The urge for specific standards of telepharmacy services: Lessons learned from qualitative study in Indonesian community pharmacies

Abstract

Objective

Like many low- and middle-income countries, Indonesia lacks specific standards for telepharmacy practices, which requires adherence to traditional pharmacy guidelines to evaluate the services. This study aims to explore the disparities between the implementation of telepharmacy services in community pharmacies and the established Indonesian pharmaceutical service standards.

Methods

This qualitative study was conducted in seven community pharmacies in Depok, an urban area near Jakarta. Data were collected in 2023 using triangulation methods: semi-structured interviews, direct observations, and simulated patient interactions. Verbatim transcriptions and thematic analysis were performed using NVivo^®12 to analyse the findings.

Results

Four identified themes were the structures, daily practices, challenges, and enablers of telepharmacy services. The scope of telepharmacy services consisted of dispensing medicines, patient education, and providing drug information through mobile applications by pharmacy electronic system organisers (PSEF) or social media platforms. Challenges in daily practice revealed gaps in traditional pharmaceutical service guidelines, including systems interoperability, effective communication among pharmacists-physician-patients, and the need for standards specific to digital pharmaceutical services. Common problems in telepharmacy were uncertain medicine availability, unclear e-prescription validity, limited pharmacist-physician collaboration, and impeded patient education, particularly in services provided through PSEF applications. On the other hand, the availability of digital technologies was seen as beneficial, highlighting the necessity for predefined standardised facilities to ensure the quality of telepharmacy services.

Conclusion

While traditional pharmaceutical service standards can be applied to evaluate telepharmacy practices, specific challenges must be explicitly addressed within a dedicated telepharmacy standard to ensure patient safety and service quality.

Introduction

Telepharmacy has become a common practice among healthcare providers, including community pharmacies.^1,2 Telepharmacy is a subset of telemedicine that provides pharmaceutical services where pharmacists interact with patients through telecommunication media and technologies. ³ Telepharmacy services may include drug selection, prescription and drug administration review, patient counselling and monitoring, and other clinical pharmacy services.^3,4 Many studies acknowledged telepharmacy benefits, including being cost-effective and time-saving, ⁵ reducing medical errors, ⁶ improving multidisciplinary collaboration, ⁷ and expanding the health services distribution and overcoming the pharmacist's shortage. ⁸ It is well-known that the coronavirus disease 2019 (COVID-19) pandemic has boosted telepharmacy implementation and is predicted to grow further. ¹

Despite all its benefits, telepharmacy also poses several challenges and potential risks to patient safety that need to be addressed in the standards or regulations. Firstly, telepharmacy is a technology-based service requiring appropriate operating systems, equipment, and skills. ⁸ Secondly, the practice of telepharmacy may be hindered by financial situation. Government, insurance providers, healthcare management, or patients might find the cost quite burdensome.^8,9 In addition, there are ethical and legal concerns related to telepharmacy practices, including privacy and confidentiality, data protection and security, integrity, and the pharmacist-patient relationship. ¹⁰ Therefore, some countries and professional organisations accommodate those concerns by providing telepharmacy policies or regulations based on their needs.^11,12

Unfortunately, there is no specific service standard for telepharmacy in Indonesia, like in many other low- and middle-income countries. ¹³ Some advisories or regulations related to telepharmacy in Indonesia have been integrated into telemedicine guidelines and other guidelines, primarily focusing on drug dispensing and standards for medical services. General service standards for telepharmacy practices are mostly the same as those for traditional practices. The available policies underscored that telepharmacy services must be conducted in accordance with national pharmaceutical services standards. For instance, community pharmacists are only permitted to dispense over-the-counter (OTC) medicines for self-medication, while prescription medications are dispensed based on electronic prescriptions issued by physicians. These prescriptions may follow a closed system, where the physician directly inputs the prescription into a system managed by a pharmacy electronic system organiser (PSEF) and transmits it to a specific pharmacy, or an open system, where the patient receives the prescription and presents it to the pharmacy. Telepharmacy services must also be provided by licensed pharmacists, which align with traditional pharmacy regulations. While the role of pharmacy technicians is not explicitly mentioned in these guidelines, it is inferred that they can assist in telepharmacy under the supervision of a licensed pharmacist, such as receiving the order and dispensing, just as in traditional pharmacy settings.^14–17 Given the absence of specific telepharmacy standards, it is generally assumed that the quality of telepharmacy services in Indonesia is evaluated using traditional pharmacy guidelines. This study aims to explore the disparities between the implementation of telepharmacy services in community pharmacies and the established Indonesian pharmaceutical services standards so it can be used to identify the potential gaps in the need for future guidelines development.

Methods

Study setting and design

This qualitative study was conducted from January to June 2023 with a phenomenology approach targeting all community pharmacies in Depok City, West Java, Indonesia. We reported the study in accordance with the Consolidated Criteria for Reporting Qualitative studies checklist ¹⁸ (see Additional File 1). The study utilised semi-structured individual interviews and then triangulated with the observation and simulated patient data (see Figure 1). Interview respondents in this study were licensed pharmacists in each pharmacy who engaged in telepharmacy practice. The observation was conducted directly by a researcher checking relevant documented evidence in the pharmacies during the interview. One of the researchers performed simulated patients through messaging services on the telepharmacy platform to purchase OTC medicines from all recruited pharmacies. This study has been approved by the Faculty of Medicine Universitas Indonesia Health Research Ethics Committee (reference no: KET281/UN2.F1/ETIK/PPM.00.02/2023).

Figure 1.

The triangulation of study methods.

The research instruments

The instruments were developed by the authors, and hence, no permission from the copyright holder(s) is required. We developed three tools: interview guidelines, observation checklists, and simulated patient checklists. The tool development process followed a content validity assessment, which involved three stages: the development stage, the judgement and quantification stage, and the revision and reconstruction stage. ¹⁹ Interview guidelines and observation checklists were developed based on the Regulation of the Minister of Health No. 73 of 2016 regarding Pharmaceutical Service Standards in Community Pharmacy ²⁰ and the Decree of the Minister of Health of the Republic of Indonesia No. HK.01.07/MENKES/4829/20 on Health Services Guidelines Through Telemedicine During the COVID-19 Pandemic. ¹⁵ The checklist for simulated patients was created following Decree No. 1027/Menkes/SK/1X/2004, Technical Guidelines for the Implementation of Pharmaceutical Service Standards at Community Pharmacies, specifically for the self-medication segment ²¹ and Guidelines for Using Over the Counter Medicines from Indonesian Minister of Health. ²² All referred documents used to develop the tools were freely available and have been included in the reference list accordingly.

The developed items were reviewed by a panel of three experts who are pharmacists with at least 5 years of relevant experience, representing academia, community pharmacists, and the Indonesian Pharmacist Association (IAI). The content validity of the developed tools was examined via estimating content validity index (Ave-CVI). The Ave-CVI at this stage was 0.792 for the interview guidelines, 0.919 for the observation checklists, and 0.944 for the simulated-patient checklist. Since the targets of Ave-CVI were above 0.8, there were some items that needed to be revised, reconstructed, and added. After the revision and construction stage, there are 43 items agreed for the interview guidelines, 36 observations checklist, and 8 simulate-patient checklist with Ave-CVI score 1.0 for each. The final versions of the interview guideline, observation, and simulated-patient checklist are available as Additional Files 2, 3, and 4, respectively.

Sampling and data collection

The participant selection was conducted by purposive sampling in collaboration with the Depok Branch Committee of the Indonesian Pharmacist Association (IAI). We asked IAI for all the community pharmacies in Depok that deliver telepharmacy services for a minimum 6-month period. Then, we contacted all listed pharmacies to send the invitation to participate in this study, along with the consent letter and informed sheet. Only participants who consented to participate were followed up with data collection.

Face-to-face interviews and observation were conducted in parallel within the recruited pharmacies at their workplace. Each respondent was not accompanied by others during the interview, and the interview was audio recorded by consent. The interview and observation of telepharmacy service take around 30–60 min for each respondent, without any repetition. Short field notes were also made during the interview and observation using the printed instrument. Afterwards, 1–2 days after the interview, one researcher performed the simulated patient using the blinding method (unknown to the pharmacy) through messaging features in the telepharmacy platforms. The researcher acted as a patient with a single minor illness symptom among constipation, diarrhoea, dyspepsia, or dental pain options. The simulated patient checklist and scenario can be seen in Additional File 4. In the simulated scenario, pharmacist-patient consultations until medicines delivery were documented to be triangulated with interview and observation data.

Data was collected by a female pharmacist researcher who received prior training in collecting qualitative data using audio recording and pre-designed validated instruments. Before obtaining the data, the interviewer explained the research background, purpose, confidentiality, research procedure, obligations and rights, and demographic data about age, gender, work experience, and status to the respondent. The respondents were also asked to fill out an informed consent form if they agreed to participate in the study.

Data analysis

Audio recordings of the interview were transcribed verbatim using the automatic transcription in NVivo^® 12 and edited by one of the researchers to meet the Indonesian language precisely. The transcripts were not returned to the respondent. Another researcher inductively analysed the transcription using NVivo^® version 12, which involved condensing, presenting data, and drawing conclusions. Thematic analysis, with major themes aligned with research questions, was used for qualitative descriptive analysis. The analysis results were reviewed and approved by the entire research team. Three researchers translated all collected themes, subthemes, and interview quotes into English. Socio-demographic profiling of the respondents was conducted using SPSS^® version 24. Data saturations were reached after the researcher interviewed seven community pharmacists.

Results

Sample characteristics

Seven of the 20 pharmacies were recruited in this study (see Additional File 5). During data collection at the seventh pharmacy, no new topics emerged, confirming the adequacy of the sample size. The district locations of recruited pharmacies were half of the total districts in Depok City, which included Tapos (n = 2) and one pharmacy each in Cimanggis, Sukmajaya, Cipayung, Pancoran Mas, and Limo districts.

This study included independent and franchise pharmacies. There were three types of respondents: responsible pharmacists, pharmacists (staff), and pharmacy owners. A pharmacist in Indonesia can hold three practice licenses, but only one can be used for a responsible pharmacist licence. A responsible pharmacist ensures that all pharmacy services comply with the standards required for a pharmacy operational permit. There may be more pharmacists at the community pharmacy, so the others are called pharmacists (staff) or companion pharmacists (“apoteker pendamping”). In Indonesia, a pharmacist or anyone (individual or company) without pharmacy experience could own a community pharmacy. ²³ The socio-demographic profile of all participants is detailed in Additional File 6.

Thematic analysis of interview results

Four main themes and their sub-themes were identified through thematic analysis and are presented in Figure 2. The themes consisted of the structures of telepharmacy practices, the daily practices of telepharmacy, the challenges of telepharmacy practices, and the enablers of telepharmacy practices.

Figure 2.

Thematic findings of telepharmacy implementation.

Understanding the structures of telepharmacy practices among community pharmacists

Pharmacy services through the app, remotely, can be through certain platforms or can be through communication media such as WhatsApp or telephone. (LM)

All respondents typically define telepharmacy as online pharmaceutical services. In telepharmacy, patients and pharmacists interact through various information technology media or applications. All respondents mentioned that there are no specific requirements for the level of skills and prior training before providing telepharmacy services. So, they have utilised their entire workforce, as no specific team is dedicated to this task.

Everyone (pharmacists and pharmacy technicians) is involved. The orders come in during every shift, so everyone is definitely involved. (AK)

There isn’t any specific training (for telepharmacy services)…… (LM)

If there is training, it's more of an introduction rather than a full-length training session. They (telemedicine application providers) just show us how to use the application and the basic rules at the start. So, when we first install the application, they give us a brief overview of how it works. (SP)

The scope of provided telepharmacy services includes prescription review, dispensing, and providing communication, information, and education. Interestingly, one respondent also included drug-related education through social media such as TikTok^® as the scope of telepharmacy services. Respondents reported that medicine counselling, drug therapy monitoring (including side effect management), and home pharmacy care were rarely provided as part of most telepharmacy services. They also claimed that the nature of service delivery depends on the platform employed. For instance, on messaging platforms like WhatsApp^®, patients can initiate consultations with pharmacists. In contrast, when using telemedicine applications, respondents indicated that pharmacy staff only conduct prescription reviews, dispense, and provide paper-based drug information without a chance to message each other directly.

Patients can consult first by phone or WhatsApp. For telemedicine app users, our services are limited to those specifically stated within the application.”(E)

All respondents stated that their pharmacies performed for more than one telepharmacy platform. Most of them are PSEF telemedicine platforms, including two private telemedicine applications mentioned during the interview and observation. The application providers also supplied the operating systems and delivery packaging with tutorials on standard operating procedures. The franchise pharmacies also have websites or e-commerce shops to deliver telepharmacy services.

The daily practices of telepharmacy versus traditional pharmacy services

Respondents claimed that their pharmacies performed telepharmacy services with focus on prescription dispensing and self-medication services. Self-medication services could be requested through websites, e-commerce, or direct internet messages with the pharmacies. In comparison, prescriptions were provided in digital forms in telemedicine applications or photos delivered by patients via Internet messaging platforms. Upon initial receipt, the prescription underwent a thorough review process by a pharmacist. This process included administrative, pharmaceutical compatibility, and clinical reviews. Still, from the observation and interview, we identified that verification was not documented as in traditional services.

We do not have a prescription verification form; we only verify the information on the prescription and give check marks on the prescription. (SP)

Pharmacists often emphasise the importance of assessing the proper use of the medication. Yet, our respondents reported that occasionally, the instructions on the prescription may be unclear, requiring additional notes from the physician, which could confuse the pharmacists.

Consequently, the challenge lies in discrepancies that sometimes occur between the instructions on the prescription and the additional notes provided by the physician. (FM)

However, pharmacists have no direct access to physicians or patients when using PSEF applications. They could only connect through a hotline, which significantly delayed the prescription review process. If the pharmacist was unable to contact the physician, this could increase the risk of compromised patient safety and medication errors.

If we use the app (telemedicine application), there is no direct contact with the patient, so a third party is used. (AK)

Medicines confirmation is hard to conduct. We must confirm through the operator, sometimes they (the physician) barely want to pick up the phone, because the calling number is unknown. (FM)

Although the telemedicine regulation has stated that the electronic prescription could be only filled once, ¹⁵ respondents encountered obstacles in determining whether the prescription had already been filled at another pharmacy. Some patients tried to fill the prescription from the screenshot of telemedicine applications, which created challenges for pharmacy staff in verifying the validity and authenticity of the prescriptions. Respondents claimed using their judgement to decide whether the prescriptions were eligible to be filled. Sometimes, they consider the prescription date or type of medications.

It is not always clear whether another pharmacy has filled a prescription or not. (AK)

Usually, we consider the dates….,. If it was only yesterday, so it is logical if the prescription has not yet been refilled. (SP)

… sometimes patients ask to fill the prescription which they screenshot from telemedicine application since there were no regulations related to that, we consider it can’t be applied since they can use the picture over and over to get the medicines. (FM)

As pharmacists, if respondents suspected any signs of falsification or questioned the validity of a prescription, they would refuse to fill the prescription. A rejected prescription was typically not eligible for administrative review. Respondents would also refuse to fill prescriptions that contain certain drugs, such as narcotics, psychotropic substances, injectable preparations (excluding insulin), and implant contraceptives in telepharmacy services. This practice aligns with national regulations set by the Indonesian FDA. ¹⁷

Another challenge was raised when the telepharmacy system's online stock did not match the actual stock due to offline sales not being updated. It has occurred because the pharmacy serves both offline pharmacy services and telepharmacy while often the stock written in PSEF applications was different and could not be updated directly with the real stock.

…sometimes there would be a time when there is an order come in, but it turns out that the medicines have just been bought by the offline patients, so there would be discrepancy found within the stock. (AS)

PSEF applications typically refer patients to the nearest pharmacy with available stock, as indicated by their system. The applications also set targeted response times, which limit the time to fulfil prescription requests. As a result, there are instances where pharmacies are unable to complete the prescription through the telemedicine platform or provide patients with a copy of the prescription instead. Due to the limited communication access when using PSEF applications, medication substitutions are challenging to perform without confirmation from either the physician or the patient, further complicating the process.

In daily practices of telepharmacy, patients have received their medication from third-party delivery services. Those third-party entities typically acted as transportation agents in partnership with PSEF platforms. Drug-related information was conveyed to the patients via annotations on the medication label. If the telepharmacy services were requested from e-commerce, websites, or direct internet messaging, some community pharmacies added drug information by direct chat with the patients. Written drug information limited pharmacists from delivering clear and concise information. Furthermore, pharmacists were unable to verify if the patient comprehended the explanation.

In certain cases, patients may misinterpret or overlook the information. (M)

The documentation of prescription and medicines being filled by pharmacists is traceable and accessible in the platform provided by the PSEF. In addition, the community pharmacists also can print the list of prescriptions they have been filled and keep it as their records.

For the electronic prescription records we can print it, so every night we would print and record it daily. Besides that, that we also can be seen in the application system, it would be automatically inputted. (AS)

The challenges and enablers of telepharmacy practices

It is essential to highlight prominent challenges in telepharmacy structures and the daily practices of telepharmacy as have been mentioned above. The challenges of telepharmacy structures in community pharmacies include limited understanding and utilisation of diverse technology to support the services, unavailable prior training for telepharmacy practices, unclear skill requirements which lead to non-specific staff allocation, and undefined scopes of services which affect the daily practices. In addition, the noted challenges in daily practices of telepharmacy versus in-person services include limited communication access with physicians and patients – particularly in PSEF applications – uncertainty of clinical judgement, unconfirmed patient understanding, unclear prescription validity, and discrepancy in medicines availability. It is clear that the fundamental challenge of telepharmacy practices through PSEF application is limited access between pharmacists and physicians/patients which raises potential risks to patient safety and quality of services.

However, as highlighted by respondents, digital technology plays a crucial role in enabling pharmacists to provide telepharmacy services. Advanced technologies facilitate the delivery of pharmaceutical services to patients who are unable to be physically present at the pharmacy.

With the advancement of technology, it has become easier for patients who cannot come to the pharmacy. (AK)

Respondents believed that patients conveniently acquired their medications from home through telepharmacy services. One example given was patients could easily inquire about medicines availability without needing to visit multiple pharmacies in person.

Patients can find medicines from home, without having to visit pharmacies one by one. (AS)

Respondents also emphasised that their patients perceived telepharmacy as a simpler and more convenient alternative to purchasing medication in person at a pharmacy. They claimed that most telepharmacy users were productive adults proficient in using the service.

Data triangulation with observation and simulated patient findings

Observation findings

Only limited evidence and practices could be recorded because telepharmacy services were not being conducted during data collection. The checklist items in three aspects – prescription review, dispensing, packaging, and delivery – were observed from the example of prescription review and the packaging used by the pharmacy to deliver the telepharmacy service. The interview results have been confirmed according to the collected documentation. For instance, there was limited communication access to physicians and patients, prescription reviews checklist form, additional short notes for longer drug information, and non-transparent, sealed medicine packaging for delivery. No documentation or evidence could be recorded for counselling, home care, or drug monitoring, as these activities were rarely conducted through telepharmacy services, according to the interview results.

In addition, we also collected other evidence, including self-medication checklist forms, active and passive drug information materials in the web service or social media platforms. However, the evidence was found in different pharmacies, which reflected various practices in each pharmacy. We also found that specific medicine packaging has been developed by each PSEF, which not only complies with regulations but is also designed to reflect and promote their brand identity.

Simulated patient for confirming self-medication practices in telepharmacy

In the interview, the pharmacists claimed that self-medication in telepharmacy practices has no significant difference between collecting patient information in telepharmacy versus traditional services. They said the questions were based on mnemonics ASMETHOD (Age/appearance; Self or someone else; Medication; Extra medicines; Time persisting; History; Other symptoms; Danger symptoms) or WWHAM (Who is the patient; What are the symptoms; How long have the symptoms been present; Action taken; Medication being taken). ²⁴

Based on our simulated patient for self-medication on WhatsApp and e-commerce platforms, the pharmacists were proven to deliver the questions. However, some questions were prone to being left behind, such as a history of illness and any dangerous symptoms. The drug information and delivery packaging matched the interview and observation results. The drug information was only limited to dosage instructions, which were provided through messages on the platform and labels on packaging.

Discussion

To the extent of our knowledge, this qualitative study is the first to compare the implementation of telepharmacy practices with Indonesian pharmaceutical services standards. Our findings indicate that the recruited pharmacists demonstrated an understanding of telepharmacy practices consistent with various studies and guidelines.^8,14,25–27 This consistent result highlights a shared comprehension of telepharmacy practices among respondents. Since COVID-19 pandemic on 2020 until now, the Indonesian FDA (Badan Pengawas Obat dan Makanan, BPOM) has regulated that community pharmacies can provide medicines transactions online through pharmacy-owned systems and PSEF. ¹⁷ PSEFs are legal entities responsible for delivering, organising, and operating electronic systems for pharmaceutical services for their own needs or those of other parties. ¹⁷ The telemedicine third-party applications mentioned by respondents in this study fall under the category of PSEF applications. PSEF platforms often operate under their own brand names and collaborate with community pharmacies integrated into their systems. While some PSEF platforms focus solely on telepharmacy services, others provide both telemedicine and telepharmacy. When patients engage with these platforms, they typically access interconnected services, including physician consultations, medicine dispensing, and delivery. Current telepharmacy services through PSEF platforms in Indonesia predominantly emphasise product-oriented services rather than clinical services from community pharmacists. Our interview results confirmed this phenomenon, revealing limited access and technical support for comprehensive pharmaceutical care.

Our study compared the implementation of telepharmacy services – including prescription dispensing, self-medication, and patient education – with the national pharmaceutical service standards for community pharmacies. We also analysed the findings concerning other laws/regulations related to telemedicine in Indonesia. The results showed significant challenges: limited communication access, legal concerns about the prescription's validity, and the unjustified patient's understanding of medication uses. It also underscores the lack of specific regulations for telepharmacy services in Indonesia, which might hinder comprehensive and effective telepharmacy and lead to inconsistencies in practices that could compromise patient safety. Our recommendations for telepharmacy services standards, which are critical to be accommodated, have been summarised in Figure 3.

Figure 3.

Recommendations for telepharmacy standards.

In Indonesia, all telemedicine and online medication transaction regulations have emphasised the importance of ensuring communication between pharmacists, physicians, and patients within the system.^15,17 However, the pharmaceutical service standards and their technical guidelines, released in 2016 and 2019, fail to address these concerns adequately. Communication access is needed to accommodate patients’ education and medication confirmation or reconciliation, which is crucial for medication safety. ¹⁰ Unfortunately, according to the respondents’ statements, our study found the opposite practices: no pharmacists had direct access to patients and physicians. The constraint within the telemedicine application underscored a notable challenge in the seamless communication and collaboration between healthcare professionals in telepharmacy services. This condition not only represented an incompliance with regulations but also posed potential harm to patient safety. In addition, limited communication hinders pharmacists’ clinical practice as required by national standards. ²⁰

The Indonesian pharmaceutical services standard for community pharmacies requires pharmacists to provide a thorough prescription review, including administration, pharmaceutical, and clinical aspects.^20,21 In contrast, our study found that pharmacists faced difficulties reviewing prescriptions and followed up on the discrepancies in telepharmacy practices. As previously mentioned, in the context of telepharmacy services via PSEF, this issue has been related to the limited access between pharmacists, physicians, and patients. In pharmacy-owned telepharmacy platforms, the primary obstacle was the legality of prescriptions, as many patients only sent pictures of their prescriptions. These legal problems also have been acknowledged as concerns in other countries with the need for standardised regulations.^10,14 The regulation from the Indonesian FDA (BPOM) has mentioned that pharmaceutical transactions using e-prescriptions should be conducted when the legal validity of the prescription is secured. ¹⁷ However, our study revealed pharmacists’ complaints that the validity of photo or scanned prescriptions was challenging to verify. There was also concern that these images could be reused at other pharmacies or times, highlighting the need for strict regulations regarding prescriptions in telehealth practices. Until now, the government or the Indonesian Pharmacist Association (IAI) did not have specific guidelines to identify the forged or counterfeit prescription. Despite that, to prevent some commonly abused medicines from being illegally distributed, the newest regulation by Indonesian FDA (BPOM) stated that they could only be filled using closed system e-prescriptions. ²⁸

In telepharmacy, providing only written medication information might become more complex in determining whether the patient fully understands the information provided. The lack of non-verbal communication diminishes clues for pharmacists to assess the patient's condition, as none of our respondents reported using video communication in their practices. This issue might highly correlate to the reluctant population to use such technology.^8,9 Along with those findings, our respondents also mentioned similar concerns, which led to the need for specific information technology facilities in regulations to deliver high-quality telepharmacy services. Furthermore, mandatory training for pharmacy workforces should be established to overcome these issues in the future.^4,10,12

The literature indicates that telepharmacy services often include clinical pharmacy, yet implementation is contingent upon various local factors. ¹ Our study highlights that certain clinical pharmacy practices, including medication counselling and therapeutic and side effects monitoring, were rarely implemented in Depok City pharmacies. This phenomenon might be attributed to significant barriers such as pharmacist shortages, limited pharmacist's relevant skills, and lack of pharmacist or patient-perceived benefits,^4,9,25,29 which challenges the full integration of clinical pharmacy practices into telepharmacy services. The future standards must also emphasise the required technology and pharmacy workforce's competencies to provide those services.

The boundaries for scope of services in telepharmacy practices are also needed due to the potential risks without specific technology support and nature weakness of remote services. It has also been recommended by Al-Alawy and Moonesar ¹¹ to reduce health costs and medical errors due to inappropriate services in telehealth. For instance, remote consultation for otitis media in community pharmacies has been avoided in England due to the required otoscopic examination for diagnosis in the clinical pathway. ³⁰ The study by Warmoth et al. ³¹ has also shown that proper technology and connectivity supports are needed to effectively deliver the services, such as video consultation technology for home care.

Another barrier cited by our respondents was the inconsistency between the medicine stock recorded in the telepharmacy system and the actual stock available in the pharmacy. This discrepancy potentially caused inconvenience to patients and emphasised the critical need for pharmacy staff to check stock levels regularly. Ensuring the accuracy of stock information is essential to guarantee the continuous availability of medications for patients relying on telepharmacy services. These conditions could be addressed by regulations as the requirement of system integration, which is necessary for continuity of care in telepharmacy services. ⁸ On the other side, it is important to consider that better to allow pharmacies provide prescription copy if integrating supply management systems is more complex. Additionally, we recommend that future standards extend beyond supply management to include broader interconnectivity aspects. Our study results revealed that current telepharmacy practices via PSEF predominantly emphasise product-oriented services rather than patient-centred care. To improve patient safety and ensure continuity of care, other critical domains – such as patient records, including pharmacist interventions and physician prescriptions – should be comprehensively managed within telepharmacy systems.

Unaddressed legal challenges in telepharmacy practices identified in this study include informed consent and autonomy, data protection and security, professional integrity, service boundaries, and payment/reimbursement, as highlighted in other studies.^10,11 This might have resulted from low awareness among the recruited pharmacists regarding these issues within telepharmacy services. Despite the security aspect of telepharmacy being stated in the regulations where the PSEF has an obligation to guarantee user access and security, another legal challenge has failed to be addressed in the relevant regulations referenced in this study. Further research on these legal challenges in Indonesian telepharmacy practices is essential to assist stakeholders in developing the necessary policies. Additionally, formal training has been found to enhance pharmacists’ knowledge, perceptions, and readiness prior to delivering telepharmacy services. ²⁵

Despite the challenges, all respondents agreed that telepharmacy is a more effective and efficient alternative to delivering pharmaceutical services. They argued that patients value pharmacies that offer telepharmacy services to broaden service ranges. They also acknowledged the possibility of a more comprehensive and tailored approach to patient care. It is aligned with the survey results on the Indonesian general population, which underscored the positive perception and willingness to use telepharmacy services. ²⁸ Telepharmacy was also claimed to offer time and cost-saving benefits, as patients do not have to spend money on transportation. ⁹ Although there are still many limitations of telepharmacy services cooperating with PSEF implemented by the community pharmacy, the system could help them to reach customers easier, facilitate the remote payment, and provide online transaction interface or history, which is more cost-effective than developing their own telepharmacy system.

There are numerous potential scopes to be expanded in the implemented telepharmacy services, particularly in clinical services and patient education. Incorporating various modes of digital communication, such as video communication in mobile applications, could alleviate some of the challenges related to the effectiveness of telepharmacy services. Although our respondents showed positive perception of and willingness to deliver telepharmacy services, a robust foundation for training and reliable-specified telepharmacy regulations are expected to help community pharmacists ensure their services are safe for patients.^8,14,25

Establishing specific telepharmacy service standards by the government is essential due to the unique challenges that differ from traditional pharmacy services. In Indonesia, creating consolidated regulations for telepharmacy may be challenging due to varying clinical settings and socio-demographic characteristics. The complexity of telepharmacy is compounded by the involvement of multiple stakeholders, including healthcare professionals, facilities management, PSEF, insurance, and delivery providers. Available regulations during 2020–2021 have mentioned the use of technology, real-time communication between pharmacists with physicians and patients, user security, and documentation.^15–17 However, this research – conducted in 2023 – indicates that the implementation has not been effectively executed in community pharmacies. Many pharmacists remain unfamiliar with the available regulations, as the relevant telepharmacy standards have been integrated into broader regulations, such as telemedicine guidelines, risk-based business activities guidelines, and controls on online drug and food circulation. Therefore, it is crucial for the government to develop more specific and comprehensive telepharmacy standards that can be implemented and communicated to pharmacists and stakeholders, similar to traditional pharmacy standards. Additionally, it is essential for regulatory bodies to conduct regular audits and supervision of all parties involved in telepharmacy services to ensure compliance with these standards.

Study limitations and strengths

This study explores telepharmacy practices in community pharmacies compared to the available standards using the triangulation method of data collection, which has been rarely conducted in Indonesia. Unfortunately, this study only included a limited area in Indonesia, did not include chain pharmacies, and the research tools have not been pilot-tested. Another limitation identified was the difficulty in utilising the developed observation checklist when telepharmacy services were not conducted during the data collection period. The observation checklist could be further developed into a checklist of the evidence, documentation, or infrastructure related to telepharmacy service. We recommend further studies of telepharmacy practices with a broader scope of geographical settings, more various types of clinical settings, and refined tools which may enrich the results for future policy development. Incorporating a panel of community pharmacists with telepharmacy experience and regulatory authorities into the development and validation of future research instruments could offer additional valuable insights and further enrich the findings.

Conclusion

This study has found the potentially dangerous situations for patient safety and services quality in telepharmacy practices that have not been adequately addressed by traditional pharmacy guidelines. The key issues include limited communication access between pharmacists and physicians/patients, invalidity of e-prescription, difficulties of reviewing prescription, unclear predefined requirements of staff competencies, and service boundaries which could potentiate the risk of medication errors. To mitigate these risks, tailored telepharmacy practices standards are essential for safeguarding patient safety and enhancing service quality.

Supplemental Material

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Supplemental material, sj-docx-2-dhj-10.1177_20552076251326018 for The urge for specific standards of telepharmacy services: Lessons learned from qualitative study in Indonesian community pharmacies by Kartika Citra Dewi Permata Sari, Adelia Nathifa Rachma Nur Setiati, Larasati Arrum Kusumawardani, Hasniza Zaman Huri and Mohamed Hassan Elnaem in DIGITAL HEALTH

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sj-docx-3-dhj-10.1177_20552076251326018 - Supplemental material for The urge for specific standards of telepharmacy services: Lessons learned from qualitative study in Indonesian community pharmacies

Supplemental material, sj-docx-3-dhj-10.1177_20552076251326018 for The urge for specific standards of telepharmacy services: Lessons learned from qualitative study in Indonesian community pharmacies by Kartika Citra Dewi Permata Sari, Adelia Nathifa Rachma Nur Setiati, Larasati Arrum Kusumawardani, Hasniza Zaman Huri and Mohamed Hassan Elnaem in DIGITAL HEALTH

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sj-docx-4-dhj-10.1177_20552076251326018 - Supplemental material for The urge for specific standards of telepharmacy services: Lessons learned from qualitative study in Indonesian community pharmacies

Supplemental material, sj-docx-4-dhj-10.1177_20552076251326018 for The urge for specific standards of telepharmacy services: Lessons learned from qualitative study in Indonesian community pharmacies by Kartika Citra Dewi Permata Sari, Adelia Nathifa Rachma Nur Setiati, Larasati Arrum Kusumawardani, Hasniza Zaman Huri and Mohamed Hassan Elnaem in DIGITAL HEALTH

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sj-docx-5-dhj-10.1177_20552076251326018 - Supplemental material for The urge for specific standards of telepharmacy services: Lessons learned from qualitative study in Indonesian community pharmacies

Supplemental material, sj-docx-5-dhj-10.1177_20552076251326018 for The urge for specific standards of telepharmacy services: Lessons learned from qualitative study in Indonesian community pharmacies by Kartika Citra Dewi Permata Sari, Adelia Nathifa Rachma Nur Setiati, Larasati Arrum Kusumawardani, Hasniza Zaman Huri and Mohamed Hassan Elnaem in DIGITAL HEALTH

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sj-docx-6-dhj-10.1177_20552076251326018 - Supplemental material for The urge for specific standards of telepharmacy services: Lessons learned from qualitative study in Indonesian community pharmacies

Supplemental material, sj-docx-6-dhj-10.1177_20552076251326018 for The urge for specific standards of telepharmacy services: Lessons learned from qualitative study in Indonesian community pharmacies by Kartika Citra Dewi Permata Sari, Adelia Nathifa Rachma Nur Setiati, Larasati Arrum Kusumawardani, Hasniza Zaman Huri and Mohamed Hassan Elnaem in DIGITAL HEALTH