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pharmacist prescribing

By Dennis Tribble posted 11-11-2016 14:05


When I was a child, my father had a round wooden coin with the letters TUIT embossed on it. Whenever I would procrastinate, he would toss it to me and say "Here's your round TUIT". That was his way of telling me to get around to it; to get whatever I was procrastinating on done.

I have to admit, I procrastinated reading through the September 15th edition of AJHP, primarily because of its rich content; I just needed the time to get through all that was written there. It took me a while, but I finally got to read through it today. There's a lot of really good stuff in there.

There's a good article on the VA system. When I was a pharmacy student finishing up my Pharm. D. (in 1974), I did a clerkship in San Diego at the Naval Regional Medical Center. I had two roommates from the same school who were doing similar clerkships at the VA in La Jolla. Even back then, the VA was way ahead of the curve in terms of deployment and use of clinical pharmacists, When we did the SOPIT vision statement on a technology-enabled practice in 2009, we asked colleagues from the VA for some articles on advanced clinical practice; they gave us over 30! I think we need to be grateful to the VA for blazing the clinical pharmacy trail in the US.

By the way, we aren't the first on this trail. I have a number of colleagues in the UK who oversee clinics (among other clinical duties). On a recent visit to some UK hospitals, two good friends and colleagues showed me their hospitals and quickly pointed out that there were very few pharmacists in the pharmacy because they were "all where they were supposed to be -- in the clinics or on the wards". I was privileged to speak on PPMI at the 2012 meeting of the UK Clinical Pharmacy Association and learned there of what they called "the PIP", short for a special certification entitled pharmacist-independent-prescriber. The program actually started in 2006. Most of the discussion I overheard at that meeting was how to encourage more pharmacists to seek that designation. Note that this is not a collaborative prescribing agreement; this is a license to prescribe... period... It does require some mentoring by a medical practitioner while training, but that's it.

The other article that really caught my eye was on a series of qualitative interviews regarding pharmacist prescribing in the community setting. According to these interviews, one of our largest barriers (and one we have not well-articulated in PAI) is the perception of the public on our fitness (or lack thereof) to prescribe. It would appear that we have some work to do. One of the issues, which I think needs some serious public discussion, involves the apparent conflict of interest between our role as prescriber and our role as dispenser (wherein we may have a financial conflict of interest). Pretty clearly this matter has been resolved to some level among physicians who also dispense medications they prescribe; perhaps there is some learning for us there. Again, perhaps not.

Whatever the answer, it appears that we are progressing firmly on our desire to practice at the top of our license. ASHP is working feverishly on getting provider recognition status. It appears to me that we need to be working as feverishly on the other end of the legislative/regulatory spectrum to free ourselves from dispensing roles currently mandated in most state laws. Please note that I am not advocating abandoning our dispensing responsibilities. All the clinical practice in the world doesn't work if the medications are not available. IMO, we will always, and should always, maintain responsibility for the dispensing of the proper medications to patients, in whatever care venue we find ourselves.

Having said that, responsibility for something is not necessarily the same as responsibility to perform that something. Pathologists are responsible for the quality of laboratory diagnostic services in a hospital, yet those services are performed and managed by a cadre of well-trained (usually college-educated) technicians using a suite of properly automated and quality-controlled analytic devices. Similarly Radiologists are responsible for the quality of diagnostic imaging and the interpretation of those images, but that imaging is actually performed by technicians with properly automated systems.Heck, my dentist has some of the most sophisticated panoramic radiology equipment I have ever seen, but it is used by his technical staff.

What this means is that we need to do two things:

  • We need to work on our state pharmacy practice acts to enable delegation of what is our currently-mandated end-process inspection roles. 
  • To do that, we need to re-engineer our compounding and distribution processes to become so reliable that we can "sell" the notion that pharmacist inspection of each item going out the door is redundant. Without that story to tell, it seems unlikely we will convince the public policy makers that we need no longer perform the roles currently written into law.
    • Our technicians need to be better educated, better trained, and licensed (as opposed to registered)
    • As much as is possible, our compounding and distribution needs to be automated both to remove opportunities for human error, and to provide for capture of sufficiently detailed process information that we can demonstrate the ongoing quality of our systems.

What do you think?

Dennis A. Tribble, PharmD, FASHP

Ormond Beach, FL

The information in this blog represents my sole opinion, and does not necessarily represent the opinions of my employer nor of ASHP.

#Informatics #PPMI



11-14-2016 10:13

David... agree that the whole credentialing piece is a bit thorny. The one thing the UK pharmacists have is a relatively unified system for all that, which takes some of the pitfalls out of the process.

I just did a quick review of physician credentialing online and looks like a potpourri of solutions, but there seem to be a few common threads:

  • There is come kind of board
  • That board issues a certification examination that seems generally respected
  • The exam by itself if not all that is required for credentials; some significant and current work experience is also required. 

Seems like a reasonably sound model that starts with a credible Board Exam. I think that's where I would start.

It seems hard to get this notion above the State level since knowledge of laws and regulations in the State where someone is practicing would be essential. Not all of that is in the Pharmacy Practice Act; I suspect that some of this is in the Physician Practice Act. Would be interesting to see.

11-14-2016 07:58

Right on target Dennis! We can build the highway, but it needs to have road signs and traffic laws to function. Developing a more consistent and scalable process for Credentialing and Privileging is also paramount. I've shared my thoughts on the need to have these processes in place in my recent blog and would love to hear more about your thinking. Especially on how we can keep some of the kind of data for these systems in a central repository so it does not need to be a unique submission for each health system, payer, etc where a provider needs to submit.