Pharmacy preparedness for upcoming role expansion in Ontario

On July 24, 2024, Ontario’s Minister of Health Sylvia Jones announced that the government would be consulting with partners  on six areas for pharmacist and pharmacy technician role expansion:

• Treating and prescribing for 14 additional common ailments, such as sore throat, calluses and corns, mild headaches, shingles, and minor sleep disorders including insomnia;
• Ordering specific laboratory tests and performing additional point-of-care tests such as strep throat testing, to make it faster and easier to assess and treat common ailments;
• Administering additional publicly funded vaccines at pharmacies, including Tetanus, Diphtheria, Pneumococcal, and Shingles to increase access to care and save people a visit to the doctor’s office;
• Allowing pharmacy technicians to administer additional vaccines, such as Hepatitis A and B, Rabies, Meningococcal, and Human Papillomavirus;
• Identifying barriers in hospital settings that limit pharmacists from ordering certain laboratory and point-of-care tests, to make it easier for people to connect to care and reduce the burden on nurses and doctors; and
• Improving the MedsCheck program to support health outcomes and reduce unnecessary service duplication and administrative red tape, while continuing to protect patient choice.

While we stay tuned to see the specific wording of the ultimately proposed legislative and regulatory amendments, there are several ways pharmacies, pharmacy owners, and pharmacy professionals can prepare for these changes and protect against liability risks, while providing excellent patient care in the community.

Common ailments

Today, Pharmacists in Ontario can prescribe for 19 common ailments, including acne, dermatitis, oral thrush, and pink eye. Nearly every Ontario pharmacy provides this health service to patients. Across the country, all provinces, as well as the Yukon Territory, allow pharmacists to prescribe for some minor or common ailments. If the additional 14 common ailments are approved, Ontario will be among the leading provinces in the country in terms of the number of common ailments for which its pharmacists can prescribe.

Ontario’s advances in this area have been quite recent, previously lagging behind other provinces, such as Saskatchewan and Nova Scotia, which introduced minor ailment prescribing in 2011, as well as Manitoba, New Brunswick, and Prince Edward Island, each of which introduced similar legislative changes in 2014. In Alberta, pharmacists with additional prescribing authority have been able to prescribe for all medications, apart from narcotics and controlled substances, since 2007. Therefore, in addition to prescribing for common ailments, Alberta pharmacists can provide medication adjustment and management for their patients.

Pharmacist prescribing has demonstrated valuable benefits and relief to the health system at a time of great strain. In Nova Scotia, the expanded scope of pharmacies contributed to a 9.2 per cent drop in emergency room visits for minor ailments.

Despite the prevalence of pharmacist prescribing for common ailments across Canada, there are very few disciplinary cases related to this practice and none noted in Ontario. Nevertheless, four cases out of Saskatchewan can provide some learnings to pharmacy professionals.

• In Saskatchewan College of Pharmacy Professionals v. Glenn Murray, 2023 SKCPPDC 1, the pharmacist was reprimanded for prescribing drugs for conditions that are not eligible minor ailments in the province.¹ In addition, College investigators did not find any Pharmacist Assessment Records for the prescriptions in question.² The pharmacist noted that his ability to document was limited by pressing patient needs and a shortage of medical professionals.³
• In Saskatchewan College of Pharmacy Professionals v. Kingsley Chukwu, 2022 SKCPPDC 1, the pharmacist was also reprimanded for prescribing drugs for conditions that are not eligible minor ailments.⁴
• In Saskatchewan College of Pharmacy Professionals v. Harvey Smith, 2021 SKCPPDC 2, the Committee made findings of professional incompetence and misconduct against a pharmacist who prescribed an unauthorized drug to a family member, in addition to having inadequate documentation.
• In Saskatchewan College of Pharmacy Professionals v. Sandra Dufour, 2019 SKCPPDC 7, the Committee made findings of professional incompetence and misconduct against a pharmacist who prescribed for her family’s common ailments and prescribed medications the Minor Ailment Guidelines did not allow.

A review of these cases highlights the importance of:

• being aware of which conditions and medications are included within regulations and guidelines;
• abstaining from prescribing for family members’ common ailments except in emergencies or where other health professionals are not available;
• ensuring adequate documentation is available for every prescription; and
• adequately staffing and overlapping among pharmacy professionals to help provide the necessary time and resources for proper documentation.

Some jurisdictions, such as British Columbia, do not limit common ailment prescribing to specific drugs, instead providing a drug category so the regulations remain practically relevant with changing clinical evidence. In Ontario, Schedule 4 to the General Regulation to the Pharmacy Act, 1991 lists the specific ailments, drug classes, and drugs pharmacists can prescribe.

Lab test ordering

Ontario remains the second last province to adopt regulations for lab test ordering by pharmacists. While pharmacists can already conduct point-of-care testing for blood sugar, lipids, and blood clotting levels, Ontario is now considering expanding their authority to the ordering of specific laboratory tests. Similar to how the addition of common ailment prescribing required pharmacies to consider staffing, space accommodations (for assessments that maintain patient privacy), and consent procedures, lab test ordering will also require pharmacies to adjust.

Provinces where pharmacists can order lab tests, such as Alberta, require pharmacies to have systems for 24/7 coverage to ensure timely follow-up on critical lab test results. Adequate staffing can be a key element to creating an effective system. Establishing an on-call schedule within pharmacist teams is one way to meet this requirement. It can also involve agreements or partnerships to form on-call groups with other pharmacists and physicians. Lab test ordering can be an integral tool to medication management and evidence-based patient care.

Vaccinations

The current regulations allow Ontarians to have eighteen different types of vaccines administered by their pharmacist, while three (influenza, COVID-19, and RSV) can also be administered by pharmacy technicians. The government has proposed adding to these lists. Recent vaccination-related cases from the Ontario College of Pharmacists shed light on several key reminders for any clinicians involved in vaccinations.

• In Ontario (College of Pharmacists) v. Forcucci, 2021 ONCPDC 2, one of the Complainant’s claims was that the pharmacist’s request that she unbutton a few buttons and slide her shirt collar down to expose her shoulder was “sexually charged”.⁵ The Panel concluded the pharmacist’s request was innocuous, routine, and did not cross any professional boundaries.⁶
• In Ontario (College of Pharmacists) v. Mourid, 2021 ONCPDC 32, the Panel reprimanded the pharmacist for, among other findings, administering influenza vaccines to ineligible patients, including some where there was missing documentation.⁷
• In Ontario (College of Pharmacists) v. Huynh and Nguyen, 2022 ONCPDC 40, the Panel found two pharmacists had “misappropriated vaccines in a manner that may have jeopardized patient safety” by transferring them outside the stated cold-chain requirements and suggesting falsifying vaccine records.⁸

Ensuring professional conduct, patient eligibility, and proper transfer and storage conditions are measures every pharmacy professional can take around vaccinations. During busy flu seasons, the expanded authority for pharmacy technicians to administer more vaccinations can be leveraged to help with managing workload and vaccine responsibilities. Expanding pharmacy roles in this area has the potential to improve access to vaccines for Ontarians and promote vaccine uptake.

The changing health regulatory landscape presents an opportunity for enhanced patient access to care. Being aware of upcoming changes that the government is considering can help pharmacies get a head start on preparing for these expansions. Especially at a time when, according to a recent report by the Ontario College of Pharmacists, a growing number of pharmacy professionals face workplace pressures to complete a set number/dollar amount of minor ailment assessment, MedsChecks, or other professional services, pharmacy owners should strive for a balance that incorporates these changes thoughtfully, and pharmacy professionals should be aware of all responsibilities related to new practices.

For more information on regulatory requirements related to pharmacies and pharmacy professionals, please reach out to any of the key contacts listed below.

The authors would like to thank BLG student and pharmacist Marianna Pozdirca for her assistance in preparing this article.