Full Scope of Pharmacy Practice: Reinventing the Future and Overcoming Barriers

The concept of moving towards a "full scope of pharmacy practice" represents a paradigm shift in the role of pharmacists and pharmacy technicians. It transcends traditional boundaries, allowing pharmacy professionals to maximize their potential in patient care. Full scope provides a perspective that is intuitive of utilizing clinical and technical abilities, education, training, and maximal capabilities to provide customized high-level care.

The original concept of full scope of practice originates from a 2018 commentary published by Ross T. Tsuyuki, BSc Pharm, PharmD, MSc, FCSHP, FACC, FCAHS, in which he states: “Full-scope pharmacist services include all proactive and comprehensive interventions that prevent or manage illness and are within an individual’s competency to perform independently.”¹ This follow-up article explores a deeper and more modernized meaning of “full scope,” its implications, barriers, and practical solutions to overcome challenges, framing a vision for the future of pharmacy practice.

Defining Full Scope of Pharmacy Practice

At its core, full scope refers to the utilization of pharmacists’ and pharmacy technicians’ complete range of skills and knowledge in health care delivery. According to Tsuyuki in 2018, this included, but was not limited to: prescribing medications, ordering and interpreting laboratory tests, administering medications, and managing chronic diseases.¹ A key part of full scope is the autonomy to independently perform and delegate these tasks. The article asks a critical rhetorical question that is key: “Shouldn’t the full scope of pharmacist practice be defined by evidence, not outdated and restrictive legislation and policy that differ across provinces and work- places?”¹

Looking at further developments in pharmacy practice, legislative, regulatory, and clinical trends, a more modernized definition of full scope is to be proposed. In addition to independent authority and various roles that pharmacy professionals may partake in, full scope can be defined more thoroughly as the following:

• Independent authority for pharmacists to perform and delegate various clinical and technical abilities
• A standard of care regulatory enforcement framework which holds professionals accountable yet is non-punitive.
• Recognizes variations between pharmacy professionals in education, training, experience, and practice settings
• Utilizes published literature, practice guidelines, standards of practice, and evidence to drive accountability and establish the standard

Vision for the Future

The future of pharmacy practice, regulation enforcement, and standards under full scope envisages a model in which pharmacists and technicians are integral in managing patient care, particularly in areas such as chronic disease management, preventive care, and emergency services.^2,3 Evidence suggests that expanded roles of pharmacists and pharmacy technicians significantly improve patient outcomes and health care accessibility.^4,5

Two question you may be asking yourself now are: “How do we get to a full scope model?” and “What are the barriers and opportunities in order to get there?”These are critical questions to examine, but first a visual (Figure 1) below should be examined to understand which various confounding factors must fit together on a path towards full scope.

Common Barriers

Despite its potential, barriers impede the realization of a full scope of pharmacy practice. These could include, but are not limited to:

• Regulatory and Legislative Constraints: Diverse state regulations and legislation along with regulatory enforcement styles lead to inconsistency in the scope of practice across regions.³ As a result and due to differences in various states, various organizations and companies lack uptake in certain services.
• Practical Operationalization and Uptake: A lack of uptake, operationalization, and adoption by pharmacies defeats efforts and access to services and care for patients.
• Professional Resistance: Perceived turf battles with other health professions and within pharmacy itself can hinder the expansion of pharmacists' roles.² As a result, other health care professionals such as physicians and associations such as state medical associations and the American Medical Association push back on “scope creep.”
• Patient Needs: Patients in various communities may have a host of health care-related needs and services they are or are not looking for.⁷
• Reimbursement and Funding Issues: The complexity of billing for pharmacist-provided services can be a significant barrier.⁸ Due to challenges with reimbursements, billing, and recognition from third parties, organizations may not implement expanded services.

Overcoming Barriers

To realize the full potential of full scope, several strategies need to be implemented.^9-12 As mentioned in Figure 1 above, there are a few major factors and areas of impact that need change to move towards full scope. These include:

• Regulatory/Legislative:
  • A standard of care enforcement strategy should be adopted by state agencies and boards of pharmacy.
  • Decrease regulatory and legislative burden (remove red tape).
  • Hold licensees accountable to standards versus bright line rule regulations.
  • Work towards licensure portability, automation, delegation, and independent allowances.
  • Utilize an evidence-based lawmaking framework to base regulatory and legislative decision making on literature, jurisdictional successes, and outcomes rather than emotions and political turf wars.
• Practice/Operational:
  • Update company policy and procedures to expand practice allowances.
  • Adopt delegatory models to effectively utilize and delineate clinical versus technical tasks.
  • Ensure operations are optimized for proper efficiencies and staffing, including automation.
  • Adopt and offer services that patients want and need access to.
• Financial:
  • Ensure services offered are financially stimulating and cost effective to patients and practice settings.
  • Develop reimbursement relationships and models based on outcomes and health savings.
  • Focus on services that patients and/or third parties find valuable and impactful.
• Patient Needs:
  • Conduct needs or gap analyses, patient surveys, or other tools to gather data on essential services.
  • Review literature and historical health care habit trends to better understand which services create highest impact with least barriers to implementation.
  • Evaluate what patients value and how much they are willing to spend (if anything).
• Mindset/Unity:
  • Stop fighting amongst each other within the profession and come to a unifying spot to advocate and move initiatives forward that will benefit patients and the profession.
  • Bring together collations of professionals to utilize the same messaging in all efforts.
  • Adopt a philosophy of permissionless innovation rather than relying on the precautionary principle.

Conclusion

The full scope of pharmacy practice offers a transformative approach to health care delivery, promising improved patient outcomes, greater access to care, and efficient utilization of health care resources. By acknowledging and addressing barriers to its implementation and opportunities for change, the pharmacy profession can move toward a future where pharmacists and pharmacy technicians fully utilize their expertise for the betterment of public health. Now more than ever, it is critical to rise, come together, and move toward a full scope of pharmacy practice for the future and reinvent what is considered “standard.”

References

1. Tsuyuki RT, Houle SKD, Okada H. Time to give up on expanded scope of practice. Can Pharm J (Ott). 2018 Aug 17;151(5):286. doi:10.1177/1715163518793844

2. Adams A. Pharmacist scope of practice expansion: The virtue of forbearance. J Am Col Clin Pharm. 2021;4(9):1067-1069. doi:10.1002/jac5.1465

3. Adams A, Weaver K. Pharmacists’ patient care process: state “scope of practice” priorities for action. Annals of Pharmacotherapy. 2020;55(4):549-555. doi:10.1177/1060028020950193

4. Donovan J, Tsuyuki R, Hamarneh Y, Bajorek B. Barriers to a full scope of pharmacy practice in primary care: A systematic review of pharmacists’ access to laboratory testing. Can Pharm J/Rev des Pharm du Can. 2019;152(5):317-333. doi:10.1177/1715163519865759

5. Turgeon, R., Semchuk, W., Thomson, P., & Bungard, T. Exploring discrepancies between pharmacists’ perceived and actual roles towards optimising care in patients prescribed direct oral anticoagulants: a survey. J Pharm Pract Res. 2019;49(4):324-330. doi:10.1002/jppr.1509

6. Alsabbagh MW, Houle SKD. The proportion, conditions, and predictors of emergency department visits that can be potentially managed by pharmacists with expanded scope of practice. Res in Social and Admin Pharm. 2019;15(11):1289-1297. doi:10.1016/j.sapharm.2018.12.003

7. Urick BY, Trygstad TK, Farley JF. Patient outcomes from implementing an enhanced services pharmacy network. J Am Pharm Assoc. 2020;60(6):843-852. doi:10.1016/j.japh.2020.05.009

8. Schweitzer P, Atalla M. Medicaid reimbursement for pharmacist services: A strategy for the pharmacy profession. Am J Health Syst Pharm. 2021;78(5):408-415. doi:10.1093/ajhp/zxaa390

9. Battling professional self-sabotage: Embracing standard of care as the future of pharmacy regulation. J Am Pharm Assoc. 2023;63(6):1685-1688.e1. doi:10.1016/j.japh.2023.08.015

10. Adams AJ. Transitioning pharmacy to “standard of care” regulation: Analyzing how pharmacy regulates relative to medicine and nursing. Res Social Adm Pharm. 2019;15(10):1230-1235. doi:10.1016/j.sapharm.2018.10.008

11. Adams AJ, Chopski NL. Rethinking pharmacy regulation: Core elements of Idaho’s transition to a “Standard of Care” approach. J Am Pharm Assoc. 2020;60(6):e109-e112. doi:10.1016/j.japh.2020.07.013

12. Thierer A. Permissionless Innovation: The Continuing Case for Comprehensive Technological Freedom (1st ed.). 2014. Mercatus Center at George Mason University. Arlington, VA.