pharmacy in the 21st century - open: improving the health ... · 3 pharmacy in the 21st century:...

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The Ontario Pharmacy Evidence Network is a team of multidisciplinary researchers working together to evaluate the quality, outcomes and value of medication management services that pharmacists and other healthcare professionals provide. We are fostering knowledge translation and exchange, building capacity in medication management research, and addressing the needs of Ontario’s vulnerable populations.

open-pharmacy-research.ca [email protected] @open_pharmacy

Lisa Dolovich, BScPhm PharmD MSc 1,2,3 Nancy Waite, PharmD FCCP 3 Zubin Austin BScPhm MBA MISc PhD FCAHS 1,4

Sherilyn Houle,BSP PhD 3

Lisa McCarthy, RPh PharmD MSc 1,5,6

Lori MacCallum, BScPhm PharmD, CDE 1,7,8 Kelly Grindrod, BScPharm PharmD, MSc3

Feng Chang, BScPhm PharmD 3

Barbara Farrell, BScPhm PharmD ACPR FCSHP 9,10 Beth Sproule, BScPhm PharmD 1,11

Prepared by: Ontario Pharmacy Evidence Network (OPEN)

PHARMACY IN THE 21ST CENTURY: ENHANCING THE IMPACT OF PHARMACY ON PEOPLE’S LIVES IN THE CONTEXT OF HEALTH CARE TRENDS, EVIDENCE AND POLICIES

1 Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON 2 Department of Family Medicine, McMaster University, Hamilton, ON 3 School of Pharmacy, University of Waterloo, Waterloo, ON 4 Institute for Health Policy, Management and Evaluation, Faculty of Medicine, University of Toronto 5 Women’s College Research Institute, Women’s College Hospital, Toronto, ON 6 Department of Family Medicine and Community Medicine, Faculty of Medicine, University of Toronto, Toronto, ON 7 Banting & Best Diabetes Centre, Faculty of Medicine, University of Toronto 8 Toronto General Hospital Research Institute 9 Department of Family Medicine, University of Ottawa, Ottawa, ON 10 Bruyère Research Institute, Ottawa, ON 11 Centre for Addiction and Mental Health (CAMH), Toronto, ON

TABLEOFCONTENTS

Executivesummary....................................................................................................................................................3

Background.................................................................................................................................................................8

Introduction................................................................................................................................................................8

I. Healthcaresystem..........................................................................................................................9

II. Currentcontextofthepharmacyprofession.................................................................................12

ObjectiveoftheWhitePaper.................................................................................................................................17

Approachusedtogeneratefutureopportunitystatementsandsummarythemes......................................17

Individuallyreviewedpharmacypracticetopics.................................................................................................18

TOPIC1:Pharmacistprescribing(includingcommonailments)...........................................................18

TOPIC2:Pharmacistsasimmunizers/injectorsinOntario...................................................................21

TOPIC3:Diabetesasanexemplarforchronicdiseasemanagement..................................................24

TOPIC4:Opioidstewardshipandcaringforpatientswithchronicpain..............................................27

TOPIC5:Medicationreview.................................................................................................................31

TOPIC6:Qualityimprovement/changemanagementinpharmacy...................................................33

TOPIC7:eHealthincludingworkflowsthatmaximizethemeaningfuluseoftechnology...................36

TOPIC8:Substanceusedisorders........................................................................................................39

TOPIC9:Deprescribing.........................................................................................................................42

TOPIC10:Integrationofpharmacytechniciansintocommunitypharmacypractice..........................44

Principlesthattheprofessionofpharmacyshouldstrivetoachieve...............................................................47

50futureopportunitiesthatsupportprinciplestheprofessionofpharmacyshouldstrivetoachieve......47

Futuredirectionsfortheprofessionofpharmacy..............................................................................................52

SummaryTheme1:Organizationalchange......................................................................................52

SummaryTheme2:Betterexternalrelationships............................................................................53

AssessmentofMESPOinrelationtoexpandedscopesofprofessionalpharmacypractice.........................53

References................................................................................................................................................................57

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ThepurposeofaWhitePaperistoprovideanauthoritative,in-depthreportonaspecifictopicbypresentinganexistingproblemandprovidingpossiblepolicypreferences,optionsorsolutions.AWhitePaperseekstoprovidestrategic,informedguidanceonanissueofinterestthatisrelevanttoavarietyofstakeholdersandcanbeusedtoinformimplementationanddecision-makingprocesses.DefinitionadaptedfromDoerr,AudreyD.TheRoleofWhitePapers.In:Doern,G.B.andPeterAucoin.TheStructuresofPolicy-makinginCanada.Toronto,MacMillan,1971.pp.179-203.

Acknowledgements:ThankyoutoAnitaDiLoretoforadministrativesupport.ThankyoutoAnnaliseMathers,ManmeetKhaira,andXioaLiforcommentsandcopy-edits.ThankyoutoSusanJames,AnneResnick,andNancyLum-Wilsonforthoughtfuldiscussion,inputandedits.

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Pharmacyinthe21stcentury:Enhancingtheimpactoftheprofessionofpharmacyonpeople’slivesinthecontextofhealthcaretrends,evidenceandpolicies

EXECUTIVESUMMARY

The use of medications continues to be essential as a means to maintain and improve health. Asmedication experts andmanagers on behalf of the health care system, the profession of pharmacyincreasingly impacts patients, health care providers, health care system planning organizations,regulatorsandotherstakeholders.ThisWhitePaperseekstoprovidetheprofessionofpharmacywithcriticalinsightandstrategicdirectiontohelpenvisionthefutureofpharmacy.Objective ofWhite Paper: The objective of thisWhite Paper is to describe opportunities for theprofessionofpharmacyinthefuture,withparticularattentiontoopportunitiesthatencouragetheuseofexistingorexpandedscopesofpharmacypracticewithinthehealthcaresysteminwaysthatmakeadifferenceinpeople’slives.ApproachusedtodeveloptheWhitePaper:Asix-stepprocesswasusedtomeettheobjectiveofthereport. First, current health care trends, evidence and policies were considered to identify anoverarchingsetofprinciplestheprofessionofpharmacyshouldstrivetoachieve.Second,10topicsthatrepresent different aspects of pharmacy practice were examined to generate topic-specific futureopportunitystatementsfortheprofessionofpharmacy.Third,thesestatementswerecombinedacrossthetopicstogenerateanoverallsetof50futureopportunitystatementsfortheprofessionofpharmacy.Fourth, the future opportunity statementsweremapped onto the overarching set of principles theprofessionofpharmacyshouldstrivetoachieve.Fifth,deliberationonthesetof50futureopportunitystatementsgeneratedtwosummarythemesthatemergedasthekeyfuturedirectivesforpharmacyinthe coming5-10 years. Finally, an assessmentofMESPO in relation to selectedexpanded scopesofpharmacypracticewasconducted.CurrentHealthcareTrends,EvidenceandPolicies:Thewayourhealthcaresystemisorganizedisinthemidstofsignificantchange.Ontariogovernmentpoliciesandstrategiesincludingtherecent‘PatientsFirstActionPlan’andtheassociatedProposaltoStrengthenPatient-CenteredHealthCareinOntarioaredriving the patient-centered transformation of health care. These policies encourage improvedintegrationofthehealthcaresystemandenhancedpatientandcommunityengagementinhealthpolicyandpractice.Thesepolicydirectivesareinresponsetooverwhelminglyobviousgapsincare(e.g.forvulnerable populations, lack of access to primary care providers, lack of home and community careservices,inconsistentpopulationhealthplanning)coupledwithincreasingfiscalchallenges.Scopesareexpanding for several front-line health care providers, including prescribing by nurses. The policydirectivespromotestrengtheningserviceintegrationforprimarycare,homeandcommunitycare,whilesimultaneouslyprovidingmoreresponsibility toLocalHealth IntegrationNetworks (LHINs) forhealthcare resource allocation and delivery. However, it is revealing that Pharmacy as a key health careproviderisalmostinvisibleornonexistentwithinmorerecentpolicydocuments.

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TheCollegeofFamilyPhysiciansofCanada(CFPC)visionofthePatient’sMedicalHome(PMH)isanotherinfluentialdriverofchangewithinprimarycare.APMHfamilypracticewilloffermedicalcarethatisseamlessandcentredonindividualpatients’needs,withintheircommunity,throughouteverystageoflife,andintegratedwithotherhealthservices.Dependingonpatients’needs,teamsmayinvolvenurses,otherspecialists,andotherhealthcareproviders,whoworktogetherinonecentreorvirtually.ThePMHmodel places pharmacy outside of the PMH, but still part of a patient’s circle of care. The maindemonstrationofthePMHvisioninOntarioisthroughFamilyHealthTeams.Therearecurrentlyover3millionOntariansenrolledinFamilyHealthTeamsinover200communitiesacrossOntario.

Thereisincreasedemphasisonunderstandingandmonitoringhealthcarequalityinalmostallsectors.The2010ExcellentCareforAllAct(ECFAA)laidthefoundationforHealthQualityOntario(HQO)astheprovince’sadvisoronhealthcarequality. HQOmonitorsandreportsonhealthsystemperformance,providesguidanceonqualityissues,assessesevidencetodeterminewhatconstitutesoptimalcare,andengageswithpatientstogivethemavoiceinshapingaqualityhealthsystemandpromotecontinuousqualityimprovement.ThepatientsafetyagendaalignswiththemandateofHQO.Technology is rapidly changing theway health care services are provided. Many pharmacies allowpatientstoaccesstheirowndispensingrecords.Themajorityofphysiciansuseelectronicrecordsandalmost20%ofCanadianphysicianscanexchangepatientsummarieselectronicallywithotherdoctors.Aspharmaciesdeveloptheirowntechnology,theintegrationofhealthcareproviderrecordsandtheemergence of patient-controlled or viewable health records are important areas of health caretransformation.Pharmaciesarenotgenerallyconnectedtophysician-basedelectronicmedicalrecordsnordopharmacieshavetheirownclinicallyfocusedrecordssystem.Dispenseddrugeventsarenoteasilyaccessiblebeyondthescopeofindividualpharmacies;however,theOntario-basedDigitalHealthDrugRepository (DHDR)andplannednationalE-prescribingsystemwill improveaccess tomorecompletemedicationrecords.Inaddition,thee-prescribingsystemisenvisionedasaplatformformanyfunctionsbeyondmedicationmanagementsuchase-referrals,patientbookings,inter-clinicianmessaging.CurrentContextofPharmacy:Pharmacyhasagrowingevidencebasethat supportsthehealthandcostbenefitsofpharmacistactivitiesinmanysettingsincludingcommunity,primarycareteam,longtermcareandhospitalsettings.Ontariopharmacistsprovidecarethroughbroadsetofexpandedpatient-focusedclinicalactivitieswithinavarietyofhealthcaresettingsincluding:conductingcomprehensivemedicationreviews(includingdiabetesfocusedreviews),andprovidingprescribingrecommendationsincludingPharmaceuticalOpinions,advisingandadministeringvaccinesagainst14diseases,counselingandprescribingforsmokingcessation,independentlyrenewingandadaptingprescriptionsandprovidingtargetedclinicalservices(e.g.anticoagulation,antimicrobialstewardship).DatafromtheOPENresearchgroupandothersdemonstratesthatuptakeofremuneratedmedicationreviewsdoneinthecommunityand injection community pharmacy services is high. OPEN’swork has also uncovered challenges inremunerated communitypharmacy service implementation includingdeliveryof services away fromthosewithmorecomplexhealthsituationstowardsyoungerlesscomorbidindividuals.

Pharmacy isaself-regulatedhealthcareprofession. InOntario,theOntarioCollegeofPharmacists isresponsible for serving and protecting the public and to hold Ontario’s pharmacists and pharmacy

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techniciansaccountabletotheestablishedlegislation,standardsofpractice,codeofethicsandpoliciesandguidelinesrelevanttopharmacypractice.TheProfessionalStandardsAuthority(PSA)intheUKhasputforwardsixcoreprinciplesforeffectiveregulationaspartoftheRight-Touchregulationapproach.Theseprinciplesareproportionate,consistent,targeted,transparent,accountable,andagile.ThemostimportantattributesofRight-Touchregulationareidentifiedasclearlyidentifyingandframingproblems,enumeratingrealrisks,focusingonoutcomes,andusingregulationasatoolforcontrollingprofessionalpracticeonlywhen it is actuallynecessary.The recentModel forEvaluationofScopesofPractice inOntario(MESPO)setoutbytheOntarioMinistryofHealthandLongTermCareprovidesstructuretothereviewofscopeofpracticerequestsandisverywellalignedwiththeRight-touchregulationapproach.Principlestheprofessionofpharmacyshouldstrivetoachieve:Considerationofcurrenthealthcaretrends,evidenceandpoliciesgeneratedanoverarching setofprinciples theprofessionofpharmacyshould strive to achieve. Theseprinciples (safe, effective, comprehensive/complete, person-focused,accessible,inclusive/equitable,longitudinal,collaborativeandintegrated)werecombinedintoasetof50challengestatementsfortheprofessionofpharmacytoconsiderinstimulatingtransformation.

FutureDirectionsforPharmacy:Twosummarythemesoforganizationalchangeandbetterexternalrelationshipshaveemergedasthekeyfuturedirectivesforpharmacyinthecoming5-10years.ThesefuturedirectionswillhelptotransformhowpharmacytacklesthemedicationmanagementneedsofOntariansforthepurposeofimprovinghealthoutcomes.Thesedirectionsapplytopharmacistsworkinginallpracticesettings.OrganizationalChange:Pharmacyneedstoundertakesubstantialorganizationalchangewithinthepharmacy setting. Organizational change involves implementing specific policies and practices tosupportproactive,comprehensive,qualitycareforindividualpatientsineverypharmacysettingandwithinorganizationsthatsupportpharmacies.Thisincludes:

• Explicitidentificationandunderstandingofeachpatient’songoinggoals,risksandneeds• Providinganddeliveringpreventativecareforindividualpatientsorgroups• Thedeliveryofprofessionalpharmacyservices,includingroutinemonitoringandfollow-up,as

anintegralpartforaholisticandpatient-centeredcareplan• Pharmacistsandpharmacytechnicianspracticingtothefullextentoftheirscopesandworking

asateamtoprovideeffective,high-qualityclinicalcare• Optimizingphysicalpharmacylayouttosupportpatientassessmentandcommunication(with

theconsiderationthatdispensingmedicationmayormaynotbeofferedon-site)

Challengestatementfortheprofessionofpharmacy:Recent healthcare trends and policies challenge pharmacists to provide safe, effective,comprehensive/completeandperson-focusedcarethat isaccessibleand inclusive/equitableforall.Byadoptingalongitudinalandcollaborativeapproach,pharmacistscanalsoensurethattheprovisionofcareisintegratedacrossthehealthcaresystemandforallstakeholders.

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• Documentationofeveryencounterintheclinicalrecord• Theuseofelectronicpharmacyrecordstosupportcomprehensiveandlongitudinalclinicalcare• Incorporating quality improvement initiatives (including patient safety) and population-based

approachestocaredeliveryasakeycomponentofregularroutinepractice• AdedicatedfocusonvulnerablepatientgroupsincludingIndigenouspeoples,peoplewithmental

healthandaddictions,ormembersofculturalgroups(especiallynewcomers);especiallythosewithmulti-morbidityoronhighriskmedications

The achievement of organizational change transformation is notdependent on first attaining newscopes of practice. Rather, this transformation can be accomplished by leveraging existingopportunitiestoenhancehowtheprofessionofpharmacyappliesthecurrentscopeofpractice.Thereisagreatneedtoensureeachpatientcanbeservedwithoptimalscopeavailableatthistimebeforeseeking additional scope. Subsequently, further enhanced scopes, such as initiation of anyprescription, making recommendations for common ailments or widening the set of approvedinjectionsgivenbypharmacists(orpharmacytechnicians),willofferadditionalbenefitforpatientcare.Better external relationships: The profession of pharmacy needs to transformhow it connects topatients where they live and with other health care organizations. Building better externalrelationships involvesbetter connectionsbetween theprofessionofpharmacyandpatientswherethey liveandwithotherhealthcareorganizations. In this transformation,apharmacistwillhavearelationshipwiththeirpatientthatstrengthensthepharmacist’sunderstandingofthespectrumofthepatient’scare.Thisincludes:• Pharmacistsdevelopingandimplementingcareplanstogetherwithothermembersofthehealth

careteam• Pharmacistseasilysharingclinicalrecordswithotherhealthcareprovidersororganizations,ina

Patient’sMedicalHomeandwithpatientsthemselves• Patientsprovidingthepharmacistswithinformationontheirhealththroughregularelectronic

(includinghealthrecordsorAppsathome)ormanualinformationexchange• Pharmacistsaccessingclinicalinformationfromotherlocations(e.g.community,hospital,home)

includinglaboratoryanddiagnostictestresults• Pharmacists triaging or referring patients to other health and community organizations or

activitiesinadditiontohavingasysteminplacetoreceivereferralsfromotherhealthcareteammemberslocatedwithinorexternaltoanorganization

• Pharmacy team members initiating and participating in local education and health policyinitiativeswithotherhealthcareteammembers

• Pharmacist integration into interprofessional health care pathways, particularly for themanagementofchronicdiseaseandhospitaladmission/posthospitaldischargecare

• Pharmaciststakinganactiveroleinlocalhealthpolicydecisionmaking• Pharmacists from different organizations or sectors establishing collaborative approaches to

theirworkthatareinthebestinterestofthepatient(i.e.intra-professionalcollaboration)

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Apharmacyprofession thatdemonstratesachievementof internalorganizational changeandbetterexternalrelationshipswillbewellsuitedtomeetthemedicationmanagementneedsofOntariansforthepurposeofimprovinghealthoutcomes.TheModelforEvaluationofScopesofPracticeinOntarioisausefulprocesstoestablishthejustificationforexpandingthescopeofpharmacy(oranyotherhealthcareprovider)practice.Atpresent,therearenopotentialscopesofpracticethatareabletoestablishanevidence-basedjustificationinallMESPOareas(i.e.apatientneed,systemneed,patientbenefitandhealthsystembenefit).Instead,mostnewscopes(e.g.commonailments,initialprescribingauthority,accessto/ordering/interpretinglaboratorytests)consideredcanbejustifiedbasedonsomeMESPOcriteria,demonstratingthatthereiseitheraneed or a benefit to considering a specific expanded scope. TheMESPO criteria are also useful tohighlightevidencegapsthatcanbeaddressedbytheprofessioninordertogenerateevidenceinfocusedareas.Newevidencewillimproveunderstandingofhowaparticularexpandedscopecanbettermeetpatientandhealthcaresystemneedsorprovideassociatedbenefits.ThereisalsoariskthatMESPOwillbeappliedinamannerthatcreatesmorehurdlesormoreregulation.Therefore, itwillbehelpfultoconsiderhowtobalanceeffortsbetweenmaximizingexistingpharmacistscopeversusworktoexpandscopeofpractice,andonlyapplytheMESPOprocesswhentheoutcomeisexpectedtomakeamajordifferenceinthelivesofOntarians.

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Pharmacyinthe21stcentury:Enhancingtheimpactoftheprofessionofpharmacyonpeople’slivesinthecontextofhealthcaretrends,evidenceandpolicies

BACKGROUNDTheOntarioCollegeofPharmacists(OCP)Council/Boardregularlyconsiderstheevolvinglandscapeofhealthcare,socialanddemographic trendsandpractices.Thisscanningactivity informstheir roletoserveandprotectthepublicandholdOntario’spharmacistsandpharmacytechniciansaccountabletotheestablishedlegislation,standardsofpractice,codeofethicsandpoliciesandguidelinesrelevanttopharmacypractice.1TheOntarioMinistryofHealthandLongTermCarerecentlydevelopedtheModelforEvaluationofScopesofPracticeinOntario(MESPO),anevidencebasedanalyticalframeworktobeusedinreviewingallscopeofpracticerequests.ThecreationofMESPOhasstimulatedtheOCPExecutiveCommitteeandOCPseniorleadershiptoconsiderthefutureofpharmacypractice,andmorespecificallyhowthatfuturevisioncanguidetheworkofOCPinthenext5-10years.OCPapproachedtheOntarioPharmacy Evidence Network to develop thisWhite Paper based on OPEN’s recent experience withresearchandinnovativepracticeinOntariotostimulatediscussionacrosstheprofessiononthefutureofpharmacy.This White Paper briefly considers the challenges faced by the pharmacy profession, including thechangingneedsanddemandsbythepublic,healthcareservicesdeliveryandpolicyorganizationsthateffectivelyinfluencetheabilityoftheprofessionofpharmacytomoveforward.Thepracticeexamplesconsidered in the White Paper include prescribing for common ailments, deprescribing, opioidstewardship/management, eHealth andworkflows thatmaximize themeaningful use and impact oftechnology,injectionservicesandothers.TheWhitePaperprovidesviewsonwheretheprofessionisgoing,sothatOCPandotherstakeholderscanassesswheretheremayberiskstopatientprotectionoropportunitiesforfurthercontributionofpharmacytopatientandpublichealth.Differentstakeholdergroupsmayconsiderdistinctopportunitiesformovingforward.INTRODUCTIONThere has never been a greater need for individuals to access high quality expertise about theeffectiveness,safetyanduseofmedications.Whiledrugsimprovehealthandsavelives,theyarenotwithoutriskwhensub-optimallymanaged.1-4InCanada,olderadultsnowoutnumberchildrenunder15yearsofage.5Atpresent,2of3peopleover65take>5differentmedicationsand2of5peopleover85take>10medications inCanada.6Drugtherapyproblemsarecommon, largelypreventable,clinicallyharmful and present an increasing burden on/to our health care system. In Ontario, adverse drugreactionrelatedemergencyroomvisitsbyseniorscostthesystemover$13.6Mannually,basedondatafrom2003-20087.TheGovernmentofOntariospent$11.5billionondrugsin2015/16.8Inlightofthesesignificantinvestmentsandcosts,ensuringthatpharmacistsarewellequippedtomakeameaningfulimpactonpeople’shealthiscriticaltoachievingthebestvaluefortheeffort,experienceandexpenseofusingmedications.

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I. HealthcareSystem RecentgovernmenthealthcarepolicystimulatinghealthsystemchangesTheorganizationoftheOntariohealthcaresystemisinthemidstofsignificantchange.Therecentlyreleased ‘PatientsFirstActionPlan’9, theMOHLTC’s2016MandateLetter10and theassociated2016Proposal to Strengthen Patient-Centred Health Care in Ontario11 are driving the patient-centeredtransformation of health care in Ontario. This transformation focuses on encouraging improvedintegrationofthehealthcaresystemandenhancedpatientandcommunityengagementinhealthpolicyand practice through the four components of Patients First – namely, Access, Inform, Protect, andConnect.Thesepolicydirectivesareinresponsetooverwhelminglyobviousgapsincarecoupledwithincreasing fiscal challenges. As outlined in the 2017 Patients First: Proposal to Strengthen Patient-CentredHealthCareinOntario,11majorgapsinpatientcareinclude:

• SomeOntarians–particularlyIndigenouspeoples,Franco-Ontarians,membersofculturalgroups(especiallynewcomers),andpeoplewithmentalhealthandaddictionchallenges–arenotalwayswell-servedbythehealthcaresystem.

• AlthoughmostOntariansnowhaveaprimarycareprovider,manyreporthavingdifficultyseeingtheirproviderwhentheyneedto,especially inevenings,nightsorweekends–so theygo toemergencydepartmentsandwalk-inclinicsinstead.

• Somefamiliesfindhomeandcommunitycareservices inconsistentandhardtonavigate,andmanyfamilycaregiversareexperiencinghighlevelsofstress.

• Publichealthservicesaredisconnectedfromtherestofthehealthcaresystem,andpopulationhealthisnotaconsistentpartofhealthsystemplanning.

ThePatient’sFirstpolicydirectiveshavealsosupportedtheexpandedscopeofpracticeforseveralfront-line health care providers, including prescribing by nurses. In addition, the directives providemoreresponsibility to Local Health Integration Networks (LHIN) for health care resource allocation anddelivery,includingthecreationofsmallergeographicunitswithineachLHINtofosterpopulation-basedcareplanninganddelivery.Thepolicydirectivesalsoemphasize the inclusionof thepatientvoice inhealth care planning and promote better service integration between primary care and home andcommunity care. In fact, a key component of the Patients First: Action Plan for Health Care is tostrengthenhomeandcommunitycare12,13inamannerthathelpspeopleliveindependentlyathome.This direction is especially important for older Canadians with multi-morbidity and relatedpolypharmacy.Theplansaretointroducegreaterconsistency,transparencyandqualityincare,createabetterunderstandingofthehomeandcommunityservicesavailable,expandcapacityforhomeandcommunitycareservicedelivery,providemoresupportforcaregivers,andupdatefundingandhealthcaredeliverymodels(includingbundledcare).Forexample,withbundledcare,agroupofproviderswillbegivenasinglepaymenttocoverallthecareneedsofanindividualpatient.MentalhealthisadedicatedpolicyfocusinOntario.TheOntario’sComprehensiveMentalHealthandAddictionsStrategy’smissionistoreducetheburdenofmentalillnessandaddictionsbyensuringthatall Ontarians have timely access to an integrated system of excellent, coordinated and efficient

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promotion, prevention, early intervention, community support and treatment programs14. The 2016MentalHealthandPrimaryCarePolicyFrameworkpublishedbyCAMHhighlightedthatmentalhealthisintricately linked to physical health, and recommends thatmental health care (including addictions)shouldbeacorecomponentofprimarycare.Itisrevealingthattheroleofpharmacyasakeyhealthcareprofessionisalmostinvisibleornonexistentinrecentpolicydocuments.Thesegapsidentifythepotentialforpharmacystakeholders(suchastheOntario Pharmacists Association) to assume an advocacy role with respect to the development ofpharmacy practice. Delineating opportunities to allow the profession of pharmacy to contribute toqualitymedicationmanagementcouldmaximizethepotentialofOntario’s14,000pharmacists(thethirdlargesthealthcareprofessionafternursesandphysicians)15,who remainan incrediblyunderutilizedhealthresource.16Patient’sMedicalHomeThePatient’sMedicalHomeoffersanapproachtoredesigningthehealthcaresystemthat isalignedwith recenthealthsystempolicies.TheCollegeofFamilyPhysiciansofCanada (CFPC)presented thePatient’sMedicalHome(PMH)asavisionforthefutureoffamilypracticeinCanada17in2011.Inthisvision,everyfamilypracticeacrossCanadaoffersthemedicalcarethatCanadianswantinamannerthatisseamlessandcentredonindividualpatients’needs,withintheircommunity,throughouteverystageof life, and integratedwith other health services. The goal of the PMH initiative is for every familypracticeineverycommunityacrossCanadatooffercomprehensive,coordinated,andcontinuingcaretotheirpopulationsthroughafamilyphysicianworkingwithhealthcareteams.ThePMHapproachinCanadamirrorssimilarinitiativesintheUnitedStates,whichdescribesthemedicalhomeasamodelorphilosophy of primary care that is patient-centered, comprehensive, team-based, coordinated,accessible,andfocusedonqualityandsafety.18ThePMHiswherepatientscanpresentanddiscusstheirpersonalandfamilyhealthconcernsandreceiveafullspectrumofexpertcare.Dependingonpatients’needs,teamsmayinvolvenurses,otherspecialists,andotherhealthcareproviderswhoworktogetherin one centre or virtually. ThePMHvision also reinforces thephysician-patient relationship and theimportanceoftheFourPrinciplesofFamilyMedicine.ThePMHmodelplacespharmacyoutsideofbutstillcloselyconnectedtothePMHaspartofpatient’scircleofcare(Figure1).Determininghowpatientscan benefit from the expertise and services provided by pharmacists as care providers within anintegrated care system such as the PMH presents an important and exciting opportunity for thepharmacyprofession.

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Figure1:TherelationshipoftheprofessionofpharmacytothePatient’sMedicalHomewithinthehealthcaresystem

ThemostalignedexampleofthePMHvisioninOntarioisthroughFamilyHealthTeams.FamilyHealthTeams (FHTs) are primary health care organizations that include a team of family physicians, nursepractitioners,registerednurses,socialworkers,dietitians,andotherprofessionalswhoworktogethertoprovideprimaryhealthcarefortheircommunity.19Theyensurethatpeoplecaneasilyaccessandreceivethecaretheyneed,aseachFHTisset-upbasedonlocalhealthandcommunityneeds.

FamilyHealthTeamswerecreatedtoexpandaccesstocomprehensivefamilyhealthcareservicesacrossOntario. Since 2005, 184 Family Health Teams have been operationalized through five waves ofimplementation,withthelast50implementedin2011/12.Therearecurrentlyover3millionOntariansenrolledinFHTsinover200communitiesacrossOntario.Therearealsoapproximately170pharmacistsworkingassalary-paidhealthcareproviderswithinFHTsettings.PharmacistswithinFHTsprovidedirectpatientcare,managespecificmedicationissues(e.g.oralanticoagulation,insulin/diabetesmanagement,smokingcessation,asthmacare),providedruginformationandeducation,andoftenworktoimprovehealthsystemperformance.20,21

HealthCareQualityAnother important trend in health care inOntario is the increased emphasis on understanding andmonitoringhealthcarequality.TheExcellentCareforAllAct(ECFAA)waspassedinthelegislatureonJune8,2010.ECFAAwasoneofthefirstexplicitsignalsfromtheGovernmentofOntarioinsupportofpolicy and clinical decisions driven by evidence and lessons learned through everyday health caredelivery.TheECFAAlaidthefoundationforHealthQualityOntario’smandate.HealthQualityOntario22(HQO)istheprovince’sadvisoronhealthcarequalityandhasbeenentrustedto:

• Monitorandreportonhowthehealthsystemisperforming• Provideguidanceonimportantqualityissues• Assessevidencetodeterminewhatconstitutesoptimalcare• Engagewithpatientsandgivethemavoiceinshapingaqualityhealthsystem

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• Promotecontinuousqualityimprovementaimedatsubstantialandsustainablepositivechangeinhealthcare

TechnologyTechnologyisrapidlychangingthewayhealthcareservicesareprovided.Informationtechnologyinhealthcare,alsoreferredtoaseHealthtechnology,mayofferapromisingsolutiontotheprovisionofbettercareandsupportpeoplewithmultipleconditionsandcomplexcareneedsandtheircaregivers.Asofthe2014NationalPhysicianHealthSurvey,75%of physicians report using electronic records to enter or retrieve clinicalpatient notes on a laptop or desktop.23 These findings were corroborated by the May 2017Commonwealth Fund studynoting that 73%ofCanadianprimary carephysiciansuse electronicrecords24 (althoughCanada’susewasstill thesecond lowestamongthestudy’s18countries).AMay2017 report fromAlberta’sAuditorGeneral noted that 19%of Canadiandoctors canexchangepatient summarieselectronicallywithotherdoctors.25 Theemergenceof integratedhealth records,including integrationofhealth careproviderandpatient-controlledor viewablehealth records is animportantareaofhealthcaretransformation. However,pharmaciesarenotconnectedtophysician-basedelectronicmedicalrecordsnordopharmacieshavetheirownclinicallyfocusedrecordssystem.TheDigitalHealthDrugRepository(DHDR)26isunderdevelopmentasthefirstfoundationalcomponentoftheprovince’sComprehensiveDrugProfileStrategy(CDPS).TheDHDRisanelectronicrepositoryofdispenseddrugandpharmacyserviceinformationthatwillexpandonwhathasbeenavailabletodateintheDrugProfileViewer(DPV).OvertimetheplanistoexpandtheDHDRtoprovideincrementallyexpandedaccesstorecordsofdispenseddrugeventsandpharmacyservicestoauthorizedhealthcareproviders. These currently include records relating to publicly funded drugs, monitored drugs andpharmacyservicesheldbytheMinistryofHealthandLong-TermCare.Overtime,theDHDRplanstoexpand further to include pharmacy records for drugs paid for directly by patients or by privateinsurance. Future enhancements to DHDR could include the addition of prescribed drug events inelectronicmedicalrecordsystems(EMRs)andhospitalinformationsystems(HIS).Ofnote,E-prescribingisalsoapriorityforCanadaHealthInfoway(CHI).InMay2017,CHIselectedTELUSHealthtocomeupwiththetechnologyforanationalE-prescribingsystem.25Thesystemisenvisionedasaplatformforavarietyoffunctionsbeyondmedicationmanagementsuchase-referrals,patientbookings,andinter-clinicianmessaging.25InQuebec,whereanintegratedHealthInformationExchange(HIE)systemwentlivetwoyearsago,mostpharmacists(80%)andthemajorityoffamilyphysicians(66%)intheprovincehaveadoptedthesystem.Medicationdatawasthemostfrequentlyuseddomain,indicatingitsbroadvalueacrossclinicalsettings.27II. CurrentContextofthePharmacyProfession EvidenceSupportingtheValueofPharmacyPharmacy has a growing evidence base that supports the benefits of pharmacist activities inmanysettings. Clinically-oriented pharmacist activities across all practice settings including hospital,

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communityorambulatorypracticeshavealsobeengenerallyfoundtobecost-effectiveorwerefoundto have a good benefit-cost ratio.28 Pharmacists working in inpatient and ambulatory care hospitalsettingscarryoutavarietyofactivitiesinareasincludingantimicrobialuse,heartfailure,antiarrhythmicmonitoringandanticoagulationmanagementthatimprovemedicationmanagementandpatienthealthaswellasreducetheuseofhospitalsandemergencydepartments. 29-32Manyoftheseactivitiesareassociatedwithcostsavingstothehealthcaresystem.33Overall,evidencestudyingmedicationreviewsorreconciliationinthehospitalandcommunitysettingshas beenmixed.34-39 Of note, evidence from a recent study of pharmacists in hospital settingswhoprovidedamulti-componentmedicationreviewinterventionincludingstructuredfollowupfoundthatpharmacistcarereducedhospitalreadmission.40Earlyin-hospitalmedicationreviewbypharmacistshasalsobeenshowntoreducelengthofhospitalstay.41A multitude of studies has demonstrated the value of community pharmacist-based targetedinterventionsincludingthoseforcardiovascularcare,renaldisease,dyslipidemia,smokingcessationanddiabetescareinimprovingoutcomesinchronicdiseasemanagement.42-45Evidencedemonstratesthatpharmacists practicing in long term care improve medication management including, for example,anticoagulation management.46 Activities including medication review carried out by pharmacistsembeddedwithinaprimarycareteamsettinghavebeenshowntoimprovemedicationprescribingandusealongwithprovidingotherbenefitstopatients,pharmacistsandphysicians.47-49ExistingandexpandingscopesofpracticeintheprofessionofpharmacyTherehavebeennotable recent changes inhealthpolicy thatpromotepharmacists’ contribution tobetter medication management across Canada.50 In communities across Ontario, pharmacists nowprovide expanded, quality, patient-focused clinical services including: advising and administeringvaccinesagainst14diseases,counselingandprescribingforsmokingcessation,independentlyrenewingandadaptingprescriptions,conductingcomprehensivemedicationreviews(includingdiabetesfocusedreviews),andprovidingPharmaceuticalOpinions.RemuneratedPharmacyProfessionalServicesOntarioresidentsvisittheirpharmaciesfrequentlytoreceiveandgeteducationabouttheirmedications(theaveragepharmacyfills54,350prescriptionseachyear).51Theyalsoaccessasignificantnumberofpharmacist-deliveredmedicationmanagementservices.AdministrativeclaimsdataanalysesconductedbyOPENdemonstrate that about 1 in 9Ontarians received aMedsCheckAnnual (MCA)medicationreview.52Additionally,duringthefirst3.5yearsofthePharmaceuticalOpinion(PO)Program,morethan700,000POsweredeliveredwiththemajority(68%)resultinginachangedprescription.53Inthe2013-14fluseason,therewasanetincreaseof448,278influenzavaccinatedpatients(manyofwhomhadnotbeenvaccinatedpreviously)duetopharmacist-administeredvaccinations.54OPENdataalsosuggeststhat once a patient receives a professional pharmacy service, they increasingly view pharmacists as

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trusted and accessible health care providers for their medication management needs, and thecommunitypharmacyasaplacewheretheycanreceiveprimaryhealthcareservices.TheOntarioMinistryofHealthandLongTermCareallocates$150millionyearlyforthesemedicationmanagement services (OPDP, 2015) and spent $83million on these services in 2016/17.55 The newGovernmentofOntariopolicy,whichprovidesprescriptionmedicationsforfreetoeveryoneundertheageof25inOntario56(OHIP+),providesadditionalopportunitiesforpharmaciststoberemuneratedforprofessional pharmacy services because professional pharmacy services including MedsCheck,ProfessionalOpinionandthePharmacySmokingCessationProgramareremuneratedaspartofOHIP+.OPEN’s work also uncovered important challenges in remunerated professional pharmacy servicesimplementation. Many of the challenges mirror those identified in the ‘Patients First Action Plan’includingtheneedtoimproveaccesstotherightcare,deliveryofbettercoordinatedandintegratedcare inthecommunity,enhancedsupport forpeopleandpatientstomaketherightdecisionsabouttheirhealthandensuringthesustainabilityofthehealthcaresystem.

OPENanalysesofMCAservicedatauncoveredashiftinfocusofMCAdeliveryawayfromseniorswithmarkers of health complexity, towards younger less comorbid individuals over time.57, 58 Highproportions of MCA recipients were dispensed gastroprotective agents (35%), narcotics (27%), orbenzodiazepines (22%), offering opportunities for deprescribing or other strategies for optimizingmedicationuse.57Organizationallevelconsiderationsinpharmacy

Whilepharmacyispracticedindiversepublicandprivatesettings,thefor-profitcommunitypharmacysector employs a large number of pharmacists and technicians. The structure of this sector iscomplicatedby thediverse typesofownershipandmanagement structures thatexist, ranging fromfranchise systems to owner-operator models to traditional employer-employee systems. Successfulchangemanagementincommunitypharmacyishighlydependentuponthesestructuresandasaresult,highlydivergentpathways topracticeevolutionhaveemerged. Further, economic incentives in thecommunitypharmacysectorcanactasabarrierorfacilitatortopracticechange,dependingonindividualand context specific factors. As the broader health system reform continues, several key themescontinuetoemergeforthecommunitypharmacysector,inparticular:

a) The organizational complexity of the sector: Beyond the different corporate structures incommunitypharmacyitself,theprimarycaresectorwithinwhichcommunitypharmacyoperatesis also extraordinarily complicated. Patchwork funding and governance models amonggovernments, employers, private citizens, and third-party payers create tension, but alsoopportunities for innovation and professional evolution. Findingmechanisms for enhancingcommunicationandarticulationamongstthesediverse“movingparts”andleveragingreciprocalpartnershipsamongstorganizationsthataremutuallyrewardingcanbechallenging,butwillbeessentialforimprovingprofessionalpharmacypractice.

b) The need to bring pharmacies “in” to the health care system: The for-profit private sectorstructureofcommunitypharmacyhashistoricallyresultedincommunitypharmaciesstanding

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somewhatapartfromotherhealthcareorganizations,attemptingadelicatebalancebetweenbeinga“business”anda“healthcareprovider”.Astheneedforsustainableandcomprehensivemedicationmanagementgrows,thereisaneedtotightlyintegratecommunitypharmacywithinthebroaderhealthcaresystem, inordertofacilitatesharingof informationandcollaborativeactivitiesrelatedtooptimizingmedicationuseforpatients.

c) Economicpressures:thecompetitivenatureofcommunitypharmacyhasresultedinaformofcommoditizationofthedrugdispensingprocess.Asgovernmentandprivatepayerscontinuetoput downward pressure on professional fees, and as the number and range of pharmacies(particularly inurbanand suburbanareas) continues to increase, communitypharmacieswillneedtofindefficienciestosupportoperationsandcurrentlevelsofprofitability.

d) Shift to chronicdiseaseprevention,managementandhealthpromotion: As theneedsof thebroaderpopulationshiftawayfromacutetochroniccare,thetraditionaldispensingtransactionalfocusof communitypharmacy is changing. Longitudinal relationshipsbetweenpatientsandpharmacists are needed to support health promotion, disease prevention, and chronicmanagement.Yet,thephysicalstructureandworkflowsystemsofmostcommunitypharmaciesarestillorientedtowardshigh-volumetransactionaldispensingpractice.

e) A fit-for-purpose workforce: As scope of practice expands and evolving patient needs areidentified, the readiness of pharmacists and pharmacy technicians tomanage these changesbecomesan importantconsideration.Pharmacistswhoare trainedandexperienced inacaremodelfocusedonmeetingphysicianneeds(versuspatientneeds)andtechnicaldispensingwillrequiresupporttolearnandgainconfidenceinnewskillsandpractices.

f) Decouplingofprofessionalservices:Inresponsetoa-dabove,newpracticemodelsareevolvingto fundamentally shift the nature of community practice by decoupling thecompounding/dispensing/drug stewardship functionsof theprofessionofpharmacy fromthemedicationmanagement/cognitiveservicesfunctions.Emergingtrends,suchas“centralfill”andquasi-automatedcallcentrestomanagerefills,willhaveimpactsonthenumbersandtypesofpharmacists and pharmacy technicians required, and on the physical design of communitypharmacyitself.

As part of the efforts to create linkages between the various organizational levels of pharmacy atpresent, the CPhA convened 106 pharmacy leaders from across Canada for the Pharmacy ThoughtLeadershipInitiativeSummitonJune23-24,2016.ThevisionthatemergedwasthattheprofessionofpharmacyinCanadashouldenablepractice settingswherepharmacyprofessionalscanusetheirfullscopeof practiceandwheretheycanfeelsupportedandpositiveabouttheir evolvingroles.Participantsidentifiedalistoftopicsthatwouldhavethegreatestimpactonadvancingtheprofessionforwardoverthenextseveralyearsandwouldbemostfeasibletoachieve.Thetopprioritieswere:Technologyandworkplaceenvironments (18.2%), Payer/Policy issues (16.0%), and Research (11.7%), with Collaborative Care(10.8%)andConfidence(10.0%)closebehind.

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Professionalaccountabilities:regulationofprofessionsinatimeofchange

Regulatorybodiesfaceuniquepressurestoserveandprotectthepublic.The“protection”mandatehashistoricallybeeninterpretedastheapplicationofregulationstocontroltheriskofharmtothepublic.Regulationcanalsobeatoolforpracticechange.

The Professional Standards Authority (PSA) in the UK has developed the concept of “Right-TouchRegulation”asatoolfordescribingbestpracticesforregulatorybodies.SixcoreprinciplesforeffectiveregulationhavebeenidentifiedforpharmacypracticeintheUK:

a) Proportionate: regulation should be used as a tool only when necessary and should beappropriatetotherisksposed

b) Consistent:regulationsshouldbefairandequallyapplytoallc) Targeted:regulationshouldbefocusedonspecificrealproblems,andconsciouseffortsshould

beundertakentominimizeinadvertentsideeffectsofregulationd) Transparent:regulationsshouldbeclearlyarticulated,simpletounderstand,user-friendlyand

readilyaccessibletoalle) Accountable:allregulationsshouldbefullyjustified,andsubjecttoscrutinybythegeneralpublic

andtheprofessionalsbeingregulated;andf) Agile: regulation should look forward and be able to adapt to anticipated changes in the

environment,thepracticecontext,andtheprofession

Within the profession of pharmacy, there has been significant evolution in scope and role for bothpharmacistsandtechniciansover thepastdecade–and it is reasonabletoanticipatethat therewillcontinuetobechangesofscopesandrolesinthefuture.AsnotedbythePSA,whenusedasabludgeoninaheavy-handedmanner,regulationnotonlystiflespracticeinnovationandchange,italsodemoralizesand demotivates professionals themselves. Conversely, the absence of appropriately weightedregulationopensthepublic tounnecessaryriskandpotentialharm,anddiminishesthecredibilityofregulatorybodiesintheeyesofthepublictheyserve.

Forregulators,theneedforagilityisfrequentlydescribedastheabilityto“…lookforwardtoanticipatechange rather than looking back to prevent the last crisis from happening again.” It is thereforeincumbent upon regulators to anticipate risks and mitigate them, but equally to “…not react toeverythingaschangesmayoccurwhichdonotneedaregulatoryresponse”.Toolittleregulationmayproduceharmandbeineffective;toomuchregulationresultsinwastedeffort,squanderedresources,andalienatedpractitioners.Clearlyidentifyingandframingproblems,enumeratingrealrisks,focusingonoutcomes,andusingregulationasatoolforcontrollingprofessionalpracticeonlywhenitisactuallynecessaryhavebeenidentifiedasimportantattributesofright-touchregulation.TherecentModelforEvaluationofScopesofPracticeinOntario(MESPO)setoutbytheOntarioMinistryofHealthandLongTermCareprovidesstructuretothereviewofscopeofpracticerequestsandisverywellalignedwiththeRight-touchregulationapproach.

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OBJECTIVEOFTHEWHITEPAPER

APPROACHUSEDTOGENERATEFUTUREOPPORTUNITYSTATEMENTSANDSUMMARYTHEMES: A six step processwas used tomeet the objective of the report. First, current health care trends,evidence andpolicieswere considered to identify anoverarching set of principles theprofessionofpharmacyshouldstrivetoachieve.Second,10topicsthatrepresentdifferentaspectsofprofessionalpharmacy practice were examined to generate topic-specific future opportunity statements for theprofession of pharmacy. Five topics address specific pharmacy services (pharmacist prescribing,pharmacistsasimmunizers/injectors,diabetesasanexemplarforchronicdiseasemanagement,opioiddependence,andmedicationreview)and5 topicscoveroverarching topicspertinent toprofessionalpharmacypractice(qualityimprovement,eHealth,substanceusedisorders,deprescribing,andtheroleoftechnicians).Anoverviewofeachofthe10topicareasisprovided,includingthecurrentcontextandtopic-specificfutureopportunitiesthatidentifyexistingstrengthswithintheprofessionofpharmacyandhowthesestrengthscanbesupportedtobestserveandprotectthepublicwhenconsideringhealthcaretrends, evidence and policies. We intentionally chose to use these 10 topics to encourage future-orientedthinkingforthepharmacyprofessionoverthenext5-10years,whilesimultaneouslygroundingthesetopicsinthepresentcontext.Itwasfeltthatthisapproachwouldprovideinspirationforhowtheprofessionofpharmacycanevolvefromthecurrentstatetoabetterfuture.Third,thetopic-specificfuture opportunity statements for the profession of pharmacy were combined across the topics togenerateanoverallsetof50futureopportunitystatementsfortheprofessionofpharmacy.Fourth,thesetoffutureopportunitystatementswasmappedontotheoverarchingsetofprinciplestheprofessionofpharmacyshouldstrivetoachievethatwasidentifiedafterconsideringcurrenthealthcaretrends,evidenceandpolicies.Fifth,deliberationonthesetof50futureopportunitystatementsgeneratedtwosummarythemesthatemergedasthekeyfuturedirectivesfortheprofessionofpharmacyinthecoming5-10 years. Finally, an assessment ofMESPO in relation to selected expanded scopes of pharmacypracticewascarriedout.Wherepossible,MESPOcategoriesareindicatedinbracketswithinthecurrentstateandfutureopportunitiessectionsforeachofthe10topicsreviewed.

TheobjectiveofthisWhitePaperistodescribeopportunitiesfortheprofessionofpharmacyinthefuture,withparticularattentiontoopportunitiesthatencourageuseofexistingorexpandedscopesofpharmacypracticewithinthehealthcaresysteminwaysthatmakeadifferenceinpeople’slives.

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Figure2:Descriptionof thestepsusedtogeneratethe futureopportunitystatementsandsummarythemesINDIVIDUALLYREVIEWEDPHARMACYPRACTICETOPICSTOPIC1:Pharmacistprescribing(includingcommonailments)Lead:LisaMcCarthyCurrentcontext:Prescribing by health care providers other than physicians (commonly referred to as non-medicalprescribing) is becomingmore commonplace inmany jurisdictions internationally. Typically, this canemerge as independentmodels (whereprofessionals have the authority toprescribe) or dependentmodels (where the authority to prescribe is delegated by an authorized professional). In Ontario,pharmacist independent prescribing in the form of renewals (for patients with chronic and stableconditions, except for narcotics and controlled substances), adaptations (changing the dose,formulation,routeorregimen)andinitiationofScheduleImedications(i.e.,bupropionandvarenicline)forthepurposesofsmokingcessationhasbeeninplacesinceOctober2012.Canadianhealthcareisprimarilyunderprovincialjurisdictionandwhilemostprovinces(andterritories)have approved legislation that supports pharmacist prescribing, there are differences in the typeofprescribingthatpharmacistsareallowedtoperform.Allprovinces(andNorthwestTerritories)inCanadacanrenewandadaptprescriptions(i.e.,changethedose,regimen,route,orformulation)withoutpriorapproval by the initial prescriber.59-61 Pharmacists in every province except British Columbia andSaskatchewancanprescribedrugsforsmokingcessation.Jurisdictions differ in whether or not pharmacists canmake therapeutic substitutions (i.e. switch amedicationtoanalternate inthesametherapeuticclass), initiatetherapyforsmokingcessation,the

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managementofcommonailments,orinemergencies(i.e.,whenimmediatetreatmentisrequired,butanotherprescriber isnotaccessible).Therapeutic substitutionsarecurrentlyallowed inallprovincesexceptManitoba,Ontario,andQuebec.PharmacistsinAlbertawhohaveobtainedadditionalprescribingauthorization(APA)canindependentlyprescribeprescription-only (i.e. Schedule I)medications, exceptnarcotics and controlled substances.PharmacistsinNewBrunswick,NovaScotia,Saskatchewan,andManitobamayalsoinitiateprescriptionsbut only within collaborative practice settings. In BC, a Draft Framework and proposal has beendeveloped toproposepharmacistprescribingwithina collaborativepractice setting.Whileoriginallyproposedasabroaderprescriptiveauthority,BChasoptedtonarrowitsfocusforpharmacistprescribingto take place within collaborative practice settings to address specific concerns that arose throughstakeholderconsultations(i.e.,pharmacists’inabilitytodiagnose,pharmacists’lackofaccesstoclinicalinformationincertainsettings,potentialforconflictofinterests).In2007,AlbertabecamethefirstprovincetoallowpharmacistswithAPAtoprescribeforminorailments(minor,self-limitingandself-diagnosedailmentssuchasrashes,coldsoresandhayfever).Currently,pharmacistsinallprovinces(withinspecifiedlimits)exceptOntarioandBritishColumbiacanassessandprescribemedicationsforthetreatmentofspecificcommonailments(thoughmost lackaconsistentremunerationmethod).While94%ofOntariansaged16andovernowhaveaprimarycarepractitioner,timelyaccesstothoseprofessionalsremainsanissue.62Aswidelyaccessiblehealthcareproviders,pharmacistprescribersforspecificconditions(e.g.,commonailments)arewellpositionedtocontributetoimprovetimelyaccesstocare(MESPOjustification:Accesstocare).CurrentlyinOntario,nursepractitioners(NPs)canperformanumberofcontrolledactsincludingdiagnosing,administeringasubstancebyinjectionorinhalation,andprescribing(includingcontrolledsubstancesaftersuccessfulcompletionofanapprovedcontrolledsubstances education), dispensing, selling or compounding a medication. In February 2017, anamendmenttoOntario’sNursingActwasproposedtotheOntariogovernmenttoexpandthescopeofpractice of RegisteredNurses (RNs) to include independent prescribing ofmedications. Currently inOntario,pharmacistscanadaptandrenewprescriptions;however,theydonothaveaccesstolaboratoryorotherdiagnostictestresults,medicalhistory,andindicationsformedicationuse(MESPOjustification:SystemNeed,Legislation/RegulatoryChanges).Sometrendsinpharmacyandhealthcareingeneralthatmayinfluencepursuitoruptakeofpharmacistsasprescribersincludeconcernsthatexistingprofessionalpharmacypracticeisofsuboptimalquality63and barriers for two-way information sharing between community pharmacies and primary careproviders.Inarecentlycompletedseriesofqualitativeinterviewswiththepublic,pharmacists’lackofaccess to clinical information was identified as a key factor influencing the public’s support forpharmacistprescribing.64Focusgroupparticipantsalsoreportedconcernsthatthebusinessaspectsofcommunitypharmaciesposedapotential conflictof interest (i.e.,pharmacistsmaybemotivatedbydesire forprofit toprescribeamedicationwhennot in thebest interestofpatients). Theyalsohadconcernsaboutaperceivedlackoftrainingandtheskillspharmacistspossesswithrespecttoprescribing

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andaboutthecapacityofpharmaciststomanageanexpandedscopeofpractice.65TheseconcernsareconsistentwithconcernswhicharoseduringconsultationsaboutBC’scertifiedpharmacistprescribermodel.Assuch,thenewestframeworkinBCmandatesthatpharmacistswhoprescribedonotdispensethemedication. In consultations conductedbyOPENand theMcMasterHealth Forum (2015) aboutfuturemodelsofpharmacistprescribinginOntario,stakeholdersurgedproponentsofexpandedmodelstoavoidfurtherfragmentationofanalreadyfragmentedhealthsystem.66Existing data sources in Ontario make demonstrating impact on health care outcomes extremelychallenging.Evidenceontherealworldeffectofpharmacistsprescribingforsmokingcessationisnotavailable, however a randomized controlled trial of a pharmacist initiated smoking cessationinterventionthatincludedprovisionofnicotinereplacementtherapy,testedinOntario,demonstratedareductioninparticipantquitrates.67Realworldevidenceisdifficulttogeneratebecauseprescriptionclaims where pharmacists are prescribers cannot be identified through conventional administrativedatabasesavailabletoresearchersinOntario.OPENundertookaseriesoffeasibilitystudieswhereitwasidentified that the number of prescription records with pharmacist prescribers was far below thefrequency with which pharmacists estimate they prescribe (based on findings from the OntarioPharmacistPrescribingSurvey).Thatsurveyalsofoundthatmanypharmacistsarereluctanttoidentifythemselvesasprescribersintheirdispensingsoftware.At present, there is no central mechanism through which Ontario pharmacists or pharmacies arecompensatedforrenewingoradaptingprescriptions.ThisisincontrasttoAlberta,wherepharmacistsarepaid for their assessment (amountbasedonAPA status) regardlessofwhether aprescription iswrittenornot,orinSaskatchewan,wherepharmacistsarepaid$18forminorailmentsprescribing.IntheOntarioPharmacistPrescribingSurvey,pharmacistsdidnotendorsethelackofremunerationasabarrier to renewing or adapting prescriptions (McCarthy et al., unpublished data). However,remuneration models were discussed during the Ontario stakeholder summit in 2015,66 wherestakeholderscautionedtheprofessiontoreflectuponalternativestofee-for-serviceremuneration.FutureOpportunities

• Exploretheopportunityforpharmaciststoprescribeorencouragebestuseofmedicationforcommonailmentstoimproveaccessandhealthbenefitsintreatingcommonailments.

• Improvepublicawarenessofthecircumstancesinwhichpharmacistscanprescribesafelyandeffectivelyandforpharmacist-administeredvaccines.

• Improve the documentation of pharmacist prescribing activities so that this can be used toevaluatetheimpactofpharmacistprescribingonhealthoutcomesforOntariansandtofacilitateknowledgesharingamonghealthcareproviders.

• Exploreexpansionofprescribingtoincludeaspecificindependentprescriberdesignationforagreaternumber/typesofmedicationstoincreasetheopportunityforpatientstoreceiveoptimalmedicationstoimprovehealth.

• Supportdevelopmentofdocumentationguidelinesaboutwhattoprovidetootherhealthcareproviders for each pharmacy based consultation including individualized recommendationsregardingmodifications,careplan,andtransmittalviae-healthtechnologies.

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TOPIC2:Pharmacistsasimmunizers/injectorsinOntarioLead:NancyWaiteCurrentContext:Despitestrongpro-vaccineevidence,therehasbeenariseinvaccine-preventablediseaseandoutbreaksinCanadaandtheUSthataredirectlylinkedtounvaccinatedorunder-vaccinatedindividuals.68Whilemanyoftheseoutbreaksarelinkedtochildhoodvaccinationdecisions,adultvaccinesdonotfaremuchbetterwithlowuptakeandsuboptimalvaccinecoverage.69InfluenzavaccinewillbeusedinthisWhitePapersectiontodemonstratetheroleandimpactofthepharmacistasimmunizer.Dataonpharmacist’srolewithothervaccinesisavailablebutmorelimited.Ata recent international pharmacists-as-immunizers research meeting,70 many of the non-influenzavaccineswerediscussedand,whilethereislessdocumentation,itbecameclearthatprinciples,lessonslearnedandunrealizedopportunitieswerecommonacrossalladultvaccines.That isnot tosay thatsomevaccineshavespecialconsiderations–suchasthechallengesofaccessingyoungmenwhoneedHPVvaccineorencouragingpregnantwomentogetpertussisvaccine–whichwouldneedtobeworkedthroughinresearchandpractice.Influenza continues to cause significant morbidity and mortality,71-73 work absenteeism, and lostproductivityandearnings.74,75It isestimatedthatinfluenzacauses3,500deathsperyearand12,200hospitalizations in Canada,76 and 272 deaths and 621,151 incidents of health care use in Ontarioannually.73 Influenza vaccination remains the most effective mechanism to prevent influenza.77, 78(Patientneed,PatientOutcomes).In2000,OntarioinitiatedtheUniversalInfluenzaImmunizationProgram(UIIP)toprovidefreeinfluenzavaccines to anyone aged 6 months and older from physician offices, public health clinics, andworkplaces.79Whilethisstrategyhasbeeneffectiveinincreasingvaccinationratesonaverage,influenzavaccine coverage in Ontario remains suboptimal.69, 80-85 (Patient need, Population need) OntarioexpandedUIIPin2012toallowinjectioncertifiedpharmacistsincommunitypharmaciestoadministerinfluenza vaccines to Ontarians aged 5 years or older based on the rationale that the widespreadaccessibilityofcommunitypharmacieswouldincreaseinfluenzavaccinationrates(20).86US public health policy permitting pharmacists to immunize has resulted in increased influenzavaccinationratesof4.7-10.7%.Buchanetal. foundthatpatients living inaCanadianprovincewherepharmacistinfluenzavaccineadministrationwasallowedwere4%morelikelytobevaccinated.87OPEN’slargeadministrativebillingdataanalysiscombinedwithdistributed/returneddosedatafromtheOntarioGovernment Pharmacy revealed that during 2013-14 influenza season an additional 468,666vaccinationsweregivenbypharmacists.88ThemostrecentOntariodataforthe2016/2017 influenzaseasonhasoveramillioninfluenzadosesadministeredbypharmacists.89(Patientbenefit,Accesstocare)Further analysis revealed that compared to those individuals immunized by physicians, those whoreceivedtheinfluenzavaccinefrompharmacistsweremorelikelytobebetween20and64years,livein

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higher incomeareas,benon-immigrantandnotbevisitingMDoffices fordiabetesandCOPD(22).88Therefore,agroupofindividualswhoarefrequentlyworkingorassumetheroleofcaregivers,areoftenboth challenging to reach and important vectors in the infection chain. It also appears there is less“reach” by pharmacists into themost vulnerable communities such as seniors and individuals withchronicdiseases,presentinganopportunityforfurtherenhancingthisservice.(Patientneed,Populationneed)In 2013, Papastergiou et al. surveyed patients from four Toronto community pharmacy locations toexamineexperiencesandperceptionsofpharmacist-administeredvaccinations.Ninetytwopercentofrespondentswere“verysatisfied”withthisserviceand28%ofpatientsingeneraland21%ofpatientsathigh-riskforinfluenzacomplicationsreportedtheywouldnothavebeenvaccinatedifthisservicewasnotavailable.90A similar studywasconductedbyPouloseetal. (2015)whereninety-twopercentofpatientssurveyedstatedtheywouldreceivetheirnextinfluenzavaccineatacommunitypharmacyand69%wantedpharmaciststoadministerothervaccines91(PatientBenefit,Patientpreferences).OPEN’ssurveyofpatientswhowerenotvaccinatedbypharmacists foundthatapproximately30%werenotawarethatpharmacistscouldprovidethisservice.92Vaccines are one of the top ten most influential public health achievements and even today areestimated to save 2.5 million lives per year and billions of dollars in health care costs.93 A recenteconomic analysis completed by OPEN using this data examined the impact of the introduction ofpharmacistadministrationofinfluenzavaccineinOntariooninfluenza-relatedoutcomesandcostsandchangeinproductivitycosts.94ResultsshowedanetincreaseincosttotheMinistryofHealthof$6.3Mwhile the money saved due to the reduction in influenza-related outcome costs was $763,158. Inaddition,thework-relatedproductivitylossesdecreasedby$4.5Mand$3.4Mforthetimeinvestedtogetvaccinatedandtimeoffworkduetoinfluenzaillness,respectively.Thisresultedinapotentialsavingsof$2.3Mindirecthealthcarecostsandlostproductivity(Economicimpact).The justification case for pharmacists to administer influenza vaccine is incredibly strong and theoutcomeshavebeenhighlybeneficial.In2016,MinisterEricHoskinscommittedtothepublictoincreasevaccine accessibility through pharmacies and in Nov 2016 the MOHLTC Pharmacy Travel VaccineWorkingGrouprecommendedandimplementedanexpansiontothirteenvaccinestopermitpatientsto get have their travel vaccines administered by a pharmacist.95 At the same time, policy changeoccurredtoallowpharmacystudentstoadministervaccine.96BothofthesedecisionsweresupportedbyevidencegeneratedbyOPENresearchers. (HealthSystemBenefit,Legislation/Regulation).Similar,althoughlessrobustdata,isavailableforthepertussis,herpeszoster,pneumococcal,meningococcal,Tdap, hepatitis A and B, HPV, and varicella vaccines,more than 40 US States allow pharmacists toadminister these vaccines,97 as do themajority of Canadian provinces.98 The challenges with thesevaccines, and in some jurisdictions influenza vaccine, lie in thepolicy restrictions regardingwhetherpharmacists canprescribe, and/or administer innon-communitypharmacy settings (oroutside theirpublic health unit) or to a limited age range. Research done byOPEN and others suggests that theinfrastructure, training, and experience of influenza vaccination have laid a solid groundwork for

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pharmacistsastheycontinuetoadministerinfluenzavaccineandthemorerecentadditional“travel”vaccinestoOntarioresidents.Severalchallengeshavealsobeenidentified,includinghowtobestcommunicatewithotherhealthcareproviderstoensureeveryoneisawareofthevaccinesthatapatientreceivedbothbeforeandafterthepharmacistvaccinatedthepatient.OPEN’sresearchhasshownthatmostpharmacistsarereactivetoapatient’srequesttobevaccinatedandarechallengedashowtobeproactiveinassessinganindividual’svaccineneeds.Inaddition,identificationandoutreachtohighriskandvulnerablepopulationsislacking.Engaging vaccine hesitant patients in quick, productive, and positive immunization conversationsremainselusiveformanypharmacists.Finally,pharmacistsexpressedtoOPENthatthebiggestchallengetofurtheringtheirimmunizationworklies inovercomingoperational issuesat thepharmacy level that theybelieve limit theirability tobeproactive,targethigherriskandvulnerablepatientsandaddressvaccinehesitancyconcerns.Tothisend,the role of the pharmacy technician should be explored and, with proper training and pharmacistsupervision,theycouldparticipateinactivitiessuchascollectingvaccinationinformationandpossiblyadministeringvaccines,whichsomepharmacistsidentifyasa“technical”task.FutureOpportunities

• Explorehowtheinfrastructure,training,evidenceandexperienceofinfluenzavaccinationaffectsthescopeofpharmacist-administeredvaccinesandconsiderimprovements.

• Explore the role of the pharmacy technician in contributing to information gathering andscreening, the delivery of medication reviews, influenza vaccinations, opioid managementactivities,andotherspecificrolestoassistpharmacistswithtechnicaltasks.


• Supportinitiativesthatencouragepharmaciststobeabletoadministerimmunizationstopeoplewithout an OHIP card; children younger than five years of age; and outside of communitypharmacies,includingresidentsofretirementhomesorduringmedicationreviewvisitsathome.

• Improvehowpharmacistsandpharmacytechnicianspromotevaccinationincludingafocusonvaccinehesitancytoimprovetheuptakeofvaccinations.

• Support approaches that ensure medication reviews or other comprehensive care servicesinclude an assessment of health promotion/prevention needs including immunization,particularly for high risk or vulnerable populations to increase the uptake of healthpromotion/preventioninthosepopulations.

• Support activities that encourage the use of electronic pharmacy records including recordspertainingtomedicationuseandhealthinformationsuchaspatientsigns,symptoms,vaccinehistoryandpoint-ofcaretestingdata)tohelppharmacistsandpatientshavethe informationneededtobettermanagetheirmedications.


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TOPIC3:DiabetesasanexemplarforchronicdiseasemanagementLead:LoriMacCallumCurrentcontextOver860,000peoplelivinginOntariohavediabetesandthenumberisexpectedtocontinuetoincrease.Thisnumbermayactuallybemuchhigherifthenumberofpeoplewiththediseaseandwhoareunawareof thediagnosisare included99 (Patientneed,Populationneed). InOntario, theeconomicburdenwasestimatedtobe4.9billionin2010andisexpectedtoreachover6.9billionby2020.100,101ArecentCanadianstudydemonstratedthatonly13%ofdiabetespatientsfromfamilypracticesettingswerereachingall3diseasemanagementtargetsforcontrolledhemoglobinA1C,bloodpressureandlipids.102Althoughnottheonlycontributor,non-adherencetomedicationisestimatedtobeashighas60%ormore103(Patientneed,Patientoutcomes).Diabetesisoneofmanychronicnoncommunicablediseasesafflictingagrowingnumberofpeopleinthedeveloped anddevelopingworld. People, especially as they age, often havemore thanone chronicdisease.Datafromthe2011/12PublicHealthAgencyofCanada’sCanadianChronicDiseaseSurveillanceSystem(CCDSS)foundthatamongCanadiansaged40yearsandoldertheprevalenceoftwoormoreandthreeormorechronicconditionswas26.5%and10.2%.1042011datafromUSprimarycarepracticesfound that overall, 45.2% of patients had more than one chronic illness (most common washypertension).105Thereisgrowingrecognitionthatchronicdiseasemanagementismanagedbestwhena person is cared for within an integrated health care system.106 The World Health Organizationframeworkonintegrated,people-centredhealthservicesadvocatesthattherearefiveinterdependentstrategiesthatwillcumulativelyhelptobuildmoreeffectivehealthservice.107Theseare:(1)empoweringandengagingpeopleandcommunities;(2)strengtheninggovernanceandaccountability;(3)reorientingthemodel of care; (4) coordinating serviceswithin and across sectors; and (5) creating an enablingenvironment.107Theprofessionofpharmacyneedstoconsiderhowtobepartofanintegratedhealthcaresystemtomaximizetheeffectitcanhaveonimprovingpeople’shealth.Peoplewith diabetes interactwith a pharmacistmore than any other health care provider so theopportunitiestoimprovecareareabundant.108 InOntario,thereare331diabetesself-managementprogramspartlyorfullyfundedbytheMOHLTC.However,arecentstudyshowedthatonly1in5peoplewith newly diagnosed diabetes attended one of these programs within 6 months of diagnosis.109Pharmacists from all sectors are an alternative to promote self-management skills to people withdiabetes(andotherchronicdiseases).Pharmacistshavedemonstratedthat,asaprofession,thereisagreatdealof activityprovidingdiabetes careandarealso the fastest growinggroup thatbecomesCertifiedDiabetesEducators. InOntario,over400,000peoplewithdiabetes receivedaMedsCheckDiabetesmedicationreviewserviceoverthefirst3.5yearsoftheprogram.110Thisrepresentsalmost50%of the populationwith diabetes (Patient benefit, access to care). There is a growing body ofevidencethatpharmacistinterventionsimproveA1C,bloodpressure,lipidsandcardiovascularriskinpeoplewithdiabetes(Patientbenefit,Clinicaloutcomes).42-44,48,111,112Thereisalsoevidenceoftheroleofpharmacistsscreening fordiabetes in thecommunity.113 TheMOHLTC implementedMedsCheckDiabetesin2010providingreimbursementtocommunitypharmacistsforaformalmedicationreview.

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Theprogramalsoprovidesreimbursement for follow-upvisits including furtherdiabeteseducation.Otherprivatepayerdrugplansalsohaveimplementedprogramstoreimburseforhealthcoachingandchronicdiseasemanagementbypharmacists.114,115Whenpharmacistshaveaccesstomorecompletepatientinformation,theyarebetterabletoidentifypotentialdrug-relatedproblems.116PharmacistsareabletoorderandinterpretlabsinanumberofprovincesincludingAlberta,Manitoba,NovaScotiaandQuebec)andlegislationispendinginotherprovincesincludingSaskatchewan,NewBrunswickandPEI)(Systemneed,Legislative/Regulatorychanges).50AstudyfromAlbertalookingattheinfluenceofpharmacypracticeoncommunitypharmacists’ integrationofmedicationand labvalue informationfromelectronic health records showed thatpharmacies thatweremorepatient-care centeredandincluded medication management activities were more likely to embrace the change than thosefocused more on dispensing.117 To effectively use the data, time constraints, workflow, roleunderstanding,communicationwithotherhealthcareproviders,knowledge,confidenceandskillsareimportant.Ifpharmacistsdohaveaccess,forexamplearetheythenliableiftheydispenseamedicationwithoutadjustingthedosebasedonrenalfunction?Integrationoflabsandotherpatientinformationwithcurrentpharmacysoftwarewouldbehelpfultoreduceworkloadburdenforthepharmacist.Oneof theopportunities to aid in the implementationofmanyof evidence-based interventions fordiabetesandotherchronicdiseaseswithincommunitypharmacyinOntarioiswithincreasingaccesstopertinentinformationaboutthepatient,includinglaboratorydataanddiagnosis.Betteraccesstothedocumentationofothercareproviders(i.e.electronichealthrecord)wouldalsoprovidepharmacistswithaccesstotreatmentgoals,(inadditiontolabsanddiagnosis)whichiscriticalformonitoringandfollow-up to ensure patients are meeting the goals of therapy. The fundamental monitoring andassessmentforallpatientswithdiabetesincludesA1C,bloodpressure,andlipidsinadditiontotheuseofdrugsforvascularprotection,andlifestylemodification.Despitethesimilarindicatorsforallpatientswithdiabetes,treatmentgoalsareindividualizedbasedonstageofdisease,co-morbiditiesandpatientvaluesandpreferences.Thisiswhyaccesstolabsanddiagnosisalone,althoughagoodstartingpoint,isnotenoughtoensurefullintegrationwithinthehealthcaresystem.Laboratorydataisalsopertinentformonitoringtheresponsetopharmacotherapyofalmosteverychronicdisease.115Pharmacistswouldbegreatlyaidedbyaccesstocompletepatientinformationincludinglaboratorydataanddiagnosistofullyapplytheirmedicationexpertise.Pharmacistsfromallsectorsareanalternativethatcanpromoteself-managementskillstopeoplewithdiabetes(andotherchronicdiseases).PharmacistscontinuetobethefastestgrowinggroupbecomingCertifiedDiabetesEducators.Howeverthedesignationisnotspecifictopharmacypracticeanddoesnotensurecompetencyofmedicationmanagementindiabetes.Inconsideringhowapharmacistandallworkinginthepharmacysettingcandemonstratecompetencyinchronicdiseasemanagement,itmaybeusefultoconsiderwhetheradditionaltrainingorcertificationisneededthatismorespecifictopharmacy.FutureOpportunities:

• Encourage approaches that incorporate expanded scope activities into longitudinal proactivecare(versusreactivecare)suchasrecognizingwhenapatient’sgoalsortargetschangeorwhen

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medications are having exaggerated effects due to the body’s aging processes to ensure apatient’sgoals,risksandneedsareaddressedateverystageoflife.

• Developapproachesthatcanencouragepharmacistaccessto,useofandsafestewardshipofpatienthealthinformation,includinglabvalues.

• Explorethedevelopmentofapharmacyaccreditationmodelfocusedonensuringpharmacieshave processes in place to provide clinically-focused chronic disease prevention andmanagement. Thismay include processes for routine clinically focused communicationwithotherhealthcareproviders,routinetriageandreferral,routinefollowupandmonitoring,routineprovisionofself-managementeducation,clinicallyorienteddocumentationinasharableformat,regularpatientandcommunityengagement/ input intopharmacistservicesandothercriticalprocesses and activities needed. This type of model would promote internal pharmacyreorganizationandbetterexternalrelationshipswithpatientsandotherhealthcareproviders.

• Develop professional competencies and further certification pertaining to the educationalmandate of pharmacists for chronic diseases and other complex pharmacotherapy needs tobetterpreparepharmaciststodeliverahigherlevelofcarerecognizingthereisadebateonhowtobestenactpharmacistdesignationsasadvancedorspecialistpractitioners.

• Supportapproachesthatencourageintraprofessionalcollaborationforpharmacistsacrosssitessuchas communitypharmacies, familyhealth teams,orhospitals to improvecommunicationbetweenpatientsandmultiplepharmacists.

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TOPIC4:OpioidstewardshipandcaringforpatientswithchronicpainLead:FengChangCurrentContextPainisasymptomofmanydisordersandchronicpain,oftendefinedaspainthatlastslongerthanthreemonths,significantlyaffectsmultipledomainsoflife.118InCanada,chronicpainaffectsnearlyoneinfiveindividualsandresultsinanannualcostof$15billion.119,120Althoughpainisbestmanagedusing a collaborative team approach, medications such as opioids form a key component ofmanagementandcanpresentconsiderableriskofharm.Canadaiscurrentlyoneofthehighestper-capitaopioidconsumptioncountries;rankedsecondonlytotheUSinopioiduse.121A2011studythatsurveyed658primarycarephysiciansinOntariofoundthatalmostallcliniciansreportedprescribingopioidsinthethreemonthsprecedingthestudy.122Onaverage,1in550patientsprescribedopioidsforchronicpaincanpotentiallydieofopioid-relatedcausesandthe riskofdeathupsurges to1 in32amongpatientsreceiving200morphinemgequivalents(MME)perday.123In2014,morethan700peoplediedinOntarioalonefromopioid-relatedproblems,124andin2016,Canada’sapparentopioid-relatedmortalityratewas8.8per100,000population,withanestimated2458opioidoverdosedeathsacrossCanada,excludingQuebec.125Patientsdealingwithopioidusedisordercanconsumesignificantproportionsofhealthcareresourcesconsistingofemergencydepartment(ED)visits,hospitalization,medicationandoutpatientmentalhealthvisits.126-129Additional informationonopioidusedisorderandrelatedtreatment isdiscussed inTopic8.A2011surveyofprimarycarephysicians inOntarioreportedthatalthoughamajority(86%)wascomfortableandconfidentwithopioidprescribing,70%ofparticipantswereconcernedaboutopioidaddiction.122Primarycarepracticevisitswithanaverageof 10 minutes in duration are also not always able to incorporate appropriate assessment, careplanningoreducationforcomplexconditionssuchaschronicpain.122

Pharmacy is viewedasapositive,highly trustedprofession130, 131 inCanadaandpharmacists ranksecondonlytophysiciansasreliablesourcesofmedicalinformation.132Individualscommonlyseekpharmacists’assistanceintreatmentchronicpainsyndromessuchas lowerbackpainorheadachedisordersastheyarehighlyvisibleandeasilyaccessible. Inaddition,pharmacistsroutinelyprovideinformation on opioid therapy, benefits and risks, overdose identification andmanagement, andproperstorageanddisposal133(Patientbenefit,accesstocare).Pharmacistsalreadyplayanintegralrole inharmreductionprogramssuchasprovidingaccess tonaloxonekitsandparticipating in thefentanyl patch return programs.134 Other services pharmacists can provide include optimizingpatients’opioid therapy throughpainassessment,medication review,monitoring for interactions,ensuringappropriatedosingandconsultingonswitchingortaperingofopioids.135Pharmacistopioidassessment and consultation alone or as part of interprofessional approaches reduce opioidprescribingandmorbidityfromchronicopioiduse.136-142(Patientbenefit,patientoutcomes)

Various harm reduction, prevention, and treatment policies have been imposed to minimize thenegative effects associatedwith opioid use.143 These include amendments to regulations to raiseawarenessonopioidusedisorder144andtheprescriptionmonitoringprogramnetworkssuchastheNarcoticMonitoring System145 launched as a key part of the Narcotic Safety and Awareness Act

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instituted inOntario in 2011.Health Canada’sOpioidAction Plan also outlines support for bettertreatmentoptionsforpatientswithopioidusedisorderincludingaccesstomedication-assisted-treatmentsupportprogramsandimprovingaccesstonaloxone.143InOntario,newqualitystandardsforopioid prescribing for chronic pain were released in 2018.146 In 2017, the Ontario College ofPharmacists developed a comprehensive opioid strategy that targetsmultiple areas of pharmacypracticeincludingopioid-relatededucationforpharmacyprofessionals,deliveryofopioiddependencetreatment,overdoseandaddictionprevention,andstrengthenedoversightfordrugdistribution.145InAlberta,pharmacistswillberequiredtoprovidecomprehensiveassessmentandmonitoringincludingconductingareviewofElectronicHealthRecords(Netcare)anddocumentingdetailsoftheevaluationandcareplanfortheopioidprescription.Pharmacistswillalsoneedtomonitorpatientsforadverseeffectsorsignsofopioidusedisorderanddevelopa treatmentplanforthoseatriskofopioidusedisorder.144Other changes include adding opioids to Schedule I under the Controlled Drugs andSubstanceAct (CDSA),modifying theCannabisAct, andestablishing stricter regulations to controlprescribing and dispensing of fentanyl patches.143 The Canadian Pharmacists Association recentlyrecommendedpharmacistsnolongerrecommendtheuseofover-the-countercodeineproductsforacute or chronic pain, as part of their Choosing Wisely recommendation list.(https://choosingwiselycanada.org/pharmacist/ 2017) Another opportunity for collaborative careexistsastheprescribingofcontrolleddrugsandsubstancesisnowwithinthescopeofpracticefornurse practitioners in provinces includingOntario.147 A pharmacist-nurse practitioner collaborativemodel canpotentially support physicians in expanding patient access to safe and effective opioidprescribingpractices.Collaborativemodelshavebeensupportedasanintegralpartofchronicpainmanagement,howeverinpractice,barriers likeoutdatedpolicies, reimbursement issuesandworkflowdesignremain.Forexample, currently there is no effective information exchange system, prescription coordinationprogramoraprovincialprescriptiondatabase;148,149pharmacistsareunable toaccess informationsuch as medical diagnosis, lab test results or opioid dosing history outside of one pharmacy;150pharmacistsinOntarioalsodonothaveprescriptiveauthoritytoinitiateanyothertrialmedicationormodify an opioid prescription.Moreover, a successful collaborativemodel requireswillingness tocooperateandadequaterolerecognitionfromallparties.150-153Pharmacistswithmoreeducationormorepracticeexperience reportedhigher knowledgeabout themanagementof chronicpain andconfidenceinpractice.154,155However,gapsinknowledgeexistedacrosstheboardwithlessthanhalf(48%)acknowledgingfamiliaritywiththeCanadianopioidguidelinesandonly52%abletoprovidetherecommendedopioidwatchfuldose.155Whileopioidprescribing isunlikelytocease,especiallywhenmanypatientswithchronicpainfindthemeffective,howopioidsareprescribedandmonitoredwillcontinuetoreceivegreaterscrutiny.The 2017 CanadianGuidelinesforOpioidsforChronicNon-CancerPain155highlightedanumberofimportantupdatesbased on synthesized evidence. High risk populations are outlinedwhere risksassociatedwithopioidusemayoutweighpotentialbenefits,andthedosingthresholdischangedto50-90MMEperday.Opioidswitchingandtaperingarealsogivenincreasedprominenceasstrategiesforminimizingdoseescalation.Thesemajorshiftsinpractice,coupledwithincreasedpublicawarenessand greater urgency placed on the primary care system to respond, provide pharmacistswith an

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opportunity to define and take on a proactive, independent but complementary role in helpingprescribersandpatientsunderstandandapplythesebestpractices.Medication stewardship refers to a set of coordinated interventions which promote the optimalselection,dosinganddurationofmedicationtherapy.Antimicrobialstewardshipisoneexamplewherepharmacistsplayaprominentroleinensuringtheappropriateuseofantimicrobials.156SucharoleinopioidstewardshipwillbeanaturalextensionoftheprinciplesofPharmaceuticalCareandalignwellwith emerging pharmacist roles in chronic diseasemanagement andmedication deprescribing. Toensure successful implementation, opioid stewardship programs will need to 1)clearly definetheservicetoprescribersand thepublic; 2) incorporate a collaborative approach between pharmacist,prescriber,andthepatient;3)bewell-structuredwithappropriateeducationandworkflowtoolstosupportuptakeatthepharmacylevel;4)applyclear,trackableoutcomestoavoidserviceduplicationandconfusion;and5)buildinassociatedreimbursementforsustainability.SpecificCoreRolesforPharmacistsinOpioidStewardship(basedoncurrentscopeofpractice):

1) Conduct assessment and education,verifymedical andmedication history, assess for riskfactorsusingstandardizedtoolssuchastheOpioidRiskTool,determinepatient’ssuitabilityasanopioid candidate and provide education and/ or recommendations on complementarymanagementstrategiesincludingnon-pharmacotherapyandnon-opioidoptions.

2) Coachpatientonbeingapartner insafeopioiduse,providecalculationofMMEdoseandstandardizedopioideducationplanincludingexpectedefficacyanddegreeofrisk,aswellasriskmitigationstrategiesincludingtrainingfornaloxoneasappropriate.Promotesafestorageofopioidsathomeandreturningunusedopioidstoreduceunintendedaccess.

3) Scheduletargetedmonitoringofopioidresponse,adverseeffects,adherenceandaberrantbehaviors.Makerecommendationsregardingopioidswitchingandtaperingasappropriate.

4) Providetimelyidentificationofat-riskpatientsincludingaberrantbehaviors,highMMEdoseandco-prescribingwithhighriskmedicationssuchasbenzodiazepines,provideearlyreferralandrecommendopioidusedisordermanagementstrategies.

Futureopportunities:

• Develop training in specific pharmacotherapy situations such as deprescribing or opioidmanagementandexploremechanismstoconfirmtrainingiscompleted.

• Support approaches that encourage pharmacists to take on stewardship activities such asmanagement of biologics, antimicrobials, or opioids, to foster safe use of medications forindividualpatientsandgroupsofpatients.


• Explore opportunities for the expansion of the pharmacist’s scope of practice, includingopportunities ormechanisms for pharmacistswhowish to operate a non-traditional, non-product-orientedpharmacytofocusonspecificpatientcareneeds(e.gforcomplexgeriatric

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medication review or opioid assessment, initiation, dose titration, and discontinuation) tostimulatenewtypesandlevelsofcaredelivery.

• Explorethedevelopmentofanupdateddefinitionofaprescriptiontoensurevitalinformationsuchasthereasonforuse,patient’sgoalsandpatient’stargetsandrelevantlabtests(i.e.liver,renalfunction)arecommunicatedwhereappropriatetoimproveeveryone’sunderstandingofwhatbenefitsandharmsareexpectedwhenusingamedication.

• Explore opportunities for the expansion of the pharmacist’s scope of practice, includingopportunities ormechanisms for pharmacistswhowish to operate a non-traditional, non-product-orientedpharmacytofocusonspecificpatientcareneeds(e.gforcomplexgeriatricmedication review or opioid assessment, initiation, dose titration, and discontinuation) tostimulatenewtypesandlevelsofcaredelivery.

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TOPIC5:MedicationreviewLead:LisaDolovichCurrentcontextMedication use is increasing which emphasizes the importance of medication review as part ofpharmacistdeliveredmedicationtherapymanagementservices.InCanada,2of3peopleover65take>5differentmedications;2of5peopleover85take>10medications.(Patientneed,patientoutcomes) Overall,evidencestudyingmedicationreviewsorreconciliationinthehospitalandcommunitysettingshas beenmixed.34-39 Of note, evidence from a recent study of pharmacists in hospital settingswhoprovidedamulti-componentmedicationreviewinterventionincludingstructuredfollowfoundthatthecareprovidedreducedhospitalreadmission.40Earlyin-hospitalmedicationreviewhasbeenshowntoreduce length of hospital stay.41 Activities (mainly medication review) carried out by pharmacistsembeddedwithinaprimarycareteamsettinghavebeenfoundtoimprovemedicationprescribingandusealongwithprovidingotherbenefitstopatients,pharmacistsandphysicians.47,49In Ontario,medication review in the community setting is generally represented by theMedsCheckprogram(includingAnnual,Diabetes,LongTermCareandHome). MajorrevisionstotheMedsCheckAnnualandMedsCheckDiabetesprogramoccurredinOctober2016.PreviouslytheMedsCheckprogramincludedmedicationreconciliationandanadherencereview.TherevisedMedsCheckprogramexpandedthescopeofa reimbursedMedsCheckmedicationreviewto includeclinical review incorporating theidentificationofdrugtherapyproblems.157Formalevaluationoftheprevious iterationoftheOntariobasedMedsCheckAnnualandMedsCheckdiabetesreviewswereundertakenbyOPENduring2013-2017.Overthefirst6yearsoftheMedsCheckAnnualprogram,approximately1in9OntariansreceivedanMCA.52Therewasrapidandwidespreaduptakeoftheservice.1,498,440Ontarians(55%seniors,55%female)receivedanMCA.One-third(36%)had2ormoreMCAswithin6years.52(Patientbenefit,patientaccess)AcohortstudyusingarandomsampleofcommunitypharmacyclaimsforMCA-eligibleOntarioseniorsusinglinkedadministrativedatafromApril2012toMarch2013comparedtoeligibleindividualswhodidnotreceiveanMCA,andfoundthatoverall,MCArecipientswerehealthier,younger,urban-dwelling,andtakingfewermedicationsthannon-recipients. However recipientsweremore likely to have a priorMCA (OR=3.03), receive a newmedicationon the claim-date (OR=1.78),behypertensive (OR=1.18)orhavea recenthospitalization(OR=1.07) demonstrating that MCA services were reaching groups of people who likely can derivebenefit fromamedicationreview.158 (Patientbenefit,populationneed). A recentpopulation-basedcohortstudyexaminedclaimsforallMedsCheckprogramsforthe2012-13fiscalyearandfoundthat27.1%(n=799,674)ofOntarianseligibleforpublicdrugcoverage(primarilythoseoverage65)receivedaprofessionalpharmacyservice,with64%(n=511,490)ofthesereceivinganMCA.58Thestudyalsofoundthataspatientcomplexity(numberofprescriptionmedicationsinthepastyear)increased,theproportionofOntarioDrugBenefit(ODB)beneficiarieswhoreceivedaprofessionalpharmacyservice,whichincludedaMedsCheckoraPharmaceuticalOpinion,alsoincreased.58(Patientbenefit,accesstocare). Whenpatientsweresurveyed73%agreedthatMedsCheckwashelpful,82%thoughtthatthe

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durationwas“perfect”and53%feltmoreconfidentmanagingtheirmedications(Patientbenefit,patientpreference). Issues with quality of the service including documentation and interprofessionalcommunicationhavebeenidentified.ApharmacyauditofMedsCheckAnnualandMedsCheckdiabetesshowedvariabilityincompletenessofdocumentationforkeyfields.(MacKeigan,2017unpublished)AnauditofPharmaceuticalOpinionsshowedthatapproximatelyhalfofthosebilledwereineligible,manyduetomissinginformation(suchasnorecommendationactuallyprovidedwithinthedocumentation).(MacKeigan, unpublished)(System need, Legislative/Regulatory Changes). In physician qualitativeinterviews,manyhadahardtimeidentifyingwhenapharmacisthaddoneamedicationreview.Thosethat experienced receiving one had mixed experiences (Dolovich, unpublished). The 2016 revisedMedsCheckreviewaddressedsomeofthequalityandcommunicationissuesidentified.(Systemneed,Legislative/RegulatoryChanges).Futureopportunities

• Developandsupportapproachesthatfocusonmonitoringandfollowupactivitiesforpatientsafteraninitialassessmentiscompleted.Thisensurescarecanbealteredortailoredbasedonresponse to taking a medication for the first time or to any medication changes that haveoccurred.

• Develop approaches for development anddocumentationof careplans that are sharedwithotherhealthcareteammembers(andco-developedwhererelevant).

• Supportapproachesthatencouragemedicationreviewactivitiesforvulnerablepatientgroups.• Supportapproachesthatensuremedicationreviewsaredocumentedincludingreasonforuseof

amedicationandavailable topharmacists,prescribers, andhealth careproviders inorder toensurethepatient/familyandallmembersofthehealthcareteamhavecompletemedicationinformationandmedicationcareplans.

• Encourage development of eHealth technology that is integrated with health care deliverysystems.

• ImprovelinkagesbetweenpharmacistsandthePatient’sMedicalHomeaspartofanintegratedcaresystem.

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TOPIC6:Qualityimprovement/changemanagementinpharmacyLead:SherilynHoule(withLisaMcCarthy)Currentcontext:Expansioninprofessionalroleandscopeofpracticenecessitatessupportingpharmaciststochangepracticefromadispensingfocustoapatient-carefocus.Workspacesinmanycommunitypharmaciesarestilldesignedtopromotedispensingefficiency.Evenwithexpandedscopeopportunities,anumberofbarrierstopatientcareserviceshavebeenidentified,includingworkflow/timeconstraints,fearofliability, lack of financial incentive, and lack of support or collaboration from other healthprofessionals.63Onemechanismtobothassureandpromotethedeliveryofhighqualitypatientcareistoinstillacultureandpracticeofqualityassuranceandimprovementintoeverydaypractice.QualityAssurance is an effort to find and over-come problemswith quality, which includes directing theperformance and behaviours of practitioners and institutions towards more appropriate andacceptablehealthoutcomes,expendituresorboth.159QualityImprovement“isasystematicapproachtomakingchangesthatleadtobetterpatient outcomes(health),strongersystemperformance(care)and enhanced professional development. It draws on the combined and continuous efforts of allstakeholders–healthcare professionals,patients,theirfamilies,researchers,plannersandeducators–tomakebetterand sustainedimprovements.”159Thefocusofmanypharmacycollege’spracticeassessments/inspectionshasshiftedfromenforcingregulationstofacilitatinghigherqualitypractice.PharmacyregulatorsinthreeCanadianjurisdictionsmanageformalqualityimprovementprograms,withonependinginOntario.Only1(NovaScotia)ismandatory.Ontario,Saskatchewan,andNovaScotiafocusonreportingofmedicationincidents,whileQuebecprogrammeasuresandreportsonclinicalperformance.Noneprovideafinancialincentive.AnumberofprogramsexistinternationallyincludingprogramsinAustralia,160NewZealand,England161,theNetherlands,162,163Switzerland(hospitalpharmaciesonly).OCPiscurrentlydevelopingamandatorystandardizedcontinuousqualityassurance(CQA) programthatwill supportongoingcontinuousquality improvement (CQI)andput inplacea mandatoryconsistentstandard for all community pharmacies in the province.164 CQI enables practitioners to learn frommedicationincidents,andbetterunderstandwhytheyhappenand howtheycanbeprevented.Usingbothapreventativeapproachthroughproactivereviewsof workprocessestoidentifyareasofriskandretrospectivereviewsofspecificmedication incidents,pharmacyprofessionalscanidentifylearningsthatwillhelppreventincidentsand enhancepatientsafety.Therearefourelementstotheprogram:

• anonymousreportingofallmedicationincidentstoanindependent,objective third-partyorganizationforpopulationofanaggregateincidentdatabasetoidentify issuesandtrends;

• documentationofappropriatedetailsofmedicationincidentsandnearmisses;• completion of a medication safety self-assessment (MSSA) within the first year of

implementationandthenevery2-3yearstoanalyzeindividualandaggregatedatato informthedevelopmentofqualityimprovementinitiatives;and

• sharedlearningthatencouragesanopendialogueaboutmedicationincidents andsafety.

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WhenOntariocommunitypharmacistsweresurveyedpharmacistsreportedpositiveperceptionsofCQIprogramsandtheassociatedbenefitstopatientcareandsafety.However,thedominantconcernwasaperceivedblame-and-shamecultureincommunitypharmacy.165There are other efforts supporting improved quality of care that have the potential to affectpharmacistpractice inOntario.HealthQualityOntarioworkswithmultiplestakeholders to identifyqualityissuestoprioritizeacross theprovince,anddefinesspecificpriorityindicatorsthatorganizationscanusetotracktheir performanceonthesekeyissues.Organizationssuchashospitalsorprimarycarepracticesareexpectedtodevelopandsubmitaqualityimprovement plan(QIP)yearly.Librariesofalreadydevelopedquality indicatorsarepotentialsourcesforclinicalandprocess outcomesforanOntario-focused program. Green Shield Canada (GSC) has introduced its Value-Based PharmacyInitiativeinFall2017.166Thisisthefirstpayer-led programinCanadathatseekstomeasure,evaluate,and eventually rank a pharmacy’s performance against a defined set of health outcomemetrics(assessed based on an analysis of GSC claims data). In the future, GSC plans to use pharmacies’performance on these metrics to determine reimbursement. Using a monthly Patient-ImpactScorecard,pharmaciesreceivefeedbackonanumberofadherence,diseasemanagementandsafetymeasures of performance.167 The GSC initiative is adapted from a similar system of the AmericanCentersforMedicareand MedicaidServices(CMS)Five-StarQualityRatingSystemwhichrateshealthplansonmultiple measures/metrics.Manyof themetricsused in theU.S.weredevelopedby thePharmacy QualityAlliance(PQA)(http://www.pqaalliance.org/),anon-profitallianceofmorethan200memberorganizationsthatincludethemajorAmericanpharmacychains,academicinstitutions, healthplans,pharmaceuticalcompanies,andnowOPEN.EvidencefortheimpactoftheseCanadian/internationalprogramsonoutcomesismodest,however,quality improvementhasbeenrecognizedasapriorityformanycountriesinternationally.AfocusonQuality Improvementwithinhealthcare isbecominganormalcomponentofhealthcaredelivery. ActivitiesthatcontributetothecultureandapplicationofQuality Improvementwithinthepharmacy environment is consistent with Quality Improvement activities within other health caresectors.Thisincludes

• Education on quality improvement concepts and practical application including evaluationmethods.

• Useofpractice facilitationwithinthepharmacysetting-modelledafterpractice facilitation inmedicaloffices.Practicefacilitationinhealthcareisaqualityimprovementprocessthatinvolvesbringingan individualwithexpertiseinchangemanagementandasolidunderstandingofhealthcareintoa practicetoassistthegroupinadaptingtheirclinicalpracticestooptimizepatientcaredelivery throughincreasedadherencetoevidence-basedguidelines.168Practicefacilitatorsfulfill7 roles of a change agent: quality improvement expert, communicator, collaborator, systemthinker,manager,educatorandscholar,andleader.169

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• Useofregularauditandfeedback.Thisinvolvescomparinganindividual’sprofessionalpracticeorperformanceto professionalstandardsortargets,wheretheresultsofthiscomparisonarethenfedbacktothe individual.170

• Incorporating review of research evidence including pharmacy practice research that wouldidentifywhatareaswouldbenefitfromattentioninqualityimprovementactivities.

Futureopportunities:

● Exploreopportunitiesforqualityimprovementwithinpharmaciestoencouragemorecompletereporting,improvedrugsafety,andreducedrugdispensingerrorsandharmfrommedications.

● Supportapproachesthatencouragetheinclusionofpharmacytechnicianswithinqualityefforts.● Explore opportunities to incorporate quality improvement activities or programs within the

pharmacysettingincludingtheuseofqualityimprovementplanswithinpharmacy.● Improvehowevidenceisusedtoinformpracticeandpolicydecisions.

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TOPIC7:eHealthincludingworkflowsthatmaximizethemeaningfuluseoftechnologyLead:KellyGrindrodCurrentcontexteHealth is an all-encompassing term used to describe the application of information andcommunications technologies in the health sector.171 It spans administrative through to health caredelivery171 functions. Research evidencedemonstrates that computer decision support can supportpatientsbyimprovingprescribing.172-174Inparticular,eHealthtechnologiessuchaselectronicmedicalrecords,telemonitoringsystems,web-basedportalsandmobilehealth(mHealth)canenableinformationsharingbetweenproviders,clientsandtheirfamiliestoimprove integration of care across health and social care systems.175 Connected health, a term recentlyproposedbysomeacademicsandindustry,referstothedevelopment,testing,andintegrationofsmarttechnologytoolsintohealthcare.176However,forconnectedhealthtoachieveitsfullpotential,issuesmust be addressed pertaining to active engagement in use, privacy, security, quality andcommercialization, as well as the development of evidence-based guidelines.176 The success oftechnologyinenhancingcollaborationforchronicdiseasemanagementdependsuponsupportingthesocialrelationshipsandorganizationinwhichthetechnologywillbeplaced.177Decision-makersshouldtakeintoaccountandworktowardbalancingtheimpactoftechnologytogetherwiththeprofessionalandculturalcharacteristicsofhealthcareteams.177Almost10yearsago,HealthCanadareviewedfederalstatutesanddeterminedthatPartCoftheFoodandDrugsRegulationsmadeundertheFoodandDrugsAct,andregulationsmadeundertheControlledDrugs and Substances Act do not present any impediments to e-prescribing, and that electronicallygenerated and transmitted prescriptions are permissible to the extent that they achieve the sameregulatoryobjectivesaswrittenprescriptions.171InOntario,theDigitalHealthDrugRepository(DHDR)representsthefirstfoundationalcomponentoftheprovince’sComprehensiveDrugProfileStrategy(CDPS).26TheDHDRisanelectronicrepositoryofdispenseddrugandpharmacyserviceinformationthatwillexpandonwhathasbeenavailabletodateintheDrugProfileViewer(DPV).26TheDHDRwillprovideincrementallyexpandedaccesstorecordsofdispensed drug events and pharmacy services to authorized health care providers. These currentlyincluderecordsrelatingtopubliclyfundeddrugs,monitoreddrugsandpharmacyservicesheldbytheMinistryofHealthandLong-TermCare.Overtime,theDHDRwillexpandfurthertoincludepharmacyrecordsfordrugspaidfordirectlybypatientsorbyprivateinsurance.FutureenhancementstoDHDRcouldincludetheadditionofprescribeddrugeventsinelectronicmedicalrecordsystems(EMRs)andhospitalinformationsystems(HIS).ThePrescribeIt178initiativeisunderwayinCanada,withTELUSHealthasthevendor.Oneaspectofthisinnovation is that prescription information will flowmore directly between prescribers (EMRs) andpharmacies.Thepharmacymanagementsystems(PMSs)willalsobegintoincorporatefeatureswhereinthepharmacistcansendqueriesandmessagesdirectlytoaprescriberregardingaprescription.Atthe

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sametime,pharmacistsinOntarioarestartingtogetaccesstoregionalelectronichealthrecordssuchasClinicalConnectinSouthwesternOntario.Thisgivesthemaccesstodiagnosticimaging,labvaluesandhospitaldischargesummaries,amongotherpiecesofinformation.However,thesesystemsdonotyetincludedatafromthefamilyphysician’sorotherprescriber’sEMR.Of note inOntario, LoblawCompanies Limitedhas acquiredQHRCorporation.179QHR is aCanadianhealth care technology company and a leader in the electronicmedical records (EMR)marketwithAccuroEMR,providingsoftwareforhealthcareprovidersandtheirpatients.Aswemovetoadoptthee-prescribingprogram,wehaveanopportunitytochangethewayprescriptioninformationisshared.Notably,wecanlookatwhatinformationmustbesharedtoaccountforchangingscopesofpractice.InworkdoneinOntario,ithasbeenidentifiedthatpharmacistsrequirethe“reasonforprescribing”foramedicationtobeabletoproperlyassessitforappropriatenessandsafety.Similarly,prescribersneedaccesstodispensingrecordstoproperlyassessifapatients’medicationisnotworkingduetonon-adherence.Further,ithasalsobeenidentifiedthatmanyprescriberswouldalsobenefitfrom“reasonforprescribing”whenaprescriptionwasprescribedbyadifferentcliniciansuchasawalk-inclinic physician or specialist. Finally, as patients begin to get access to EHRs such as in Nova Scotia(MyHealthNS)orwillhavecontrolovertheirownsharablepersonalhealthrecord(e.g.KindredPHR),180they have a similar need to know the “reason for prescribing” when accessing or creating theirmedicationlists.IndiscussionswithTELUSHealth,theyhavepointedoutthatitisuptotheregulators(OCP,CPSO)tomake“reasonforprescribing”amandatorypieceofinformationonprescriptions.However,theyalsoacknowledgethatphysiciansorotherprescribersdonotwanttodothis.Thatsaid,thedesignsofthe“reasontoprescribe”fieldinthecurrentEMRshavelowusabilityandusefulness.Toooften,theylimitthe“reasontoprescribe”tooneoption,toanICD9/10codeortoadiagnosisinthepatient’schart.Theydonotallowformultipleindications(e.g.,duloxetineforpainanddepression)orwhenmedicationsarebeingusedindiagnosis(e.g.,levodopainParkinson’sdisease).Another consideration is thatpharmacists arewell known tobepoordocumenters.Aspharmacists’scopeexpands,theyneedtohavetheopportunitytodocumenttheirdecisionsandtocommunicateefficiently with physicians. Pharmacy management systems rarely include any support fordocumentation of conversations. High quality documentation of pharmacy activities orrecommendationsisoftenidentifiedasamajorbarrierinpractice.FutureOpportunities

• Encourage development within Electronic Medical Records of the design of a “reason toprescribe/reasonforuse”fieldonEMRformsforphysiciansandpharmacists(i.e.tolistmultipleusesforonemedication)andexplorehowtoincorporatea“reasontoprescribe/reasonforuse”fieldwithin a prescription to improve everyone’s understanding ofwhy someone is taking amedication.

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• Supportpharmacymanagementsystemvendorstodevelopdocumentationfeaturesthatalignwithworkflow,meetcurrentstandardsofpractice,andprovideacomprehensivepatientrecordtohelpimprovetheeffectivenessandefficiencyofpharmacistdeliveryofcare.

• Support opportunities to improve pharmacy health policy and practices related to use andsharingofelectronicpharmacyrecordswithotherhealthcareproviders.

• Supportapproaches thatencourage sharingofelectronicpharmacy records including recordspertainingtomedicationuseandhealthinformationsuchaspatientsigns,symptoms,andpoint-of-caretestingdata)withpatientsandotherhealthcareproviders/organizations.

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TOPIC8:SubstanceusedisordersLead:BethSprouleCurrentContextPharmacistsplayakeyroleinoptimizingpharmacotherapyinthemanagementofopioid,nicotineandalcohol usedisorders.Pharmacistsalsoplayakeyroleintheprevention,monitoring,detection andtreatment of medication use disorders that arise during the therapeutic use of pharmaceuticalproducts, for example, opioids, benzodiazepines, and medical cannabinoids. Health professionalsreportfrequently identifyingaddictiontomedicinesamongpatients, includingthosewithlong-termpain,mentalhealthproblems,sleepdisorders,andothersubstanceusedisorders,butalsoreportthatthese addictions were often not addressed.181 The prevalence rates of use of these substances isextremelyhigh, somuch so thatpharmacistscanexpecttobepresentedwithopportunitiestohelppeoplepreventormanagesubstanceusedisordersaspartofeverydaypractice.Thecurrentopioidcrisisisthemosturgentproblem.182Theincreasedprescribingofopioids,particularlyforchronicnon-cancerpainconditions,hasresultedinlargenumbersofpeopleexposedtoopioidsandassociatedharms.183Ratesofdevelopingopioidusedisorder(addiction)inpatientsusingopioidsforchronicpainhaverangedbetween5%to10%.184,185Wenowhavealargecohortpeoplewithopioidusedisorderwhomayalsohavecomplexmedicalandpsychiatriccomorbidities,andwhomayaccessopioidsfromnon-medicalsources.Therehasbeena4-foldincreaseopioid-relateddeathsinOntariointhelast25years.186Ina2009study,overhalfofthosewhohaddiedhadhadaprescriptionforopioidsinthemonthbeforedeath,andhadamedianof10prescriptionsintheyearbeforedeath.187Thereisalsoaclearrelationshipbetweenprescribeddoseandoverdosedeath.186Recently,thedeathratefromopioids has increased due to the contamination of ‘street’ drugswith very potent fentanyl-relatedsubstances.186 Thechallengesnoware toprovide rapid,wide-spreadaccess toopioidusedisordertreatment, reduce theharmsof ongoingopioiduse, andpreventmorepeople fromdeveloping anopioidusedisorder,particularlyfromtherapeuticexposures.Despitethegrowingprescriptionopioidproblemoverthelast15years,thepharmacyprofessionhasnotyetfullysteppedup,withmultiplecontributingfactors.188Opioidstewardshippracticesbypharmacistsaspreventionandharmreductionstrategies are discussed in Topic 4 in this document. Opioid agonist therapy has been available incommunitysettingssincethe1990’s,yetstillnotavailableinallpharmacies.Theprevailingsocietalandhealth care professional views around drug use and addiction produces stigma and judgmentalattitudestowardsdrugusers,whichdirectlyimpactstreatmentseekingbypeoplewhousedrugs,aswellastheavailabilityofqualitytreatmentservices.189Asachronic,relapsingdisorderwitheffectivepharmacotherapyatthecoreoftreatment,pharmacistshaveanimportantrole inthecollaborativecareofthesepatients.Additionalrolesincludeprovidingtake-homenaloxonekitsforopioidoverdosereversalandpharmacy-basedneedle/syringeexchangeprogrammesthatareeffectiveforreducingriskbehavioursamongpeoplewhoinjectdrugs.190Anongoingconcernisthatofthe77%ofCanadiansthatconsumealcohol,20%exceedtheCanadianlowriskdrinkingguidelinerecommendedlimitstoreducelong-termhealthrisks,and15%exceedtherecommended limits to reduce the risk of injury and harms.191, 192 There aremore hospitalizations

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entirelycausedbyalcoholthanforheartattacks.193Nearly3outof4ofthesehospitalizationsaredueto mental health conditions (e.g., alcohol use disorder, alcohol withdrawal), with the rest due tophysicalconditions (e.g.,alcoholic liverdisease,pancreatitis).193Unfortunately,prescribingratesarelowforsupportivepharmacotherapyinthemanagementofalcoholusedisorder(e.g.,acamprosate,naltrexone) and advocacy is required to promote their usewhere indicated. Inaddition,ithasbeenrecognizedthatpharmacistsareinanexcellentpositiontobeinvolvedindelivering an alcohol briefintervention.194Patientsandpharmacistsaresupportiveofaroleforpharmacistsinalcoholscreeningandbrief intervention (SBI)bypharmacists,195,196however there isaknowledgeandskillsgap,andstigma/lack of comfort working in this area. Limited skills and confidence among communitypharmacistsinraisingsensitivealcohol-relatedissueswithclients,suggesttheneedforspecificalcohol-relatedtrainingandsupport.197,198Fortunately,ratesofsmokinginCanadaaredecreasing,butapproximately13%ofCanadiansarecurrentsmokers,withhigherrates(18%)inyoungadults20-24years.192Halfofdailycigarettesmokershavemadeatleastonequitattemptinthepastyearandone-thirdtrytoquitontwoormoreoccasions.Most daily smokers (63%) consider quitting in the next 6months.192 Smoking continues to be theleadingcauseofprematuredeathinCanada,with29%ofallsmoking-relateddeathsrelatedtoheartdiseaseandstroke.Pharmacotherapyisanimportantcomponentoftreatmentinwhichpharmacistshave been taking an active role. Pharmacist delivery of smoking cessation services is effective inimprovingquitrates.67Analogous to opioids, therapeutic exposures to benzodiazepines andmedical cannabis can lead tomedication use disorders. Of the 10% of Canadians who had used sedatives in the past year, 3%reported non-medical use.192 Benzodiazepine-relatedmorbidity problems are common, particularlyamongolderadultsandbenzodiazepinesareidentifiedasacontributingfactorinpoisoningdeaths.199CannabisuseisincreasinginCanada,withaprevalenceofpast-yearuseof12%in2015,withusemoreprevalentamongyouthaged15to19(21%)andyoungadultsaged20to24(30%)thanamongadultsaged25orolder(10%).192Amongpast-yearcannabis users, 24% (or 831,000) reported using it formedicalpurposes.192Pharmacistshaveanimportantroletoplayinpreventingunnecessaryexposurestobenzodiazepinesormedicalcannabis,andtoassessandmonitorforthedevelopmentofproblemssuch as risky combinations, withdrawal symptoms that require management and/orbenzodiazepine/cannabisusedisorders.KeypolicyinitiativesinOntario/CanadaThere are a number of initiatives that support pharmacist involvement inmanaging substance usedisorders including thePharmacy SmokingCessationProgram reimbursed service from theOntarioMinistryofHealth,andprescribingauthorityforvareniclineandbupropionforsmokingcessation.TheOntarioNaloxoneProgramforPharmacieshasjustexpandedtoincludeintranasalformulations.HealthQuality Ontario has developed standards for the treatment of opioid use disorder. The NarcoticsMonitoring System data has been added to the Digital Health Drug Repository available in theConnectingOntario Clinical Viewer. The Federal governmenthas introduced the Access to Drugs inExceptionalCircumstances initiative in response to theopioidcrisis. In thecaseofanurgentpublichealthneed,medicationsforthetreatmentofopioidusedisorderthatarenotavailableinCanada,but

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areapproved intheUSorEuropecanbe importedforuse inCanada(e.g.,buprenorphine implant,naltrexone injectable). The Section 56 exemption requirement to prescribe methadone is beingremoved, the impact of which will require close monitoring to ensure it has increased access tomethadone treatment, as well as to detect any increases in methadone-related harms. Access toCannabis for Medical Purposes Regulations (ACMPR) and the coming legalization of cannabis willchangehowallhealthcareprovidersapproachinclusionofcannabiswithinhealthassessmentsofferingopportunitiestopromotejudicioususe.Futureopportunities

• Exploreopportunitiesformorepharmaciestobesitesfornaloxonedistributionandexpandingthescopeofpharmacistprescribingforopioidagonistmaintenancetherapy,particularlyincertaincircumstances(i.e.Improvingrapidaccess);simultaneouslysupportpoliciesapproachestoexpandopioidagonistmaintenancetreatment.

• Support approaches that encourage pharmacists to take on stewardship activities such asmanagement of biologics, antimicrobials, or opioids, to foster safe use of medications forindividualpatientsandgroupsofpatients.

• Supportapproachesthatencouragepharmaciststoconductalcoholscreening,deliverbriefinterventionsandprovideexpertiseonalcoholusedisorderpharmacotherapysuchasrecommendingusewhereindicatedandmonitoringoutcomestoreduceharmfromalcohol.

• Improveandexpandthereachofsmokingcessationservices.• Supportapproachesthataddresshowpharmacistscanconsidertheeffectofmedicalcannabis

productswithinmedicationmanagementactivities.• Supportapproachesthatencouragepharmaciststoincreasetheirfocusonoptimal

managementofhighriskmedications(e.g.deprescribingopioids,antipsychotics,benzodiazepines)bytakeresponsibilityinmonitoring,referring,managing,taperingregimensincludingprescribing(adapting)toincreasethebenefitandreduceharmsfromthesemedications.

• Supportapproachestoencouragepharmacists toconductsubstanceusescreening includingalcohol,illicitdrugs,cannabis,screening,deliverbriefinterventionsandprovideexpertiseonsubstance use including alcohol use disorder pharmacotherapy such as recommending usewhereindicatedandmonitoringoutcomes.

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TOPIC9:DeprescribingLead:BarbFarrellCurrentcontextDeinvesting’ in screening and diagnosis is gainingmomentum globally (e.g., programs like ChoosingWisely).200, 201Many are also looking forways to reduce unnecessary treatments, as is evident in agrowing international emphasis on deprescribing (i.e., reducing or stoppingmedications no longerneeded or causingmore harm than benefit – particularly for the elderly).202-206 Deprescribing is theplannedprocessofreducingorstoppingdrugsnolongerofbenefitorwhichmaybecausingmoreharmthanbenefit.Deprescribing is a particularly promising approach tomitigate the growingproblemofpolypharmacy in the elderly, where adverse effects and drug interactions often lead to morbidity,hospitalizationandevendeath.7,207-212OlderCanadiansareconsumingmoreandmoremedicationsthatcancauseharm.Olderadultsareatrisk of medication adverse effects (memory loss, confusion, dizziness, balance problems, falls andfractures) that contribute to emergency room visits, motor vehicle accidents, hospitalization anddeath.“Potentiallyinappropriatemedications”arethoseconsideredriskyforolderadults.InCanada,2of3peopleover65take>5differentmedications;2of5peopleover85take>10medications.And,nearly 50% of adults over 85 take potentially inappropriatemedications. The number of seniors inOntarioaged65andoverisprojectedtoalmostdoublefromabout2.3million(16.4%ofthepopulationin2016)toover4.6million(25%ofthepopulation)by2041.In2013Canadiansspent$419milliononpotentiallyinappropriatemedicationsforseniorsandanestimated$1.4billiononhealthcarecoststotreat related adverse effects. Based on the total costs reported for Canada as awhole, it could beestimatedthatthecoststoOntarioamounttoashighas$167millionforthedirectcostsofpotentiallyinappropriatemedicationsandupto$560millionfortotalonwardhealth-relatedconsequences.Weoftendonothaveaccurateinformationabouthoweffectivedrugsareaspeopleage.Medicationsaddedaspartofahospitalization,orbyaspecialist,mayconflictwithothermedicationsapersonistakingandleadtoseriousadverseeffects.Familyphysiciansandpharmacistsareoftennotinformedbyspecialistsor each other about the reasons for medications and therefore find it difficult to know when amedicationshouldbecontinued,reducedorstopped,orhowtodososafely.Through research fundedby theGovernmentofOntario,wedevelopedand implemented3priorityevidence-baseddeprescribingguidelines(forprotonpumpinhibitors,benzodiazepinereceptoragonistsandantipsychotics)astoolsforhealthcareproviders.213-216Themostsuccessfulimplementationeffortswerethoseledbypharmacistsconductingmedicationreviewsaspartofinterprofessionalteams.Oneofourpracticesitesconductedadrugutilizationreviewandconfirmedanapproximate20%reductionin PPI use following deprescribing guideline implementation.217 An increase in self-efficacy fordeprescribing was observed among health care professionals in sites where the guidelines wereconsistentlyused.218Afourthdeprescribingguideline(forantihyperglycemics)hasbeenfundedbytheCanadian Institutes of Health Research. Our finding that pharmacists were integral to theimplementationofdeprescribingguidelines isconsistentwithotherpublishedstudiesonmedicationmanagement approaches to polypharmacy. Several trials have demonstrated the positive impact of

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pharmacist-conductedmedicationreviewsonreductioninmedicationuseandimprovementofhealthoutcomesofolderpatients.219-223While 70-90% of patients are willing to stop a medication if their prescriber advises it, theseconversationsarechallengingduetolackofguidelinesandprocesses,briefpatient/doctorencounters,andlackofclarityaboutoptimaldeprescribingguidelineimplementation.224,225Lowpublicawarenessofthe issue further compounds the challenges of deprescribing.226, 227 In addition, non-pharmacologicalternativestodrugs(suchasphysiotherapyforpainrelieforcognitivebehavioraltherapytoimprovesleeppatterns, or simple sleephygienemeasures) areoftenpreferable todrug therapybut arenotalwaysaccessibleduetocostorawareness.

Initiated in January 2015, the Canadian Deprescribing Network (CaDeN) has established a nationalframework aimed at reducing the use of potentially inappropriatemedicines. Founded by Drs. CaraTannenbaumandBarbaraFarrellandothers,CaDeNbeganasagroupofpatients,healthcareproviders,andpolicyleadersinhealthcareworkingcollaborativelytomakeprogresstowardachievingthatgoal.This diverse group developed a comprehensive approach to promoting action on potentiallyinappropriatemedicines,focusedonthepracticeof“deprescribing”.Pharmacists practicing in the community are ideally positioned to become champions fordeprescribing,andmanyhaveindicatedthattheyarewillingtotakeonthisrole.Whenempoweredbytraining,communicationtoolsandimplementationstrategiesbasedondeprescribingguidelines,theywill be equipped to successfully partner with patients and health care professionals to facilitatedeprescribing,resultinginimprovedpatientoutcomes.

Futureopportunities

• Support approaches that encourage a focus on those with multi-morbidity or complexpolypharmacy.Forexample,thefrailelderlywhohaveanincreasedneedformanagingcomplexmedication regimens, including facilitatingdecision-making regardingwhento lowerdosesorstopmedicationsthatmaybecausingmoreharmthanbenefit.

• Supporttheinclusionofdeprescribingconceptsandcontentintoqualityimprovementactivitiestoimprovethecultureandapplicationofdeprescribinginpractice.

• Develop training in specific pharmacotherapy situations such as deprescribing or opioidmanagementandexploremechanismstoconfirmtrainingiscompleted.

• Explore approaches to incorporate deprescribing activities within everyday professionalpharmacy practice to identify ways for prescriptions to be adapted to taper or stop at riskmedicationswhereharmclearlyoutweighsbenefit.

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TOPIC10:IntegrationofpharmacytechniciansintocommunitypharmacypracticeLead:ZubinAustin

CurrentcontextPharmacy regulatory authorities (PRAs) in diverse jurisdictions have created the role of pharmacytechnician(RPT),asawayofoptimizingandrationalizingrolesandresponsibilitieswithinpharmacytomanageworkloadandtimerequiredfordirectpatientcareactivities.228,229ItwasanticipatedthatRPTswould relieve pharmacists of technical tasks to facilitate greater time and focus on therapeutic andcognitiveaspectsofmedicationmanagementservices.230

Aroundtheworld,largenumbersofRPTsnowexist,yetthereisscantliteraturehighlightingwhetherthe initial expectations of their role has actually been fulfilled, andwhat barriers and facilitators tooptimizingRPTs’roles(particularlyincommunitypractice)exist.230-232Instead,afterregulatorychangehasoccurred,ithasbeenleftsubstantiallytoemployersandmanagerstoworkoutintegrationdetailsatthelocal/storelevel.233,234

InOntario,therewere4145pharmacytechniciansemployedasofSeptember2016;92%werefemaleand87%workedinasinglepharmacy.Mosttechnicianshadbeenregisteredintheprevioustwoyears.ThescopeofpracticeforRPTsincludesacceptingoftelephoneordersforverbalprescriptions(withtheexception of narcotics, controlled drugs, benzodiazepines, and targeted substances), providingprescription transfers, and checking of prescriptions for dispensing accuracy (e.g. correct patient,prescriber,dosageform,routeofadministrationanddirectionsforuse).235

Ontariobasedresearchconductedin2017identifiedseveralkeythemesthatcouldprovideinsightsintohowbesttoleveragetheroleoftheRPT.236

a. PhysicalLayout/EnvironmentThephysicalenvironment/layoutofthepharmacywasidentifiedbyallparticipantsasacrucialpredictorof successful integration. Physical layout was a particular concern: several studies had previouslyidentifiedthephysicallayoutofcommunitypharmaciesasbeingapotentialbarriertodeliveryofdirectpatientcareservices,butnonehadfocusedonRPTsinparticular(Jonesetal;Beneyetal).1,3,229,230Oneimportantdesignfeaturehighlightedbymanyparticipantsinvolvedadedicated/designatedworkstationforRPTsthatprovidedsomemeasureofprivacyorinsulationfromdistraction/disruption.

b. ManagementpracticestoenhanceinterpersonalcommunicationWiththeintroductionofRPTs,anentirelynewteamdynamichasbeenevolvingincommunitypharmacypractice, particularly due to potential overlapping/redundant functions shared by both RPTs andpharmacists.Arecentstudysuggestedthatthismayproduceconflictwithinthepharmacyteambasedonroleambiguityandadesirefor“turfprotection”(Gregoryetal).10,237

ParticipantsinthisstudyhighlightedtheimportanceofeffectivemanagementpracticeswithinthetheprofessionofpharmacytosupportintegrationofRPTs.Akeyaspectofthisinvolvedclearroledefinitionsforpharmacists,RPTs,andassistants,andclearboundariesaroundwho-does-what.Someparticipantsinthisstudyreportedsomefrustrationwiththelackoftrustdisplayedbysomepharmacistsastotheircompetencies,particularlysincethereissufficientevidencetoconfirmthataccuracyratesoftechniciansincheckingprescriptionsisatleastsimilar(ifnotsuperior)topharmacists.

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c. DelegationofcognitivetasksutilizingRPT’sknowledgeandskillsParticipants inthisstudy–particularlypharmacists–notedthatthereare importanttasksthatRPTscouldpotentially take responsibility for thatarenotcurrentlypartof their scopeofpractice. Theseparticipants noted that the knowledge and skills required to successfully complete RPT registrationrequirementstranslateintootherareasbeyondprescriptionchecking.SomespecificadditionalareasforexpansionofRPTscopeofpracticediscussedbyparticipantsincluded:

a) Adherencescreeningprograms:Theprocessofidentifyingpatientsathighriskforadherenceissues is both important and time consuming. It is also somewhat proceduralized, involvingasking patients questions regarding their real-world experience of taking medications andcarefully documenting responses. Both pharmacists and technicians indicated that a moreformalizedadherencescreeningprogramincommunitypharmacy,builtupontheworkofRPTscouldbeasignificantvaluetopatientsandpharmacistsifitweretobecomeamorecommonpartofpractice.Pharmacistsinparticularnotedthattheyknowtheyshouldbemorediligentinadherence screening activities but currently experience time pressures that make thischallenging.

b) Medicationreviews: Thebestpossiblemedicationhistory(BPMH)isthefoundationformanyimportantpharmacyservices,includingMedsCheck,medicationsynchronization,andseamlesscare/transitionsofcareactivitiesbetweenhospitalandhome.RPTsmaybeinastrongpositiontosupporttheworkofpharmacistsbytakinggreaterresponsibilityforBPMHandmedicationreview lists, leavingthepharmacists toundertaketheactualassessmentandproblemsolvingactivitiesassociatedwiththeseroles.

c) Trainingondevices:Increasingly,devicessuchasglucometers,peakflowmeters,spirometers,andovulationdetectionkitsareimportantincommunitypharmacypractice.Currentlyeducationonuseof thesedevices is leftmainly topharmacists, though theremaybeopportunities forexpandedrolesforRPTsintheseareas.

d) Releasing refills before therapeutic double-check by pharmacist: The timing of release ofprescriptionscheckedbyRPTswashighlightedasanareaofpotentialfutureinterest.Theuniquerole of the pharmacist in ensuring therapeutic appropriateness of all medications used bypatientsiswellestablished;on-goingmonitoringofdrugtherapyisintegraltothecareprovidedbypharmacists.Ensuring,forexample,thatpatientsarenotexperiencing(orareappropriatelymanaging)sideeffectsofmedicationsrequiresapharmacotherapeuticknowledgebaseandskillsetthatisalignedwiththeeducationandtrainingofpharmacists.Pharmacistshaveauniqueopportunityduringtherefillprocesstoengageinconversationwithpatientsaroundtherapeuticresponse, management of side effects, potential drug interactions and other topics ofimportance. While a completely independent technician-run refill pathwaymay have someimmediateappealintermsofoperationalefficiency,itmustbebalancedagainstthepotentiallossassociatedwiththeon-goingmonitoringandfollow-uprolesthatareanessentialpartofthepatientcareprocessandthatareuniquelyassociatedwithpharmacists’scopeofpractice.

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Futureopportunities• Exploreopportunitiestoimprovethephysicallayoutofthepharmacytosupportthepharmacy

technician’s role in medication management activities, such as the space and workflowrequirements.

• Support activities that promote teamwork between pharmacists and technicians within thepharmacy.

• Explore how the role of pharmacy technicians can be enhanced to support medicationmanagementandhealthpromotionactivities suchas identifyingandapproachingpatients tointeractwiththepharmacistusingstandardizedprotocols,ensuringstandardizeddatacollection,preparing clinical documents, conducting portions of medication reconciliations and othertrainingactivities.

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PRINCIPLESTHATTHEPROFESSIONOFPHARMACYSHOULDSTRIVETOACHIEVEA setofprinciples that theprofessionofpharmacyshould strive toachievewas identifiedbasedonrecent demographics, health care and policy trends, namely: person-focused, effective, safe,comprehensive/complete,longitudinal,collaborative,inclusive/equitable,accessibleandintegratedcare.Theseprinciplesactasaguidetotheprovisionofcaredeliveredbytheprofessionofpharmacytoovercomethe‘challenge’totheprofessionofpharmacythatwasgeneratedearlierbasedoncurrenthealthcaretrends,evidenceandpolicies.Theseprinciplesareessentialastheyhaveasignificantimpactwithrespecttopatientsbeingservedthroughsaferandmoreeffectivecare.Theseprinciplesapplytopharmacistsworkinginallpracticesettings.

50FUTUREOPPORTUNITIESTHATSUPPORTPRINCIPLESTHEPROFESSIONOFPHARMACYSHOULDSTRIVETOACHIEVE Considerationofthe10topicsdescribedpreviouslyhasgeneratedasetof50futureopportunitystatementsthathavebeenmappedontoanoverarchingsetofprinciplestheprofessionofpharmacyshouldstrivetoachieve.Theseprincipleswereidentifiedbyreflectingoncurrenthealthcaretrends,evidenceandpolicies.The50futureopportunitystatementsareprovidedbelow.Thesefutureopportunitystatementscanbeconsideredbypharmacistsworkinginallpracticesettings. Person-focused

• Explore approaches that emphasize pharmacist understanding of an individual patient’sexperiencewithmedicationincludingpositiveandnegativeeffectsinordertohelppharmacistswork with patients to weigh risks and benefits and identify steps to increase benefit whileminimizingrisk.

• Support approaches that encourage a focus on those with multi-morbidity or complexpolypharmacy. For example, the frail elderly with an increased need for managing complexmedication regimens, including facilitatingdecision-making regardingwhento lowerdosesorstopmedicationsthatmaybecausingmoreharmthanbenefit.

• Support activities that encourage the use of electronic pharmacy records including recordspertainingtomedicationuseandhealthinformationsuchaspatientsigns,symptoms,vaccinehistory andpoint-of-care testingdata tohelppharmacists andpatientshave the informationneededtobettermanagetheirmedications.

• Improvehowpharmacistsandpharmacytechnicianspromotevaccinationincludingafocusonvaccinehesitancytoimprovetheuptakeofvaccinations.

Challengestatementfortheprofessionofpharmacy:Recent healthcare trends and policies challenge pharmacists to provide safe, effective,comprehensive/completeandperson-focusedcarethat isaccessibleand inclusive/equitableforall.Byadoptingalongitudinalandcollaborativeapproach,pharmacistscanalsoensurethattheprovisionofcareisintegratedacrossthehealthcaresystemandforallstakeholders.

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• Improvetheprovisionofholisticcarebylinkingclinicalencounters,services,andactivitiesforeachindividualpatient(i.e.apreventativehealthgroupofactivities)sothatcareisorganized,proactive,plannedandfollowedupinamannerthatisunderstoodbythepatient,canbebettertailoredtopatientneedsandcanpreventorminimizedrugtherapyproblems.

Effective

• Improvehowevidenceisusedtoinformpracticeandpolicydecisions.• Explore opportunities to incorporate quality improvement activities or programs within the

pharmacysettingincludingtheuseofqualityimprovementplanswithinpharmacy.• Improve the documentation of pharmacist prescribing activities so that this can be used to

evaluatetheimpactofpharmacistprescribingonhealthoutcomesforOntariansandtofacilitateknowledgesharingamonghealthcareproviders.

• Explore opportunities for the enhancement of the pharmacist’s scope of practice, includingopportunities or mechanisms for pharmacists who wish to operate a non-traditional, non-product-orientedpharmacy to focusonspecificpatientcareneeds (e.g. forcomplexgeriatricmedication review or opioid assessment, initiation, dose titration, and discontinuation) tostimulatenewtypesandlevelsofcaredelivery.

• Develop professional competencies and further certification pertaining to the educationalmandate of pharmacists for chronic diseases and other complex pharmacotherapy needs tobetterpreparepharmaciststodeliverahigherlevelofcare,recognizingthatthereisadebateonhowtobestenactpharmacistdesignationsasadvancedorspecialistpractitioners.

Safe• Explorethedevelopmentforanupdateddefinitionofaprescriptiontoensurevitalinformation

suchasthereasonforuse,patient’sgoalsandpatient’stargetsandrelevantlabtests(i.e.liver,renalfunction)arecommunicatedwhereappropriatetoimproveeveryone’sunderstandingofwhatbenefitsandharmsareexpectedwhenusingamedication.

• Developapproachesthatcanencouragepharmacistaccessto,useofandsafestewardshipofpatienthealthinformation,includinglabvalues.

• Develop training in specific pharmacotherapy situations, such as deprescribing or opioidmanagement,andexploremechanismstoconfirmtrainingiscompleted.

• Exploreopportunitiesforqualityimprovementwithinpharmaciestoencouragemorecompletereporting,improvedrugsafety,andreducedrugdispensingerrorsandharmfrommedication.s

• Encourage development within Electronic Medical Records of the design of a “reason toprescribe/reasonforuse”fieldonEMRformsforphysiciansandpharmacists(i.e.tolistmultipleusesforonemedication)andexplorehowtoincorporatea“reasontoprescribe/reasonforuse”fieldwithin a prescription to improve everyone’s understanding ofwhy someone is taking amedication.

• Support approaches that encourage pharmacists to take on stewardship activities, such asmanagement of biologics, antimicrobials, or opioids, to foster safe use of medications forindividualpatientsandgroupsofpatients.

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• Support approaches that encourage pharmacists to conduct alcohol screening, deliver briefinterventions and provide expertise on alcohol use disorder pharmacotherapy, such asrecommendingusewhereindicatedandmonitoringoutcomestoreduceharmfromalcohol.

• Supportapproachesthataddresshowpharmacistscanconsidertheeffectofmedicalcannabisproductswithinmedicationmanagementactivities.

• Supporttheinclusionofdeprescribingconceptsandcontentintoqualityimprovementactivitiestoimprovethecultureandapplicationofdeprescribinginpractice.

Comprehensive/Complete

• Exploretheopportunityforpharmaciststoprescribeorencouragebestuseofmedicationforcommonailmentstoimproveaccessandhealthbenefitsintreatingcommonailments.

• Exploreexpansionofprescribingtoincludeaspecificindependentprescriberdesignationforagreaternumber/typesofmedicationstoincreasetheopportunityforpatientstoreceiveoptimalmedicationstoimprovehealth.

• Explorethedevelopmentofapharmacyaccreditationmodelfocusedonensuringpharmacieshave processes in place to provide clinically-focused chronic disease prevention andmanagement. Thismay include processes for routine clinically focused communicationwithotherhealthcareproviders,routinetriageandreferral,routinefollowupandmonitoring,routineprovisionofself-managementeducation,clinicallyorienteddocumentationinasharableformat,regular patient and community engagement/input into pharmacist services andother criticalprocesses and activities needed. This type of model would promote internal pharmacyreorganizationandbetterexternalrelationshipswithpatientsandotherhealthcareproviders.

• Explore how the infrastructure, training, evidence and experience of influenza vaccinationinfluencedtheabilityofpharmaciststoadministerothervaccinesandconsiderimprovements.

• Support approaches that ensure medication reviews or other comprehensive care servicesinclude an assessment of health promotion/prevention needs, including immunizationparticularly for high risk or vulnerable populations to increase the uptake of healthpromotion/preventioninthosepopulations.

• Supportpharmacymanagementsystemvendorstodevelopdocumentationfeaturesthatalignwithworkflow,meetcurrentstandardsofpractice,andprovideacomprehensivepatientrecordtohelpimprovetheeffectivenessandefficiencyofpharmacistdeliveryofcare.

• Explore how the role of pharmacy technicians can be enhanced to support medicationmanagementandhealthpromotionactivities suchas identifyingandapproachingpatients tointeractwiththepharmacistusingstandardizedprotocols,ensuringstandardizeddatacollection,preparing clinical documents, conducting portions of medication reconciliations and othertrainingactivities.

• Supportapproachesthatencouragepharmaciststoincreasetheirfocusonoptimalmanagementof high riskmedications (e.g. deprescribing opioids, antipsychotics, benzodiazepines) by takeresponsibility in monitoring, referring, managing, tapering regimens including prescribing(adapting)toincreasethebenefitandreduceharmsfromthesemedications.

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Longitudinal• Encourage approaches that incorporate expanded scope activities into longitudinal proactive

care(versusreactivecare),suchasrecognizingwhenapatient’sgoalsortargetschangeorwhenmedications are having exaggerated effects due to the body’s aging processes, to ensure apatient’sgoals,risksandneedsareaddressedateverystageoflife.

• Developandsupportapproachesthatfocusonmonitoringandfollowupactivitiesforpatientsafter an initial assessment is completed to ensure care can be altered or tailored based onresponse to taking a medication for the first time or to any medication changes that haveoccurred.

• Supportapproachesthatensuremedicationreviewsaredocumentedincludingreasonforuseofamedicationandavailable topharmacists,prescribers, andhealth careproviders inorder toensurethepatient/familyandallmembersofthehealthcareteamhavecompletemedicationinformationandmedicationcareplans.

Collaborative

• Develop approaches for development anddocumentationof careplans that are sharedwithotherhealthcareteammembers(andco-developedwhererelevant).

• Support opportunities to improve pharmacy health policy and practices related to use andsharingofelectronicpharmacyrecordswithotherhealthcareproviders.


• Encourage development of eHealth technology that is integrated with health care deliverysystems.

• Supportapproachesthatencourageintraprofessionalcollaborationforpharmacistsacrosssitessuchas communitypharmacies, familyhealth teams,orhospitals to improvecommunicationbetweenpatientsandmultiplepharmacists.

Inclusive/Equitable

• Supportinitiativesthatencouragepharmaciststobeabletoadministerimmunizationstopeoplewithout an OHIP card; children younger than five years of age; and outside of communitypharmacies,includingresidentsofretirementhomesorduringmedicationreviewvisitsathome.

• Supportapproachesthatencouragemedicationreviewactivitiesforvulnerablepatientgroups.• Supportapproachesthatencouragetheinclusionofpharmacytechnicianswithinqualityefforts.• Support approaches to encourage pharmacists to conduct substance use screening including

alcohol,illicitdrugs,cannabis,anddeliverbriefinterventionsandprovideexpertiseonsubstanceuse,includingalcoholusedisorderpharmacotherapysuchasrecommendingusewhereindicatedandmonitoringoutcomes.

Accessible


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• Improveandexpandthereachofsmokingcessationservices.• Exploreopportunitiesformorepharmaciestobesitesfornaloxonedistributionandexpanding

the scope of pharmacist prescribing for opioid agonist maintenance therapy, particularly incertain circumstances (i.e. Improving rapid access); simultaneously support policies andapproachestoexpandopioidagonistmaintenancetreatment.

• Exploreapproachestoincorporatedeprescribingactivitieswithineverydaypharmacypracticetoidentifywaysforprescriptionstobeadaptedtotaperorstopatriskmedicationswhereharmclearlyoutweighsbenefit.

• Exploreopportunitiestoimprovethephysicallayoutofthepharmacytosupportthepharmacytechnician’s role in medication management activities, such as the space and workflowrequirements.

Integrated

• Supportapproaches thatencourage sharingofelectronicpharmacy records including recordspertainingtomedicationuseandhealthinformationsuchaspatientsigns,symptoms,andpoint-of-caretestingdatawithpatientsandotherhealthcareproviders/organizations.

• ImprovelinkagesbetweenpharmacistsandthePatient’sMedicalHomeaspartofanintegratedcaresystem.

• Explorethedevelopmentofapharmacyaccreditationmodelfocusedonensuringpharmacieshave processes in place to provide clinically-focused chronic disease prevention andmanagement. This may include processes for routine clinically focused communication withotherhealthcareproviders,routinetriageandreferral,routinefollowupandmonitoring,routineprovisionofself-managementeducation,clinicallyorienteddocumentationinasharableformat,regularpatientandcommunityengagement/ input intopharmacistservicesandothercriticalprocesses and activities needed. This type of model would promote internal pharmacyreorganizationandbetterexternalrelationshipswithpatientsandotherhealthcareproviders.(note: also listed in comprehensive/complete section above; it is repeated because it is animportantopportunitytoconsiderandisrelatedtobothprinciples).


• Supportapproachesthatimprovepharmacistaccesstoandabilitytointerpretrelevantdatainordertoprovideoptimalmedicationmanagement.


+notdiseaseoriented238*comprehensiveasitrelatestodrugtherapy**somefutureopportunitiesarerepeatedastheyrelatetomorethanoneprofessionalgoal

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FUTUREDIRECTIONSFORTHEPROFESSIONOFPHARMACYTwosummarythemes,organizationalchangeandbetterexternalrelationshipshaveemergedasfuturedirections theprofessionofpharmacy can takeover the coming5-10 years thatwill transformhowpharmacytacklesthemedicationmanagementneedsofOntariansforthepurposeofimprovinghealthoutcomes.Thesedirectionsapplytopharmacistsworkinginallpracticesettings.SummaryTheme1:OrganizationalChange Theprofessionofpharmacyneedstoundertakesubstantialorganizationalchangewithinthepharmacysetting. In this transformation, specific policies and practices to support proactive, comprehensive,quality care for individual patientswill be in place in every pharmacy andwithin organizations thatsupportpharmacies.Theongoinggoals,risksandneedsofapatientwillbeexplicitlyidentifiedandwellunderstoodbythepharmacistandformthebasisofcareprovidedbythepharmacist.Preventativecarewillbeplannedandorganizedforanindividualpatientorgroupsofpatientsaspartofacontinuous,routinecare.Deliveryofaprofessionalpharmacyservicetoanindividualwillbeconsideredasatoolorcomponentofamoreholisticcareplan.Linkingmultipleserviceprovidersasameanstodelivermorecomprehensive care will be commonplace. Monitoring and follow-up will be part of routine care.Pharmacistsandpharmacytechnicianswillpracticetothefullextentoftheirscopesandworkasateamtoprovideclinical care.Apharmacywilloptimizephysical layout to supportpatientassessmentandcommunication including theuseofeHealth technology,private rooms, inter-professionaland intra-professional teamwork. Documentation of any encounter in the clinical record will be consideredessentialsoastoensurecompleteclinicalinformationwillbeavailableforthenextencounter.Electronicpharmacyrecordswillbearrangedtosupportcomprehensiveandlongitudinalclinicalcarethatwillalsoincorporate or link with dispensing and service delivery records, electronic records from otherorganizations (e.g.primarycareorhospitals)andelectronic softwareapplications (Apps).Dispensingmedication may or may not be a component of on-site pharmacy services. Quality improvement(includingpatient safety)andpopulationbasedapproaches tocaredeliverywillbepartofeverydaypractice. Patients who are more vulnerable, including those on high risk medications or withmultimorbidity,willbeafocusofincreasedattention.Mostimportantly,thetransformationwilloccurinallpharmacysettings.

Theachievementoforganizationalchangetransformationisnotdependentonfirstattainingnewscopesof practice. Rather, this transformation can be accomplished by leveraging existing opportunities toenhancehowtheprofessionofpharmacyappliesthecurrentscopeofpractice.Thereisagreatneedtoensureeachpatientcanbeservedwithoptimalscopeavailableatthistimebeforeseekingadditionalscope. Subsequently, further enhanced scopes, such as initiation of any prescription, makingrecommendationsforcommonailmentsorwideningthesetofapprovedinjectionsgivenbypharmacists(orpharmacytechnicians),willofferadditionalbenefitforofpatientcare.

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SummaryTheme2:BetterExternalRelationships Theprofessionofpharmacyneedstotransformhowitconnectstopatientswheretheyliveandwithotherhealthcareorganizationsincludinghowconnectionsoccuramongcommunity,hospital,primarycare, other health care professionals, long-term care and home settings. In this transformation, apharmacistwillhavearelationshipwiththeirpatientthatstrengthenspharmacistunderstandingofthespectrumofthepatient’scare.Pharmacistswilldevelopandimplementcareplanstogetherwithothermembersofthehealthcareteam.Pharmacistswilleasilyshareclinicalrecordswithotherhealthcareprovidersororganizations,includingthoseinaPatient’sMedicalHome,andwithpatientsthemselves.Patients will provide the pharmacist with information on their health through regular electronic(including health records or Apps at home) ormanual information exchange. Pharmacistswill haveaccess to and interpret clinical information from other locations (e.g. community, hospital, home)includinglaboratoryanddiagnostictestresults.Pharmacistswillbeabletoeasilytriageorreferpatientstootherhealthandcommunityorganizationsoractivitiesandhaveasysteminplacetoreceivereferralsfromothersinsideoroutsideanorganization.Pharmacyteammemberswillinitiateandparticipateinlocaleducationandhealthpolicyinitiativestogetherwithotherhealthcareteammembers.Pharmacyinitiativeswillbeintegratedintointerprofessionalhealthcarepathwaysforthemanagementofchronicdiseaseorhospitaladmission/posthospitaldischargecare.Pharmacistswillbeactiveinlocalhealthpolicydecisionmaking.Pharmacistsfromdifferentorganizationsorsectorswillhaveestablishedwaysofcollaboratinginthebestinterestofthepatient(i.e.intra-professionalcollaboration).ASSESSMENTOFMESPOINRELATIONTOEXPANDEDSCOPESOFPROFESSIONALPHARMACYPRACTICETheMinistry of Health & Long-Term Care (MOHLTC) has developed theMESPO Framework to givestructuretothewayscopeofpracticerequestsarereviewedinOntario.TheMESPOFrameworkrequiresthesubmissionofcomprehensivedocumentationoutliningjustificationforscopeofpracticerequestsbasedonasetofcriteria.Evidencefromtheliterature,theministry’scriteriaforreviewingproposals,andkeypopulationandhealthsystemvalues,frameworksandstrategiesinformedthedevelopmentofMESPO.Thisevidence-basedanalyticalframeworktakesapatient-andsystem-centredapproachandwill be used to review all outstanding and future scope of practice requests, while creating moretransparency in this process. The two intended outcomes are improved patient outcomes and anenhancedreviewprocess.Inthiscontext,theMESPOFrameworkprovidesafoundationfortheOCP(andtheprofessionofpharmacy)toutilizeinordertoensureevidence-basedresearchandpractice,andcansupportadditionalscopeofpracticeactivitiesthatprovidethebestcombinedsetofjustifications.WhenascopeofpracticerequestorinitiativeissubmittedtotheMOHLTC,itwillbeassessedthroughthe2-stepMESPOmethodoutlinedhere.Step1askswhetherthescopeofpracticerequestservesasa“PatientNeed”ora“SystemNeed”.IfitservesaPatientNeed,therequestisthenassessedforalignmentwith the following5 categories:PatientOutcomes,Access toCare, Equity, Patient Preference, andPopulationNeed.IfitservesaSystemNeed,therequestischeckedagainstthefollowing4categories:Government Strategic Objectives, Health Care Workforce Planning, Technological

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advances/innovation, and Legislative/Regulatory Changes. The submission must address specificquestions associated with the category, reference desired outcome, potential metrics and includesourcesofevidence.Iftherequestsubmissionmeetstheaforementionedcriteria,theapplicationwillmoveforwardtostep2.Step2featuresa“ValueAssessmentFramework”.Atthisstage,theinitiativemustfitintooneofthefollowing4categories:PatientBenefit,HealthSystemBenefit,EconomicImpact,or Patient Safety. Again, the application is evaluated with respect to answers to specific categoryquestions, assessing desired outcome, potential metrics and sources of evidence. If alignment andevidenceislow,theapplicationwilllesslikelyconsideredfurtherforapprovalandmayconsequentlybedismissed at this stage. If alignment and evidence is high, the application will move forward forconsiderationtobeapprovedatoneofthreelevels:fullapproval,limitedapprovalorapprovalunderspecifiedconditions.MESPO provides a structure and process for OCP and other stakeholders to assess future scope ofpractice requests and develop strategic priorities. Consideration of future opportunities for theprofessionof pharmacy, alongsideMESPO, is intended to help informpharmacy policy andpracticeopportunitiesinthecoming5-10years.TheModelforEvaluationofScopesofPracticeinOntarioisausefulprocesstoestablishthejustificationforexpandingthescopeofpharmacy(orotherhealthcareprovider)practice.Atpresent,therearenopotentialscopesofpracticethatareabletodemonstrateanevidence-basedjustificationinallMESPOareas(i.e.apatientneed,systemneed,patientbenefitandhealthsystembenefit;seeTables1and2below). Instead, most new scopes (e.g. common ailments, initial prescribing authority, accessto/ordering/interpreting laboratory tests) considered canbe justifiedbasedon someMESPOcriteriademonstratingthatthereiseitheraneedorabenefitforconsideringaspecificexpandedscope.Thereis also a risk thatMESPOwill be applied in amanner that createsmorehurdlesormore regulationbecause the MESPO process requires consideration and supply of justification across many areas.Therefore,itwillbehelpfultoconsiderhowtobalanceeffortsbetweenmaximizingexistingpharmacistscopeversusworktoexpandscopeofpracticeandonlyapplytheMESPOprocesseswhentheoutcomeisexpectedonbalancetomakeamajordifferenceinthelivesofOntarians.

Table1.Justificationtoexpandorenhanceprofessionalpharmacypracticebasedon“PatientNeed”ora“SystemNeed”accordingtotheModelforEvaluationofScopesofPractice(MESPO)forselectedtopics

Category TypeofNeed Pharmacistprescribingincludingcommonailments

PharmacistsasImmunizers/injectors

Chronicdisease

management(diabetes)

Opioiddependence

Medicationreview

Patientneed

Patientoutcomes x x x X

AccesstoCare x

Equity

PatientPreference

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PopulationNeed x x x

Systemneed

Governmentstrategicobjective

Healthcareworkforceplanning

TechnologicalAdvancement/Innovation

Legislation/Regulatorychanges

Table2.JustificationtoexpandorenhanceprofessionalpharmacypracticebasedonpotentialforValueaccordingtotheModelforEvaluationofScopesofPractice(MESPO)forselectedtopics

Category Pharmacistprescribingincludingcommonailments

PharmacistsasImmunizers/Injectors

Chronicdisease,diabetes

Opioiddependence

Medicationreview

Patientbenefit

ClinicalOutcomes x

PatientPreferences x x x

AccesstoCare x x x x

Equity

PopulationNeed x

Healthsystembenefit

StrategicObjectives

HealthcareWorkforce

Innovation

Legislation/Regulation x x x

EconomicImpact

Otherprofessions x

PatientSafety

ProfessionalCompetencies

TheMESPOcriteriaarealsousefultohighlightevidencegapsthatcanbeaddressedbytheprofessioninordertogenerateevidenceinfocusedareas.Evidencegapsincludetheneedfordataonimplementationofnewprofessionalpharmacypractice/medicationmanagementapproachesfromtheperspectiveof

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patients,pharmacists,othercareprovidersandhealthrelatedorganizations.Evidencegapsalsoincludethe need for data on the health outcomes and health care resource utilization changes due toimplementation of new professional pharmacy practice/medicationmanagement approaches. Newevidencewillimproveunderstandingofhowaparticularexpandedscopecanbettermeetpatientandhealth care system needs or provide associated benefits. In turn, this will help the profession ofpharmacy transform toencourageorganizational changewithin thepharmacy settingand transformhowitconnectstopatientswheretheyliveandwithotherhealthcareorganizations.

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