Collaborative Drug Therapy Agreement - Decision Tree



-593124-700216 00 14068393895Collaborative Drug Therapy Agreement (CDTA) – Decision Tree00Collaborative Drug Therapy Agreement (CDTA) – Decision Tree22479002200275YesNoNoNoYesYes00YesNoNoNoYesYesFAQs and Information on the Collaborative Drug Therapy Agreement (CDTA) Decision TreeDefinitions“Proposed action” refers to the final action being taken by the pharmacist e.g. writing a prescription for a patient or dispensing medication to a patient.“Preliminary steps” refers to any tasks that must be completed before the proposed action is completed. Examples include, but are not limited to:The ordering and reviewing of any necessary laboratory tests,Conducting a drug utilization review, orConsultation and examination of a patient.QuestionsWhat is meant by “unprofessional conduct – practicing beyond the scope of the pharmacist’s credential”?The Pharmacist statute provides the Pharmacy Quality Assurance Commission (PQAC) with authority to take disciplinary action against pharmacists who have committed unprofessional conduct. RCW 18.64.163, RCW 18.130.180. It is unprofessional conduct for pharmacists to practice beyond their scope of practice as defined by law or rule. RCW 18.130.180(12). A pharmacist’s scope of practice is delineated in the Pharmacists statute. Specifically, a pharmacist is able to engage in the practice of pharmacy. RCW 18.64.011(25) and (28). If pharmacists engaged in conduct within their scope of practice they have committed unprofessional conduct by practicing beyond the scope of their credential.Is a standing order or protocol distinct from a CDTA?Generally, a CDTA would be distinct from a standing order or protocol. The following table provides general definitions for those terms:TermDefinitionCDTAAs used by the Commission, a CDTA comprises written guidelines or protocols previously established and approved for a pharmacist’s practice by a practitioner authorized to prescribe drugs. The existence of a CDTA allows pharmacists to have their own prescriptive authority as outlined in the CDTA.Standing OrderWritten care directives from an authorized provider delineating the circumstances and describing the parameters of specific situations under which another individual may act to carry out specific medical orders.ProtocolA series of actions (which may include a number of medications) that may be implemented to manage a patient’s clinical status. A protocol allows the application of specific interventions to be decided by an individual based on the patient meeting certain criteria outlined in the protocol as long as the intervention is within the scope of practice of the individual. A protocol includes alternative actions or “exceptions” to the prescriptive orders that allows for individual patient circumstance as assessed by the individual. These “exceptions” are addressed by application of an algorithm that is a step-by-step procedure for solving a problem or accomplishing the intervention.From this table, the key distinction between a CDTA and a standing order or protocol is that a CDTA provides pharmacists with their own prescriptive authority. As a result, if a practitioner enters into written guidelines or protocols that provide a pharmacist with prescriptive authority: this is a CDTA. If the written guidelines or protocols do not provide the pharmacist with prescriptive authority it is not a CDTA.When are pharmacists using their own prescriptive authority?A pharmacist’s prescriptive authority is outlined in a CDTA. Once a CDTA is adopted, a pharmacist may initiate or modify drug therapy in accordance with the terms of the CDTA. RCW 18.64.011(28).A CDTA enables a pharmacist to act as an independent prescriber of legend drugs and/or controlled substances depending on the terms of the CDTA. This is supported by provisions of the Legend Drug Act (RCW 69.41.010(17) and RCW 69.41.030(1)) and the Uniform Controlled Substances Act (RCW 69.50.101(kk)(1) and (ll)). This interpretation also comports with the Commission’s current rules that refer to a pharmacist’s “prescriptive authority.” WAC 246-863-100.When prescribing under the terms of a CDTA, pharmacists should be writing and dispensing a prescription in their own name and credentials e.g. NPI and/or DEA registration number, and not the name and credentials of the practitioner. A prescription written on behalf of a practitioner by a pharmacist may amount to unprofessional conduct under the Uniform Disciplinary Act. See e.g. RCW 18.130.180(13).Can a pharmacist write a prescription in the name of another provider (who will not provide final approval of the prescription) pursuant to a CDTA?No, a pharmacist cannot write a prescription in the name of another provider under a CDTA. The provider must provide final approval of a prescription written in his or her name, e.g. the pharmacist calls the provider who authorizes the relevant prescription.A pharmacist is not an agent of the practitioner when prescribing under a CDTA. An agent is “[s]omeone who is authorized to act for or in place of another; a representative.” Black’s Law Dictionary (10th ed. 2014). If a pharmacist is a practitioner’s agent when entering into a CDTA, then the pharmacist is not exercising any prescriptive authority under a CDTA. Instead, the pharmacist is exercising the prescriptive authority of the practitioner. This was not the intent of the legislature when this provision was added in 1989. See Senate Bill 6152 (1989). For controlled substances, the DEA has provided interpretive guidance that practitioners may not delegate their own personal prescriptive authority to others because it is the sole responsibility of a practitioner to ensure a prescription for a controlled substance is for a legitimate medical purpose pursuant to 21 C.F.R. § 1306.04(a). The DEA’s argument is persuasive and would apply in equal measure to legend drugs as the Legend Drug Act does require a prescription to be issued “for a legitimate medical purpose.” RCW 69.41.040(1).For example: a patient contacted the provider’s office after running out of refills for a prescribed medication. The provider’s office routes the patient’s call to a call center. After speaking with a pharmacist, the patient receives a new prescription written in the name of the patient’s provider. The provider does not take any affirmative action to approve this prescription. Instead, the pharmacist orders the new prescription in the name of the patient’s provider under a CDTA.This approach is problematic on its face. If pharmacists are not exercising their own prescriptive authority, which includes issuing the prescription in their own name, any written guidelines they are operating under cannot accurately be described as a CDTA. In addition, to be a prescription for a “legitimate medical purpose”, providers should not be delegating their own prescriptive authority to a pharmacist. Instead, the provider should be taking some affirmative action to approve the prescription created by the pharmacist.What “preliminary steps” can a pharmacist take before initiating or modifying drug therapy under a CDTA?The CDTA should provide guidance as to what preliminary steps are necessary before a pharmacist initiates or modifies drug therapy. Although an exhaustive list of preliminary steps would not necessarily be possible, the key indicator of permissibility is whether the preliminary steps are within a pharmacist’s scope of practice. For example:Hypothetical No. 1: Patient A has been prescribed warfarin for many years and has been a patient of an anti-coagulation clinic during that time. Patient A has run out of refills for their warfarin prescription and needs a new prescription. Patient A meets with Pharmacist X to obtain a new prescription. Pursuant to a CDTA, Pharmacist X can prescribe Patient A their warfarin but only if new bloodwork is obtained. Pharmacist X orders the blood work for Patient A. Once the bloodwork results are obtained, Pharmacist X writes a new warfarin prescription for Patient A.The preliminary steps in this hypothetical were: (i) examination of the patient, and (ii) ordering and reviewing laboratory tests. A pharmacist’s scope of practice includes the monitoring of drug therapy (RCW 18.64.011(28)) which has been defined in rule as including measuring and reviewing vital signs of a patient, and ordering and evaluating the results of laboratory tests relating to drug therapy (WAC 246-863-110). Consequently, these preliminary steps are within the scope of practice of a pharmacist and this exercise of prescriptive authority is appropriate.Hypothetical No. 2: Patient B has presented at a community pharmacy complaining of nausea and abdominal pain. Patient B discloses not having been diagnosed with any medical condition and these symptoms have been present for about three days. The pharmacist does have a CDTA to prescribe certain medications and to provide immunizations. The pharmacist, based on the patient’s presentation, engages in a differential diagnosis. The pharmacist conducts a physical examination of the patient, and orders multiple laboratory tests based on the patient’s presentation. None of these preliminary steps is outlined in the CDTA. Based on the results, the pharmacist prescribes a medication not listed on the pharmacist’s CDTA.The preliminary steps in this hypothetical were: (i) examination of the patient, (ii) conducting a differential diagnosis, and (iii) ordering and reviewing laboratory tests. The concern in this hypothetical is the pharmacist providing services and prescribing a medication that is not contained in the CDTA. This could be considered as practicing beyond the scope of a pharmacist license. ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download