PHARMACIST PRESCRIBING IN INTERPROFESSIONAL PATIENT CARE

To define pharmacist prescribing as follows: patient assessment and the selection, initiation, monitoring, adjustment, and discontinuation of medication therapy pursuant to diagnosis of a medical disease or condition; further,

To advocate that health care delivery organizations establish credentialing and privileging processes that delineate the scope of pharmacist prescribing within the hospital or health system and to ensure that pharmacists who prescribe are competent and qualified to do so.

Rationale

The Pharmacy Practice Model Initiative (PPMI) Summit recommended that “through credentialing and privileging processes, pharmacists should include in their scope of practice prescribing as part of the collaborative practice team.” (Recommendation B14) With the demand for health care growing as the nation ages and increasing concern about the shortage of primary care providers, expanding the pharmacist’s role will contribute to the overall capacity of the health care workforce to meet patients’ primary health care needs.

As pharmacist prescribing is an innovative concept, a clear, concise definition of what it means and does not mean has yet to be established. Unlike physician prescribing, which is commonly understood to be the diagnosis and treatment of diseases and conditions, various terms are currently used to describe pharmacists’ medication ordering activities, such as prescriptive authority, collaborative practice, and collaborative drug therapy management (CDTM). These differ in definition and interpretation, depending on state scope of practice laws and other factors. A standard definition of pharmacist prescribing will facilitate future discussions on the role of pharmacists in interdisciplinary health care, help delineate health care team roles, enhance collaborative patient care, and clarify the meaning of pharmacist prescribing for other health care providers. 

In the proposed definition, pharmacist prescribing differs from that by other authorized prescribers and from medication therapy management (MTM) and CDTM in three significant aspects. First, prescribing by pharmacists requires active participation in the patient’s health care team or active engagement and coordination with other individual practitioners responsible for the patient’s care. Second, pharmacist prescribing must take place in concert with assessment, diagnosis, and other clinical findings contributed by the patient’s other care providers, and changes in the patient’s medication therapy must be communicated to these individuals in a readily available and timely manner. Third, pharmacists who prescribe are accountable to patients and to the health care team for exercising professional judgment in pharmacotherapy and medication-use decision-making according to their defined scope of services, as well as for the outcomes of those services. While many pharmacists may currently order medications under protocols for MTM or CDTM, prescribing entails a higher degree of autonomy and is a role for advanced practitioners with demonstrated competency and expertise. 

Although clinical pharmacy specialists practicing in highly focused clinical areas such as oncology and transplant often become skilled at diagnosing and treating symptoms in their respective patient populations, and pharmacists are prepared and qualified to interpret medication-related clinical laboratory results, the education and training pharmacists receive in physical assessment does not prepare or qualify them to be diagnosticians. Pharmacist prescribing may therefore be described as interdependent, but under this interdependent model, review, approval, and co-signature of pharmacist-prescribed medications by a licensed independent prescriber should be unnecessary, if pharmacists are in fact accountable for medication therapy outcomes. ASHP policy supports pharmacist authority in matters of medication therapy, autonomy in exercising professional judgment, and accountability for medication therapy outcomes. Patients are best served, however, when the expertise of pharmacists is applied to therapeutic use of medicines after definitive diagnosis indicates that medicines are the appropriate therapy. 

The American Medical Association and the American Academy of Family Physicians have publicly and staunchly opposed any expansion of pharmacist scope of practice perceived to encroach on the practice of medicine. Pharmacist prescribing is implicit to interdisciplinary care delivery, however. Independent drug therapy decision-making by pharmacists in hospitals is already common. It is often accepted and even expected by physicians. Physicians participating in multidisciplinary teams with pharmacists come to rely on their knowledge and see an opportunity to free themselves from tasks that can be done by another professional with demonstrated competency and expertise. Pharmacists in specialty practices such as anticoagulation management, solid organ transplant, and nutrition support have long functioned in roles in which near-independent authority to manage drug therapy has resulted in improved outcomes. In settings such as the Indian Health Service and Veterans Affairs health systems, where access to a primary care provider is limited, care provided by pharmacists with prescribing authority has demonstrated the benefits of this model.

Most hospitals authorize pharmacists to manage drug therapy by enacting Pharmacy and Therapeutics Committee policies that require use of an approved medical staff protocol and physician oversight for pharmacist-initiated orders. In practice, however, pharmacists often manage patients’ clinical needs that cannot be appropriately treated per protocol with minimal physician oversight. Depending on the patient, medication, and degree of trust, physicians may co-sign such orders with only cursory review. To the extent allowed by hospital policy, physicians often delegate therapeutic decision-making to pharmacists, secure in the trust developed through established professional relationships and shared experiences in successfully dealing with challenging clinical situations, rather than through formal collaborative practice agreements. Common examples of de facto pharmacist prescribing include independently managing symptoms and side effects in oncology patients, identifying and resolving drug-induced disease or problems, managing anticoagulant therapy for patients whose clinical status falls outside protocol-specified parameters, and responding to general directives to simply “fix the problem” when medication therapy is indicated. 

Credentialing by individual health care organizations is a natural selection process for determining who is authorized to prescribe that avoids distinguishing pharmacists by practice setting and allows more latitude in scope of practice. The credentialing procedures to establish pharmacists’ competency to prescribe must ensure that patients receive treatment from highly qualified caregivers. In addition to verifying appropriate education, licensure, and certification, the process should include:

• the same transparency and rigor applied to other prescribers,

• criteria used to measure patient care quality, and

• peer review by pharmacists and others who are authorized to prescribe.

Health care organizations should use privileging methods that establish the scope of practice and clinical services that pharmacists are authorized to provide commensurate with their demonstrated competency within an area or areas of clinical expertise. Pharmacists practicing in hospitals and health systems do not have or need privileges, such as admitting, that are not related to medication use. 
Finally, interdisciplinary health professional training programs should incorporate the concept of pharmacist prescribing in a standard way.

This policy was reviewed in 2017 by the Council on Pharmacy Practice and by the Board of Directors and was found to still be appropriate.