ALBERTA, CANADA
From The Messenger, a publication of the College of Physicians and Surgeons of Alberta
NEW PROGRAM SHOWS SUCCESS
Alberta Wellnet’s new Pharmaceutical Information Network (PIN) has been running as a pilot project in Westlock since February this year, and in Leduc since May.
As of August 1, 2002, 45 physicians and pharmacists in 18 sites within these two communities were using PIN; 5,096 prescriptions were recorded; and practitioners viewed patient medication profiles a total of 2,332 times. Over the past few months, the level of usage has been accelerating as more patients are enrolled. Ongoing discussion between the practitioners using PIN and the system developers at Alberta Wellnet helped fix any problems quickly and improved PIN functionality throughout the course of the pilot.
More than just a dispensing record, the PIN system is designed to put knowledge tools in practitioners’ hands at the point of patient service in order to avoid problems and optimize prescribing. Functionality will be boosted in two more stages over the next three to four months, and other enhancements will make PIN a more user-friendly system. Scheduled changes include enhanced drug search, multiple drug-to-drug interaction checking, and suggested dosage calculators.
User surveys and focus group interviews have been used in an ongoing evaluation process. Preliminary feedback from users reflected a high level of satisfaction with PIN after the installation and learning period. Users were particularly enthusiastic about upcoming enhancements. The main difficulty in its use has related to soliciting patient consent, as required by the Health Information Act.
MANITOBA, CANADA
From From the College, a publication of the College of Physicians and Surgeons of Manitoba
JOINT STATEMENT ON CONTINUED CARE PRESCRIPTIONS
Situations may arise in which a patient requires a renewal or refill of a prescribed medication, yet is unable to contact the prescribing physician. In such a situation, the pharmacist may be asked to provide a renewal or refill of the prescription (a “continued care prescription”). Pharmacists who are asked to provide continued care prescriptions should consider the following principles:
Continued care prescriptions cannot and do not take the place of ongoing medical care.
Each request for a continued care prescription must be judged on the individual nature of the patient’s need and that patient’s history.
Pharmacists may provide a continued care prescription only when the following conditions are met:
The pharmacist must be satisfied that the physician would in all likelihood provide the authorization were the pharmacist able to contact the physician.
The medication to be continued must be for a chronic or long-term condition.
The patient must have an established stable history (no recent changes to dosages or drug therapy) with that medication.
The original prescription must have been filled at that particular pharmacy, and the patient must be within the care of the pharmacist.
Narcotics or controlled substances must not be provided by a continued care prescription.
Benzodiazepines must not be provided by a continued care prescription unless:
the medication is being used for management of convulsive disorders, or
there is a legitimate risk of seizure due to sudden withdrawal.
The amount of medication provided must be determined by the pharmacist based upon the circumstances of the particular patient, but must not exceed the previous amount filled.
All medication dispensed pursuant to a continued care prescription must be:
recorded by the pharmacist at the time of dispensing
reported no later than the next business day by telephone or facsimile to the original prescribing physician and to the primary care physician if different from the original prescribing physician
entered into the Drug Program Information Network
documented in the patient record
Provided these conditions are met, the continued care prescription will be viewed as a “collaborative practice agreement” between the pharmacist and the physician, i.e., a temporary delegation of function where an urgent need for patient drug therapy management has arisen and the prescribing physician is unavailable to provide refill authorization.
SASKATCHEWAN, CANADA
From College Newsletter, a publication of the College of Physicians and Surgeons of Saskatchewan
PRESCRIBING WITHOUT AN APPROPRIATE DOCTOR-PATIENT RELATIONSHIP
At a summer meeting of the Council, a bylaw was passed that prohibits prescribing unless the physician has the necessary information to reach a conclusion that the prescribed medication is appropriate for the patient. In most cases, that will include direct contact with the patient, a physical examination of the patient, and a history from the patient.
There are a number of situations in which physicians may be asked to prescribe medications when they have not examined the patients. The situations that are of most concern to regulatory bodies across Canada are Internet prescribing and “countersigning” prescriptions issued by American physicians to be dispensed in Canada.
Internet pharmacies are relatively common in the United States and a number of physicians have prescribed to patients using an online questionnaire without ever knowing anything more about the patients. A number of American physicians have been subject to professional discipline and criminal prosecution for doing so.
Of more recent concern in Canada are arrangements between physicians and pharmacies whereby American patients will receive a prescription from a Canadian physician without ever being examined by the Canadian physician who prescribes. Usually, this occurs on the basis of a prescription that has been issued by an American physician.
It is the College’s view that neither of these situations meets the expected standards of the medical profession. It is the College’s position that it is unprofessional to prescribe to patients if the physician has not obtained the necessary information to determine that the prescription is appropriate and the necessary follow-up care will be provided.
The College is also concerned that physicians who engage in the business of prescribing for American patients may not be covered by the Canadian Medical Protection Agency if a patient comes to harm as a result of the prescribing and the patient sues the physician in an American court.
There are a number of regulatory bodies in the United States and Canada that have rules or policies that specifically prohibit a physician from prescribing without having established an appropriate doctor-patient relationship. With the July meeting of Council, this practice is specifically prohibited in Saskatchewan as well.
The bylaw defines “prescribing to a patient without establishing an appropriate doctor-patient relationship” as unprofessional conduct. That term is defined in the bylaw as follows:
(h) prescribing to a patient without establishing an appropriate physician-patient relationship includes any situation in which a physician issues a prescription via electronic or other means unless the physician has obtained a history and has performed an appropriate physical evaluation of the patient adequate to establish diagnoses and identify underlying conditions and/or contra-indications to the treatment recommended/provided.
Prescribing to a patient without establishing an appropriate physician-patient relationship does not include a situation where the prescription is issued:
in an emergency situation to protect the health or well being of the patient
in consultation with another Saskatchewan physician who has an ongoing relationship with the patient, and who has agreed to supervise the patient’s treatment, including use of any prescribed medications
in an on-call or cross-coverage situation in which the physician has access to the record of the patient for whom the prescription is issued
in an on-call or cross-coverage situation, or in a situation of dealing with a physician’s own patient where a doctor-patient relationship has been established, in which the physician is able, on the basis of a telephone discussion with the patient or a repre sentative of the patient, to reach an appropriate diagnosis that is consistent with good medical practice.
