At the Forefront of Patient Care
More pharmacists are collaborating with prescribers to manage drug therapy

Massive changes in health care have been occurring at a rapid pace during the past decade. The pharmacy profession has responded with the evolution of pharmaceutical care, a term defined by Hepler and Strand as “the responsible provision of drug therapy for the purpose of achieving definite outcomes that improve the patient’s quality of life.”1  In addition to dispensing medication, pharmacists who provide pharmaceutical care services prevent, identify and resolve potential and actual drug-related problems; recommend effective, yet cost-saving drug therapies; and counsel patients so that they understand the complexities of their drug therapies. One of the tools used to provide pharmaceutical care is collaborative drug therapy management (CDTM).

Definition of CDTM
CDTM is the terminology used to describe the partnering between physician and pharmacist to manage drug therapy. Collaborative drug therapy management is “practiced whenever pharmacists work with physicians and other health professionals to solve patient and medication-related problems or make decisions regarding drug prescribing, monitoring and drug regimen adjustments.”2  By taking on these responsibilities, pharmacists share the responsibility for patient outcomes with the physician.

CDTM activities may include initiating, modifying and monitoring drug therapy; ordering and performing lab tests; assessing response to therapy; educating and counseling patients; and administering medications.2 

Background
Recent reports in medical and pharmacy literature support increased pharmacist involvement in the management of medication therapy, such as occurs in CDTM. With the publication of the Institute of Medicine report on medical errors,3  more attention than ever has been focused on the role of the pharmacy profession in the prevention of adverse drug events and errors. A study published in the Journal of the American Medical Association described the presence of a pharmacist on rounds as a member of an ICU patient care team. This resulted in a substantially lower rate of adverse drug events caused by prescribing errors.4  Yet another study demonstrated that pharmacists can reduce drug-related morbidity and mortality accounting for 28.2% of hospital admissions and an estimated cost of $76.6 billion in the ambulatory setting.5 

Many pharmacy organizations and individuals have advocated the involvement of pharmacists in collaborative drug therapy management. The American College of Clinical Pharmacy (ACCP) published a position paper advocating the role of qualified pharmacists in managing collaborative drug therapy.6  The American Society of Health-System Pharmacists (ASHP) has long promoted the role of the pharmacist in collaborative drug therapy management. This organization and its professional staff assist states in passing legislation to allow CDTM to occur and routinely publish advocacy materials which are made available to ASHP’s state affiliates.

Where is it?
So where is collaborative drug therapy management taking place? CDTM initiatives have been more commonly implemented in hospital or health-system pharmacy practices where the oversight of the pharmacy and therapeutics committee have made such arrangements more comfortable to the medical community. A 2000 survey of hospital pharmacy directors across the United States revealed that virtually all (95.4%) pharmacists monitored medication therapy along with other duties.7  Many hospital pharmacy departments provide drug therapy management services such as aminoglycoside dosing or total parenteral nutrition monitoring and modification per protocol.

 The National Association of Boards of Pharmacy (NABP) recently conducted a survey of states as a part of NABP’s Survey of Pharmacy Law. The survey revealed that 29 states allow pharmacists to collaborate with prescribers to initiate, modify and/or discontinue patient medication therapy.8  Of these, 24 states have enacted statutes authorizing CDTM and four states have only regulations in place governing CDTM. In Iowa, a published interpretation of current laws and regulations serves as a guideline for CDTM activities.9  Considerable variations exist from state to state as to what is allowed. Some states limit CDTM to certain practice sites, while others specify the qualifications a pharmacist must have in order to participate in CDTM. Still others specify the terms of an agreement between physician and pharmacist. Some examples of successful collaborative drug therapy management initiatives include anticoagulation, immunization administration, emergency birth control, pain management, and hyperlipidemia management.10 

Wisconsin pharmacists can participate in CDTM through delegation of a medical act as allowed by sec. 448.03 (2)(e), Stats. Recently, the Wisconsin Pharmacy Examining Board discussed pharmacist involvement in collaborative drug therapy management and asked the Medical Examining Board and its legal counsel for their interpretation of Section 448.03 (2)(e). In a letter dated August 29, 2000, the Wisconsin Medical Examining Board confirmed that a physician can delegate medical acts to pharmacists pursuant to mutually approved protocols and this section of the Wisconsin Statutes [see previous page]. This interpretation makes it feasible for pharmacists in Wisconsin to develop collaborative drug therapy management agreements with physicians in all facets of patient care and drug therapy management.

Getting started
A Wisconsin pharmacist interested in developing a partnership with a physician for the purposes of collaborative drug therapy management may initiate a discussion with a physician known to him or her. A description of the type of drug therapy management that the pharmacist and/or pharmacy would like to collaborate on could be presented to the physician for discussion of feasibility, etc. A protocol could then be developed to clearly define the roles and responsibilities of each party – the physician’s role in diagnosis and the pharmacist’s responsibility for monitoring or initiating therapy and modifying it as necessary. This sort of collaborative relationship capitalizes on the expertise of the physician in diagnosis and the pharmacist’s extensive knowledge in drug therapy.

A written protocol would represent a formal agreement between physician and pharmacist. It should represent the voluntary participation of each party and be written carefully and succinctly, defining the role of each. It could describe the specific responsibilities authorized by the supervising physician, the method of documentation to be used, the types of initiation and modification of drug therapy that the pharmacist can perform and the procedures or plans that the pharmacist should follow. Algorithms can be included in the protocol to aid in drug therapy modification in response to blood levels, patient response or side effects, etc. A protocol could specify training requirements for the pharmacist involved. The protocol should facilitate frequent, quality communication between the physician and pharmacist and provide for oversight and quality assurance activities.

Other concerns
Unresolved issues on the national and state level related to collaborative drug therapy management include the necessity of mandatory additional training or certification, as well as compensation. Another issue that should be explored is that of liability. It would be prudent for pharmacists to find out whether participation in a collaborative drug therapy management agreement is covered by their respective liability policies.

Conclusion
Collaborate drug therapy management agreements allow a physician to delegate to the pharmacist what can be considered “medical acts,” including the ability to initiate and modify drug therapy and order lab tests based on a clearly defined written protocol. Awareness by the medical and pharmacy communities of successful CDTM initiatives will help to build support for more collaborative efforts in the future. Pharmacists are encouraged to contact JPSW with descriptions of any CDTM initiatives they are involved in. n

References

1. Hepler CD, Strand LM. Opportunities and responsibilities in pharmaceutical care. AJPE. 1989; 53:7S-15S.
2. Koch KE. Pharmaceutical care trends in collaborative drug therapy management. Drug Benefit Trends. 2000; 12:45-54. 
3. Kohn LT, Corrigan JM, Donaldson MS. To err is human-building a safer health system. Washington, DC. National Academy Press, 1999.
4. Leape LL, Cullen DJ, Clapp MD, et al. Pharmacist participation on physician rounds and adverse drug events in the intensive care unit. JAMA. 1999; 282:267-270.
5. Johnson JA, Bootman JL. Drug-related morbidity and mortality. Arch Intern Med. 1995; 155:1946-56.
6. Carmichael JM, O’Connell MB, Devine B et al. ACCP position statement-collaborative drug therapy management by pharmacists. Pharmacotherapy. 1997; 17:1056-1061.
7. Pedersen CA, Schneider PJ, Santell JP, Kelly EJ. ASHP national survey of pharmacy practice in acute care settings: monitoring, patient education, and wellness – 2000. Am J Health Syst Pharm. 2000; 57: 2171-87.
8. NABP Newsletter. Dec 2000; 29: 143. 
9. American Society of Health-System Pharmacists. Collaborative drug therapy management. ASHP State Advocacy Packet. Bethesda, MD: ASHP; November 2000.
10. Barry CP, Fuller TS. A path to pharmaceutical care (part 2): evolution of collaborative drug therapy management. Hosp Pharm. 1998; 33:490-97.  

More resources on collaborative drug therapy management:
Fuller, TS, Christensen, DB, and Williams, DH. Satisfaction with Prescriptive Authority Protocols. J Am Pharm Assoc.  1996 (Dec);NS36(12);739-745.

Fuller, TS.  The pharmacist as a prescriber:  Stories from Washington state.  Pharm Pract Manag Q.  April 1995; 15:15-47.

Collaborative Drug Therapy Management, a regular feature in Lippincott’s Hospital Pharmacy, April 1998-present.

For sample protocols, see the following references:
Fuller TS. Handbook of Collaborative Drug Therapy Management. Renton WA: Washington State Pharmacists Association; 1996. To order call 425-228-7171

The APhA Drug Treatment Protocols. Washington DC: American Pharmaceutical Asooication; 1999. To order call 800-878-0729