Millcroft Hospital Pharmacy Leadership Conference - June 1 - 3, 2007

Theme:Scope of Pharmacy Practice - What Will the Future Look Like?

Scope of Practice—Views of Pharmacy

Sheri Koshman, BScPharm, PharmD, ACPR, Clinical Postdoctoral Fellow
Division of Cardiology, Faculty of Medicine and Dentistry
University of Alberta
Edmonton, AB

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 BCE:

•	Until approximately 1860, the pharmacist was the manufacturer of drugs.
•	With 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.
•	By 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 care.
•	Into 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 for self-care.

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 Prescribing Authority.

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.”