Interprofessional Collaboration Practice Topic

The Regulated Health Professions Act has provisions to allow a regulated health professional to delegate their authority to perform a controlled act to a person (regulated or not) who does not have that authority. Delegation of authority can be implemented by use of a Direct Order or a Medical Directive. In this case, the controlled act is “prescribing”. 

The College's Medical Directives and the Delegation of Controlled Acts Policy sets out the expectations for registrants who are considering authorizing or implementing delegated acts. 

A prescription issued pursuant to a directive must include the: 

• Name of prescriber (delegator; authorizer of the directive) 

• Name and signature/unique authorization of the person issuing the prescription (delegate; implementer of the directive) 

• Name and number of the medical directive 

• Contact information for the authorizer and implementer 

The prescriber’s name (delegator; authorizer of the directive) should be recorded on the dispensing record as they are ultimately responsible for the prescription, even though they have delegated the authority to perform the act to someone else to implement via a directive. 

Should there be questions about the prescription, registrants should contact the implementer. If the questions cannot be resolved, the prescriber would be contacted for clarification. Where requested, a copy of the directive may also be forwarded to the pharmacy. 

More information can be found in the Health Professions Regulators of Ontario Interprofessional Guide, FAQ, and templates. 

The College does not maintain information on the scope of practice of practitioners other than pharmacy professionals in Ontario. Questions about the scope of practice and prescribing authority of another health professional should be directed to their regulatory body. Collaboration with the practitioner is also encouraged, as self-regulated health professionals should be aware of – and practicing within – their legal scope of authority and the policies and guidelines of their College. This topic was covered in the Summer 2017 Pharmacy Connection article Prescriptions from Other Healthcare Professionals. 

The Cross-Jurisdictional Pharmacy Services Policy explains that dispensers may accept a prescription written by a prescriber licensed in any province or territory of Canada. The Drug and Pharmacies Regulation Act (DPRA) defines “Prescriber” as “a person who is authorized under the laws of a province or territory of Canada to give a prescription within the scope of his or her practice of a health discipline”. An out-of-province prescriber is registered and regulated by their province’s (or territory’s) health disciplinary college. Therefore, the regulations and corresponding scope of practice of the same health discipline in Ontario cannot be applied to an out-of-province practitioner. Similarly, a pharmacist licensed in another province whose scope includes prescribing authority (for example, to initiate treatment for minor ailments or to renew a prescription) is considered a prescriber for the purposes of the Act. 

The requirements for a prescription to be “signed” are established in the federal regulations relevant for the schedule of the drug. There is nothing in the regulations mandating the use of a “wet” signature (e.g., “pen-and-ink” signature). As explained in the related 2014 article, Navigating Electronically Generated Prescriptions, “Health Canada has broadly defined ‘signing’ as whatever is determined to be necessary to authorize and validate the order”. 

The College’s Position Statement Authenticity of Prescriptions using Unique Identifiers for Prescribers  describes three examples of distinct authorization methods: 

• a traditional pen-and-ink signature, or 

• an electronically captured image of a unique signature (generated on a signature pad), or 

• a unique prescription authorization process which ensures that the prescriber has reviewed and authorized each individual prescription 

There may be many different technologies available to prescribers, especially as computerized order entry and electronic prescriptions become increasingly common, to implement a unique authorization process and generate an order without an actual image of a signature. 

Dispensers should review the Position Statement in its entirety, especially the guidance provided in the section “The Responsibility of the Registrant”. If the pharmacist decides that they need to verify the authenticity of the order, this may be done verbally or in writing (via fax). Prescribers should seek guidance from their regulatory College. 

Regular e-mail (as opposed to a secure healthcare portal) is not a secure medium for prescription transmission.¹ In addition to cybersecurity risks, when a prescriber e-mails a prescription directly to a patient, it increases the likelihood of fraud and duplication of the prescription. Therefore, unsecured email is not an acceptable mechanism for transmitting prescriptions, especially for monitored drugs and those listed under the Controlled Drugs and Substances Act (CDSA). 

Upon receiving a prescription via unsecured email, pharmacists are encouraged to contact the prescriber to verify its authenticity and collaborate with them and the patient to determine the best method of transmitting a prescription from the prescriber directly to the pharmacy via established channels (e.g., fax, verbal confirmation, secure electronic transmission). 

There may be times when a pharmacist needs to use their professional judgement when accepting an e-mailed prescription – for example, when a prescriber cannot be reached and the patient is at risk of going without necessary medication. In these cases, pharmacists should exercise their professional judgment in determining whether to dispense the prescription and follow-up with the prescriber at the earliest available time. Prescribers should also seek guidance from their regulatory College. 

Reference 

1. Information and Privacy Commissioner Ontario. Fact Sheet: Communicating Personal Health Information by Email (2016). Retrieved at https://www.ipc.on.ca/wp-content/uploads/2016/09/Health-Fact-Sheet-Communicating-PHI-by-Email-FINAL.pdf.