Provincial Summary
British Columbia
The B.C. government’s 2008 Health Professions (Regulatory Reform) Amendment Act (Bill 25) formalizes a pharmacist’s authority to “renew existing prescriptions.” The College of Pharma-cists of British Columbia (CPBC) developed Professional Practice Policy #58 (PPP-58), entitled “Protocol for Medication Management – Adapting a Prescription,” to guide pharmacists in the safe and effective adaptation, including renewal, of existing prescriptions. This policy took effect January 1, 2009.
Before they can adapt prescriptions, pharmacists in B.C. must possess a minimum of $2 million in professional liability insurance and must declare in writing that they understand the CPBC’s Orientation Guide for PPP-58 as well the Amendment to the Orientation Guide, released Decem-ber 2008 (both are available at www.bcpharmacists.org).
Once those conditions are met, pharmacists in B.C. have the authority to adapt prescriptions without prior approval from the prescriber; however, they are not obligated to do so. The deci-sion to adapt or not to adapt a prescription is at the discretion of the individual pharmacist. Once a pharmacist adapts a prescription they assume full responsibility, and liability, for it. PPP-58 sets out seven fundamental elements that must be fulfilled when adapting a prescription, detailed in the Orientation Guide:
- Individual competence;
- Appropriate information;
- Prescription;
- Appropriateness of prescription;
- Informed consent;
- Documentation; and
- Notification of other health professionals.
Types of Adaptation
The current scope of practice in B.C. specifies three professional activities as adapting a prescription:
- Changing the dose, formulation or directions of use of a prescription to enhance patient outcomes;
- Renewing a prescription for continuity of care; and
- Making a therapeutic substitution within the same therapeutic class for a prescription to best suit the needs of the patient.
Renewals apply only to stable, chronic conditions for which the patient has taken the same medication for at least six months. The maximum renewal is up to six months from the date of the original prescription. For psychiatric medications, pharmacists must be working within a multidisciplinary practice in order to make renewals.
Changes to dose, formulation or directions for use, as well as therapeutic substitutions, are restricted to specific conditions or classes of drug unless the pharmacist is in a practice setting where collaborative relationships or appropriate protocols are established (e.g., hospitals, long-term care facilities and multidisciplinary practices).
Pharmacists cannot adapt a prescription if the original prescription has expired (one year from the date the original prescription was written, or two years for oral contraceptives). Pharmacists also cannot adapt a prescription for narcotic, controlled drugs or targeted substances.
Payment for prescription adaptations
An agreement between the B.C. government and B.C. Pharmacy Association to remunerate pharmacies for clinical services associated with adapting and renewing prescriptions took effect Dec. 12, 2008. Pharmacies that have signed up for clinical service fees receive, on top of the regular dispensing fee, a maximum fee of $8.60 for adaptions/renewals and a maximum fee of $17.20 for therapeutic substitutions. For each patient, pharmacies are limited to two clinical service fees per drug in a six-month period.
Prescribing activity so far
From January 1 to March 17, pharmacists in B.C. submitted 20,314 claims to Pharmacare for prescription adaptations. Roughly speaking, when divided by the number of pharmacies (1,075, including hospital pharmacies) that translates to 19 prescriptions per pharmacy over a six-week period. By far the majority of adaptations (83%) were for renewals, followed by changes to dose, formulation or directions for use (14%) and therapeutic substitution (3%).
Web links
www.bcpharmacists.org (College of Pharmacists of British Columbia)
www.bcpharmacy.ca (British Columbia Pharmacy Association)
www.health.gov.bc.ca (British Columbia Ministry of Health)
Last updated April 2009Alberta
Alberta is the first province to introduce independent prescribing by pharmacists, starting in April 2007. Alberta’s Pharmacists Profession Regulation of the Health Professions Act gives pharmacists authority to prescribe in three ways:
- in an emergency;
- to adapt an existing prescription; and
- to prescribe an initial prescription or manage ongoing therapy.
The Alberta College of Pharmacists (ACP) has developed Standards for Pharmacist Practice and an Orientation Guide that details the responsibilities of pharmacists who choose to prescribe (available at www.pharmacists.ab.ca). Pharmacists who prescribe must have at least $2 million in professional liability insurance and they must fulfill seven fundamental elements when prescribing (detailed in the Orientation Guide):
- Professionalism;
- Individual competence;
- Appropriate information;
- Informed consent;
- Approved indications;
- Documentation; and
- Notification of other health professionals.
Prescribing in an emergency will likely only occur in rare circumstances when a patient has an immediate need for drug therapy and does not have immediate access to another authorized prescriber (for example, in remote rural areas). A pharmacist may provide a small amount of drug to treat a patient’s symptoms until the patient can see a health professional for diagnosis.
Three activities fall under the category of adapting a prescription:
- altering the dosage, formulation or regimen;
- renewing a prescription to ensure continuity of care; and
- substituting another drug that is expected to have a similar therapeutic effect.
Certain restrictions apply when altering a dosage: it must be an initial prescription (not a refill) and the patient’s age, weight or organ function necessitates a dosage adjustment or the prescribed dosage is not commercially available. These restrictions, however, do not apply to altering a formulation or regimen or to therapeutic substitution.
Clinical pharmacists who wish to prescribe for initial access or to manage ongoing therapy must obtain additional prescribing authorization from the ACP by undergoing a rigorous application process.
Additional prescribing authorization will assist some pharmacists, in some situations, to respond in a more timely and effective manner to the drug therapy needs of patients. Most often this will be to manage ongoing therapy; however, there may be circumstances where an authorized pharmacist may initiate therapy when they are the first point of patient contact. The pharmacist may prescribe any drug (other than narcotics or controlled substances) for any disease or condition, within the limitations of their personal competence, for any duration deemed appropriate for the patient and the particular situation.
Prescribing activity so far
In April 2008, a year after prescribing authority took effect, three out of four pharmacists in Alberta reported they regularly write prescriptions, resulting in an average of 35 scripts per pharmacy per month, according to the Trends & Insights 2008 Survey of Pharmacists, conducted by the Pharmacy Group, Rogers Publishing. The majority (85%) were prescription adaptations, and of those most were renewals (85%).
Vaccinations
Alberta’s Pharmacists Profession Regulation also enables pharmacists to administer drugs or blood products by injection, upon completion of an ACP-approved training program. Currently, the Alberta Pharmacists’ Association (RxA) is the only provider of such a training program, offered as a two-part course in Calgary and Edmonton. According to the Trends & Insights research, 12% of owners and managers in Alberta say at least one of their pharmacists had completed the training as of April 2008, while half (51%) planned to send at least one pharmacist for training. Almost one in three (29%) said they have no plans to administer injections in their pharmacy.
Payment for expanded services
With funding from Alberta Health and Wellness, selected community-based pharmacists are participating in the Alberta Pharmacy Practice Models Initiative (PPMI), which explores how to pay pharmacists for medication management services. Medication management refers to the pharmacist’s expertise in identifying, taking responsibility for and resolving a patient’s drug-related needs. The PPMI service model includes expanded scope activities such as adapting a prescription, prescribing in an emergency, additional prescribing authorization, administering injections, making recommendations or referrals and chronic disease education. Pharmacists participating in the PPMI are collecting data from March 2009 to March 2010 to evaluate the impact on patients’ health and drug therapy outcomes. The results will help decision makers as they explore the fu-ture of programs and payment models.
What’s next
Alberta is preparing to pass amendments to the Pharmacists Profession Regulation that will result in the regulation of pharmacy technicians and the expansion of their role in order to better support pharmacists. As well, ACP and RxA recently launched a three-year public awareness campaign to improve the public’s understanding of the broadened scope of practice for pharmacists.
Web links
www.pharmacists.ab.ca (Alberta College of Pharmacists)
www.rxa.ca (Alberta Pharmacists’ Association)
www.health.alberta.ca (Alberta Health & Wellness)
Last updated April 2009Saskatchewan
Bill 22, An Act to Amend The Pharmacy Act (1996), includes the concept of pharmacist prescribing and grants the Saskatchewan College of Pharmacy (SCP) the ability to create supporting regulatory bylaws (which must then be approved by government). SCP’s first bylaw, giving pharmacists authority to prescribe emergency contraceptive pills, has been in effect since September 1, 2003.
At its annual meeting in early May this year, SCP announced a new bylaw to enable pharmacists to prescribe most medications (except narcotics or controlled substances) as follows:
- to continue therapy (interim supplies and maintenance therapy)
- in emergency circumstances (for previously prescribed medication)
- to rectify incomplete or inaccurate prescriptions
- to refill medications during a physician’s absence (with limitations)
- to assist patients in making selfcare decisions (e.g., by prescribing an antifungal for athlete’s foot)
- to capture the sales of exempted codeine products
- to obtain third-party coverage for nonprescription drugs
- to reconcile medications for seamless care.
The bylaw is currently before the government for approval. The SCP will hold district meetings across the province in May to discuss the policy and implementation plan, and educational sessions are planned for summer and early fall. Barring unforeseen delays, pharmacists who choose to prescribe may be able to do so by early October, 2009.
The prescribing activities contained in this new bylaw represent what SCP is describing as “level one” prescribing authority, available to all licensed pharmacists. Level two authority requires additional training and credentials. The SCP has defined two parts under level two prescribing:
- Part A: For oral contraception and to support lifestyle changes and/or health promotion (e.g., for smoking cessation); and
- Part B: Collaborative prescribing agreements, therapeutic substitutions, and altering dosage and/or dosage regimen.
The SCP has not yet indicated a timeline for the development of bylaws to enable level-two prescribing by pharmacists.
Additional programs
Trained pharmacists can receive additional payment for smoking cessation counselling ($2 per minute, up to $300). Payment comes from the Alternative Reimbursement Program, a pharmacy-based funding mechanism that collected three cents from each prescription dispensed. Unfortunately, the fund was tied up in litigation for years until recently, when an agreement was struck to transfer the money to the provincial drug plan, which pays pharmacies as services are provided. The fund grew in size as it sat in litigation; however, contributions have ceased and there are no plans to replenish the fund as it is depleted.
Web links
www.saskcollegepharm.ca (Saskatchewan College of Pharmacists)
www.skpharmacists.ca (Pharmacists’ Association of Saskatchewan)
www.health.gov.sk.ca (Saskatchewan Ministry of Health)
Last updated April 2009Manitoba
The Manitoba Legislative Assembly gave its new Regulated Health Professions Act first reading in April 2009, despite the fact that regulations to guide pharmacist prescribing have yet to be completed. To move things along, the government has appointed Price Waterhouse Coopers as a mediator to facilitate completion of the regulations, apparently by the summer.
Despite widespread support among pharmacists for the concept of pharmacist prescribing, development of the supporting regulations has proven to be a long, difficult process because the Manitoba Pharmaceutical Association (MPhA) requires approval from its members. Manitoba is one of only two provinces in Canada in which licensed pharmacists have the right to vote on their own regulations (in other provinces, the regulatory bodies consult with their members but do not need majority approval).
MPhA’s members rejected the first set of draft regulations in March 2008. Since that time, various subcommittees have worked to address concerns raised. The points of contention focus on issues such as the roles of technicians, the qualifications of pharmacy managers and loyalty programs.
According to MPhA, it is expected that as a general practice, pharmacists will have the authority to write continued care prescriptions. They already do this as a result of a joint agreement with the Manitoba College of Physicians and Surgeons and the Manitoba College of Nurses, but the authority will shift to pharmacists. As well, pharmacists will likely have the ability to prescribe Schedule II and III drugs and in an emergency situation. The legislation enables pharmacists to order and interpret tests, and those tasks will be described under the regulations. Under general practice, all pharmacists will also be able to administer drugs such as inhalations and topicals, while it’s expected that pharmacists working in established collaborative teams and in specialized practice areas, such as diabetes or infectious disease, can seek the authority to initiate prescriptions.
As well, support is growing among pharmacists and policy advisors alike for a minor ailments program similar to what’s proposed in Ontario, giving pharmacists authority to prescribe from a limited formulary of Schedule I drugs to treat minor, self-diagnosed or self-limiting conditions.
Web links
www.mpha.mb.ca (Manitoba Pharmaceutical Association)
www.msp.mb.ca (Manitoba Society of Pharmacists)
www.gov.mb.ca/health (Manitoba Health)
Last updated April 2009Ontario
In May 2009, the Ontario government introduced the Regulated Health Professions Statute Law Amendment Act, 2009, which proposes expanded scopes of practice for numerous healthcare providers, including pharmacists. Barring unforeseen delays, it’s anticipated that the legislation will receive final approval in the fall; however, provincial regulatory bodies, including the Ontario College of Pharmacists, must create supporting regulations before healthcare providers can practice under the expanded scopes.
Based on recommendations made earlier in the year by the Health Professions Regulatory Advisory Council (HPRAC), the new legislation revises the Pharmacy Act by giving pharmacists the authority to:
- administer drugs by injection or inhalation as specified in regulations;
- prescribe drugs specified in regulations (e.g., for smoking cessation);
- extend, adapt or adjust prescriptions, in accordance to regulations;
- pierce or lance the skin for patient education and demonstration; and
- order lab tests for the purpose of medication monitoring and management.
As well, the new legislation would include pharmacists among all other regulated health professions in the definition of “health practitioner.” Pharmacists’ new scope of practice statement would include the promotion of health and the prevention and treatment of disease, disorders and dysfunctions through monitoring and management of medication therapy.
In related news, HPRAC has also recommended that Ontario introduce a minor ailments program, to be developed by the Ontario College of Pharmacists and the Ontario Pharmacists Association in collaboration with other health professionals’ associations and stakeholders. An interprofessional working group would come up with the details including the list of minor ailments that pharmacists could treat, an agreed formulary of Schedule I, II and III drugs, and protocols for referral and communication with other health professionals.
It’s important to note that, while independent prescribing or medication-management authority is pending in Ontario, the province’s current Regulated Health Professions Act already allows the delegation of authority between healthcare providers. For instance, a physician can delegate authority (also described as giving a medical directive) to an individual pharmacist to prescribe and administer travel medicine.
MedsCheck and ColonCancerCheck
In early 2009, Ontario initiated a pilot project for MedsCheck Consult, to facilitate collaboration between pharmacists and physicians when medication-related issues are identified during a regular MedsCheck review. A MedsCheck Consult service would be conducted when a physician requests that the pharmacist provide recommendations and options to resolve a particular problem, or when a patient or caregiver identifies a problem or concern that requires follow-up with the physician by the pharmacist on his/her behalf. The pilot will run for three months and include a minimum of 30 pharmacy practice sites from across the province.
The original MedsCheck program, launched in April 2007 for Ontario Drug Benefit patients taking three or more medications for chronic conditions and expanded in July 2007 to include all Ontario residents, pays pharmacies $50 for each review. In November 2007 it expanded again to include Follow-Up MedsChecks, for which pharmacies are paid $25. According to the Ministry of Health, approximately 195,573 Ontarians received a MedsCheck review during the first year, of whom 2,500 received a follow-up review. During the second year, ending Dec. 31, 2008, pharmacists conducted 145,995 MedsCheck reviews and 7,054 follow-up reviews.
In addition to MedsCheck, the Ontario government pays pharmacists $7 to distribute Fecal Occult Blood Test (FOBT) kits and provide information and counselling under ColonCancerCheck, a colorectal cancer screening program.
Web links
www.ocpinfo.com (Ontario College of Pharmacists)
www.opatoday.com (Ontario Pharmacists' Association)
www.health.gov.on.ca (Ontario Ministry of Health & Long-Term Care)
Last updated May 2009Quebec
Bill 90, an Act to Amend the Professional Code and other legislative provisions regarding the health sector, came into effect on Jan. 30, 2003. It enables physicians to delegate authority to individual pharmacists so that they may initiate or adjust medication therapy, according to direction from the physician and to make use, where applicable, of appropriate laboratory results. Quebec pharmacists may also prescribe and dispense emergency oral contraceptive medications upon completion of additional training.
As far as independent prescribing or medication-management authority for pharmacists, similar to what's available in Alberta and B.C., Quebec is currently not pursuing this as a formal expan-sion to the pharmacist's scope of practice.
Pharmaceutical opinions
Since 1978, Quebec's drug plan has paid pharmacists for their “pharmaceutical opinions,” which are recommendations–usually to physicians–to change, adapt or discontinue therapy. As of April, 2009, payment increased to $18.65 for each pharmaceutical opinion. Pharmacists are also paid to transfer pharmacological profiles to emergency clinics, and receive $8.44 (the regular dispensing fee) for “refusal to fill” prescriptions.
Web links
www.opq.org (Ordre des Pharmaciens du Québec)
www.aqpp.qc.ca (Association Québécoise des Pharmaciens Propriétaires)
www.msss.gouv.qc.ca (Quebec Ministry of Health and Social Services)
Last updated April 2009New Brunswick
Bill 60, An Act to Amend the Pharmacy Act, adds pharmacists to the definition of a prescriber. A pharmacist licensed by the New Brunswick Pharmaceutical Society, who meets the qualifications or conditions set out in the regulations, may prescribe drugs and treatments under certain conditions, administer drugs, interpret client-administered automated tests, and order and receive reports of screening and diagnostic tests.
Since 2003, New Brunswick pharmacists have been prescribing medications under a Continuing Care Protocol for patients in an emergency basis, who have been unable to contact a physician and whose medication has expired. With the passing of Bill 60, which came into effect Oct. 30, 2008, pharmacists now have the authority to adapt prescriptions (including renewals), prescribe in emergency situations, prescribe nonprescription drugs, treatments and devices, and prescribe within a collaborative practice setting.
Although pharmacists are not obligated to prescribe, all licensed pharmacists are considered to have the competencies to prescribe as described by the regulations. Pharmacists in collaborative practice also may prescribe medications and treatments in a collaborative agreement under certain conditions. As well, a pharmacist who meets certain requirements may administer a drug or blood product through injection.
Adapting a prescription includes: altering the dose, formulation or regimen; renewing a prescription for continuity of care; continuing therapy without a prescription for a previously diagnosed condition; and therapeutic substitution. The pharmacist must have an original prescription that is current, authentic and appropriate; must determine whether adapting the prescription is appropriate in the circumstances; and must document the adaptation and inform the original prescriber.
To prescribe in an emergency, a pharmacist must be satisfied that it is not reasonably possible for the patient to receive acute medical care in a timely manner, be satisfied that there is an immediate need for drug therapy, and only prescribe the minimum amount of the drug or blood product necessary to give the patient sufficient time to see their primary healthcare provider.
A pharmacist is authorized to prescribe a drug, treatment or device where the pharmacist has:
- made an assessment to determine that the drug will be safe and effective in the circumstances of the client;
- assessed the client in compliance with the Standards of Practice, Code of Ethics and any applicable practice directives;
- acted within his or her area of practice, knowledge and skills or specialty;
- determined that a prescription is reasonably necessary to treat the client; and
- discussed with the client, or their agent, reasonable and available therapeutic options.
Web links
www.nbpharmacists.ca (New Brunswick Pharmaceutical Society)
www.nbpharma.ca (New Brunswick Pharmacists’ Association)
www.gnb.ca/0051/index-e.asp (New Brunswick Health)
Last updated April 2009Nova Scotia
The Conditional Authority Regulation, approved in 2004 as part of the Pharmacy Act, allows the Nova Scotia College of Pharmacists (NSCP) to enter into written agreements with the College of Physicians and Surgeons of Nova Scotia to exercise conditional authority for pharmacists. The first example of this is the Continued Care Prescriptions Agreement of 2006, which authorizes pharmacists to extend an existing prescription. NSCP is currently fine-tuning proposed regulatory amendments for a greater scope of practice, including the provision of immunizations and adjustment of dosages.
Medication Review Program
The Nova Scotia Department of Health and the Pharmacy Association of Nova Scotia worked together to develop the Medication Review Program (MRP), which was rolled out province-wide in May 2008. Community pharmacists may offer the program to Pharmacare patients who are over 65 and who take four or more chronic medications. Pharmacies receive $150 per review, of which patients may be required to pay 30% (based on Pharmacare reimbursement criteria).
Web links
www.nspharmacists.ca (Nova Scotia College of Pharmacists)
www.pans.ns.ca (Pharmacy Association of Nova Scotia)
www.gov.ns.ca/health (Nova Scotia Ministry of Health)
Last updated April 2009Prince Edward Island
The Prince Island Pharmacy Board is developing regulations to support the implementation of Bill 10, An Act to Amend the Pharmacy Act, which will expand the pharmacist's scope of practice to include prescribing under certain circumstances. While the government passed the Act in May 2008, it cannot go into effect until the regulations are finalized.
It is expected that the regulations will initially address continuous care prescribing (i.e., renewals), and eventually the ordering and receiving of lab tests.
Web links
www.napra.ca/pages/PEI/default.aspx (Prince Edward Island Pharmacy Board)
www.peipharm.info (Prince Edward Island Pharmacists Association)
www.gov.pe.ca/health/index.php3 (Prince Edward Island Department of Health)
Last updated April 2009Newfoundland & Labrador
The Newfoundland & Labrador Pharmacy Board is in discussions with the provincial govern-ment and the College of Physicians and Surgeons of Newfoundland & Labrador in order to propose amendments to the Pharmacy Act, which would see an expanded scope of practice for pharmacists.
Web links
www.nlpb.ca (Newfoundland & Labrador Pharmacy Board)
www.panl.net (Pharmacists’ Association of Newfoundland and Labrador)
www.health.gov.nl.ca/health (Newfoundland and Labrador Department of Health and Commu-nity Services)
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