Hospital Pharmacy Leadership Conference - June 1 - 3, 2007
of Pharmacy Practice - What Will the Future Look Like?
Scope of Practice—Views of Pharmacy
Sheri Koshman, BScPharm, PharmD, ACPR, Clinical
Division of Cardiology, Faculty of Medicine and Dentistry
University of Alberta
Sheri Koshman prefaced her remarks with the words of William Zelmer
on the ethical life of the pharmacist:
“This awareness creates in me a profound duty to do what
I can to align my work, and the work of my profession, with the
needs people have for help in making their use of medication as
safe, effective, and affordable as possible. I can fulfill this
professional duty through continuous self-development, through
mindful attention to the people I serve, through the mentorship
of students and new practitioners, and through my support of collective
efforts to advance my profession.”
According to Koshman, there have been five stages of major change
in pharmacy practice since the time of ancient Babylonia in 2500
approximately 1860, the pharmacist was the manufacturer of
the advent of industry and technology, the role of pharmacy
shifted to mostly compounding.
The 20th century brought legislation restricting who could
prescribe. Hospital pharmacists supported drug distribution
within the institution, whereas community pharmacists focused
only on dispensing.
the 1960s, the community pharmacist role had expanded to include
drug consultation, while hospital pharmacists began to take
on broader clinical roles with deeper involvement in patient
the 1990s, clinical pharmacy continued to evolve into “pharmaceutical
care,” broadly defined as the “responsible provision
of drug therapy for the purpose of achieving definite outcomes
that improve the patient’s quality of life.”
The role of the pharmacist has evolved over time from a process-based
to a product-centred approach, eventually leading to a scope that
includes both, Koshman explained. The most contemporary model
of practice, the Total Pharmacy Care Model, incorporates all five
models of historical practice. The contemporary model is flexible
enough to encompass the vastness of what pharmacists can do in
both clinical and community settings, including offering support
There is ample evidence of positive outcomes for the expanded
scope of pharmacy practice, Koshman said. Recent systematic reviews
of in-patient and ambulatory care have produced clear evidence
of the benefits. A recent report by Bond et al. found beneficial
outcomes from five core pharmacy clinical services, including
improved hospital mortality, lower drug costs per occupied bed,
and fewer medication errors.
Despite the evidence, barriers to clinical practice remain, Koshman
said. These include attitudinal issues, such as lack of motivation
and self-confidence, practice inertia, unsupportive employers,
and deficiencies in education and training. Other barriers are
due to external factors, such as time management, access to medical
records, and legislative resistance to change.
Nevertheless, changes are under way. Recent amendments to Alberta’s
Health Professionals Act removed the requirement that all health
professionals be bound by exclusive scopes of practice. Instead,
role expansion is allowed, based on abilities and the range of
services that can be competently offered in a given environment.
New pharmacy practices include prescribing Schedule 1 drugs and
blood products and administering vaccines. Practitioners are able
to renew prescriptions, alter dosage, therapeutically substitute,
or prescribe in emergency situations. She noted that the legislation
in no way obliges pharmacists who do not wish to expand their
practice. And, in all cases, the Registrar must authorize Additional
An Alberta pilot project is in development to review outcomes
of Additional Prescribing Authority. The pilot will involve 10–20
pharmacists of diverse backgrounds, representing the whole broad
scope of the profession, and then will open to all Alberta pharmacists
by the fall of 2007.
Koshman spoke of her experience with the Cardiac EASE (Ensuring
Access and Speedy Evaluation) Program at the University of Alberta
Hospital, to illustrate the potential of expanded pharmacy practice.
The model is not a thoroughly integrated interdisciplinary approach,
since many of the services are provided in a parallel fashion,
but nevertheless has resulted in one-stop shopping, shorter waiting
times, better communication with patients, and more time per visit.
The pharmacist role in this collaborative overlapping approach
is expanded to include physical examination, medical history,
and diagnostic test interpretation. The anticipated “pushback”
from physicians has dissipated due to the positive outcomes. Physicians
have gained increased time and capacity for new patients, more
time to spend with existing patients, and more time to dictate
cases, letters, and follow-up.
A good model for expanded practice should include clinical training,
practice environment, motivation, infiltration, empowerment, and
mentorship, Koshman said. Expanded clinical training for pharmacists
is crucial. Pharmacists only receive as little as 22 weeks of
clinical training, compared with physicians who take two years
of clinical training followed by up to five years of residency.
“The breadth and scope of extra training and exposure makes
you a better pharmacist, with better clinical and research skills
and with more confidence,” she said.
Infiltration is also extremely important. Increased buy-in from
other groups and professions leads to increased opportunity for
practice and greater visibility.
An expanded scope of practice leads to many challenges as well
as benefits, Koshman noted. She recommended smaller peer groups,
better credentialing, and more interaction with other professions
who have “already walked this path.” She advised against
attempts to move the whole group forward at the same time, and
against efforts to simultaneously confront all aspects of resistance.
Instead, those people who are willing and capable should be allowed
to move more quickly and push the envelope for the rest.
The Canadian Society of Hospital Pharmacists (CSHP) has established
a set of goals to achieve by 2015. “Now we just need to
‘build it and they will come,’” Koshman said.
“But we need to invest in infrastructure, to lead by example,
to think of transitioning from in-patient to ambulatory care,
and to jump on every opportunity to collaborate.”