Pharmacists' Patient Care Process: A State "Scope of Practice" Perspective

Words matter: Comments in support of diagnosis education in pharmacy

Diagnosis education is explicitly included in the Draft Accreditation Standards 2025 and should be wholeheartedly supported. To address the staggering number of diagnostic errors in the US, the National Academy of Medicine advocates for diagnosis education for all health professions. Misperceptions of pharmacists' involvement in diagnosis are exacerbated by use of implicit language and euphemisms, and it's long overdue that we provide clarity. Pharmacists are engaged in diagnosis and diagnostic reasoning in everyday practice whether realized or not. Diagnosis education is implicitly included in US pharmacy curricula in the Pharmacists' Patient Care Process, and it is time to give students the language to engage in it responsibly to be practice-ready in all states. The explicit inclusion of diagnosis in the Draft Standards 2025 has positive implications for education, practice, and graduates.

Regulating Pharmacist Clinical Services: Is Legal Silence Golden or Deafening?

In the United States, the scope of practice of pharmacists is determined primarily at the state level. Not all state laws expressly permit or prohibit pharmacists from providing certain services; in between is a grey area of legal silence. Does legal silence permit pharmacists to perform a service that is not specifically permitted, but not expressly prohibited? Point-of-care testing provides a useful case study in legal silence: there are 1536 pharmacies currently holding a CLIA-waiver to administer tests in states reporting that pharmacists are not expressly permitted to administer tests. Legal silence may even provide a better framework for pharmacy based testing as it is naturally inclusive of any point-of-care test and no laws need updated when a new test comes to the market. Other health professions navigate this legal silence by governing according to a "standard of care." Rather than specifying a list of services a health professional can or cannot provide in law, it provides a flexible framework for the health professional to provide any service that other similarly situated health professionals would provide in the same or similar situation. A standard of care regulatory framework should thus be the target of the pharmacy profession in order to advance patient care.

Pharmacists' awareness and confidence in performing Pharmacists' Patient Care Process-related activities

BACKGROUND

The Pharmacists' Patient Care Process (PPCP) is a 5-step approach for patient-centered evidence-based pharmaceutical care. The PPCP was developed by the Joint Commission of Pharmacy Practitioners in 2014; however, little is known about PPCP terminology and process uptake across the profession.

OBJECTIVES

This study aimed to explore practicing pharmacists' awareness of and confidence in performing PPCP-related activities in various practice settings.

METHODS

This is a cross-sectional observational study of practicing pharmacists using a multiphase quantitative survey research design. A previously validated instrument, the PPCP Self-Efficacy Scale, was revised and distributed. The 28-item instrument addressed activities mapped to each of the 5 PPCP components (Collect, Assess, Plan, Implement, and Follow-Up). The survey was distributed via Qualtrics to an IQVIA pharmacist e-mail listserv in 2021 and to pharmacist state license rosters containing e-mail addresses in 2022.

RESULTS

A total 853 practicing pharmacists completed the survey. Most participants identified as female (62.5%) and white (74.6%). Almost 60% of participants reported practicing for 16 or more years. Forty-four percent practiced in a community pharmacy setting, whereas 23.6% and 15.4% practiced in a health-system setting and ambulatory care setting, respectively. Sixty-two percent indicated they had no previous knowledge of the PPCP, and 12.5% were unsure. Overall participants had relatively high self-efficacy mean scores for each of the PPCP components. Participants working in an ambulatory care setting had the highest mean self-efficacy scores across all PPCP components (P < 0.05). Participants who were affiliated with a college or school of pharmacy (e.g., faculty, preceptor) had higher mean self-efficacy scores than participants who were not affiliated (P < 0.01).

CONCLUSION

Most of practicing pharmacists are unaware of PPCP terminology. Their confidence in performing tasks associated with PPCP components is relatively high and varies based on PPCP component and practice setting.

Pharmacist Prescribing Models for HIV Pre-exposure and Post-exposure Prophylaxis

State strategies for pharmacist prescribing exist on a continuum from most restrictive to least restrictive. Using human immunodeficiency virus (HIV) pre-exposure prophylaxis and post-exposure prophylaxis as a case study, there are 3 viable pharmacist prescribing models: (1) population-based collaborative practice agreements; (2) government protocols; and (3) standard of care prescribing. The advantages and disadvantages of these 3 models are reviewed.

How to implement a "standard of care" regulatory model for pharmacists

National pharmacy associations have increasingly explored regulation according to a "standard of care." In such a model, pharmacists can provide a wide range of clinical services aligned with their education and training. Based on Idaho's experience implementing this model, there are five critical steps states must take to enact a standard of care: 1) Adopt a broad definition of "practice of pharmacy;" 2) Allow elasticity for practice innovation over time; 3) Decide which limited instances still necessitate prescriptive regulation; 4) Eliminate all unnecessary regulations; and 5) Strengthen accountability for deviations from the standard of care. States wishing to adopt a standard of care approach can follow this five-step process to enhance patient care and mitigate the lag that is otherwise constant between laws and practice.

Battling professional self-sabotage: Embracing standard of care as the future of pharmacy regulation

Laws and regulations are intended to protect the public; however, overregulation of the profession can block initiatives focused on patient safety and public health. This article discusses the 3 main regulatory approaches to pharmacy practice: standard of care (SOC), bright line, and right touch. An SOC regulatory model supports practitioners delivering patient care within their scope of practice and clinical training. Patient safety is maintained by measuring care against other practitioners within the same practice setting while supporting practitioners practicing at the top of their clinical ability. Compared with bright line and right touch approaches, the SOC regulatory model provides the adaptability needed to respond to different practice scenarios and settings, thus increasing access to health care and opportunities for innovation. To have a lasting impact on the profession and support patients, all pharmacy professionals must be fluent in regulatory approaches and advocate for states to transition to SOC regulatory models.

Opportunities for pharmacist prescriptive authority of buprenorphine following passage of the Mainstreaming Addiction Treatment (MAT) Act

In December 2022, Congress passed the Mainstreaming Addiction Treatment Act, which removed the federal legal barrier to pharmacist buprenorphine prescribing. As a result, each state can now decide whether or not to allow pharmacists to prescribe buprenorphine as an additional access point to reduce fatal opioid overdoses. At least 10 states allow pharmacists to prescribe controlled substances under collaborative practice agreements. Two states (California and Idaho) have also created pathways for independent prescribing of buprenorphine by pharmacists. Additional states should seek to enable pharmacists to prescribe buprenorphine to increase access to a proven beneficial treatment and help reduce fatal opioid overdoses.

Federal pharmacist Paxlovid prescribing authority: A model policy or impediment to optimal care?

The U.S federal government leveraged emergency authority to allow pharmacists to prescribe Paxlovid (nirmatrelvir and ritonavir) during the COVID-19 pandemic. While heralded by pharmacy associations, the FDA framework included restrictions that arguably ran counter to clinical guidelines and evidence-based research and recommendations. These restrictions will limit the utility of pharmacist prescriptive authority for Paxlovid in practice. The experience of Paxlovid prescribing and a similar recent federal action illustrate the challenges inherent in federal oversight of pharmacist prescriptive authority. While initially more difficult to navigate for stakeholders, working with state legislatures and state boards of pharmacy has much stronger long-term potential to enable broad pharmacist prescriptive authority and benefit patient care. This commentary uses Idaho's pharmacist prescribing regulations as a comparison to the federal actions.

Update and recommendations: Pharmacists' prescriptive authority for tobacco cessation medications in the United States

To characterize state laws in the United States regarding the expansion of pharmacists' prescriptive authority for tobacco cessation medications, compare key components across different models, and discuss important considerations for states that are considering similar legislation or policies. Legislative language was reviewed and summarized for all states with pharmacist prescriptive authority for tobacco cessation medications, and state boards of pharmacy were contacted to determine the number of registered complaints or safety concerns received as a result of pharmacists' prescribing under these authorities. As of June 2022, 17 states have enacted laws for pharmacists' prescriptive authority for tobacco cessation medications; most (N = 16) have implemented procedures, and 1 is in the process of adopting a similar prescribing model. Of 16 states with fully delineated protocols, 8 (Colorado, Idaho, Indiana, New Mexico, North Dakota, Oregon, Utah, Vermont) include all medications approved by the U.S. Food and Drug Administration for smoking cessation, and 8 (Arizona, Arkansas, California, Iowa, Maine, Minnesota, Missouri, North Carolina) include nicotine replacement therapy medications only. Most protocols specify minimum cessation education requirements for pharmacists and define required intervention elements (e.g., screening, cessation intervention components, follow-up, and documentation requirements). Personal communications with state boards of pharmacy revealed no complaints or safety concerns regarding pharmacists' prescribing for cessation medications since these authorities were first implemented, in New Mexico, in 2004. The number of states with pharmacists' prescriptive authority for tobacco cessation medications has increased substantially in recent years. There have been no registered complaints or safety concerns since the inception of this expanded scope of practice. Although the profession has made meaningful progress, there are inconsistencies across states with respect to medications that are included and requirements for implementing tobacco cessation services, which may impede broader adoption.

The impact of the COVID-19 pandemic on addressing common barriers to pharmacy-based point-of-care testing

Introduction: Pharmacy-based point-of-care testing has long had the potential to improve patient access to timely care, but adoption has been slowed by financial and regulatory barriers. The COVID-19 pandemic reduced or temporarily eliminated many of the barriers to pharmacy-based testing. This review examines how the changes brought on by may impact pharmacy-based testing after the pandemic.Areas covered: This review searched peer-reviewed, lay, and regulatory literature to explore the implementation of pharmacy-based COVID-19 testing. This includes a review of regulatory and financial changes that removed barriers to testing. Additionally, it reviews the literature related to the growth of pharmacy-based testing.Expert opinion: It is clear that the COVID-19 pandemic created an awareness and opportunity for pharmacy-based point-of-care testing. The changes made in response to the pandemic have the potential to increase the role of pharmacy-based testing, but additional regulatory changes and wider pharmacy adoption are still needed to maximize the value of such services.

Pharmacy Regulatory Innovation Index: Benchmarking the regulatory environment in 10 western states

BACKGROUND

Pharmacy is among the most regulated of health professions on the basis of both word count and restrictions. State-level restrictions limit the ability of pharmacists to be fully engaged as members of the health care team.

OBJECTIVE

This paper aimed to create a simple benchmark-the Pharmacy Regulatory Innovation Index (PRII)-that takes into account the scope-of-practice allowances that a state provides to pharmacists and the overall regulatory burden for the pharmacy profession using 10 western states as a sample.

METHODS

A scorecard was developed on the basis of the activities reported as necessary for pharmacists to fully engage in the Pharmacists' Patient Care Process (PPCP). The laws and regulations of 10 western states were analyzed using plain-text interpretation.

RESULTS

The 10 western states fall into 3 of 4 distinct quadrants. Three states appear in the highly regulated, low-innovation quadrant (Oregon, California, and Nevada), and 2 states appear in the low-regulated, high-innovation quadrant (Idaho and Washington). The remaining 5 states fall in the low-regulated, low-innovation quadrant (Alaska, Hawaii, Montana, Utah, and Wyoming).

CONCLUSION

The PRII has been created to assess a state's regulatory burden and its scope-of-practice allowances, using the PPCP as a guide for innovation. States can use the PRII tool to benchmark their regulations in comparison with those of peer states and identify opportunities for improvement.

Pharmacists’ Patient Care Process: State “Scope of Practice” Priorities for Action

To fully engage in the Pharmacists’ Patient Care Process, pharmacists must be able to (1) participate in a Collaborative Practice Agreement, (2) order and interpret laboratory tests, (3) prescribe certain medications, (4) adapt medications, (5) administer medications, and (6) effectively delegate tasks to support staff. Each of these activities is dependent on state scope of practice laws, but these laws are not binary. Various state-level restrictions allow us to view these activities on a continuum from more restrictive to less restrictive. This continuum will allow pharmacy and public health stakeholders to identify priorities for action in their states.

The Hematopoietic Cell Transplant Pharmacist: A Call to Action

Recently, the required training and credentials for as well as the various roles of the hematopoietic cell transplant (HCT) pharmacist have been endorsed by the leading organizations in cellular therapy, the American Society of Transplant and Cellular Therapy and the European Society of Blood and Bone Marrow Transplantation. While these documents establish the roles a HCT pharmacist can fulfill within the multi-disciplinary team, few reports have evaluated the impact of the HCT pharmacist on clinical, financial, or quality outcomes. Further, a paucity of information has been reported on types of practice models, such as the use of collaborative practice agreements, or described effective methods to overcome the barriers to the increased utilization of HCT pharmacists. Herein, a brief summary of available information is provided to aid readers in understanding the state of the science for pharmacists practicing in this specialty with the goal to stimulate further research to justify the roles of HCT pharmacists and the correlation of such research to various outcome measures. Practitioners are encouraged to build upon this existing knowledge to create the novel integration and elevation of pharmacy practice to improve outcomes for patients, providers, and payors.