link during all hours of operation.

                K.            “Remote tele-pharmacy technician” means a board registered pharmacy technician employed by the hub pharmacy, with a minimum of 2,000 hours of experience working as a certified registered pharmacy technician who under the computer aided supervision of an off-site pharmacist, handles the day to day operation of a remote tele-pharmacy, including the preparation and dispensing of prescription drugs.

                L.            “Practice of tele-pharmacy” means the provision of pharmacist care by board licensed pharmacies and board licensed pharmacists through the use of telecommunications or other technologies to patients or their agents at a remote tele-pharmacy site.

[ NMAC - N, 05-14-10; A, 06-09-17]             PURPOSE:  The board is responsible for maintaining, continuing and enhancing the development of the education and professional role of the pharmacist for the protection of the health, welfare and safety of the citizens of New Mexico.  In order to maintain, augment or expand the availability of pharmacy services in communities that have pharmacy access issues, rules are necessary to permit remote tele-pharmacy services and remote dispensing.

[ NMAC - N, 05-14-10; A, 06-09-17]             OPERATIONS:

                A.            A remote tele-pharmacy shall comply with all standards of NMAC governing the procedure for obtaining a license to operate a pharmacy in New Mexico.

                                (1)           The license holder of the hub pharmacy must apply for a license to operate a remote tele-pharmacy.  A remote tele-pharmacy license is established for the purpose of conducting a remote tele-pharmacy.  The license is issued to a remote tele-pharmacy connected to a hub pharmacy via an electronic link.  The initial licensure fee and subsequent license renewal fee are the same as those for retail pharmacies, as required by Subsection E of NMAC.

                                (2)           A remote tele-pharmacy that operates under different ownership than the hub pharmacy to which it is attached; shall have a written contractual agreement outlining the responsibilities of each pharmacy.  This written agreement shall be submitted with the initial licensure application for a remote tele-pharmacy.  Any subsequent changes to that contractual agreement shall be submitted to the board’s executive director for approval.  The applicant must provide sufficient evidence that the addition of a tele-pharmacy will augment or expand the availability of pharmacy services and pharmacy access within the proposed area of location.

                                (3)           A remote tele-pharmacy shall comply with all the applicable requirements for a pharmacy as contained in 16.19.6 NMAC, including the requirement that all medications are stored under proper conditions.

                                (4)           A remote tele-pharmacy shall be connected to a hub pharmacy via HIPAA-compliant electronic link.  All links must be fully operational during all hours of operation of the remote tele-pharmacy. If the link malfunctions, the remote tele-pharmacy must be closed to the public unless a pharmacist is physically present at the remote tele-pharmacy site.

                                                (a)           Video equipment must be capable of providing not less than four simultaneous camera views of the pharmacy operation at the remote tele-pharmacy.

                                                (b)           The video equipment at the remote tele-pharmacy site must be capable of resolution sufficient to allow for pharmacist identification of medication dosage forms and the reading of bottle labels via video camera.

                                                (c)           The video equipment at the remote tele-pharmacy site must be capable of recording and maintaining at least 90 days of video surveillance of the remote tele-pharmacy site and operations for future review.

                                                (d)           Only a remote tele-pharmacy technician designated for that site or a pharmacist who is physically present at the remote tele-pharmacy may access a remote tele-pharmacy site, linked to a hub pharmacy via an electronic link.

                                                (e)           The remote tele-pharmacy may only remain open to the public as long as the designated pharmacy technician is present in the remote tele-pharmacy and the hub pharmacist is providing indirect supervision from the hub pharmacy or the hub pharmacist is physically present at the remote site.

                                                (f)            The name of each certified pharmacy technician that works at a remote tele-pharmacy shall be recorded with the board.

                                (5)           The remote tele-pharmacy shall utilize bar coding or similar technology that effectively recognizes the drug or device selected to fill the prescription is the same as indicated on the prescription label.

                                (6)           The hub pharmacy and hub pharmacist are responsible for ensuring fulfillment of all pharmacist responsibilities in accordance with NMAC.

                                (7)           Written policies and procedures must be submitted to the board prior to the issuance of any license.  The pharmacist-in-charge is responsible for the development, implementation, maintenance, and review of written policies and procedures for the safe and effective operation of the remote tele-pharmacy and the oversight by the hub pharmacy.  These policies and procedures shall comport with board regulations and laws and shall be available for board inspection in both the remote tele-pharmacy and the hub pharmacy.  The policy and procedure manual shall be reviewed by the pharmacist-in-charge at least annually and revised if necessary to promote improvements in safety and service at the remote tele-pharmacy.  The annual review and any changes to the manual shall be documented.  The policy and procedure manual must address each of the following, at a minimum:

                                                (a)           standards and practices necessary to ensure safety, accuracy, security, and patient confidentiality;

                                                (b)           standards and practices necessary to ensure drugs and devices are procured, handled, stored, and dispensed or otherwise dispositioned in accordance with state and federal laws and regulations;

                                                (c)           identification of pharmacy personnel authorized to access drug storage and dispensing areas at the remote tele-pharmacy and to receive drugs delivered to the remote tele-pharmacy;

                                                (d)           standards and practices necessary to ensure all records are maintained in compliance with board laws and regulations;

                                                (e)           processes to assure the integrity, legitimacy and authenticity of prescriptions;

                                                (f)            criteria for monthly inspections conducted during pharmacist site visits and appropriate site visit documentations;

                                                (g)           medication error prevention;

                                                (h)           training standards and practices to ensure facility personnel are properly trained and comply with all applicable policies and procedures.  Training shall be required for the remote tele-pharmacy technicians and pharmacists to ensure the competence and ability of each person that operates the electronic verification system, electronic record keeping, and communication systems.  Technician training documentation shall be maintained in accordance with 16.19.22 NMAC.

                                (8)           The pharmacist-in-charge is responsible for an ongoing review of incident reports and outcomes, with appropriate corrective action taken and documented.

                                (9)           The pharmacist-in-charge must ensure each remote tele-pharmacy location records, for each prescription dispensed, the identification of each pharmacist who performed:

                                                (a)           order interpretation;

                                                (b)           order entry verification;

                                                (c)           prospective drug utilization review;

                                                (d)           final order verification;

                                                (e)           any intervention required; and

                                                (f)            patient counseling, when there are no other means of definitively determining the identity of the pharmacist who provided counseling.

                                (10)         A hub pharmacist shall not provide direct or indirect supervision for more than four pharmacies.

                                (11)         The hub pharmacist must conduct pharmacist site visits and complete inspections of the remote tele-pharmacy at least once monthly.  The pharmacist shall increase frequency of the monthly site visits if issues are identified, and additional pharmacist intervention shall be taken and documented until the issue is resolved.  A list of inspection criteria shall be included in the policy and procedure manual for the remote tele-pharmacy.  The pharmacist’s inspection shall include a determination of the average number of prescriptions filled per day.  A copy of the inspection report shall be reviewed and signed by the pharmacist-in-charge of the hub pharmacy and a copy of the inspection report shall be maintained at both the remote tele-pharmacy and at the hub pharmacy for the board of pharmacy inspection.

                                (12)         The number of pharmacy technicians that a hub pharmacist shall oversee shall be limited according to NMAC.  Any pharmacy technician on duty at the hub pharmacy site shall be taken into account along with any remote tele-pharmacy technicians working at a remote tele-pharmacy site, when computing the ratio of pharmacists to pharmacy technicians.

                                (13)         A remote tele-pharmacy may have a dangerous drug inventory.  Any controlled substances shall be kept at the remote site in accordance with 16.19.20 NMAC.

                                                (a)           If controlled substances are kept, the remote tele-pharmacy shall be registered with the drug enforcement administration and obtain a DEA number.

                                                (b)           If controlled substances are kept, the remote tele-pharmacy shall have a valid New Mexico controlled substance registration as required in 16.19.20 NMAC.

                                                (c)           All controlled substances kept in inventory by the remote tele-pharmacy shall be listed on a perpetual inventory log, which shall be updated upon the dispensing of each controlled substance prescription or other disposition.

                                                (d)           The pharmacist shall perform monthly inventory of all controlled substances during pharmacist site visits to the remote tele-pharmacy.  If a perpetual reconciliation is not achieved through the use of technology, the pharmacist shall perform and document a complete monthly reconciliation.

                                (14)         Prescriptions may be received, entered and filled or re-filled by the hub pharmacy and sent to the remote tele-pharmacy for distribution to the patient during hours when the technician is present in the remote tele-pharmacy.  A pharmacist at the hub pharmacy must complete a final check of each prescription before it leaves the remote tele-pharmacy site, in accordance with Subsection B of NMAC.

                                                (a)           The pharmacist’s initials and the technician’s initials shall be recorded.

                                                (b)           The pharmacist shall compare the stock bottle, drug dispensed and drug strength.  The entire prescription label must be checked for accuracy.  All prescriptions distributed by the remote- tele-pharmacy must have the label affixed to the prescription container prior to being inspected by the pharmacist via electronic link.

                                (15)         Patient counseling shall be done by a hub pharmacist via patient-pharmacist audio-visual link in accordance with Subsection F of NMAC.

                                (16)         A remote tele-pharmacy is limited to filling no more than 200 prescriptions per day.  If filling more than 200 prescriptions per day, the remote tele-pharmacy shall be converted to a retail pharmacy and is subject to all applicable requirements of 16.19.6 NMAC.

                                (17)         No drug compounding shall occur at any remote tele-pharmacy.

                                (18)         All records required by this part shall be kept on-site at the tele-pharmacy for a period of at least three years and shall be readily retrievable for inspection by the board or the board’s agent.

[ NMAC - N, 05-14-10; A, 06-09-17; A, 06-23-17]