Collaborative Practice

A SSO CI A T IO N REPORT

Collaborative Practice

APhA–APPM

Six Honest Serving Men Jean-Venable “Kelly” R. Goode

Collaborative practice and collaborative drug therapy management (CDTM) are not new to pharmacy and the pharmacy literature. The first CDTM arrangement was implemented in the 1960s, when the U.S. Indian Health Service began allowing trained pharmacists to provide primary care to ambulatory patients.1 Today, the profession is seeing a resurgence of interest in CDTM as the focus of outcome-based studies and pharmacy news. However, pharmacists in all practice settings still have questions about CDTM, which remains an underused and sometimes misunderstood process. Rudyard Kipling wrote in Just So Stories, “I keep six honest serving men. They taught me all I knew: Their names are What and Why and When and How and Where and Who.” In making the case for CDTM, this column considers these six “characters.”

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W hat Is CDTM ? Collaborative practice (or CDTM) involves pharmacists working with physicians, other health care professionals, and patients to improve therapeutic outcomes. Normally, these arrangements are formalized through a collaborative practice agreement in which the physician delegates authority to the pharmacist, within specified limits to select, initiate, modify, continue, discontinue, and monitor drug therapy, assess patients’ response to therapy, and/or order laboratory tests. Efforts to decrease medication errors and adverse effects are a key component of collaborative practice.2 4 Pharmacists may also be granted the authority to administer medications; the latter privilege has been extremely useful for pharmacists involved in pharmacy-based immunization delivery programs.4-6 W hy Enter Into a Collaborative Practice Agreem ent? Collaborative practice agreements elevate the level of practice. They are important in validating the pharmacist as an essential member of the patient care team. Formalized agreements allow for ver-

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ification of patient outcomes and increase the possibility of compensation for pharmacists’ services. Recently, the largest U.S. medical society recognized the value of collaborative arrangements between pharmacists and physicians.4 Advantages of CDTM include increasing patient adherence and decreasing medical costs, delays in modifying regimens, emergency department or unplanned physician office visits, medical errors, and mortality. Project ImPACT: Hyperlipidemia, a 2-year community pharmacy-based demonstration project, demonstrated that collaboration among pharmacists, physicians, and patients promoted increased adherence to medication regimens and achievement of National Cholesterol Education Program goals.7

W hen S hould I Enter Into a C ollaborative Practice Agreem ent? Pharmacists interact daily with other health care providers. Most of the time these are informal interactions aimed at improving care or verifying data. Pharmacists need to formalize these relationships through collaborative practice agreements, and they should enter into collaborative practice agreements if they are providing patient care services that go beyond dispensing. Several components should be in place before a pharmacist enters into a CDTM agreement. It is generally recognized that pharmacists should

have access to patients and patient information, including medical history and laboratory and procedure results. Pharmacists should have the knowledge and skills to manage the drug therapy of the patient and be willing to share in the responsibility for his or her care. This may require further training and/or certification in the subject area. Pharmacists should also make sure that adequate time is available for management of patients. The pharmacy should have a documentation system for keeping a record of patient care. Lastly, a mechanism should be in place to compensate both the pharmacist and the physician for collaborative services.

How Do I Enter Into a Collaborative Practice Agreem ent? A Virginia family practice physician offered this advice for pharmacists paying visits to physicians to build partnerships in patient care: Don’t forget to bring a banana. He was emphasizing the need to be prepared with a short message that can be delivered in approximately the time it would take the physician to eat the banana. Like pharmacists, physicians have busy schedules and, sometimes, quotas for patient visits; therefore, carving out time for meetings may be difficult. It might be most productive to to try and schedule time with a physician before his or her first patient visit of the day. Also, it helps to “get in the back door” and “do your homework.” Getting in the

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back door means educating patients, caregivers, and employers about the value of pharmacists’ services in hopes they will share the information with physicians. Doing your homework means being prepared for a productive dialogue with a potential collaborator. In preparing to meet with physicians or other providers, pharmacists should anticipate the following questions: Why do my patients need the service being proposed? What is your specific training? How will I benefit? Why should I pay for it, or who is going to pay for it? Can you do it? Being prepared to answer questions like these helps take the uncertainty out of approaching physicians when building relationships and demonstrating the value of pharmacist patient care. Still, obstacles to collaborative relationships with physicians do exist. These include turf battles, lack of understanding of pharmacists’ clinical abilities, and distances between practice sites.8,9 However, proper preparation and persistence can help pharmacists overcome some of these obstacles. Remember that, ultimately, physicians and pharmacists have the same goal: to improve patient care.

W here Can Collaborative Practice Agreem ents Be Im plem ented? Currently, 32 states allow CDTM in varying degrees, from medication administra-

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tion to prescribing medications under protocol.10 In some states, collaborative agreements also allow pharmacists to order drug therapyrelated laboratory tests and to modify drug therapy. Limits to state legislation regarding collaborative practice agreements include the type of practice setting and pharmacist training. For example, Indiana only allows collaborative practice arrangements in acute care facilities and mental health institutions.2 Another limitation may be the type of training needed before a pharmacist can enter into collaborative practice agreements and receive compensation for services rendered under these agreements. Unfortunately, there is no easy way to obtain what specific states may allow under a collaborative practice. The best way to obtain this information is to contact the state board of pharmacy. However, legislation is not always necessary because physicians are allowed to refer their patients for any level of care that they think appropriate. This referral is usually done through a Certificate of Medical Necessity (CMN). Many innovative community pharmacy practitioners are using CMNs for validation of their patient care services and as a mechanism for receiving compensation.

W ho Should Enter Into Collaborative Practice Agreem ents? Pharmacists in all practice settings should be involved in CDTM. Formalized collabora-

tive practice agreements in the hospital setting would help remove the barriers in community and rural hospitals that are just beginning to develop expanded patient services. Pharmacists practicing in clinics in hospitals or physician offices would be able to further document, enhance, and increase patient care through CDTM. The community pharmacy is different from other settings because the pharmacy is usually located at a site other than the physician’s office. Therefore, a formalized relationship with the physician may allow the pharmacist access to crucial health care information and improve the type of care that is provided to the patient.

Strength in N um bers Hopefully, pharmacists will take their cue from Kipling’s “six honest serving men” and make CDTM a priority in their practice. A few pharmacists are doing great things, but more need to follow their lead before the innovative services made possible through collaborative practice agreements begin making an impact on patient care on a wide scale. Pharmacists need to network with each other and other health care providers to make this happen in all practice settings. Henry Ford said it best: “Coming together is a beginning, keeping together is progress, working together is success.”

ginia–Virginia Commonwealth University, and chair-elect, Clinical/Pharmacotherapeutic Practice Section, APhA–APPM.

References 1. Paavola F, Dermanoski K, Pittman R. Pharmaceutical services in the United States Public Health Service. Am J Health Syst Pharm 1997;54: 766 72. 2. Koch KE. Trends in collaborative drug therapy management. Drug Benefit Trends. January 2000:45 54. 3. Carmicheal JM, O’Connell MB, Devine B, et al. Collaborative drug therapy management by pharmacists. America n College of Clinica l Pharmacy. Pharmacotherapy. 1997;17:1050 61. 4. American College of Physicians–American Society of Internal Medicine. Pharmacist scope of practice. Ann Intern Med. 2002;136:79 85. 5. Ernst ME, Chalstrom CV, Currie JD, et al. Implementation of a community pharmacybased influenza vaccination program. J Am Pharm Assoc. 1997;NS37:570 80. 6. Weitzel KW, Goode JR. Implementation of a pharmacybased immunization program in a supermarket chain. J Am Pharm Assoc. 2000;40:252 6. 7. Bluml BM, McKenney JM, Cziraky MJ. Pharmaceutical care services and results in Project ImPACT: Hyperlipidemia. J Am Pharm Assoc. 2000;40:157 65. 8. Ferro LA, Marcrom RE, Garrelts L, et al. Collaborative practice agreements between pharmacists and physicians. J Am Pharm Assoc. 1998;38: 655 66. 9. McDonough RP, Doucette WR. Developing collaborative working relationships between pharmacists and physicians. J Am Pharm Assoc. 2001;41:682 92. 10. Pharmacists finding solutions through collaboration. American College of Clinical Pharmacy Web site. Available at: w w w. acc p. co m/ po s iti on / paper10.pdf. Accessed March 5, 2002.

Jean-Venable “Kelly” R. Goode, PharmD, BCPS, is associate professor, School of Pharmacy Medical College of Vir-

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APhA APRS

Opportunities and Challenges of Collaborative/ Multidisciplinary Research Teams Mary E. Teresi

Diseases such as AIDS, cystic fibrosis, and cancer have led to an increased emphasis on rapidly moving research from bench to bedside. Tests, procedures, treatments, and analyses are becoming more specialized and complex. Funding resources are growing more limited. The protection of human subjects continues to draw the media’s spotlight as researchers, institutions, and funding sources grapple with issues of informed consent and the ethics of study design and conduct. An institutional review board and/or sponsor often requires that a licensed physician collaborate on a clinical study being led by a pharmacist, nurse, respiratory therapist, microbiologist, statistician, or epidemiologist, depending on the procedures and the risks to the participants. Urgency, complexity, costeffectiveness, safety: All of these necessities are increasing the need for collaboration between basic and clinical researchers and the formation of multidisciplinary research teams. Establishing and maintaining a collaborative research team can be frustrating, time-consuming, and challenging, but the experience is often rewarding to the researchers, and the results are often beneficial to the health care community and society.

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Advantages of Expertise and Access Pharmacists may seek out collaborators who have expertise in specific analytic methods or sophisticated statistics, or who have different clinical perspectives. These collaborators may be identified through local and national meetings, through discussion of research projects with other health care professionals in the course of patient care, or by contacting the local university or college of pharmacy for suggested names. Involvement with such researchers gives pharmacists opportunities to grow professionally by exploring areas outside their niche, expanding their research, augmenting their own clinical expertise, and bringing greater knowledge to bear on a research question. Equally important, especially given the dwindling availability of research funds, collaborators may have access to specialized equipment, highly-trained research personnel, or specialized computer programs that are integral to the research project. Collaborating with an established laboratory offers clear advantages over trying to find the funding, space, and resources to start from scratch and set up a facility. If a colleague has a laboratory in which a trained research assistant is performing a specialized procedure, using what is in place rather than duplicating the system and learning to conduct the test oneself is usually quicker and may produce less variable results. However, understanding the nuances of any system—its limitations, sources

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of variability, and confounding factors—is important. A drawback to using or sharing someone else’s resources is the loss of control over the scheduling or prioritizing of projects. The project will likely need to be scheduled around someone else’s work. If the research expands to the point where the current system is unable to handle the workload, a pharmacist may want or need to establish and support his or her own laboratory to conduct the procedure. The National Institutes of Health-sponsored General Clinical Research Centers and Pediatric Pharmacology Research Centers (PPRU), the Cystic Fibrosis Foundationsponsored Therapeutics Development Network (TDN), and many other collaborative groups provide support for establishing a central research facility. Advantages of participating in groups such as PPRU or TDN include access to standardized procedures and larger numbers of potential subjects.

O vercom ing Recruitm ent Difficulties Enrolling and keeping enough subjects to successfully complete a study is becoming increasingly challenging. Although normal, healthy adult subjects are plentiful, children, patients with asthma, or people with “disease x” can be more difficult to recruit. Developing collaborative relationships with health care professionals who care for the population of interest can make recruitment easier. Providing physicians, nurses,

and other providers with information on the study being planned and soliciting their support can minimize misunderstandings and enhance recruitment efforts. If possible, identify potential collaborators who follow the desired population and who have the time and interest to help with a clinical trial. Next, working with the collaborators, develop a plan for conducting the study without interrupting the flow of the clinic. Keeping the people who have contact with the clinic patients and/or other potential research subjects informed about the progress of the study helps them answer questions or at least know to whom to refer research questions. Likewise, if one is planning to conduct a study using subjects currently in a hospital, it it is essential to inform the health care team responsible for the potential subjects’ care about the study and to address any concerns they may have. Otherwise, recruiting subjects and getting research-related procedures completed may prove difficult.

The Process Collaboration often begins with a brainstorming session, one of the more exciting steps in the multidisciplinary research process. Bringing in others who have varying research focuses often lends a fresh perspective to the research questions and helps pharmacists better anticipate potential problems. Whether the topic being brainstormed is a potential new study or a completed project, the

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exchange of ideas and interpretations with others can be exhilarating. This process provides intellectual stimulation and a sense of professional development. The key to successful brainstorming is to allow unfettered expression of opinions while maintaining some sense of focus. Without eventually reaching consensus, however, work would never get started or completed. Once a study is completed, members of a multidisciplinary team can and should collaborate on analyzing the results, preparing the abstract, presenting the data, and writing the manuscript. Interpreting results provides another opportunity for brainstorming, as team members debate the meaning of the findings and discuss how to present them. Again, this process can be intellectually stimulating, and the vigorous exchange of ideas should lead to a more interesting manuscript. Manuscript preparation presents its own set of challenges for a research team. Problems can occur with authorship, differences in writing styles, and disagreements over the interpretation and application of results. Many journals are recognizing and addressing the apparent trend of including too many authors on a paper. With what seems to be an increase in the frequency of collaboration in the medical field in general, manuscripts often have more than five authors. Although guidelines for minimizing the number of authors have been suggested, they can be difficult to follow. I recommend that research team members discuss authorship ahead of time and agree on a lead

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author (generally listed as the first or last author) who will be responsible for pulling together the overall article—including deciding on and incorporating comments, making the article flow, and setting up conferences to discuss ideas. The lead author would also be responsible for ensuring that the manuscript meets the requirements of the journal it is being submitted to. Whoever else should be designated as an author should also be addressed early on, although other colleagues may need to be brought in if the results and analyses necessitate additional collaboration.

A Final N ote Collaborating with colleagues in other disciplines allows pharmacists to increase their expertise and permits access to a more complete array of resources. A broader representation of expertise on a research team also raises the likelihood that a project will be successful and its results interesting to a broader group. In addition, collaboration promotes respect for and a better understanding of pharmacists’ capabilities by team members, study sponsors, and subjects. But anyone considering forming or joining a research team should be aware that a collaboration gone sour can negatively affect one’s overall image and ability to be part of future collaborative teams. Constant, respectful communication among team members, equitably shared responsibilities, and timely submission of input are the keys to a successful multidisciplinary research team.

Mary E. Teresi, PharmD, is director of pediatric allergy/pulmonary clinical trials, College of Medicine, University of Iowa, Iowa City, and chair, Clinical Sciences Section, APhA–APRS. APhA ASP

Pharmacy School as a Training Ground for Collaborative Practice Christine Bartels

As the pharmacy profession and its leading practitioners begin to recognize the benefits of interdisciplinary teamwork and collaboration, pharmacy students need to become familiar with cooperating with other health care professionals while in school. At the University of Minnesota College of Pharmacy, I have had the opportunity to dive into the interdisciplinary arena early. The university’s Center for Health Interdisciplinary Programs (CHIP) provides multiple occasions for students from the school’s 12 health care professional programs to discover the educational, leadership, and service benefits of interdisciplinary interaction. As a pharmacy representative and president of CHIP, I have learned much about other health professions and have had productive interactions with future professional colleagues. The highlight of my 3 years of professional education and organizational work was participating in Immunization Tour 2000, the winning project of the Phi Lambda Sigma

Leadership Challenge. This event increased the general awareness of the need for immunizations and demonstrated that pharmacy students could also administer immunizations in Minnesota. In 2000 interdisciplinary collaboration between students and faculty from the College of Pharmacy and the School of Nursing was an important component of the project. At times, there were misunderstandings between the pharmacy and nursing students, but, looking back, the conflicts arose out of simple ignorance of each other’s professions. Even with a vaccine shortage, the program was hugely successful. Focusing on the patient allowed us to immunize 867 university students, faculty, and staff in 2 clinics in a single day. I have had many wonderful learning opportunities during my final year of pharmacy school, but the most beneficial in terms of preparing for the real world of health care have been the experiences that emphasized interdisciplinary teamwork and multidisciplinary collaboration. My clinical rotations have been priceless experiences, allowing me to broaden my knowledge while working with other health care professionals. In my acute care rotation in the medical intensive care unit and the solid organ transplant unit at Fairview University Medical Center in Minneapolis, I participated in daily medical team rounds. The pharmacist was a vital member of the team, offering suggestions and corrections that improved patient care in the hospital. As a part of my rotation at the

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Minneapolis Veterans Affairs Medical Center’s Warfarin Clinic, I was able to converse with a patient about his therapy while having access to his complete medical chart I and adjusted his therapy according to the patient’s activities and international normalized ratio. At the White Earth Indian Health Center, I also used medical charts to make drug therapy recomendations while having easy access to the other providers if I had any questions. The unique opportunity to speak with each patient about individual medications allowed me to conduct a more complete assessment and provide better pharmaceutical care for patients. At Walgreens in Blaine, Minn., where I recently served a rotation, I assisted in developing a collaborative practice agreement with prescribers under which pharmacists would be allowed

A P h A

to substitute a similar medication in the event that a medication was not on the third party payer’s formulary. As a result of my interdisciplinary activities during my first 3 professional years as a student, evaluations of my communication with and understanding of other health care professionals have been excellent. Many of my preceptors have commended me for my ability and level of comfort in talking with members of other professions. My interactions during the rotations I served have made me more confident in approaching other health care professionals with recommendations and questions. I have used these discussions as opportunities to demonstrate to others the importance of the pharmacist in the patient care process and to establish a certain level of credibility that will, hopefully,

improve patient outcomes while augmenting others’ respect for and use of the pharmacist. Interdisciplinary work is challenging, but worth the difficulty in the end. The next step for students is to channel the energy and stimulation they experience during these projects into actual practice. Always remember that the word “team” in the context of interdisciplinary and multidisciplinary teamwork stands for “Together Everyone Achieves More” for the patient. Christine Bartels is a fourthyear PharmD candidate at the School of Pharmacy, University of Minnesota, Minneapolis.

Corrections

2002 JAPhA, the two individuals in the portrait to the left of the first paragraph of text were identified as Daniel B. Smith (left) and William Procter Jr. (right). This was incorrect; the personages shown are William Procter Jr. (left) and George Coggeshall (right). Also in the March/April 2002 JAPhA, on pages 193, 215, and 263, the expiration dates for the three CE articles were incorrect. The correct date for all three articles is March 31, 2005 (not 2004). The correct numbers of contact hours and continuing education credits for “Beyond the 4Ps: Using Relationship Marketing to Build Value and Demand for Pharmacy Services” (see page 193 of the March/April JAPhA) are 1.5 and 0.15, respectively.

In the In This Issue column (page 147) of the March/April

SESQ U ICEN T EN N IA L : V O ICES FR O M

P A ST ISSU ES O F JA Ph A

Pharmacist and Physician Attitudes and Perceptions of the Two Professions Unveiled at the 1984 APhA Annual Meeting in Montreal were the results of the latest of Schering Laboratories’ ongoing series of reports examining facets of the pharmacy profession…. It was reassuring to discover that both physicians and pharmacists viewed the pharmacist as a professional, and felt that pharmacists rated higher in professional image than nurses and pharmaceutical representatives. Both groups also felt that pharmacists are not overeducated, in light of their important responsibilities, and that pharmacists only rarely overstep their professional bounds. Pharmacists and physicians both strongly agree that they have good rapport with each other and that physicians are likely to rely on pharmacists for information. Yet, there was nevertheless some disparity in self-perception of professional image. More than 60% of all pharmacists agreed with the notion that they are the professional equivalents of physicians. But 45% of the physicians disagreed with this characterization. The Schering Report asserts that “this variance in perception can be altered by a conscious effort on the part of each profession.” Further, the pharmacists in the survey acknowledged that they themselves didn’t expect that physicians—or patients—would think of them as professional equals. 1984 Schering Report explores pharmacist–physician relationships. Am Pharm. 1984;NS24:641.

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