Client: Ontario Hospital Association

2003

Head: Are We Ready For Change?

Deck: Pharmacists are poised to take the leap from a product focused to patient focused model. That could mean an expanded scope of practice to include prescribing privileges. Are we ready? The truth is, in some cases, we're already there.

When Della Croteau thinks about today's new batch of eager pharmacy students moving out into the workforce, her heart goes out to them. Their training involves education in pharmaceutical care and moving away from a product focus to rest squarely on a patient focus model.

It's an exciting development, but when Ms. Croteau, deputy registrar and director of programs for the Ontario College of Pharmacists, shows them the barebones Pharmacy Act, they're taken aback. Nowhere does is talk about improving patient's lives, ordering lab results or making recommendations, instead using words such as, "custody, compounding and dispensing."

"Our students are now being educated in pharmaceutical care so when I show them our scope of practice statements, their faces just fall," she says.

While these keen pharmacists-in-training seem ready for an expanded scope of practice and a change, are the rest of us? When the issue of prescribing privileges being extended to pharmacists came up at the OHA scope of practice summit earlier this year, an immediate buzz filled the room. Sometimes there seemed to be more questions than answers.

Question number one: If pharmacists are granted prescribing privileges, how are other professions such as physicians affected? And how can we ensure the disciplines work intercollaboratively without creating redundancy?

Glen Pearson, assistant professor of medicine at the University of Alberta, and co-chair for the Canadian Society of Hospital Pharmacists Task Force on Pharmacist Prescribing, is confident we're already halfway there. In the past decade he says he has seen a shift and "an evolution, a letting down of guard amongst individual professions and a willingness to work together to achieve better outcomes."

Question number two: How can we find solutions to scope of practice issues that speak both to hospital and community settings when there is no cookie-cutter answer for both? Some say this is one of the most complex issues and can have a direct impact on shifting employment trends if pharmacists in one area have expended scope and the other does not. As Ms. Croteau's students suggest, new pharmacists want to take on more responsibility and expanded scope in only one area could result in a popularity contest.

Question number three: How does pharmacy handle the tricky issue of remuneration when moving away from a product-focused model?

While some disciplines such as the respiratory therapy profession have been able to develop scope of practice solutions for themselves, these newer disciplines had the luxury of working from scratch.

Pharmacy, however, is an excellent example of an older profession -- 130 years of regulation in Ontario -- that comes with a hefty amount of baggage to wade through before instigating widespread transformation. That makeover includes pharmacists being granted the thumbs up to prescribe medication.

But change hangs on the horizon and, says Pearson, in many cases change is already here.

"Pharmacists prescribing is not in the future. It's in the current way we operate," he says.

Ms. Croteau agrees, naming off examples such as Quebec and British Columbia pharmacists with prescribing privileges for emergency contraceptive. Ontario had also initiated a similar pilot project, and Nova Scotia and Saskatchewan professionals will have the ability to prescribe the medication soon. She also mentions that as of January 31, Quebec pharmacists were granted the right to adjust doses.

"Are we ready for prescribing? Ready or not, here we come," she says.

Beyond the emergency contraceptive example, there are other models in which pharmacists take a more leading role in patient care. At the University of Alberta's Cardiovascular Risk Reduction Clinic, pharmacists work alongside other professionals such as physicians, dieticians, nurses, exercise physiologists and psychologists to form a team dedicated to comprehensive patient care. The team comes together to develop each patient's personalized wellness plan.

What is so interesting about this collaborative model is the expanded scope of the pharmacist's duties. Patients visit the pharmacist follow-up clinic so he or she can monitor progress, offer dosage modification, monitor lab results, select new drugs or even decide to discontinue a certain drug.

There's a good reason why pharmacists are the most capable of making these decisions, says Mr. Pearson. Over only a few short years, didactic education in drug therapy has been reduced for med school students. Their drug therapy training now depends on learning via other people in their clerkship and having the information integrated into other subjects. Only pharmacists are given the intense focus needed to understand the minutia of drug therapy.

Of course there are the other reasons why pharmacists and their organizations are pursuing expanded scope of practice -- reasons that seem very similar to those put forth by other regulated professionals. These include wanting to increase patient outcomes, offering a cost-effective solution, increasing accessibility to qualified healthcare professionals in small communities and because others have already succeeded in expanding their scope.

Pharmacists are starting to make noise -- and government seems to be taking notice. In a 2002 CphA Conference, Roy Romanow is reported to have said, "...pharmacists remain a tremendously underutilized resource."

Today's reality means there are still challenges to be addressed before changes such as prescribing rights can be offered to other professionals. There is competition for controlled acts. There is the thorny issue of remuneration and how pharmacists should get paid if they move away from product focus to service focus models. And of course there has to be an efficient and effective system for information sharing between disciplines.

But at the end of the day it is still the patients who must benefit if there is an actual need to change. Patient safety has to be improved. The solution? Innovation.

"I think the challenge for all of us is to try to facilitate innovation in what we do and fight for improvements in healthcare. It's a challenge, but there are lots of opportunities. People who persist will get there," Mr. Person says.

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