Certified Pharmacist Prescriber Initiative
Development of a framework and proposal for pharmacist prescribing stretches back to 2010 when the College Board first decided to move forward with a feasibility study. It was later included in the College’s 2014/15 – 2016/17 Strategic Plan.
A Certified Pharmacist Prescriber Draft Framework was developed in 2015/16 – it includes information on societal need, proposed eligibility criteria and standards limits and conditions, as well as practical use cases. In November 2015, the Draft Framework was approved by the College Board to help facilitate stakeholder engagement and a series of consultations were held in Spring/Summer 2016.
The College completed its engagement on pharmacist prescribing in October 2016, including analyzing the extensive feedback received, and prepared a report on the results of the engagement. The report was shared with the College Board in November 2016 to aid in decision making on the next steps for pharmacist prescribing in BC.
Pharmacist Prescribing Engagement Results
Stakeholder engagement is an essential part of moving forward with pharmacist prescribing. The Certified Pharmacist Prescriber Draft Framework was formed with the intention of seeking input from pharmacy professionals, other prescribers and patients prior to developing the final proposal for pharmacist prescribing in BC.
The consultation period ran from February 2016 to August 2016 and included 15 different workshops and stakeholder meetings with over 25 different groups and organizations as well as an online survey which received more than 11,400 comments from over 1,500 respondents.The College would like to thank everyone who contributed feedback during this engagement.
The Engagement Report consolidates all the feedback received through the pharmacist prescribing engagement under four key themes:
- Confidence in pharmacists prescribing
- Collaboration and communication
- Improving patient care
- Support for the initiative.
Overall, stakeholder groups were quite divided in their level of confidence in pharmacists prescribing as well as their support for the initiative. Feedback indicated overwhelming support from pharmacists and pharmacy technicians, but strong resistance from other prescribers, while the public was divided.
The greatest convergence across stakeholder groups surrounded the opportunity pharmacist prescribing could have in providing greater access to care, especially for minor ailments, emergency situations, continuity of care and for patients without a primary care provider. Feedback from pharmacists and other prescribers also highlighted that pharmacist prescribing might work best in interdisciplinary team-based settings where access to more patient information and lab test results, and having a physician or nurse practitioner available to provide a diagnosis, provided respondents with greater confidence in pharmacist prescribing.
Learn more about the results of this engagement through the Certified Pharmacist Prescriber Engagement Report.
Decision on Next Steps
Five Board Members met to review the results of the pharmacist prescribing engagement. After much consideration they recommended to the full Board that the scope of the Draft Framework and the proposal to the Minister of Health be narrowed to pharmacist prescribing within a collaborative practice setting.
Collaborative practice settings for pharmacist prescribing would include interdisciplinary team-based settings where physicians and nurse practitioners continue to be responsible for the diagnosis; and where access to health records and diagnostics, including lab tests, would also be required. Certified Pharmacist Prescribers would also be restricted from dispensing medications they prescribed for a patient.
Reasons for restricting pharmacist prescribing to collaborative practice include:
- Conflict of Interest
Separating pharmacist prescribing from dispensing and business interests removes the concern for a potential business conflict of interest – a frequent point of concern for respondents.
- Interdisciplinary team-based settings
Collaborative practice settings involve working closely in an interdisciplinary team to care for patients. In this setting, physicians or nurse practitioners provide the diagnosis – an area many other prescribers felt pharmacist prescribers would not have the expertise to practice in.
- Access to patient health information and lab tests
Pharmacists working in collaborative practice settings already have access to patient health information and lab tests. Lack of access to patient information, and diagnostic tests (including lab tests) outside of interdisciplinary settings was a key point of concern identified by many pharmacists and other prescribers.
Minor Ailments and Emergency Refills
Pharmacy professionals, the public and other prescribers all highlighted some examples where pharmacist prescribing could have the opportunity to improve access to care for minor ailments, refills and renewals. However, significant concerns still remained around prescribing for minor ailments including access to electronic health records, access to and ordering of lab tests, and conflict of interest with prescribing and dispensing.
The working group of the Board suggested that the College may want to look more closely at how the authority in Professional Practice Policy 58 to adapt prescriptions (including renewals) could help improve access to safe and effective drug therapy for patients.
The College will revise the Draft Framework to reflect the revised scope and collaborative practice requirements. Feedback on other areas of the Draft Framework, such as education program requirements, will also be used to further develop the Draft Framework. It will also be revised to focus more closely on the benefit to patient care.
Based on a revised Draft Framework, the College will also develop a proposal for collaborative practice pharmacist prescribing in BC to submit to the Minister of Health for consideration.
See the presentation and College Board discussion on next steps for pharmacist prescribing through the BCPharmacy Periscope Channel.
The pharmacist prescribing consultation period ran from February 2016 through to August 2016. The level of participation during the Certified Pharmacists Prescriber Engagement was one of the largest the College has ever experienced.
To solicit feedback on pharmacist prescribing in BC and the Draft Framework, the College conducted extensive stakeholder engagement on pharmacists prescribing. Feedback was collected in the follow ways:
- 1,501 completed responses through an online survey (over 11,400 comments provided)
- 13 in-person workshops/discussions (a web-conference was used for those who could not attend in person)
- 3 meetings with other prescribing regulatory bodies
- 10 official letters of response
- 7 emails from individuals
The Certified Pharmacist Prescriber Draft Framework is a major step in the College’s work towards forming a proposal for pharmacist prescribing in British Columbia.
The Draft Framework was approved for stakeholder engagement at the College’s November 2015 Board meeting – it includes information on societal need, proposed eligibility criteria and standards limits and conditions, as well as practical use cases.
Need for Pharmacist Prescribing in BC
As the most accessible health care providers and the first point of contact for health services for most patients, pharmacists have the opportunity to provide efficient care, and offer care when other providers are unavailable or unable to see patients in a timely manner. Pharmacist prescribing could ease some of the pressure on access to health care for British Columbians, and ensure quality continuity of care as patients move from hospital to community pharmacy care.
Benefits of a Certified Pharmacist Prescriber
Patient care, health outcomes, and BC’s health care system will benefit from pharmacist prescribing. Here are some of the well-known benefits of pharmacist prescribing:
- Patients have increased overall access to health care service
- Patients have increased access to assessments by a health professional – the number of practitioners a patient must visit to be assessed is reduced
- Patients have improved access to drug therapy
- Continuity of care for patients is improved with additional practitioners available to assess patients, provide care and contribute to patient care teams
- Delays in receiving care are reduced for patients – drug therapy can be initiated or modified right away
- Adverse drug events can be reduced when pharmacists “the drug experts” are more closely involved with prescribing drugs
- Delays in hospital admissions and discharges for patients are prevented and continuity of care following a hospital visit is improved
- Pressure is reduced on other parts of the health care system as pharmacists provide more drug therapy care for patients
- Capacity to meet rising health care demands (like an aging population and chronic disease) is increased
- Greater collaboration among health care professionals is supported with a collaborative approach to patient care and prescribing
At one time, prescribing was limited largely to physicians. However, growing pressure on the health care system, including limited access to primary care services and an increasing focus on a multidisciplinary collaborative approach in the delivery of health care services, especially with chronic diseases, have led to expansion of prescribing authority for other health care professionals including pharmacists.
Professionalism and Ethics in Prescribing
The Health Professions Act requires all health professions with prescribing authority to:
- abide by a Code of Ethics
- follow standards, limits, and conditions
- prescribe within the scope of their education, training and competence
- promote and enhance interprofessional collaboration
Pharmacists would be held to the same expectations should we receive prescribing authority in BC.
Proposed Standards, Limits, and Conditions for Pharmacist Prescribing
The Certified Pharmacist Prescriber Draft Framework includes standards, limits and conditions that build the on ethics and professionalism requirements that already exist for all prescribers in BC.
The Draft Framework includes that a pharmacist prescriber must:
- prescribe only within the scope of their education, training and competence
- prescribe only Schedule I, II, or III drugs – authority is not provided to prescribe controlled drug substances, such as opioids
- be solely accountable for their prescribing decision
- obtain patient consent before prescribing
- review the patient PharmaNet profile
- conduct a patient assessment
- document the prescribing decision, rationale, monitoring and follow-up plan
- notify and collaborate with patient’s primary care provider and other members of the health care team as appropriate
- monitor whether any changes to the prescription are required and follow-up with patients
PODSA legislation prohibiting pharmacy owners from prescribing
Currently there is legislation that prohibits pharmacy owners from prescribing within the provincial government’s Pharmacy Operations and Drug Scheduling Act (PODSA).
5 (1) A person authorized by an enactment to prescribe drugs must not, directly or indirectly, own a pharmacy.
These requirements are set out within provincial legislation and are not within the College’s control as a regulatory body.
The Certified Pharmacist Prescriber Draft Framework has been intentionally designed to work within current provincial legislation with the addition of pharmacist prescribers being added to the list of practitioners allowed to prescribe in BC.
However, we have consistently heard through our initial consultations that small independent pharmacy owners could provide significant benefits to patients through pharmacist prescribing, especially in small, rural or remote communities.
This consultation, and the report on what the College has heard, will be an important opportunity to document this issue, and help begin the conversation with pharmacies, the College and the provincial government on exploring an exception for this requirement for pharmacist prescribing.
Proposed Eligibility Criteria and Renewal Requirements
To be qualified to apply as a Certified Pharmacist Prescriber you must:
- Be a full pharmacist registered with the College
- Be in good standing
- Successfully complete an educational program and assessment
The Draft Framework proposes that the educational program will include testing on therapeutics, patient assessment, and the ordering and interpreting of laboratory tests. We want to hear from you on what you think should be included in the educational program as well as ideas for how it could be delivered.
Renewal requirements for a Certified Pharmacist Prescriber includes:
- proof of an additional 15 units of continuing education in the area of prescribing
- annual self-declaration
LABORATORY TESTS AND THE CERTIFIED PHARMACIST PRESCRIBER INITIATIVE
Many pharmacy professionals have expressed the need for pharmacists to have clear access to order and review lab tests. This Draft Framework also identifies the need for pharmacist prescribers to access and order lab tests.
While some access to lab tests may be already available through the “My ehealth” portal or patient charts, access, ordering and payment is not consistently available to support pharmacists in providing drug therapy.
The College Board recognizes the need to address this issue. However, elements of lab tests, including ordering and payment, is outside of the College’s direct control and as a result involves additional complexity to resolve. As a result, the decision was made by the College Board to move forward with the Certified Pharmacist Prescriber Initiative while recognizing the need to address issues with consistent access to lab tests.
We also believe this Draft Framework, and the input we receive from registrants and other stakeholders, will help demonstrate the need for pharmacists to consistently have access to, and order and interpret lab tests.
For this reason, scoping out the path towards ensuring all pharmacists can order and access lab tests is beyond the direct focus of this initiative.
What does Pharmacist Prescribing look like?
Assessment - All pharmacist prescribing includes an assessment of the patient and the condition by the pharmacist prescriber. The assessment involves considering many details including past medical history, social history, history of the present illness, medication history, mental health and more. The assessment may also include a physical assessment, or reviewing diagnostic information or laboratory values.
Synthesis - A synthesis, or conclusion, of the patient’s needs is reached by the pharmacist based on the assessment of the patient. This guides the prescribing decision.
Action - Based on the pharmacist prescribers’ assessment and synthesis, they will make a prescribing decision. They document the prescribing decision and rationale, and collaborate and communicate with other members of the patient’s health care team as appropriate.
Monitoring plan - All pharmacist prescribers must also develop a monitoring and follow-up plan. Examples of these can be found in the patient use cases.
Not all prescribing decisions will necessarily result in prescribing a drug. After assessing a patient, a pharmacist prescriber may find it is appropriate to prescribe, to de-prescribe, or not to prescribe. They could also decide it is appropriate to consult with, or refer the patient to, other members of the health care team. For example, a pharmacist would refer a patient when their condition is outside of the pharmacist prescriber’s scope of expertise or when patient care needs to be escalated.
Collaboration in Pharmacist Prescribing
Patients are cared for through the collaboration of many health care professionals. Pharmacist prescribing increases the collaboration among the health care professionals in a patient’s care team.
While a pharmacist prescriber is solely accountable for their prescribing decision, pharmacist prescribing still requires collaboration with others involved in the patient’s care.
After conducting a patient assessment, and making a prescribing decision, a pharmacist prescriber is required to communicate with patients and others involved in the patient’s care.
The pharmacist prescriber informs the patient of the need for follow-up to monitor whether any changes to the prescriptions are required. They also provide relevant information to the patient’s primary care provider and other health professionals.
A Range of Use Cases for Pharmacist Prescribing
The draft framework includes a range of use cases where pharmacist prescribing improves patient outcomes. They are all based on real cases.
These cases vary in the complexity involved in the prescribing process In some cases patients may be practicing self-care and actively managing their conditions, or patients may have minor illnesses that will resolve themselves with or without drug therapy. In some cases additional information may be already available, such as a diagnosis or lab work, in other cases the pharmacist prescriber may complete the assessment independently. It is also possible that a pharmacist prescriber may discover other issues as part of the assessment which would increase the complexity of the prescribing decision.
The draft framework is designed to provide authority for the full range of prescribing decisions. Like all health professionals, pharmacist prescribers will be required to “self-limit” and prescribe within the scope of their education, training and competence.
Less Complex Use Cases
We expect to see the majority of use cases in community pharmacies where less complexity is involved in the prescribing process
Many patients seek care from community pharmacists as their first point of contact for conditions that are minor or self-limiting – these conditions last for a short period of time, are less serious in nature and typically do not require lab tests or doctors’ visit. Pharmacist prescribers could identify patients who are not receiving treatment for these kinds of conditions that would benefit from drug therapy. If needed, patients with underlying serious issues discovered upon patient assessment would be referred to their family physician.
Moderately Complex Use Cases
We expect to see moderately complex cases where patients would benefit from pharmacist prescribing in community pharmacies, primary care clinics, residential care facilities, and hospitals.
These moderately complex cases include pharmacist prescribing involved with medication reconciliation (a review of the patient’s conditions and medications), polypharmacy (patients taking 5 or more medications), and chronic disease state management (existing patient diagnosis).
Complex Use Cases
We would expect to see the majority of complex cases where patients would benefit from pharmacist prescribing in hospitals, primary care clinics and residential care facilities. However, we know we can expect to see some pharmacist prescribing for complex cases in community pharmacies as well. While pharmacist prescribing for complex cases may not happen as frequently, it provides an opportunity to improve patient safety and patient outcomes, especially during transitions in care as well as in team-based care.
Complex cases would also involve polypharmacy (where patients are on five or more medications), and additional information, such as a diagnosis, may not always be available, increasing the complexity of the prescribing process