Most states now allow collaborative practice

When the Governor signed the legislation in May, New Hampshire became, by at least one count, the 41st state to permit pharmacists to enter collaborative practice agreements with physicians. But no one knows for sure how many pharmacists are taking advantage of the professional privilege.

Forty-one states now permit some form of collaborative practice, according to Maria Spencer, director of state government affairs, ASHP. By the association's count, seven states-Alabama, Delaware, Maine, Massachusetts, Missouri, New York, and Oklahoma-do not yet permit collaborative practice. And the laws and regulations of the remaining states are open to interpretation.

Some states, such as Louisiana, Pennsylvania, and West Virginia, have adopted collaborative practice legislation but implementation is festooned with regulatory red tape. For example, the Pennsylvania pharmacy practice act was amended in June 2002 to permit drug therapy management in an institutional setting, but the regulations the pharmacy board was required to write are not yet finalized, according to Cathy Ennis, deputy press secretary, department of state. She added that the state was hopeful the regulations would be finalized in June.

"We believe the minimum standard should be licensure, which should suffice," Spencer said. "We don't think additional requirements are necessary to be able to work under collaborative practice, and we've expressed that to states looking at it."

From a statutory and regulatory standpoint, the profession is "making great progress," said Susan Winckler, R.Ph., VP for policy and communications and staff counsel, American Pharmacists Association. Noting that collaborative practice is the same as the new catchphrase collaborative drug therapy management, she added, "From the practice uptake of collaborative authority, it's a little different. Uptake depends in part on how detailed the state's requirements are and also whether prescribers are willing to collaborate. In some states you might have physicians willing to collaborate on immunizations and emergency contraception but who are a little more hesitant about collaborating on [treating] patients with diabetes or asthma."

While physicians' reluctance to let pharmacists into their club may be one barrier, pharmacists themselves are another roadblock to moving the profession into collaborative practice. "It's not so much that pharmacists don't have the clinical knowledge because they often do," said Winckler. "It's the confidence in how a collaborative agreement should be structured and confidence in how to approach prescribers to establish those agreements. We might be seeing some difference with pharmacists trained on academic healthcare campuses with other healthcare professionals. They may be more willing to do collaborative practice because they should have had more interaction with other professionals."

Where pharmacists can enter collaborative practice agreements depends on state laws and regulations, said Winckler. "In several states you don't have to be in a clinic, you can be in the community or just about anywhere," she said. "In some states collaborative authority may be restricted by patient populations, such as long-term care. If you've seen the authorizing language for regulation in one state, you've seen it in one state. There are some similarities, but there are distinctly different approaches to collaborative practice."

Winckler and Spencer agreed that collaborative practice is happening, but no one has a real handle on how many pharmacists are actually working under such agreements. "We hear about it anecdotally," said Spencer. "We're working on trying to get a better sense of what's happening. It's probably not happening as much as it could or as much as it should be."