Abstract
Objectives
Telehealth represents a fundamental change to the health care delivery process. Despite the burgeoning literature on the rapid expansion of telehealth services during the COVID-19 pandemic, the consequences of these changes for clinicians’ workload are seldom examined. This study addresses that gap by describing the interactions between patient activity, work processes and pharmacists’ experience of an Australian hospital outpatient telepharmacy service that was rapidly upscaled during the pandemic to ensure all patients continued to access pharmaceutical care.
Methods
A three-phase explanatory mixed methods design was used: (1) a retrospective audit quantified changes to patient use of telepharmacy before (August 2019-March 2020) and during (March-September 2020) COVID-19 lockdowns; (2) process mapping to visualise and compare all the work steps involved in delivering telepharmacy and its face-to-face equivalent; (3) interviews with pharmacists (n = 10) to explain the patterns of patient use identified in the audit data and explore the impact of telepharmacy on their work.
Results
Telepharmacy occasions of service (N = 1442) increased 6-fold during COVID-19 lockdown, with a significant increase in metropolitan and express deliveries. Comparing the process maps reveals the inherent efficiencies of face-to-face care, as remote dispensing involved substantially more administrative steps than in-person encounters. Three themes emerged from the interviews that illuminate pharmacists’ experience of delivering telepharmacy: increased and less satisfying work; shifting responsibility for medication management from patients to pharmacists; and questioning the cost of convenience.
Conclusions
Telepharmacy successfully maintained access to pharmaceutical care for highly immunocompromised outpatients during, and long after the COVID-19 pandemic, but this came at the cost of increased administrative workload and reduced professional satisfaction for pharmacists. As telehealth becomes embedded in routine care, service models must account for these hidden workload consequences and ensure telehealth is targeted to settings where it delivers value rather than just convenience.
Supplementary Information
The online version contains supplementary material available at https://doi.org/10.1186/s12913-026-15469-z.
Background
Telehealth represents a fundamental change to the entire health care delivery process [1, 2], but the consequences of these changes for clinicians’ workload are seldom examined. Studies frequently mention the need to change work processes to accommodate new modes of remote care delivery [3–6], but what this entails is never specified. The small number of studies that ask clinicians about the impact of telehealth on their workload report an increase [5, 7, 8]. Inadequate technology infrastructure and the imperfect adaptation of work processes are implied in this increase [7, 9–11], but this has never been directly studied.
In contrast, telehealth reduces patients’ care-seeking workload by eliminating the need for travel [12]. For geographically remote patients, and those with limited mobility, telehealth means they can access services they otherwise could not [13–17]. However, when used as a supplement to face-to-face care, the convenience of telehealth has been shown to drive excess use, while increasing costs for providers through additional technology and staffing requirements [18, 19]. Indeed, in the limited number of economic evaluations that have found telehealth to be more cost effective than usual care [18–20], cost savings often accrue to patients in reduced travel rather than to the health system [21, 22].
As providers and funders examine the sustainability of telehealth models beyond their critical role in reducing COVID-19 transmission [23], there is a critical evidence gap in our understanding of its impact on the nature and volume of clinicians’ work, including any workload consequences of increased patient convenience. This study addresses that gap by examining an existing hospital outpatient telepharmacy service that was rapidly upscaled during the pandemic.
Telepharmacy refers to the remote delivery of pharmaceutical care. It has been successfully implemented to complement or substitute face-to-face care across the full spectrum of pharmacists’ activities. These included conducting medication reviews [2, 8–13], obtaining pre-treatment medication histories [14], performing chart reviews and medication reconciliation [9, 13, 15], supporting remote dispensing [6, 16, 17], and delivering patient education [24, 25].
Telepharmacy shares many of the implementation challenges common to all telehealth models. Difficulties with the cost and availability of technology (for institutions and patients alike), as well as user competency (for clinicians and patients) are frequently reported [26–31], as are patient privacy and data concerns [29]. Unique implementation challenges for telepharmacy are the often ambiguous legal status of remote dispensing [32], and the logistical complexities of medication delivery. From a clinician perspective, pharmacists have generally supported telepharmacy for its role in reducing barriers to patient access [26, 28]. However, in the limited studies that measured pharmacists’ job satisfaction, the results were mixed - with one study reporting no change [33] and another indicating a decline [34]. In contrast, non-pharmacy clinicians such as nurses have reported high levels of satisfaction with telepharmacy, as it often shifts pharmacy-related responsibilities - including medication reviews and patient education - away from their workload [27, 28, 33–35]. The impact of telepharmacy on pharmacists’ workload has never been explored.
As with many telehealth interventions prior to the COVID-19 pandemic, telepharmacy was primarily used to improve access to care for patients in rural and remote areas [15, 36, 37]. The shift to telehealth consultations for many appointments with hospital specialists during the pandemic [38, 39] necessitated a parallel growth in telepharmacy services to close the loop in the care process - ensuring that patients could continue to receive their medications, regardless of location [8, 40, 41].
This study aimed to address a critical gap in the literature by exploring how changes in patient use of a hospital outpatient telepharmacy service - rapidly upscaled during the COVID-19 pandemic and ongoing at the time of publication - affected pharmacists’ work processes and workload. While telehealth is often acknowledged as requiring new ways of working, the specific nature of these changes and their consequences for clinicians have rarely been examined. By analysing the relationship between patient usage patterns, care delivery processes, and the nature and volume of pharmacists’ work, this study provides new insights into the operational impacts of telepharmacy. In doing so, it raises important questions about the long-term sustainability of telehealth models that are used as a complement, rather than a substitute for face-to-face care.
Method
A three-phase explanatory mixed methods design was used to gain an holistic understanding of the interactions between patient use, work processes and pharmacists workload [42, 43]. In the first phase, a retrospective audit measured the quantitative changes to patient use of telepharmacy following the onset of the COVID-19 pandemic. The audit was followed by two sequential qualitative phases: interviews and work process mapping. Interviews with pharmacists sought to explain the patterns of patient use identified in the audit data, and to explore the impact of the telepharmacy service on the nature and volume of their work. Process mapping used the interview data to visual and compare the work steps involved in delivering telepharmacy and its face-to-face equivalent.
Setting
The study was conducted in the outpatient pharmacy at a 360-bed metropolitan public hospital in Sydney, Australia. In Australia, while most medications prescribed by hospital specialists on discharge from hospital, or during an outpatient appointment can be obtained from community pharmacies, certain highly specialized and high-cost medications, known as “Section 100” medications, are exclusively dispensed by hospital pharmacies [44]. The hospital has speciality units for heart and lung transplants, bone marrow transplants, immunology/infectious diseases, and cancer, whose patients often require Section 100 medications. The hospital’s outpatient pharmacy therefore supports highly immunocompromised patients, making a telehealth model crucial during COVID-19 lockdowns.
The outpatient pharmacy operates on weekdays during office hours (8am to 5pm). Before the pandemic, it was typically staffed by two pharmacists (including the outpatient pharmacy manager) and one pharmacy technician. Pharmacists would provide medication education and dispensing to outpatients prescribed specialist medications not available from community pharmacy. A telepharmacy service was in place prior to the pandemic but was limited to providing medication advice by telephone, along with remote dispensing and delivery of medications and was only available to outpatients living in rural and remote areas.
In Australia, public health measures are the responsibility of individual States and varied significantly in both timing and scope. In addition, hospitals implemented their own telehealth responses based on local infection rates. On March 18, 2020, the New South Wales Government introduced COVID-19 containment measures, including limits on indoor and outdoor gatherings and non-essential travel. Non-essential services were closed on March 23, 2020 [45] at which point the study hospital - located in a high-risk metropolitan area – shifted outpatient consultations with specialists to telehealth wherever possible. To support this transition, the telepharmacy service which enabled remote dispensing and medication delivery was extended to all patients, regardless of where they lived. To manage the increased demand, an additional pharmacist and technician were added to the outpatient pharmacy roster. The service relied solely on telephone communication between patients and pharmacists. As was the case in other metropolitan hospitals [8], face-to-face outpatient pharmacy services remained available for patients attending in-person medical appointments at the hospital.
At the time of writing, the outpatient telepharmacy service, including remote dispensing and home delivery remains in place at the study hospital with no changes to the original model.
Retrospective audit of patient use
A retrospective audit of patients’ utilisation of the outpatient telepharmacy service was conducted. Occasions of telepharmacy service are defined as incidents of remote medication dispensing and delivery between August 2019 and September 2020 and were divided into two epochs: (i) before the first New South Wales COVID-19 lockdown (1st August 2019 to 17th March 2020); and (ii) during COVID-19 lockdown (18th March 2020 to 30th September 2020). Pharmacy records entered into dispensing software, electronic medical records and paper delivery ledgers were reviewed. Data collected for each occasion included patient characteristics (age, sex, treating team, residential postcode), number and type of medications dispensed (drug class, Pharmaceutical Benefits Scheme (PBS) classification) and whether an express delivery service was used. Residential postcodes were categorised as metropolitan or rural, according to the Australian Statistical Geography Standard [46]. Delivery distance was estimated as the radial distance from the hospital to the centre of the recipient’s delivery postcode, using Geotool [47].
Statistical analyses were performed with IBM SPSS Statistics software, v26 (New York, USA). Descriptive statistics summarised participant characteristics, medications dispensed and service activity. Non-parametric between-group comparisons of activity (before vs. during COVID-19 lockdown) used chi-squared (categorical variables) and Mann-Whitney U (continuous variables) tests. Results are considered significant where p < 0.05.
Pharmacist interviews
In line with the study’s explanatory mixed methods design [41], a semi-structured interview guide (Supplementary Material 1) was developed after analysis of the audit data identified changes in patients’ use of the telepharmacy service. The guide was informed by relevant literature and designed to explain emerging patterns in the audit findings and explore those aspects of clinicians’ workload that cannot be identified in the qualitative data. Interviews focused on pharmacists’ description of their work process and experiences of delivering the telepharmacy service, their perceptions of changes in patient use, and the impact on the nature and volume of their work.
All hospital pharmacists who had worked in the outpatient pharmacy since the COVID-19 lockdowns at the time of research were invited to participate in an interview via email. All those eligible (n = 10) agreed to participate and provided written consent prior to the interview. Pharmacists could be rostered to provide either face-to-face or telepharmacy services on any given shift therefore all interviewees had recent experience of both models.
Interviews were conducted over the telephone or video from July to September 2021. They lasted 30 to 60 min and were audio recorded, transcribed, and de-identified.
Interviews were conducted by VS, a fourth-year medical science student at the time, whose ‘outsider’ status supported clarification of assumed knowledge in participants’ responses. However, this lack of insider experience may have limited recognition of implicit content or nuances. To address this, transcripts were reviewed by the full research team, including members with pharmacy expertise, enabling deeper insight.
The thematic analysis was conducted by three researchers [SW, JC, VS] using NVivo v12 (QSR International Pty Ltd). Open codes were created by noting frequently recurring and evocative phrases, ideas and perceptions, which were then grouped into meaningful themes by three researchers [48]. Coding discrepancies and the interpretation of themes were resolved through discussion among the research team.
Work process mapping
Process mapping involves the visual representation of the sequential steps, decision points and resources used within a defined work process (e.g. for each dispensing event). Process maps can help illuminate the reality of a work process, the workload involved and identify opportunities for improvement [49]. In this study, pharmacists’ descriptions of their work processes, gathered during interviews, were used to develop two process maps: one illustrating the telepharmacy model for outpatient care (i.e. remote dispensing and delivery), and the other representing its face-to-face equivalent. Both maps begin with the mode(s) by which an outpatient pharmacy encounter is initiated and conclude at the point where the patient receives their medication. The maps were drafted by two researchers [VS, JC] based on interview data and available documentation of outpatient pharmacy work processes and refined in an iterative process with the senior clinical pharmacist on the research team with extensive experience of both models of care [ML]. The map was developed in an iterative process, refining the steps until an accurate representation of each model of care was reached. The maps were visualised using Microsoft Visio.
Results
Below, we present the results from each phase of the study. We start with the retrospective audit, followed by the process maps, which outline the steps in delivering outpatient pharmacy services face-to-face and compared to the telepharmacy model. This context is crucial for a comprehensive understanding of the interview results that follow afterward.
Retrospective audit of patient use
Patient and medication characteristics
A total of 1442 outpatient telepharmacy occasions of service (remote dispensing with delivery) were included in the audit, across the two epochs (pre-and post COVID lockdown), delivered to 687 unique patients (Table 1). The majority of patients were cardiopulmonary transplant recipients (68.2%). In keeping with the population, immunosuppressant medications were the most commonly dispensed, followed by antibiotics. The majority of dispensed medications were classified as Schedule 100 (Table 2). There were no statistically significant differences between the two epochs in patient characteristics, or the types of medications delivered.
Table 1.
Characteristics of patients serviced by outpatient telepharmacy (August 1 2019 to September 30 2020)
| Patient characteristics | Total cohort n = 687 |
|---|---|
| Age median [IQR] | 59 [47–66] |
| Sex | |
| Male | 406 (59.1) |
| Female | 281 (40.9) |
| Treating Team a | |
| Lung Transplant | 291 (42.4) |
| Heart Transplant/combined heart-lung transplant | 177 (25.8) |
| Infectious Diseases & Immunology | 99 (14.4) |
| Haematology & Oncology | 41 (6.0) |
| Renal transplant & Nephrology | 25 (3.6) |
| Thoracic Medicine | 18 (2.6) |
| Endocrinology | 14 (2.0) |
| Gastroenterology | 13 (1.9) |
| Otherb | 5 (0.7) |
Data are presented as n (%) unless otherwise indicated
a Treating team data were missing for n = 4 patients
b Other treating teams included neurology, cardiology and dermatology
Table 2.
Profile of medications dispensed by the outpatient telepharmacy service
| Medication characteristics | Total drugs dispensed N = 2,937 |
|---|---|
| Drug Classification | |
| Immunosuppressant | 1352 (46.0) |
| Antimicrobial | 707 (24.1) |
| Supplement | 249 (8.5) |
| Anti-viral | 225 (7.7) |
| Anti-retroviral | 197 (6.7) |
| Endocrinology | 54 (1.8) |
| Anti-cancer | 51 (1.7) |
| Cardiothoracic | 29 (1.0) |
| Othera | 73 (2.5) |
| Medication Classification | |
| Schedule 100 | 2266 (77.2) |
| PBSb | 299 (10.2) |
| Over-the-counter | 273 (9.3) |
| Non-PBSc | 88 (3.0) |
| SAS Category Cd | 11 (0.4) |
|
Months of supply dispensed per medication median [interquartile range] |
3 [2–4] |
Data are n (%) unless otherwise indicated
a Other drug classes include anaesthetic, antiarrhythmic, antidepressant, antirheumatic, cholinergic agonist, diuretic, erythropoietin stimulating agent, immunoglobulin, nasal decongestant, peptide, phosphate binders, phosphodiesterase inhibitor, platelet reducing agents, vitamin
b Medications listed under the Pharmaceutical Benefits Scheme schedule
c Medications not listed under the Pharmaceutical Benefits Scheme schedule
d Special Access Scheme Category C medications - medicines for rare conditions not yet approved by the Therapeutic Good Administration [50]
Delivery use and characteristics
Table 3 shows medication deliveries via telepharmacy increased six-fold during COVID lockdown. The average number of deliveries dispensed per month increased significantly from 24.1 ± 4.4 (mean ± standard deviation) before lockdown, to 183.6 ± 25.1 during lockdown (p < 0.001). There was a significant increase in the number of medications included in each delivery, and in the use of express delivery. Registered deliveries include tracking and require a signature on delivery. Express deliveries also offer tracking and optional signature but are significantly faster, with delivery times depending on the destination. Median delivery distance from the hospital decreased during lockdown (from 265.8 km to 63.7 km), with the majority of deliveries sent to metropolitan addresses (Table 3). Before lockdown, only n = 12 (5.8%) delivery addresses were located within 20 km of the hospital pharmacy; compared to n = 299 (24.2%) during lockdown (χ2 = 35.9, p < 0.001).
Table 3.
Delivery characteristics before and during the 2020 New South Wales COVID-19 lockdown
| Characteristics | Before lockdown n (%) |
During lockdown n (%) |
Between group statistical comparison |
|---|---|---|---|
| Total number of deliveries | 208 | 1234 | - |
| Delivery Type | |||
| Registered delivery | 201 (96.6) | 965 (78.2) | x2 =39.1, p < 0.001 |
| Express delivery | 7 (3.4) | 269 (21.8) | |
| Delivery address | |||
| Rural | 115 (55.3) | 359 (29.1) | x2 =55.4, p < 0.001 |
| Metropolitan | 93 (44.7) | 875 (70.9) | |
| Delivery distance from hospital (km) | 265.8 [98.5–397.0] | 63.7 [21.7 -249.6] | U = 72,813, p < 0.001 |
| Number of medications per delivery | 1 [1–2] | 2 [1–3] |
U = 111,397, p = 0.001 |
Before COVID-19 lockdown: 1st August 2019–17th March 2020
After COVID-19 lockdown: 18th March 2020–30th September 2020
Data are presented as n (%), or median [interquartile range], unless otherwise indicated
Χ2 = Chi-squared value, U = Mann Whitney U test statistic
The retrospective audit demonstrates significant changes in the volume and destination of deliveries provided by the outpatient telepharmacy service, as well as a significant increase in the use of express deliveries for urgent requests.
Outpatient pharmacy work process maps
The work process maps visualise the steps involved for each outpatient pharmacy occasion of service from the pharmacists’ point of view. Figure 1 illustrates the face-to-face service work process, with the occasion of service always triggered by the patient presenting to the outpatient pharmacy. In one visit, the pharmacist can interact with the patient “in the moment” to confirm medication needs, discuss any related medication issues, before finally dispensing the medication(s) and providing any education required to the patient.
Fig. 1.
Outpatient pharmacy face-to-face service work process map. Dashed lines indicate steps in the process that could be completed by a pharmacy technician. Points of direct patient interactions are shaded
Figure 2 illustrates the steps involved in a telepharmacy occasion of services, which are usually triggered by a script sent to the outpatient pharmacy electronically. Note, patients who present face-to-face could have paper scripts and/or electronic scripts. Pharmacists must confirm the patient’s history (including clinical diagnosis, previous medications dispensed and doses) in the medical record before calling the patient to confirm the need for, and urgency of, a medication delivery. A “mailout checklist” was developed by the outpatient pharmacy manager to guide pharmacists in their phone calls with patients, and to ensure each delivery was compliant with dispensing regulations. A paper-based ledger was used to track deliveries. This process remained unchanged from the pre-pandemic service, when only a small number of mailouts were required.
Fig. 2.
Outpatient telepharmacy service process map. Dashed lines indicate steps in the process that could be completed by a pharmacy technician. Direct patient interaction is in bold
A comparison of the two process maps reveals there were many more steps involved in the telepharmacy service, due to a range of new administrative tasks associated with remote dispensing and delivery, as well as more time-consuming and fragmented communication with patients - such as repeated call attempts before direct contact could be made - compared to face-to-face interactions. When taken with the large increase in telepharmacy activity identified by the audit, these findings suggest significant changes in both the volume and nature of pharmacists’ workload. Interviews explored pharmacists’ experience of these changes.
Pharmacist interviews
Ten outpatient pharmacists were interviewed. Table 4 shows the majority had 1–5 years of pharmacy experience, but only one had more than a year’s experience working in the outpatient pharmacy. This was because the service was mainly staffed by pharmacists on rotation through the hospital.
Table 4.
Interviewee characteristics
| N (%) | |
|---|---|
| Gender | |
| Male | 2 (20.0) |
| Female | 8 (80.1) |
| Years registered as a pharmacist | |
| < 1 year | 1 (10.0) |
| 1–5 years | 7 (70.0) |
| 5 + years | 2 (20.0) |
| Years working in outpatient pharmacy | |
| < 1 year | 9 (90.0) |
| 1–5 years | 1 (10.0) |
| 5 + years | 0 (0) |
Three themes emerged from the data that illuminate pharmacists’ experience of delivering the telepharmacy service: increased and less satisfying work; shifting responsibility for medication management from patients to pharmacists; and questioning the cost of convenience.
Increased and less satisfying work
Universally, interviewees perceived the telehealth service had increased their workload, and the nature of the work was much less satisfying than face-to-face care. Increased workload was driven by the additional steps involved in remote patient interactions and medications delivery.
All the steps of receiving the script, or getting a phone call from the patient, making notes of what they want, and organizing, posting - none of that would have been happening before. Before someone would have just turned up with scripts, then we had the conversation of what they needed then and there. (P10)
Due to the rapid expansion of the telepharmacy service, there was no end-to-end IT solution in place for efficient prescribing, dispensing, payment, and delivery. Instead, pharmacists had to reconcile the hospital’s electronic prescribing system with a paper-based ledger to track deliveries, while any medication payments were managed by the finance department at a later stage.
As Fig. 2 illustrates, pharmacists undertook the majority of these additional tasks. Despite an additional pharmacist and technician being added to manage the workload, the increased administrative workload reduced the time available for meaningful patient interactions. In face-to-face care, pharmacists provide education and counselling to patients as they hand over medications to take home. Interviewees expressed frustration over the loss of time and opportunity for patient counselling, feeling that their clinical knowledge and skills were underutilised. Telepharmacy work was thus perceived to be supply-oriented, tedious and demotivating.
…it makes your job very unfulfilling when we end up being treated a little bit like a postal service. We studied Clinical Pharmacy, we’re not here to be mailing stuff to people all day. (P06)
I used to joke that, “I feel like I’m working in a call centre, I need a headset. … I feel like I’m working at Amazon”. (P02)
Some interviewees felt there was scope for technicians to undertake some routine phone calls to free up pharmacists’ time for higher-order clinical tasks.
If I was running the outpatient pharmacy, I would have technicians do the phone calls… because some are as good as, “Would you like your medications?” And they’ll be like, “No, I wouldn’t.” (P04).
Some were hesitant to delegate tasks to technicians because they were unsure about their legal responsibilities regarding remote medication supply. Moreover, even if task substitution allowed more time for patient education and counselling, all the interviewees reported patient interactions over the phone to be less effective than in-person. The absence of non-verbal cues made it difficult to illicit patients’ needs and to gauge their understanding, particularly older patients and those with language, cognitive or hearing difficulties.
…if you’re explaining a medication to [a patient], often you could tell from their facial expression that there’s something that’s puzzling them…but you can’t pick those up when you’re on the phone. (P07)
Overwhelmingly, pharmacists perceived the telepharmacy model had increased their administrative workload and deteriorated their job satisfaction, as the time and opportunity to provide patient education and counselling were squeezed out of the care delivery process. The multiple phone calls required to complete a transaction were particularly problematic for pharmacists’ workload and thought to be symptomatic of another, subtler shift in responsibilities.
Shifting responsibility for medication management from patients to pharmacists
A recurring frustration expressed in the interviews was that the telepharmacy service seemed to have transferred some of the responsibility for medication management from patients to pharmacists. In face-to-face care, dispensing was triggered by patients physically presenting at the pharmacy (as depicted in Fig. 1). With telepharmacy, the interaction was initiated by pharmacists calling patients to confirm if they needed a prescription filled. A common complaint was that patients often did not answer their phone or respond to voicemails or text messages. Consequently, pharmacists had to make multiple follow-up calls (as shown in Fig. 2), despite medications being life-preserving for many patients.
… we try to call someone, we leave a voicemail message, then we put the script and a note on their patient file, then we’ll have to repeat the call or text message … I just felt, “why are we chasing these people?” It should be “I need something, I should take ownership and contact the hospital.” (P02).
This pattern led some interviewees to conclude that patients were “…losing touch of their medication management” (P09). Another indicator of this behaviour was the high demand for express deliveries (as shown in Table 3) with some patients only contacting the pharmacy when they had run out of medications. As this pharmacist explains, these urgent requests had a significant impact on their workload:
Sometimes we have to stop what we’re doing so we can organise express delivery before the cut-off time. It interrupts workflow, because you’re always getting these calls… I think if there was more understanding from patients to get organized, earlier on, before they’re running out, to take a bit more responsibility for their medications, that would really help. (P03)
The delivery and tracking process was a major driver of pharmacists’ increased workload when compared to face-to-face care where medications were dispensed and simply handed to patients. Even after medications had left the hospital, pharmacists retained responsibility for their safe arrival. It was pharmacists, not patients, who tracked the deliveries. One pharmacist commented on the day of the interview, “I’ve spent half my day on the phone to [the delivery service] trying to chase up where meds have been sent to” (P06).
This shifting of patients’ basic responsibilities for their medication management to pharmacists suggests that the convenience of the delivery service may drive excess demand, particularly given there was no cost to patients.
Questioning the cost of convenience
All interviewees considered telepharmacy an essential service to reduce the risk of exposure to COVID-19 for immunocompromised patients during lockdowns. They also perceived patients appreciated the service. However, all expressed concern about the costs of free delivery beyond the pandemic. This pharmacist summarises the concerns of many:
I think it’s very convenient for patients, especially the ones that live a lot further away. They definitely appreciate having things sent to them in the mail. At the moment, because we’re not charging them for postage I think patients are pretty impressed that we’re offering this service. I think they appreciate it, but some probably really take advantage, and exploit it really. There are those who live a lot closer and still ask for it. (P10)
Pharmacists pointed to two behaviours that suggested that some patients were ‘taking advantage’ of the service. First, patients attended face-to-face appointments with their specialist in the hospital but opted to have their medications delivered to their homes instead of picking them up from the outpatient pharmacy. The second was an excessive, unrestricted use of the free delivery service by some patients.
Some patients will get multiple mail outs in a week, they’re just not organized enough to try and group things all in one. They don’t have to pay… it’s all a cost absorbed by the hospital. (P01)
Some interviewees suggested that a delivery charge may encourage patients to reengage with their medication management and “self-select” for the appropriateness of a delivery, as well as contribute to the additional costs of running the telepharmacy service.
If [patients] appreciate the cost a bit more, if we charge them for it, then they would not abuse the system too much, and maybe think twice before they request stuff to be posted out to them. That would save us a lot of money… Extra income for the pharmacy is always good, that means we have the capacity to maybe improve on our infrastructure. Get our extra computers, our extra phones. (P07)
Some advocated for a return to the pre-COVID process, where pharmacists would assess the appropriateness of individual delivery requests based on the patient’s location. However, interviewees felt that continuing to offer free delivery to all, regardless of location, was inevitable. Patients valued the convenience of the service so highly that management were unwilling to take the unpopular decision to discontinue, despite its lower effectiveness and the additional workload placed on pharmacists. One pharmacist put it simply “It’s very convenient for patients, but to the staff it’s a lot of pressure.” (P04).
Discussion
Similar to other telehealth services worldwide [40, 51, 52], the rapid expansion of outpatient telepharmacy during COVID-19 provided a natural experiment for understanding the consequences of delivering pharmacy services remotely. Although implemented in response to the pandemic, telepharmacy has since become embedded in routine care across many health systems, with many of the organisational and governance challenges persisting [53, 54]. At the Australian metropolitan hospital studied, telepharmacy ensured vulnerable patients continued to receive care essential care during lockdowns. However, process mapping revealed that this continuity of care came at the cost of substantially increased administrative workload [8]. In line with other studies [55, 56], the logistical complexity of remote dispensing shifted pharmacists’ work towards medication supply and away from higher-value clinical activities, limiting opportunities for patient counselling and contributing to lower job satisfaction. Consequently, pharmacists viewed telepharmacy as both less efficient and less effective than face-to-face care. Despite this, the hospital has retained the telepharmacy model unchanged.
The WHO Global Strategy on Digital Health 2020–2027 [57] emphasises that digital health should strengthen health systems by improving equitable access, efficiency and sustainability, rather than simply digitising existing processes or extending convenience. Our findings suggest that, while telepharmacy can improve access for vulnerable patients, maintaining it as a routine complementary service without redesigning workflows, staffing models and governance risks increasing administrative burden and reducing opportunities for higher-value clinical care, potentially undermining these broader system objectives.
Adaptations to work processes and staffing mix could reduce the ‘tedious’ components of telepharmacy for pharmacists. Similar to many health services, the necessary information technology for delivering telehealth was inadequate when COVID-19 emerged [26, 29, 58]. Investing in end-to-end technology to manage workflow from prescription to dispensing and delivery, rather than relying on a patchwork of electronic and paper-based systems, could relieve some of the administrative burden and allow pharmacists more time for higher-value patient interactions. The substitution of pharmacists with technicians in some routine non-clinical tasks (e.g. data entry, parcel packing, delivery coordination) could help reduce the administrative burden on pharmacists [59, 60]. However, professional apprehension about further delegation is understandable, particularly given the legal ambiguity surrounding remote medication dispensing [32]. To date, no Australian jurisdiction has amended legislation to clarify the legal status of remote dispensing. If this is to be reviewed, it must consider which tasks are essential for pharmacists to perform directly, and where responsibility can be safely and appropriately delegated. Without such clarification, concerns about liability and professional standards are likely to persist.
While these adaptations may help streamline telepharmacy and mitigate some of its inefficiencies, they do not fully address the limitations of remote care models - particularly when compared to the inherent advantages of face-to-face service delivery revealed through the mapping process. Handing medication directly to a patient is not only significantly faster and simpler than arranging delivery, but it also provides a natural opportunity for real-time problem-solving and in-person medication counselling. Although medication counselling can be delivered by phone and was generally accepted by both clinicians and patients during the pandemic [61], and in other circumstances where face-to-face care is not feasible [62], these interactions often lack the richness and immediacy of in-person communication. Consistent with findings across a range of health professions [5, 7, 9, 63], pharmacists in this study reported that remote patient interactions were often suboptimal - particularly when dealing with older adults or patients with hearing, language, or cognitive impairments. Training pharmacists in telephone-based counselling may improve these interactions where remote care is necessary, but it does not replace the immediacy and quality of in-person care.
Considering lower-quality patient interactions, along with the significant increase in administrative steps involved in telepharmacy, suggests that, even with improved technology and task substitution, telepharmacy is unlikely to achieve the same level of cost-effectiveness as face-to-face care. While the study acknowledges that telehealth offers substantial convenience by saving patients time and travel costs [13–15], this very convenience may drive unintended patterns of overuse, placing additional strain on already stretched health services [18, 19, 21]. Examples of potentially excessive use include patients who physically attend hospital appointments but request home delivery of medications, request multiple deliveries within the same week, or frequently rely on express delivery.
In addition to reducing travel needs, the telepharmacy model further enhances convenience by shifting the responsibility for filling prescriptions from patients to pharmacists. However, this shift has raised concerns, particularly when patients fail to respond to pharmacists’ phone calls or delay requesting essential medications. This reflects a fundamental change common to many telehealth models: patients are not required to be physically or cognitively present at the point of care, which may contribute to reduced engagement. Similar patterns have been observed by primary care clinicians, who report that patients often ignore phone calls, even for scheduled appointments, ultimately increasing follow-up workload for staff [7, 9]. Together, these behavioural shifts highlight a tension in telehealth between patient convenience and system efficiency, where ease of access may inadvertently reduce accountability and increase provider burden. One possible solution is the implementation of automated digital tools, such as app-based medication reminders that prompt patients to confirm refill needs. While such systems may help shift some responsibility back to patients, it remains unclear whether these tools would significantly alter the cost-effectiveness balance, given the ongoing administrative demands of remote service delivery.
Another potential solution is to introduce a delivery fee, which could encourage patients to assess their need for home delivery more carefully, take greater responsibility for medication management, and ease some of the cost burden on the service. However, pharmacists widely believed that the hospital would be reluctant to make the unpopular decisions of reinstating eligibility criteria or introducing co-payments. At the time of writing, their predictions have been confirmed, the free delivery service remains available to all patients, regardless of clinical or geographic need.
This raises important questions about the long-term sustainability of telepharmacy. Addressing the logistical and behavioural challenges identified in this study would require substantial investment in technology and redesigned workflows. Yet, even with such improvements, fundamental issues, such as reduced quality of pharmacist–patient interactions, increased administrative workload, and diminished job satisfaction, are unlikely to be resolved. Given the inherent efficiency, immediacy, and relational benefits of face-to-face care, it is reasonable to question whether universal telepharmacy access represents an effective use of limited health system resources. While telehealth remains valuable as a substitute for in-person care, its use as a routine complement has proven problematic. These findings suggest that telepharmacy is likely to deliver greatest value when targeted to patients who face genuine barriers to attending in person, rather than being offered universally for convenience alone. Matching telepharmacy to clinical need may better balance patient access, clinician workload and the efficient use of health system resources.
Limitations and future research
This pragmatic evaluation was conducted in a single Australian tertiary hospital, and aspects of the telepharmacy model - including the regulatory environment, funding arrangements and universal home-delivery service - may differ from other settings. However, the model broadly resembled telepharmacy services introduced elsewhere during the COVID-19 pandemic [8], and there is emerging evidence that similar models have been retained beyond the pandemic [53, 54]. Likewise, the organisational challenges and task shifting identified in this study have also been reported across a range of telehealth models [55, 56], suggesting that the underlying mechanisms are likely to be relevant wherever remote care complements, rather than replaces, face-to-face services. The magnitude of these effects will inevitably vary according to service design, workforce configuration, technology integration and local governance arrangements.
The audit was retrospective and therefore limited to routine documentation generated during service delivery. Retrieving comparable data on face-to-face outpatient pharmacy interactions was not feasible, preventing direct comparison of total service volume before and during the lockdown. We were also unable to quantify the time pharmacists spent delivering the two models of care because they operated concurrently. Finally, we did not interview prescribers to determine whether prescribing practices influenced patients’ uptake of home delivery.
In simple terms, we know that service costs increased through the addition of two pharmacists to the daily roster and substantially higher delivery costs, while patients benefited from free medication delivery. However, a formal economic evaluation comparing telepharmacy with face-to-face care would provide a more comprehensive assessment of costs and benefits. Such analyses should incorporate not only direct service costs, but also the unintended consequences identified in this study including increased administrative workload and potentially avoidable demand [64], alongside patients’ willingness to pay for the convenience of home delivery [65].
Conclusion
COVID-19 accelerated the adoption of telehealth and demonstrated its value in maintaining access to care. However, our findings highlight the hidden costs of convenience when telepharmacy is used as a routine complement to face-to-face care rather than to overcome genuine access barriers. By shifting responsibility for medication supply from patients to pharmacists, telepharmacy increased administrative workload, reduced opportunities for higher-value clinical care, diminished job satisfaction, and weakened patient engagement. As telehealth becomes embedded in routine care, decisions about service delivery should consider not only access, but also the workload, efficiency and sustainability of the care model.
Supplementary Information
Below is the link to the electronic supplementary material.
Acknowledgements
Not applicable.
Author contributions
JC, CS, VS and SW designed the research study. VS collected the data. CS performed the quantitative analysis. JC and ML drafted the process maps. SW, CS, VS performed the initial interview analysis. JC, CS and SW drafted the manuscript. VS, TM and ML provided critical edits to the draft. SW wrote the discussion, implications and conclusions.
Funding
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Data availability
No datasets were generated or analysed during the current study.
Declarations
Ethics approval and consent to participate
The study received ethics approval from the St Vincent’s Hospital Sydney Human Research Ethics Committee (2020/ETH02853). A waiver of consent was granted for the retrospective audit. Written consent was provided by all interview participants.
Consent for publication
Not applicable.
Competing interests
Four of the authors are employed in the hospital where the study was conducted. The two authors employed specifically in the pharmacy department (ML and TM) were not involved in collection, or analysis of the data (other than process mapping). SW conceived and wrote the discussion, implications and conclusions.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Jane E. Carland and Christine T. Shiner are joint first authors.
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Supplementary Materials
Data Availability Statement
No datasets were generated or analysed during the current study.