"Pharmacy to Dose": An Approach to Enhancing Team-Based Care.

To achieve the promise of comprehensive medication management, some have called for greater authority for pharmacists to co-manage therapy by titrating medications to help patients reach their therapeutic goals.[1]

In inpatient and ambulatory care settings, this has been achieved in some cases through a “pharmacy to dose” protocol, where physicians order a specific drug or drug class, and the pharmacist selects an appropriate dose for the individual patient. Studies have found that these protocols have significantly improved the appropriateness of drug product selection, reduced medication errors, and improved efficiency.[2-3]

In outpatient settings, co-management has most commonly occurred through collaborative practice agreements (CPA), which are formal contracts between physicians and pharmacists.[4] Physicians can set parameters of a CPA, allowing pharmacists to select or titrate doses in specifically defined circumstances.[5]

Idaho became the first state to meld these two approaches. In the law that specifies what elements must be on a prescription in order for it to be valid, an exemption was created for non-controlled substances, regardless of practice setting.[6] Specifically, a prescriber may now “omit drug information and directions if the prescriber makes an indication for the pharmacist to finalize the patient’s drug therapy plan.”[6]

Thus, a prescription could now be written with only a diagnosis, and the pharmacist could select and dispense medication tailored to the individual patient’s needs. Similarly, a prescription for a diabetic patient could be written with a hemoglobin A1c goal and the pharmacist could titrate the dose and manage therapy toward this goal. Safeguards are in place, such as placing the decision at the discretion of the original prescriber and holding pharmacists accountable to the prevailing standard of care.[7] Additional states may consider this approach in order to leverage the strengths of both health professions while enhancing team-based care.