HEALTH-SYSTEM EDITION
PROFESSIONAL PRACTICE

Five states pass collaborative practice laws

To the delight of pharmacists, collaborative practice acts have passed in a flurry of states recently. The laws, which enable pharmacists to initiate or modify drug therapy under protocol with physicians, were enacted in Connecticut, Hawaii, Maryland, Oklahoma, and Pennsylvania.

These laws vary somewhat from state to state. In Pennsylvania, collaborative drug therapy management (CDTM) is limited to hospital practice. But community pharmacists are not necessarily excluded. They can participate in the vaccination portion of the law, and they can help manage drug therapy in nursing homes that fall under the definition of health facilities.

"Managing drug therapy is not about who you work for but where the patient is," said Robert Patti, Pharm.D., JD, clinical coordinator at York Hospital in York, Pa., and the legislative chair for the Pennsylvania Society of Health-System Pharmacists. Patti said he expects that most pharmacists will wait for the state pharmacy board to develop regulations before initiating any drug administration or vaccination protocols. This could take as long as 18 months. "The board could add more to what's required or add finer details," he said.

He noted, however, that many hospital R.Ph.s are already involved in CDTM, which, under the new law, includes drug therapy protocols approved by hospital P&T committees. "We've done that already," he said. "The law is a validation of a practice that was already in place across the country." He expects the law to have the biggest impact in hospitals that have no such protocols in place yet.

Pharmacists in Pennsylvania intend to broaden the CDTM law to include patients in community settings. "We're going to be very involved," said Patti of his organization.

Connecticut is following a similar strategy. By limiting CDTM to inpatients, pharmacists were able to make the bill in this state more palatable for physicians and legislators. Connecticut's CDTM, too, includes protocol-based practice.

"We are certainly going back this session to ask that it be extended to the long-term care and community practice settings," said Margherita Giuliano, R.Ph., executive v.p. of the Connecticut Pharmacists Association. Pharmacists already have the support of the medical society to establish CDTM in long-term care facilities, and they would like to do pilot studies in community settings. Giuliano envisions recruiting pharmacists who are involved in disease state management. "Collaborative practice is the next step in disease state management."

Hawaii has just accomplished what both Pennsylvania and Connecticut plan to try. The state's CDTM law, which once applied only to the hospital setting, has now been extended to all other institutions and to community practice, said Les Krenk, R.Ph., president, Hawaii Pharmacists Association.

Under the new law, pharmacists could enter into agreements with physicians to do a range of drug therapy management, from starting patients on blood glucose monitors and test strips to more complex tasks such as ordering lab tests and adjusting doses (per protocol only).

Krenk believes the entrepreneur in the community pharmacy will take advantage of the new CDTM law. "There are also some innovative pharmacists in chains," he said. As owner of Maui Clinic Pharmacy, Krenk can capitalize on the good working relationship he has with the physicians in his clinic. "We're interested in starting something with anticoagulants," he said.

Krenk envisions the demand for CDTM services building as physicians see the positive results their colleagues have had. His next project is to get an emergency contraception bill passed in the next legislative session. "We think that will be the next big step."

Like their counterparts in Pennsylvania, Maryland R.Ph.s waged a protracted battle before getting their bill through the legislature. The bill met with a good bit of resistance, mostly from the state's medical society. Unlike Pennsylvania, however, Maryland was able to get CDTM privileges for community pharmacists. The pharmacists must, however, have either a Pharm.D. or equivalent training, and there are very specific requirements for protocol standards and approvals.

"The 'equivalent training' is a sore spot," said Howard Schiff, PD, executive director of the Maryland Pharmacists Association. The state must now determine what exactly constitutes that training. "But, it is a step for us," said Schiff.

Oklahoma pharmacists managed to get approval for CDTM, but they did it without using the term. It started with a legal problem when the state's attorney general warned that if the definition for "administer" was not added to the state statutes, pharmacists would not be able to counsel patients on using inhalers, applying patches, injecting insulin, and so on.

In the legislation created to correct that omission, said Phil Woodward, Pharm.D., executive director of the Oklahoma Pharmacists Association, the lawmakers included the ability for pharmacists to enter into agreements with physicians. Even though the term "collaborative practice" is not in the new law, by including this provision for agreements, "it does give us the right to do collaborative therapy with physicians," Woodward said. "We went a long way this time with [this legislation]."

Jillene Magill-Lewis, R.Ph.

Jillene Lewis. Five states pass collaborative practice laws.

Drug Topics

2002;22:HSE36.