Group



|Group |Evaluation Criteria |

|1 |Group 1: Diagnosis Requirement on Prescription |

| |Atla Adera, Shawna Austin, Jessica Fiedelak, Reina Nakasone, My Phan, Inna Vasilyev, Jenny Wong |

| | |

| |1. Technical Feasibility |

| | |

| |We propose to add diagnosis to the current prescription requirements (RCW 69.41.040[1]) in order to reduce medication errors, improve patient quality |

| |of health, provide better patient counseling, and reduce the overall cost of hospitalizations associated with drug related problems. According to the |

| |Journal of the American Pharmaceutical Association[2], the United Stated spends over 177 billion dollars on drug-related morbidity and mortality. The |

| |American Pharmacists Association also suggests that pharmacists should gain more access to patient profiles in order to achieve the abovementioned |

| |goals. One of the main concerns of having the diagnosis on a prescription is patient confidentiality. As electronic prescriptions become more |

| |available to community pharmacies, prescription information may not even be disclosed to the patient, bypassing all routes where privacy is an issue |

| |by going directly from one health care provider to another. Another foreseeable obstacle of having the diagnosis on a prescription is that prescribers|

| |may feel it creates a higher workload for them, however, a prospective descriptive study has shown that a new prescription form, including the |

| |indication for medication, can be used to achieve our goal to provide pharmaceutical care[3]. The study shows that most practitioners and pharmacists |

| |would be willing to collaborate (89%) and use the new prescription format to reduce medication errors as well as to deliver effective counseling from |

| |the pharmacist to the patient. Most physicians did not think that using the new prescription form was time consuming, therefore it is feasible to have|

| |either the diagnosis or indication for the medication on a prescription. |

| | |

| |Political Viability |

| |In order to determine political viability of the proposed polity, it would be necessary to determine who will be supportive, opposing, or neutral. |

| |Also it will be useful to estimate the reasons behind their position. Pharmacists will be very supportive of adding intended use to the requirement |

| |for prescription. It will help them to reduce the number of wrong-drug errors, reduce time spent on clarification of prescription, and therefore save |

| |money. A second group of supporters would be insurance agencies - reduced medication errors will reduce costs associated with hospitalizations from |

| |adverse drug reactions related to errors. Patients will also benefit from this proposal and will therefore be supportive. Having intended use on the |

| |prescription will contribute to there safety and education, especially for those with complicated multi-drug regimens. Also, drug manufactures can |

| |take advantage of this new prescription requirement - they will be able to track off-label uses of their products to give them a better idea about how|

| |the drug is used. Last but not least state government will be supportive - our proposal will decrease healthcare costs through reduction of |

| |medication errors. |

| |Physicians may represent opposition. It is hard for them to comply with the current prescription requirements the way they are, and adding the |

| |intended use to the prescription may seem more time consuming to them and unnecessary since they prefer being in charge of all prescribing and |

| |decision making. Another concern that they may raise is patients' privacy and compliance with the Health Insurance Portability and Accountability Act|

| |(HIPAA) along with liability for diagnosis made. In addition to physicians, some patients may be against having an indication on the prescription |

| |feeling that their privacy is being invaded. |

| |If the proposed policy does not get implemented, there are several alternatives. If the opposition thinks that having the intended use on the |

| |prescription violates HIPPA, then having this information coded will help to protect privacy. For all who oppose the new requirement - having |

| |immediate availability of the diagnosis to health care providers (including pharmacists) who are directly involved in the patient's care can solve |

| |the problems involved in many drug errors and would be a viable alternative to having intended use on the hard copy. Despite opposition the |

| |liability for misdiagnosis always exists. Having the diagnosis on a prescription can reduce the potential for errors, thus decreasing the liability. |

| | |

| |Administrative Operability |

| | |

| |The Board of Pharmacy (BOP) currently regulates requirements for controlled substances prescriptions, labeling of prescriptions, parenteral |

| |prescriptions, and other areas of record keeping and dispensing. Given the BOP’s current authority in these areas, it would seem that the agency would|

| |be authorized and capable of regulating the requirement for a diagnosis on a prescription. When electronic prescriptions take the place of paper |

| |prescriptions, the BOP would have authority to adopt rules pertaining to electronic prescriptions.[4] The Board would thereby be able to enforce a |

| |requirement for diagnosis on electronic prescriptions as well as paper prescriptions. Implementation of this policy would require altering the current|

| |paper prescription format used currently to provide a space where the diagnosis would be recorded. Again, with the advent of electronic prescribing, |

| |no changes would be required as the diagnosis field could be implemented into the requirements once that mode of prescribing is standardized. The |

| |Department of Health (DOH) in conjunction with the BOP should be willing to support this legislation. In a study done by the DOH on medication |

| |errors[5], one recommendation made to reduce errors was to “Require prescribers to include a notation of purpose (not necessarily diagnosis) on all |

| |prescriptions.” The DOH noted that this would require new legislation to be passed. Given the DOH’s recommendation and the BOP’s commitment to public |

| |health and safety, it seems that both agencies would be willing to support this policy. |

| |The current bottleneck is the resources required to do an analysis of this issue and getting feedback from stakeholders like physicians and |

| |pharmaceutical companies. Our project may play an important role in reducing medication errors and give the BOP the backing to push the idea through |

| |legislation. |

|2 |Group : 2 Time frame that a prescription for Schedule II drugs is valid |

| |Group Members: Aimee Breitfelder, Candace Kim, Christopher McCowan, Uzoma Okeke, Diana Regina, Christopher Schaffner, Naomi Sweeney, Lincoln Wright. |

| | |

| |Technical |

| |The number of reported adverse drug reactions due to schedule II drugs is one tangible way to measure how effective shortening the duration of |

| |schedule II prescriptions has when considering patient health. In order to measure the abuse, misuse and diversion of schedule II drugs it would be |

| |appropriate to compare whether written prescriptions have increased or decreased. As a long-term change the direct effect will be closer monitoring of|

| |patients to ensure the proper use, as well as closer monitoring of those prescribing schedule II drugs. |

| |We believe that our proposal will be supported by decision makers, officials, and voters because it addresses the patient's safety as its primary |

| |goal. An alternative would be to leave the current law regarding the expiration date of Schedule II prescriptions unchanged, so that they are valid |

| |for one year. This one-year period being longer than the six-month expiration date of drugs with less abuse potential that are found in classes III |

| |and IV. Another plausible alternative would be to make the expiration date of CII prescriptions equal to that of CIII-IV prescriptions. |

| | |

| |Political |

| |A proposal that helps ensure that a patient fills a CII prescription for the indication intended would theoretically improve their safety by reducing |

| |the number of adverse drug reactions. This also could potentially decrease the number of lawsuits seen with regards to adverse drug reactions that |

| |are the result of incorrect usage of the medications in this category. For these reasons it is likely that decision makers, officials, and voters |

| |will approve this proposal. |

| |If the decision makers choose to implement one of the alternatives to our original proposal, ultimately we will be conceding the best possible patient|

| |care by not fully reducing the potential for adverse drug reactions. Furthermore, there will be an increased likelihood for lawsuits against |

| |pharmacists regarding adverse drug reactions due to the improper usage of prescribed medications. |

| |Our proposal, while strict, has the patient’s best interests in mind. Because of this, we are not willing to change the statues of our original |

| |proposal in order to get it accepted into legislature. However, the six-month expiration date alternative would be better for patient safety than |

| |allowing the current law to remain as it is. |

| | |

| |Administrative operability: Uzo & Chris M. |

| |The existing administrative system, which is the Board of Pharmacy, is capable of delivering a policy that requires that all prescriptions for |

| |Schedule II drugs have an expiration date after which it cannot be filled or refilled. The Board of Pharmacy also has the ability to combine the |

| |common rules that they have adopted, according to WAC 246-856-001. These rules in turn are enforceable and defendable under the primary law in our |

| |state, as defined by the Washington Administrative Code (WAC) 1. Prescribers and their professional associations or boards, MD, DO, DPM, DVM, NP, PAC |

| |etc., play a vital role in insuring that revisions to state law governing their practice are followed. However, within the board of pharmacy there may|

| |be those who adamantly oppose the revision of the current RCW and its implementation into a new Washington Administrative Code. |

|3 |Pharm 543 Evaluation Criteria |

| |Group 3, Introduction of CPR Certification for Pharmacist Licensure in Washington State |

| |Group Members: Kellie Dillin, Anna Knopp, Elena Meeker, Jamie Mensik, Lindsey O’Malley, Jason Orthel, Kevin McDermott |

| | |

| |Technical feasibility |

| | |

| |The primary intent of requiring pharmacists to maintain current CPR certification is to prolong and, ultimately, save patient lives. In order to |

| |measure whether such a requirement would effectively achieve this objective a baseline data set would be needed to determine current survival rates of|

| |patients who experience cardiac arrests in pharmacies. This data set would then be compared to future data sets to determine the outcome of the CPR |

| |requirement. This time-series model would help control for “secular trends”, such as an increase in survival rates due to improved response times by |

| |medical emergency teams. Improved survival rates in the long term would thus be a direct and measurable impact of our proposal’s implementation. |

| |However, taking the initial and follow-up data would be a complicated endeavor that may not be needed. The proposal of CPR training for pharmacists in|

| |daily practice has a close parallel. It is a requirement for pharmacists that administer vaccines to be CPR certified in the rare event that |

| |anaphylaxis occurs. It is proposed here that similar rare events could occur in daily practice and CPR qualification in this setting is simply an |

| |extension of the vaccination protocol. Indeed, such events may well become a more common occurrence in pharmacies due to the fact that patients are |

| |spending increased amounts of time in pharmacies and pharmacists are involved in more areas of patient care than was the case several years ago. |

| |Additionally, in accordance with data that indicates that early CPR performed by bystanders improves survival rates of cardiac arrest victims[6], |

| |implementation of a CPR requirement for pharmacists is adequate in that it would likely have a direct impact on survival rates of individuals who |

| |experience out-of-hospital bodily collapse in pharmacies. |

| | |

| |Political Viability |

| | |

| |The proposal to require CPR certification of pharmacists has several possible alternative pathways but the end result is without a viable alternative.|

| |Either a pharmacist is CPR qualified or not. There is no middle ground involving the actual certification. However, there could be concessions made as|

| |to how pharmacists would go about becoming certified. If the Board does not approve of adding this to the Continuing Education requirements for |

| |Washington State, they may approve of it elsewhere in the law book. Another concession that may be negotiable would concern the details of maintaining|

| |the CPR certification. The proposal is flexible on how a pharmacist becomes qualified and is able to make trade-offs as long as the pertinent point of|

| |the issue remains intact, pharmacists will be required to be CPR certified. |

| | |

| |Administrative Operability |

| | |

| |The Washington State Board of Pharmacy is capable of implementing the proposed policy of continuing CPR certification. The Board has the power to add |

| |this new requirement via regulation and to enforce it in the license renewal process, just as it implemented the requirement of seven hours of AIDS |

| |education for pharmacists. Agencies providing CPR certification must be relied upon to continue to offer certification programs to pharmacists. The |

| |status of CPR certification could be verified along with continuing education credits prior to license renewal by the Board. Aside from minor |

| |paperwork involved in providing a copy of CPR certification there should be no administrative bottlenecks. While no new bottlenecks are anticipated, |

| |it is acknowledged that administrative time will be spent enforcing this regulation, especially in the first months after implementation. Furthermore,|

| |because of the high status pharmacists have with the general public, it is anticipated that the majority of professionals will be willing to support |

| |and commit to implementing this new regulation to ensure continued public trust in the pharmacy profession. |

| | |

|4 |Recommendation for a statute on minimum patient counseling requirements |

| |Group #4 |

| |Melissa Buss, Tracy Chen, Rhea Coquia, Stephanie Kormeier, Ken Lau, Chris Stevens-Brodl, Shannon Wittke, Judd Wright |

| | |

| |Technical feasibility |

| | |

| |We wish to see a reduced report on medication error released from Institute of Medicine due to misadministration and a reduced medical expense from |

| |hospitalization caused by adverse drug events. By implementing this set of minimum counseling guidelines, pharmacists educate patients and double |

| |check that the right medications with the right strengths are given to right patients. The direct impacts are again, our main goal, to reduce |

| |medication errors, increase their medication adherence, and lower medical expenses caused by adverse drug events as well as to educate patients about |

| |their therapies and enhance the patient-pharmacist relationship. Some indirect impacts can include utilizing the medical expense saved to further |

| |research and strengthen public health. Both the policy and the change will be long term once it is implemented. |

| | |

| |Economic and Financial Possibility |

| | |

| |When considering increased regulations regarding patient counseling, pharmacists are generally concerned about the increased demand on their |

| |time—employers may be concerned that they would have to hire additional, already scarce, pharmacists. Several studies have published estimates of the |

| |time needed for pharmacists to counsel patients according to OBRA ’90 standards. The Health Care Financing Administration estimated this time to be |

| |3-5 minutes.[7] One small 1996 study found that most Massachusetts pharmacists spend between one and two minutes counseling a patient.[8] Based on |

| |this data, most pharmacists could expect to spend an extra 2-3 minutes per counseling session if the Washington Patient Counseling law is amended to |

| |reflect the OBRA ’90 standards. With a pharmacist wage rate of $40/hr, this represents an increase of $1.33-$2 per patient counseled. Therefore, the |

| |non-financial benefits (such as utility a patient gets from counseling) must be weighed against administrative costs (via the WA State Board) and the |

| |cost of a pharmacist’s time. |

| | |

| |Political Viability |

| | |

| |The muscle in political power to move the proposed change forward lies in the lineup of interest groups which have demonstrated a promise towards |

| |advancing the practice of pharmacy and ensuring that the public receives optimal pharmaceutical care. These include the Washington State Pharmacy |

| |Association, National Community Pharmacists Association, American Society of Health-System Pharmacists, the University of Washington School of |

| |Pharmacy, and working pharmacists who have realized the clinical benefits to adequate patient counseling. The primary tool to gather support for a |

| |statute requiring minimum counseling requirements will be providing evidence to the Washington State Board showing the obvious benefits of counseling |

| |and the enormous cost of errors made when counseling was not adequate. The only forseeable opposition to such a statute will be the small portion of |

| |patients who ought not to get a consultation on their prescriptions—perhaps they have not yet perceived the benefits on consultations--and pharmacists|

| |who are plainly satisfied with the status quo. |

| | |

| |Administrative operability |

| | |

| |We believe that administrative operability is the biggest challenge for our project. First, we need to draft a statute instead of a guideline. A |

| |statute is something that the Board of Pharmacy has the authority to enforce. However, a statute that mandates specific counseling requirements would|

| |be difficult for the Board to enforce. Individual pharmacists would need to be relied upon for the benefits of counseling to have an effect in our |

| |communities. The Board of Pharmacy is limited by the number of inspectors employed to enforce laws throughout the whole state. In the past the Board |

| |was unwilling to enact a more stringent law due to the fact that they did not want to restrict the ability of the pharmacist to employ professional |

| |judgment. Our plan also lacks an effective system to measure the extent to which the law is being followed. |

|5 |Group #5 Intern/Preceptor Relations |

| |Group Members: Alen Chen, Jaqueline Dierck, Meghin Gjerswold, Katy Lashua, Katharine Monaco, Christopher Stephens, Sovanny That. |

| | |

| |In an effort to better explore the evaluation criteria for intern/preceptor relations, we have spent some time in redefining the goals of this |

| |project. Our new goal/plan is as follows: |

| | |

| |We want to establish a minimum accountable time that preceptors must spend with an intern. Using a 3:1 ratio; for every 3 hours and intern works, |

| |he/she would get at least one hour with the preceptor. This would be tracked by a sign off sheet on a weekly basis; if an intern works a 40 hour week |

| |then at least 10 of those hours should have been directly with a preceptor, not an agent of the preceptor such as a tech or non-preceptor pharmacist. |

| |This would still allow time to train with/as a tech, but also require some "quality" time with the preceptor each week. |

| | |

| |Technical feasibility |

| | |

| |The effectiveness of a time ratio system can be measured by examining the weekly time sheets to verify that the required time is being spent together |

| |or to have a paper trail of inadequate compliance. A time ratio system ensures that interns will get a minimum amount of one on one time with a |

| |preceptor and have a way to document that time. The goal of a time ratio system is for interns and preceptors to take an active role in the training |

| |of future pharmacists by setting aside "quality" time with one another and being accountable for that time; quality training cannot always be measured|

| |only by time spent with the preceptor, other real-world factors do impact the quality of training, the time ratio merely sets a standard by which |

| |training can be measured. A direct impact of a time ratio system is that interns will experience an increase in one on one time with preceptors which |

| |ideally will have a direct impact on overall education quality. Implementing a time ratio system could happen reasonably quickly, requiring only |

| |education of preceptors and interns to their new responsibilities. For those preceptors who already spend time with their interns this only adds one |

| |additional item of signing for weekly accomplishments. For those preceptors who don't have the time to put into this minimal additional step, they |

| |probably don't have the time to invest in the training of their interns in the first place and should reevaluate their desire to have interns. Some |

| |institutions may take longer to rework their schedules to allow for this time, requiring interns and preceptors both to take responsibility for |

| |setting aside time together. Delays may also come from designing a sign off sheet and deciding who or what agency monitors those sheets. The time |

| |ratio system does address the issue of some interns only rarely seeing or working with a preceptor by establishing a minimum requirement. |

| | |

| |Political viability |

| | |

| |A chief complaint of interns has been that they don’t have enough direct training of pharmacist duties by a preceptor or supervising pharmacist. Our |

| |policy is that for every 40 hours of work, the intern is required to spend 10 hours working directly with a pharmacist; a 3:1 ratio. From a pharmacist|

| |perspective, this amount of time should be reasonable as to not interfere with their duties. There needs to be a balance between time spent with their|

| |intern and time spent focusing on their job. For instance, it would be unreasonable to require that 20 hours of a 40 hour work week be dedicated to |

| |interns. It would be acceptable to pharmacists to spend an adequate amount of time with their intern without getting in the way of their tasks.  |

| |From an intern perspective, an intern might want to spend more time with their pharmacist than the technician. In reality, interns do need to have |

| |knowledge of how to complete technician work. It would be acceptable for the intern to spend 10 out of 40 hours with their pharmacist. This way they |

| |can have adequate technician training in addition to building the skills needed to be a good pharmacist.  |

| |Each facility should be able to choose how they will divide up the hours that the pharmacist and intern spend together. For example, one pharmacy may |

| |have the intern work with the pharmacist for a short amount of time every shift. On the other hand, another pharmacy may want to have the intern and |

| |pharmacist work together for an entire shift per week. This doesn’t mean that the whole shift is spent solely working with a pharmacist, but there is |

| |more interaction than on a regular basis.  Our conclusions are that this ratio system should be accepted by both preceptors and interns as it allows |

| |for flexibility for both groups. Concessions can be made in the ratio if necessary to gain more support from preceptors. An 8 hour per 40 would be |

| |acceptable to most interns if there is resistance to the 3:1 ratio plan. |

| | |

| |Administrative operability  |

| | |

| |The implementation of this new policy mandating the preceptor to designate a specified amount of “quality” hours to his/her intern can and should be |

| |delivered by the Board of Pharmacy to enforce the policy. The Board of Pharmacy has as much control over this new policy as they did before. We must |

| |rely upon the preceptors and interns to accept the new policy. Most importantly we have to depend upon the Board of Pharmacy members and authors of |

| |the Experiential Learning Manual (for Preceptors) to rewrite the policy and make the change or accept the policy as we present it. The administrative |

| |should not have a problem implementing the change in policy. This revision to the preceptor and intern relationship is solely to reinforce the |

| |intern’s learning experience; therefore it is up to all parties involved with the aid of the Board of Pharmacy to ensure that this policy will be put |

| |into action, we would be relying heavily on interns and preceptors to make it work. |

| |The Board of Pharmacy is currently reviewing and evaluating all of the necessary documents submitted by both the preceptor and intern after completion|

| |of an internship. A change in the manual can be made by the state board; and implementation of this policy can be assured through the assessment of a |

| |vital document, as yet to be designed, which must be signed off every week by both preceptor and intern. |

|6 |Group 6 Project: Changing Sudafed to Schedule V |

| | |

| |Melanie Petilla, Tasha Wong, Jason Boyd, Nick Dire, Thoa Vo, Joyce Wang, Huong Nguyen |

| | |

| |Technical feasibility |

| | |

| |In order to determine whether our proposed policy of changing Sudafed to a schedule V drug is successful in decreasing the production of |

| |methamphetamine in Washington State, we could directly oversee the amounts of Sudafed dispensed and indirectly monitor arrests related to |

| |methamphetamine drug use or production and hospitalizations due methamphetamine overdose. If a reduction in methamphetamine production does occur, we |

| |acknowledge that this change may only be short term due to the fact that our regulation of Sudafed distribution would prohibit one avenue of |

| |methamphetamine production. However, as student pharmacists we feel that it is our responsibility to our community to regulate the misuse of such |

| |medication. |

| | |

| |Economic and financial possibility |

| | |

| |According to the Kansas City Star , the number of methamphetamine labs decreased by 124 in Oklahoma six months after pseudoephedrine was classified as|

| |a schedule 5 drug. This decrease saved tax-payers almost $500,000 in clean up costs. |

| |It costs approximately $800 to clean up one methamphetamine lab, including labor and disposal fees. Waste products from methamphetamine synthesis can|

| |weigh up to 6 times more than the final product. Although the federal government pays for the disposal of materials and clean up supplies, local |

| |governments must pay for the remaining clean up costs. |

| |The costs of implementing the program will mostly be observed at small retail (non-pharmacy) stores and pseudoephedrine wholesalers. The average |

| |wholesale price of a box of 24 pseudoephedrine 30 mg tablets is $1.43. Thus, this resolution should have a minimal impact on such stores. The main |

| |impact will be on drug wholesalers. However, there appears to be a very low cost:benefit ratio considering community, environmental, and economic |

| |(government expenditures) savings in dissolving methamphetamine laboratories. |

| | |

| | |

| | |

| |Political viability |

| | |

| |The two groups that may oppose legislation are the drug companies and consumers. In other states these were the only two groups that opposed |

| |legislation.[9]One Alternative to scheduling pseudoephedrine (PSE) would be to make it only available in licensed pharmacies. This would stop the |

| |major source of diverted PSE, which is from convenience stores, but it would not satisfy our two opposition groups. This alternative would, however, |

| |most likely be acceptable to pharmacies, law enforcement, and politicians. The pharmacies, law enforcement and politicians are still going to be |

| |better able to protect their communities with our alternative, while drug companies and consumers will be happier with fewer regulations to purchase |

| |PSE that go along with schedule V designation. |

| | |

| |Administrative Operability |

| | |

| |The regulation of professions is the area of law primarily handled by the states and the board of pharmacy is the administrative agency that creates |

| |the regulations. So the board of pharmacy is capable of delivering this policy “classifying Pseudoephedrine (pse) as a schedule V drug”. Currently, |

| |the Board of Pharmacy (BOP) is the main administrative system regulating pse sales in Washington State. In January of 2004, the state legislature had |

| |passed regulations limiting the sales of pseudoephedrine-containing products to no more than three packages per transaction, with a single package |

| |containing no more than three grams of “ephedrine, pseudoephedrine, or phenylpropanolamine, their salts, isomers, or salts of isomers, or a |

| |combination of any of these substances.”[10] Furthermore, sales of pseudoephedrine and ephedrine are “limited to 10% of OTC drug sales during March |

| |through October and 20% during November through February.” [11] This applies to pharmacy and vendors registered with the department of health. |

| |However, in reality, nobody is keeping track of these sales in retails. The current regulations only require wholesalers to document and report to the|

| |board about any “suspicious transactions” of pse, as defined by RCW 69.43.035. Currently, only wholesalers have to document and report sales greater |

| |than 10% of the total order. Retailers and convenience stores are exempt from this documentation.[12] |

| |Till now it is very hard for the board to keep track of the total sales of pse as well as determine the effectiveness of the current regulations based|

| |on the standards above. This lax in regulation is also one of the current administrative bottlenecks in the existing system. |

| |By making pseudoephedrine into a schedule V drug, it would be much easier for the board to keep tracking pse sales. As a schedule V drug, a |

| |prescription is required, and the transaction is logged out like other schedule V drugs. The hassle of keeping track of pse sales in other places |

| |besides the pharmacy, such as small convenience stores and gas stations, would be eliminated. |

| |In carrying out this regulation, the board would need the help of conscientious providers and pharmacists, who will not abuse their professional |

| |credibility and prescribe/dispense only the amount of pse that is needed for each patient. Also the board needs the support from the state legislature|

| |and the governor. |

| |Overall, the board would have the authority to implement the policy with the approval from the state legislature and the governor. |

|7 |Evaluation Criteria, Group 7 |

| |Jennifer Fidler, Virginia Krause, Trang Le, Anh Nguyen, |

| |Vinh Phan, Kristen Soo Hoo, Christy Weiland |

| | |

| |We will know that the policy has had its intended effect by evaluating the amount and type of errors caused by verbal translation. Pharmacies can keep|

| |a log of these errors prior to and after the amendment. This will supply quantified results, showing our anticipated outcome. The proposed action has |

| |a high degree of importance because it will reduce medication errors, which will reduce costs, adverse effects, and potential deaths. A decreased |

| |amount of medication errors from verbal orders will be traced back to the amendment due to the recording of the errors; however, some of the decrease |

| |may be due to a heightened awareness of having to report the errors. This revision will have a direct and long-term impact on medication errors, |

| |because professionals with increased drug knowledge can more adequately evaluate a prescription for appropriateness and accuracy. |

| |An alternative to our proposed policy change available to prescribers for translating prescriptions includes electronic transmission using fax or |

| |email. It seems like our proposed policy change would be more feasible than requiring prescribers to transmit new prescriptions electronically, |

| |however. Another alternative to our proposed change is to allow medical assistants to call in prescriptions, in addition to nurses and prescribers. |

| |This would only exclude non-medical assistants, such as office personnel from phoning in new prescriptions. |

| |The various groups we have identified who have a stake in this proposed change are pharmacists, prescribers, and patients. Pharmacists should be very |

| |receptive to our proposal, because it will allow them to receive phoned-in prescriptions more confidently and will reduce the amount of time spent |

| |clarifying prescription orders. Prescribers will most likely resist our proposed change, because it will create more work for themselves and their |

| |more skilled staff. They might also lose money if they have to hire more nurses at higher salaries instead of medical assistants, who are paid |

| |significantly less. Prescribers might accept a proposal that does not exclude medical assistants from calling prescriptions, because this is currently|

| |a common practice. Patients are generally unaware of the details regarding phoned-in prescriptions, but it seems that they could accept either the |

| |pharmacists’ view or the prescibers’ depending on the persuasiveness of each group. Patients will undoubtedly be concerned about their safety, |

| |however, which may lead them to support our proposal. |

| |Prescribers are going to have to concede their right (according to federal law) to choose any person who works in their office as their agent in order|

| |to have their cooperation with this proposed policy change. We may have to concede our desire to only allow nurses and prescribers to phone in |

| |prescriptions and include medical assistants in our proposal in order to gain prescribers’ cooperation. |

| |A trade-off that we are willing to make is to allow medical assistants to call in new prescriptions, as long as they have some drug knowledge or drug |

| |experience. We would also request that they follow these specific guidelines: Before calling in a new prescription to the pharmacy, the medical |

| |assistant needs to know the following information for the particular patient whom they are calling in the prescription for: |

| |Drug name and spelling |

| |Drug strength |

| |SIG with drug dose, frequency, and directions |

| |Authorized number of refills |

| |Whether generic or brand name drug is requested |

| |Prescriber’s first and last name and title |

| |Phone number at the prescriber’s office |

| |A trade-off that the prescriber will have to make is to schedule and plan on having his/her nurses’ time spent on verbally translating new |

| |prescriptions in order to help pharmacists meet the mutual goal of providing optimum care to shared patients. |

| |Together with the Department of Health, the Board of Pharmacy is capable of delivering the policy. The Board of Pharmacy has total control over |

| |pharmacy practice, and they have already dictated that only pharmacists and interns can take phoned in prescriptions.[13] They certainly can also |

| |limit who may call in a prescription.  However, the policy that we are attempting to change will require the cooperation of medical doctors and other |

| |prescribers, since they are the ones directly affected by this policy change.  Although the Board of Pharmacy may introduce this policy, physicians |

| |might oppose it, and the policy will not be followed. However, it is within the Board of Pharmacy’s authority to enforce this policy, because they can|

| |work with other state agencies to enforce the law when it comes to the scope of pharmacy practice.[14] |

|8 |Group 8: Clearing Confusion: Identifying PAs Authorized to Prescribe Schedule II Medications. |

| | |

| |Rick Bockovich, Julie Duong, Sunshine Gascon, Yvonne Hewett, Esther Labib-Kiyarash, Leonie Neville, Allison Pham, Janna Tseng |

| | |

| |Project Evaluation Criteria |

| | |

| |Technical Feasibility: Establishment of a website or information registry containing the prescriptive authorities or the practice limitations of |

| |physician assistants (PA) in Washington State would decrease confusion in pharmacies concerning the prescriptive authority of PAs with regard to |

| |controlled medications. An open database, that is available all hours, would provide verification of prescriptive authority directly to pharmacies |

| |and other authorized individuals 24 hours a day without need to contact the Medical Quality Assurance Commission (MQAC) within office or business |

| |hours. Outcome measures could include changes in call volume to the MQAC to verify prescriptive authority or the number of prescriptions for |

| |controlled substances that are written by PAs with prescriptive authority. |

| | |

| |Political Viability: The relative simplicity of establishing an online listing of the prescriptive authorities of all the Physician Assistants in |

| |Washington State precludes many of the political challenges typically faced with regulatory amendments. We do not seek to alter existing professional|

| |or personal freedoms or responsibilities, we seek only to elucidate the vast differences in prescriptive authority of PAs in Washington State and to |

| |ensure the proper dispensation of controlled substances to patients. At this time we are unaware of any interagency ramifications that may affect the |

| |political viability of our proposal. Alternatives to our proposal include; no change, leaving the regulation and implementation as it stands, that |

| |pharmacies make a good faith effort to determine the prescriptive authority of a PA which might include a call to the MQAC. Other alternatives |

| |include; establishing a 24 hour hot-line to provide information concerning the prescriptive authority of various health professionals, or periodic |

| |publication of a list that defines the prescriptive authority of various health professionals, including Physician Assistants. Administrative |

| |Operability: The solution we propose is within the limits of the Washington State Department of Health. It does, however, involve at least 3 agencies|

| |or |

| |commissions: the Health Professions Quality Assurance agency (HPQA), which maintains the provider credential search engine, the Medical Quality |

| |Assurance Commission (MQAC), which licenses physician assistants, and finally, the Board of Pharmacy (BOP), which oversees the activity of registered |

| |pharmacists. |

| | |

| |The limitation of the current Washington State Department of Health provider credential search engine is that it fails to distinguish between PAs with|

| |prescriptive authority, and those without. Addressing the issue by updating the search engine will entail the cooperation of all three agencies. |

| |Development of a new website (to search PA credentials only) could prove expensive. The implementation process for an expanded search engine should |

| |proceed smoothly, and the time involvement is likely to be minimal, as approximately 20 to 25 new physician assistants are licensed in Washington each|

| |year. The current time commitment for pharmacists is much greater, however, and is multiplied by the number of Schedule II prescriptions written by |

| |each new PA, and the time required to resolve the legitimacy of each one. |

|9 |Group 9: Revision of Schedule II Prescription Expiration Date |

| |Group Members: Brionne Alvord, Carson Huntoon, Nicole Miller, Dora Banjanin, Cori Nelson, Angie Lambert, Abdi Tache |

| | |

| |1. Technical Feasibility |

| | |

| |Our proposal is to change the expiration date on CII prescriptions and in doing so we hope to accomplish the following objectives; increase proper use|

| |of CII prescriptions, encourage better patient/provider relationships and make Washington law more consistent regarding the expiration date of other |

| |controlled substances within our state. These objectives would be difficult to measure, requiring retrospective analysis. There are additional |

| |factors that could influence our objectives and these would need to be taken into account such as changes in drug abuses trends. We are looking for |

| |direct and long-term effects. |

| | |

| |2. Political Viability |

| | |

| |Alternatives are available to our proposed action, including extending the expiration date on schedule II prescriptions to greater than seven days. |

| |In order to facilitate the transition to a new expiration date, pharmacists will be able to call doctors and verify the legitimacy of expired |

| |prescriptions. Our proposal limits stimulant medication prescriptions to six months. It would be possible to include more CII medications in this |

| |six-month category such as medications used for chronic conditions. |

| | |

| |3. Administrative Operability |

| | |

| |The Washington State Board of Pharmacy is very capable of implementing our proposal. They have sufficient power and authority. We are not aware of |

| |any bottlenecks. We must also rely upon prescribers and pharmacists to not only follow the new CII prescription expiration dates, but also to be |

| |instrumental in educating patients about the new policy and how it may affect them. |

|10 |Curriculum Change |

| | |

| |Technical Feasibility |

| |Our direct goal is to have the ACPE recommend course work in complementary and alternative medications for all schools of pharmacy. Additionally, the |

| |indirect impact of this project will be demonstrated by an increase in the number of schools of pharmacy requiring course work in herbal and dietary |

| |supplements in their curriculum. Ultimately we would like to see pharmacists educated thoroughly in the use of herbal and dietary supplements. The |

| |effect of the change will be long term but hopefully results will be seen within three years. |

| | |

| |Political Viability |

| | |

| |One alternative to the proposed action would be to have the ACPE encourage pharmacy schools to offer courses in dietary and herbal supplements as |

| |electives. Another alternative is to leave ACPE guidelines as they are. If we are unsuccessful in petitioning the ACPE we can publish papers |

| |outlining our ideas through available professional pharmacy organization publications. |

| | |

| |Administrative Operability |

| | |

| |The administrative system will have the ability to implement the change. The ACPE is the governing board that has the authority to accredit and rank |

| |schools of pharmacy. Rankings are based on how closely a given school follows the recommendations set forth by the ACPE. Schools will not be forced |

| |to adopt the recommendations, however, many schools will adopt the recommendations to improve their ranking. |

|11 |Medication Therapy Management Services (MTMS) |

| |Michelle Mai, Jeong Park, Lisa Choe, Kathleen Amazona, George Guenther, Margaret Sopalski, Yen Duong |

| | |

| |Technical feasibility: |

| | |

| |The proposal, if administered, would evaluate the effectiveness of medication therapy management by comparing the billing for these services with |

| |emergency visits due to health complications. Patient compliance can be evaluated through consistent filling of maintenance medications. |

| |Administrators could conduct an annual compilation of surveys performed by prescribers to assess patient outcomes. Another measure is to see how |

| |often pharmacists bill for these services. Also, the quality of MTMS can be determined by measuring the ratio between patients obtaining services |

| |from their primary care physicians compared to obtaining pharmacy-offered services. |

| | |

| |Political viability: |

| | |

| |If the policy is not implemented, protocols to regulate pharmacy services would ensure that the services are consistent with pharmacy standards. |

| |Another alternative is that doctors and other health professionals can refer patients to pharmacists for certain services. Other health care |

| |providers (HCPs) would find this acceptable because it would give the HCPs an option to provide the service if they are certified or refer the patient|

| |to qualified pharmacists if the HCP decides to not provide the service themselves. The main focus would be to optimize the outcome for patients by |

| |maintaining consistent services. One allowable concession would be to allow other qualified HCPs to be listed in the protocol as well. |

| | |

| |Administrative operability: |

| | |

| |The Board of Pharmacy could intervene but they would need to collaborate with other administrative organizations representing other HCPs. Pharmacists|

| |would need to implement the system otherwise there would be no reason for the legislature to promulgate it. Medicare and other third party payers |

| |need to be relied upon since they must agree to this proposal. Patients should also be involved in this policy proposal because they are the primary |

| |recipients of these services. A possible impediment would be physicians, nurses or other HCPs who feel that they are being slighted by loss of |

| |control; however, the intent of this proposal is to alleviate physician overwork and allow higher quality physician to patient interaction and |

| |essentially optimize patient care. The capability to implement this system does exist as long as there is cooperation and compromise among all |

| |administrative health care organizations. |

|12 |Evaluation Criteria |

| |Ping Zeng, Hoa Tran,Nadia Ordonez, Phong Tran, Richard Dyke, Angelique Williams, Cathy Taketa |

| | |

| |Technical Feasibility |

| | |

| |We are not proposing a new regulation. We want to change the language of the existing law to match the intention of the State Board of Pharmacy, which|

| |is already being enforced. Therefore there should be minimal roadblocks in petitioning the Board for clarification. Our only burden is to show that |

| |this clarification is necessary. This we will do with anecdotal evidence and statistics of disciplinary actions against practicing pharmacists in |

| |Washington State. |

| | |

| | |

| |Political viability |

| | |

| |The political viability of this project depends on which perspective is adopted. The Washington State Board of Pharmacy should favor any program that|

| |serves to improve compliance of existing laws. On the other hand, resistance may be encountered from groups that benefit from the current situation. |

| |Pharmacies that are concerned with staffing and time constraints may oppose; some pharmacies may prefer a law that is vague so that they can claim |

| |ignorance and avoid making the necessary changes in their practice, changes that they believe might be costly. |

| | |

| |Administrative Operability |

| | |

| |As the disciplinary body governing pharmacy in the state, the Washington State Board of Pharmacy has the authority to amend an existing law and the |

| |capability to enforce it. Since the changes being proposed are consistent with the Board’s interpretation and current enforcement of the law, the |

| |Board should be both supportive of this program and capable of implementing it. |

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[1] Pharmacy Lawbook 2003, Washington State Department of Health Board of Pharmacy

[2] Millonig M, Jackson T, Ellis W. Improving Medication Use Through Pharmacists’ Access to Patient-Specific Health Care Information. J AphA Vol 42 (4) July/August 2002.

[3] Liddell M, Goldman S. Attitudes to and Use of a Modified Prescription Form by General Practitioners and Pharmacists. MJA 168: 322-325, 1998.

[4] Revised Code of Washington 69.41.055. Pharmacy Lawbook 2003. Washington State Department of Health, Board of Pharmacy.

[5] Washington State Department of Health, Office of the Secretary. Medication errors report and recommendations [report on the internet]. [cited 2004 Oct 18]. Available from:

[6] Chamberlain DA, Hazinski MF; European Resuscitation Council; American Heart Association; Heart and Stroke Foundation of Canada; Resuscitation Council of Southern Africa; Australia and New Zealand Resuscitation Council; Consejo Latino-Americano de Resusucitación. Education in Resuscitation: An ILCOR Symposium: Utstein Abbey: Stavanger, Norway: June 22–24, 2001.Circulation 2003;108:2575-2594

[7] Nightengale B, Reeder CE. The financial impact of OBRA-90 on community pharmacies: an overview. Clin Ther. 1993;15(3):581-92.

[8] Barnes JM, Riedlinger JE, McCloskey WW, Montagne M. Barriers to compliance with OBRA ’90 regulations in community pharmacies. Ann Pharmacother. 1996;30(10):1101-5.

[9]

[10]

[11] ; 2004 newsletter

[12] Steven Hodgson-WA Board of Pharmacy representative; interviewed 10/19/2004

[13] RCW 18.64.005 State board of pharmacy -- Powers and duties. (1)

[14] RCW 18.64.005 State board of pharmacy -- Powers and duties. (6)

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