How Does Your State Compare?
In the United States, most states use “collaborative practice agreements” as a mechanism to provide direct public access to EC in pharmacies. As of June 2003, all but seven states permitted pharmacists to administer drug therapy pursuant to a collaborative drug agreement with a prescriber — generally a physician — or a physician’s order. Authority for these practices can be statutory and/or regulatory.
In some states, the authority for collaborative practice agreements is extremely restrictive and cannot be used to facilitate EC pharmacy programs without substantial change. At the other extreme, there are approximately 12 states that currently would allow pharmacists to initiate EC under a collaborative practice agreement with a physician without any further changes!
The three sections below categorize US states by how permissive their current “environments” are for collaborative practice agreements. However, the authority for collaborative practice agreements is only one of several factors influencing state readiness to allow direct pharmacy access to EC. A strong track record in legislative support for women’s health issues and a progressive pharmacy community can be pivotal in creating policy change at the state level.
OPTIMAL ENVIRONMENTS: No Revision to Authority Necessary
In these states, existing statutes and regulations would accommodate pharmacists’ initiation of emergency contraception, generally under a collaborative practice agreement (protocol) with a prescriber. In most states prescribers are physicians, but in Alaska and Washington, nurse practitioners in addition to MDs may authorize protocols. In New Mexico pharmacists are the designated prescribers for EC.
Alaska
Implementation requires:
- Development of protocol
- Pharmacist completion of continuing education training on EC
- MD, Nurse Practitioner or Physician Assistant authorization of protocol
- File protocol with State Board of Pharmacy
California
Implementation requires:
- Development of protocol
- MD authorization of protocol
- Pharmacist completion of an EC training program
Guam
Pharmacists practicing in any setting may implement a collaborative practice agreement with one or more physicians pursuant to a protocol that specifies the type of patient care functions the pharmacist is authorized to perform, and under what conditions or limitations. No outside review is required. Implementation would require development of a protocol and securing prescriber authorization.
Hawaii
Implementation requires:
- Development of protocol
- Pharmacist completion of an EC training program, including ACPE programs, “curriculum based programs from an ACPE-accredited college of pharmacy, state or local health department programs, or programs recognized by the board of pharmacy”
- MD authorization of protocol
- File protocol with State Board of Pharmacy
Illinois
Statutory/regulatory authorization for a collaborative practice agreement does not require Board review/approval for new activity, but confirmation and/or approval from the Board of Pharmacy is recommended. Implementation would require development of a protocol and securing prescriber authorization.
Kansas
Statutory/regulatory authorization for a collaborative practice agreement does not require Board review/approval for new activity, but confirmation and/or approval from the Board of Pharmacy is recommended. Implementation would require development of a protocol and securing prescriber authorization.
Maine
Implementation requires:
- Development of protocol
- MD authorization of protocol
- Pharmacist completion of an EC training program
Michigan
Statutory/regulatory authorization for a collaborative practice agreement does not require Board review/approval for new activity, but confirmation and/or approval from the Board of Pharmacy is recommended. Implementation would require development of a protocol and securing prescriber authorization.
Montana
Regulations would require filing a copy of the protocol with the Board of Pharmacy. Implementation would require development of a protocol and securing prescriber authorization.
New Mexico
The State Board of Pharmacy, Nursing and Medical Examiners approved a statewide EC protocol in 2003. New Mexico pharmacists have authority to prescribe EC under this protocol.
Implementation requires:
- Pharmacist maintaining a current copy of the Boards’ approved protocol
- Pharmacist completion of initial EC training program, and 0.2 CEU of live ACPE training every two years thereafter.
South Dakota
Implementation would require:
- Development of protocol by pharmacist and securing an authorized prescriber
- The Pharmacy Board reserves the right to have the protocol submitted to it and the Board of Medicine for approval.
Tennessee
Implementation would require:
- Development of protocol by pharmacist and securing an authorized prescriber
Washington
Implementation requires:
- Development of protocol
- MD or Nurse Practitioner authorization of protocol
- File protocol with State Board of Pharmacy
Wisconsin
Implementation would require:
- Confirmation and/or approval from the Board of Pharmacy is recommended, although, statutory/regulatory authorization for collaborative practice agreements do not include specific requirements for approval.
- Development of a protocol and securing prescriber authorization required.
POSSIBLE ENVIRONMENTS: Revision to Existing Authority Required
Virtually all of the states listed below permit collaborative practice agreements between physicians and pharmacists. Exceptions include Colorado, Missouri and Oklahoma, where pharmacists can administer medication pursuant to a prescriber’s “order”.
However, states listed in this section require modification of existing statutes and regulations, and in some cases the required revision is substantial. The most common types of barriers to implementing EC services in the pharmacy are requirements that make collaborative practice agreements:
| 1. |
“patient-specific” |
| 2. |
for use in modifying, as opposed to initiating, drug therapy |
| 3. |
for use in an institutional, as opposed to community retail setting |
Arizona
Meaningful implementation would require:
- Revising statute to authorize collaborative practice agreements in any pharmacy setting. (Current authority is limited to hospitals, staff model of a health care services organization, nursing care institution with an on-site pharmacy, contractual relationship with a pharmacy service, or long-term care consultant pharmacist, qualifying community health care center with an on-site pharmacy.)
- Modifying the requirement for a patient-specific protocol
- Modifying the current training and education requirements
- Promulgation, review and adoption of implementing regulations by both the Board of Pharmacy and the allopathic board of medical examiners and the board of osteopathic examiners in medicine and surgery
Arkansas
Implementation would require:
- Revising statute to exempt emergency contraception from patient-specific protocols or to remove the patient-specific requirement, AND
- Promulgating regulations establishing standard protocol for emergency contraception
Colorado
Implementation would require:
- Modifying the requirement that pharmacists “administer” medications pursuant to a patient-specific order from a physician
Connecticut
Implementation would require:
- Revising statute to expand authority beyond hospitals and nursing home settings
- Modifying the requirement for patient-specific protocols
Delaware
Implementation would require:
- Revising statute to expand authority to include emergency contraception,
- Modifying the requirement for patient-specific protocols
Florida
Implementation would require:
- Addition of emergency contraception to regulations addressing medications permitted to be ordered by pharmacists OR
- Modifying the requirement for patient-specific protocols
Georgia
Implementation would require:
- Modifying the requirement for patient-specific protocols
- Modifying the requirement that only prescribers may initiate drug therapy
Idaho
Implementation would require:
- Modifying the requirement for patient-specific protocols
Indiana
Implementation would require:
- Revising statute to expand authority beyond hospitals or private mental institution setting
- Modifying the requirement for patient-specific protocols
Iowa
Implementation would require:
- Confirmation and/or approval from the Board of Pharmacy that collaborative practice agreements may be used to provide EC
- Modifying the requirement for patient-specific protocols?
Kentucky
Implementation would require:
- Modifying the requirement for patient-specific protocols
Louisiana
Implementation would require:
- Modifying the requirement for patient-specific protocols, AND
- Promulgation, review and adoption of implementing guidelines by both the Board of Pharmacy and the Board of Medical Examiners
Maryland
Implementation would require:
- Modifying the requirement for patient-specific protocols, AND
- Promulgation, review and adoption of an emergency contraception “Therapy Management Contract” by both the Board of Pharmacy and the Board of Physician Quality Assurance
Minnesota
Implementation would require:
- Modifying the requirement for patient-specific protocols
Mississippi
Implementation would require:
- Modifying the requirement for patient-specific protocols in community practice, AND EITHER
- Modifying the requirement for certification in emergency contraception OR
- Seeking Board approval for a certification program focusing on the provision of emergency contraception
Missouri
Implementation would require:
- Modifying the requirement for patient-specific “orders” from a physician or a nurse operating under a collaborative agreement with a physician
Nebraska
Implementation would require:
- Securing clarification from the Board of Pharmacy that general ( vs. patient-specific) protocols are allowed
Nevada
Implementation would require:
- Modifying the requirement for patient-specific protocols
New Jersey
Implementation would require:
- Modifying the requirement for patient-specific protocols
- Promulgation by the Board of Pharmacy of issuing regulations defining appropriate pharmacist education, and joint rules by the Boards of Pharmacy and Medicine for pharmacist initiation of EC
North Carolina
Meaningful implementation would require:
- Modifying the requirement that only “Clinical Pharmacist Practitioners” be allowed to engage in collaborative practice agreements with prescribers.
North Dakota
Implementation would require:
- Revising statute to expand authority beyond institutional settings
- Modifying the requirement for patient-specific protocols
Ohio
Implementation would require:
- Modifying the requirement for patient-specific protocols
Oklahoma
Implementation would require:
- Modifying the Pharmacy Practice Act to authorize pharmacists to administer emergency contraception
- Modifying the requirement for patient-specific “orders”
- Promulgation by the Board of Pharmacy of EC training requirements for pharmacists
Oregon
Implementation would require:
- Modifying the requirement for patient-specific protocols
- Modifying the requirement that only prescribers may initiate drug therapy
Pennsylvania
Implementation would require:
- Revising statute to expand authority beyond patients in institutional settings
- Modifying the requirement for patient-specific protocols
Rhode Island
Meaningful implementation would require:
- Revising statute to authorize initiation of drug therapy, AND
- Modifying the requirement for extensive pharmacist training, including 20 hours of CE annually
South Carolina
Implementation would require:
- Securing clarification from the Board of Pharmacy that general ( vs. patient-specific) protocols are allowed
Texas
Implementation would require:
- Modifying the requirement that protocols are only valid for existing patients of the authorizing prescriber.
Utah
Implementation would require:
- Securing clarification from the Board of Pharmacy that general ( vs. patient-specific) protocols are allowed
Vermont
Implementation would require:
- Revising statute to authorize initiation of drug therapy
Virginia
Implementation would require:
- Modifying the requirement for patient-specific protocols, AND
- Revising statute to authorize initiation of drug therapy
Wyoming
Implementation would require:
- Modifying the requirement patient-specific protocols, AND
- Review and approval of an emergency contraception protocol by relevant regulatory boards
UNFRIENDLY ENVIRONMENTS: New Authority Required
In these states, no authority exists for collaborative practice agreements. Any initiative to provide direct pharmacy access to EC would require significant advocacy activity to secure statutory and/or regulatory authority.
Alabama
Massachusetts
New Hampshire
New York
West Virginia
District of Columbia
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