Patient care more of a focus in 21st century

Pharmacists play role in disease state management

Pharmacists will once again become more directly involved in patient care, reclaiming some of the ground they have lost over the years.

So says Edward D. Rickert, RPh, JD, partner with Smith, Rickert & Smith in Downers Grove, IL. Rickert spoke about pharmacists becoming more patient-centered in his presentation, "Practicing Pharmacy in the 21st Century: Liability and Practices Concerns," at the American Pharmaceutical Association’s 2002 Annual Meeting and Exposition in Philadelphia in March.

Rickert offers this definition of pharmaceutical care: a patient-centered, outcomes-oriented pharmacy practice that requires the pharmacist to work in concert with the patient and other health care providers to promote health; prevent disease; and assess, monitor, initiate, and modify medication use to ensure that drug therapy regimens are safe and effective.

As part of these responsibilities, pharmacists will be playing a larger role in disease state management (DSM) activities, he says. Some signs that indicate a positive direction for pharmacists in this area include:

Pharmacists have documented value in DSM processes. "There’s a documented evidence of value in connection with key conditions, such as lipid management, anticoagulation, diabetes, and asthma," Rickert says.

The National Institute for Standards in Pharmaceutical Credentialing has developed a process to credential pharmacists to provide care in these areas. "Let’s credential pharmacists in these areas so not only can they provide the care, but they might even get paid for it, which is kind of a novel concept for pharmacists, who are used to giving away information for free," he says.

Twenty-four states allow some form of collaborative practice agreement for pharmacists.

Collaborative pharmacy practice and pharmaceutical care are key components of DSM, Rickert explains. Collaborative practice agreements with physicians generally allow pharmacists to initiate, modify, or more directly monitor a patient’s drug therapy. If a pharmacist wants to change a patient’s antibiotic because the bacteria is causing a problem, for example, the pharmacist can make the change within the confines of the collaborative practice agreement without calling the physician.

Although it is encouraging that 24 states have such an agreement, 50 states allow collaborative practice agreements between nurses and physicians and between physician assistants and physicians. "Those states that don’t recognize the pharmacist as a full member of the health care team need to recognize that pharmacists can fulfill that role and allow pharmacists to enter into these types of agreements," Rickert says.

A survey of state pharmacy laws shows that several states don’t say anything about collaborative practice. Instead, some state boards of pharmacy say that if a doctor wants to delegate to pharmacists the ability to make changes to a patient’s drug therapy without calling the doctor, then maybe they have the freedom to do that under the Medical Practice Act. The Medical Practice Act generally holds that a physician can delegate certain duties and responsibilities to somebody else.

"One view of the law is that if it’s not prohibited, then maybe it’s permitted," Rickert says. "The other way of viewing the law is that if it’s not expressly permitted, it’s prohibited. Unless the state legislators sit down and write a law that says pharmacists can do this, then they can’t. I think that kind of a view of the law prevents the profession from moving forward."

Disease state management is made up of clinical activities, but it is also more proactive, Rickert says. He sees other activities falling under the description of DSM, such as:

  • targeting high-risk/high-utilizing patients for education and/or intervention;
  • conducting outcomes research to form the basis for educational programs;
  • educating other practitioners and influencing prescribing patterns.

The issues facing DSM

Pharmacists becoming more involved in DSM activities will face several issues, one of which is the question of how these pharmacists should be credentialed. Rickert is concerned that the credentialing process may go too far, shutting out competent pharmacists who may not have access to DSM review courses or who are not good test-takers. "There is probably going to be some litigation over the disease state management credentialing process," he says.

Another issue for these pharmacists is the greater need for access to records and the sharing of health information. "You can’t really provide care for a patient unless you know what’s wrong with the patient and the patient’s history," Rickert says.

Several questions about the sharing of health information during DSM activities need to be addressed on a state and national level, he adds. These include:

  • Should other entities have access to confidential information?
  • Should non-patient-identifiable information be protected?
  • Is the release of information for measuring quality of care, assessing patient satisfaction, preventing fraud and abuse, and coordinating payment to providers a legitimate use of patient-identifiable information?

In regard to the privacy of health information, many states mirror the language in the National Association of Boards of Pharmacy’s Model Act, Rickert says. This language reads: "Information accessed, maintained by, or transmitted to the pharmacist in the patient’s records or which is communicated to the patient as part of patient counseling, which is privileged and may be released only to the patient or, as the patient directs, to those practitioners, other authorized health care professionals, and other pharmacists where, in the pharmacist’s judgment, such release is necessary to protect the patient’s health and well-being."

With the Health Insurance Portability and Accountability Act of 1996, patients will be allowed to limit the amount of information that is released, he says. "They’ll be able to narrow the scope of the consent, and you will have all these different consent forms. When someone calls for health information, you’ll have to figure out what the patient agreed to have you disclose."