BILL ANALYSIS Ó SB 493 Page 1 Date of Hearing: August 13, 2013 ASSEMBLY COMMITTEE ON HEALTH Richard Pan, Chair SB 493 (Ed Hernandez) - As Amended: August 5, 2013 SENATE VOTE : 34-4 SUBJECT : Pharmacy practice. SUMMARY : Establishes a new category of pharmacists referred to as advance practice pharmacists (APPs), authorizes the Board of Pharmacy (BOP) to recognize APPs, and establishes functions for APPs; authorizes a pharmacist to independently initiate and administer vaccines, as specified; authorizes a pharmacist to perform additional functions including the furnishing of nicotine replacement products (NRPs), as specified; and, the ordering and interpreting of tests, as specified. Specifically, this bill : 1)Defines APP as a licensed pharmacist who has been recognized as an advanced pharmacist by the BOP, as specified. Provides that a BOP-recognized APP is entitled to practice advance practice pharmacy, as specified, within or outside a licensed pharmacy, as specified. 2)Authorizes APPs to initiate a prescription and provide clinical advice, services, information or patient consultation if certain conditions are met. Applies all of the following existing conditions to APPs when initiating a prescription or providing clinical advice or patient consultation: a) The clinical advice, services, information, or patient consultation are provided to a health care professional or to a patient; b) The pharmacist has access to prescription, patient profile, or other relevant medical information for purposes of patient and clinical consultation and advice; and, c) Access to the information specified in 2)b) above is secure from unauthorized access and use. 3)Authorizes pharmacists to additionally do the following: a) Perform procedures or functions authorized for APPs; b) Provide consultation, training, and education to patients about drug therapy, disease management, and disease prevention; SB 493 Page 2 c) Participate in multidisciplinary review of patient progress, including appropriate access to medical records; d) Furnish the following medications: i) NRPs, as specified; and, ii) prescription medications not requiring a diagnosis that are recommended by the Federal Centers for Disease Control and Prevention (CDC) for individuals traveling outside the United States. Requires the pharmacist to notify the patient's primary care provider (PCP) of any drugs or devices furnished to the patient. If the patient does not have a PCP, requires the pharmacist to provide the patient with a written record of the drugs or devices furnished and advise the patient to consult a physician of the patient's choice; and, e) Order and interpret tests for the purpose of monitoring and managing the efficacy and toxicity of drug therapies. 4)Authorizes pharmacists to furnish self-administered hormonal contraceptives in accordance with standardized procedures or protocols developed and approved by both the BOP and the Medical Board of California (MBC) in consultation with the American Congress of Obstetricians and Gynecologists, the California Pharmacists Association, or other appropriate entities. Requires the standardized procedures or protocols to require that the patient use a self-screening tool, based on the United States Medical Eligibility Criteria for Contraceptive Use developed by the CDC, and the pharmacist to refer the patient to the patient's PCP, or, if the patient does not have a PCP, to nearby clinics. Requires pharmacists to provide a recipient of self-administered hormonal contraception a fact sheet about the drug, as specified. 5)Authorizes the BOP and the MBC to ensure compliance with 4) above, and each board is charged with its enforcement with respect to their respective licensees. Indicates that 4) above does not expand the authority of a pharmacist to prescribe any prescription medication. 6)Authorizes pharmacists recognized by the BOP as an APP to do all of the following: a) Perform patient assessments; b) Order and interpret drug therapy-related tests; c) Refer patients to other health care providers; d) Participate in the evaluation and management of diseases and health conditions in collaboration with other health care providers; and, SB 493 Page 3 e) Initiate, adjust, or discontinue drug therapy, pursuant to the manner specified in existing law which includes: the requirement of a specific written order or authorization made by the individual patient's treating prescriber, in accordance with policies, procedures, or protocols, as specified, that adjusting a regimen does not include substituting or selecting a different drug, except as authorized by the protocol, and requiring the pharmacist to provide written notification to the patient's treating prescriber, or enter the appropriate information in an electronic patient record systems shared by the prescriber, of any drug regimen initiated within 24 hours. 7)Requires pharmacists who adjust or discontinue drug therapy to promptly transmit written notification to the patient's diagnosing prescriber or enter the appropriate information in a patient record system shared with the prescriber. Requires pharmacists who initiate drug therapy to promptly transmit written notification to, or enter the appropriate information into, a patient record system shared with the patient's PCP or diagnosing provider, as appropriate. Requires pharmacists, prior to initiating or adjusting a controlled substance therapy to personally register with the federal Drug Enforcement Administration (DEA). 8)Provides that 6) and 7) above is not to interfere with a physician's order to dispense a prescription drug as written, or other order of similar meaning. 9)Authorizes pharmacists, in addition to the current authority of pharmacists to administer immunizations pursuant to a protocol with a prescriber, to independently initiate and administer vaccines listed on the routine immunization schedules recommended by the federal Advisory Committee on Immunization Practices (ACIP), in compliance with individual ACIP vaccine recommendations, and published by the CDC for persons three years of age and older. Requires pharmacists to do all of the following to initiate and administer such immunizations: a) Complete an immunization training program endorsed by the CDC or the Accreditation Council for Pharmacy Education (ACPE) that, at a minimum, includes hands-on injection technique, clinical evaluation of indications and contraindications of vaccines, and the recognition and treatment of emergency reactions to vaccines, and maintain SB 493 Page 4 that training; b) Be certified in basic life support; and, c) Comply with all state and federal recordkeeping and reporting requirements, including providing documentation to the patient's primary care provider and entering information in the appropriate immunization registry designated by the immunization branch of the Department of Public Health; 10)Authorizes pharmacists administering immunizations to also initiate and administer epinephrine or diphenhydramine by injection for the treatment of a severe allergic reaction. 11)Authorizes pharmacists to furnish NRPs approved by the Food and Drug Administration for use by prescription only in accordance with standardized procedures and protocols developed and approved by both the BOP and the MBC in consultation with other appropriate entities and provide smoking cessation services if all of the following conditions are met: a) The pharmacist maintains records of all prescription drugs and devices furnished for a period of at least three years for purposes of notifying other health care providers and monitoring the patient; b) The pharmacist notifies the patient's PCP of any drugs or devices furnished to the patient. If the patient does not have a PCP, the pharmacist provides the patient with a written record of the drugs or devices furnished and advises the patient to consult a physician of the patient's choice; c) The pharmacist is certified in smoking cessation therapy by an organization recognized by the BOP; and, d) The pharmacist completes one hour of continuing education (CE) focused on smoking cessation biennially. 12)Authorizes the BOP and the MBC to ensure pharmacists' compliance with 11) above, and each board is specifically charged with enforcement, as specified, and prohibits construing 11) above to expand the authority of a pharmacist to prescribe any other prescription medication. 13)Requires a person seeking recognition as an APP to meet all of the following requirements: a) Hold an active license to practice pharmacy, as specified; SB 493 Page 5 b) Satisfy any two of the following criteria: i) Earn certification in a relevant area of practice, including, but not limited to, ambulatory care, critical care, nuclear pharmacy, nutrition support pharmacy, oncology pharmacy, pediatric pharmacy, pharmacotherapy, or psychiatric pharmacy, from an organization recognized by the ACPE or another entity recognized by the BOP; ii) Complete a postgraduate residency through an accredited postgraduate institution where at least 50% of the experience includes the provision of direct patient care services with interdisciplinary teams; or, iii) Have provided clinical services to patients for at least one year under a collaborative practice agreement or protocol with a physician, APP, pharmacist practicing collaborative drug therapy management, or health system. c) File an application with the BOP for recognition as APP and pay the applicable fee. 14)Indicates that APP recognition issued pursuant to 13) above is valid for two years, coterminous with the certificate holder's license to practice pharmacy. 15)Requires the BOP to adopt regulations establishing the means of documenting completion of the requirements for an APP recognition, as specified. 16)Requires the BOP, by regulation, to set the fee for the issuance and renewal of APP recognition at the reasonable cost of regulating the practice of an APP. Prohibits the fee from exceeding $300. 17)Requires a pharmacist recognized as an APP to complete 10 hours of CE each renewal cycle in addition to the other CE requirements. Requires the subject matter to be in one or more areas of practice relevant to the pharmacist's clinical practice. 18)Finds and declares that pharmacists are health care providers who have the authority to provide health care services. 19)Makes other technical, clarifying, and conforming changes. EXISTING LAW : 1)Establishes the BOP to regulate the practice of pharmacy, SB 493 Page 6 including the licensure of pharmacists. 2)Provides that the practice of pharmacy is a dynamic patient-oriented health service that applies a scientific body of knowledge to improve and promote patient health by means of appropriate drug use, drug-related therapy, and communication for clinical and consultative purposes. Indicates that pharmacy practice is continually evolving to include more sophisticated and comprehensive patient care activities. 3)Makes it unlawful for any person to manufacture, compound, furnish, sell, or dispense any dangerous drug or dangerous device, or to dispense or compound any prescription of a prescriber unless that person is a pharmacist. 4)Defines prescription to mean an oral, written, or electronic transmission order that is both: a) given individually for the person or persons for whom it was ordered, as specified; and, b) issued by a physician, dentist, optometrist, podiatrist, veterinarian, or naturopathic doctor, as specified, by a certified nurse-midwife, nurse practitioner (NP), physician assistant (PA), or naturopathic doctor or by a pharmacist, as specified. 5)Authorizes a pharmacist to initiate a prescription in specified settings, including a licensed health care facility, home health agency, or a licensed clinic, as specified. 6)Authorizes a pharmacist to furnish emergency contraception drug therapy in accordance with standardized procedure or protocols developed by the pharmacist and an authorized prescriber, as specified. 7)Authorizes a pharmacist to do the following: a) Furnish a reasonable quantity of compounded drug product to a prescriber for office use by the prescriber; b) Transmit a valid prescription to another pharmacist; c) Administer, orally or topically, drugs and biologicals; d) Perform procedures or functions in a licensed health care facility, as specified; e) Perform procedures or functions as part of the care provided by a health care facility, licensed home health agency, a licensed clinic, a provider who contracts with a licensed health care service plan, or a physician, as specified; SB 493 Page 7 f) Manufacture, measure, fit to the patient, or sell and repair dangerous devices or furnish instructions to the patient or the patient's representative concerning the use of those devices; g) Provide consultation to patients and professional information, including clinical or pharmacological information, advice, or consultation to other health care professionals; and, h) Administer immunizations pursuant to a protocol with a prescriber. 8)Requires a pharmacist who is authorized to issue an order to initiate or adjust a controlled substance therapy to personally register with the DEA. 9)Prohibits the BOP, unless exempted, from issuing or renewing a license to conduct a pharmacy to: a) person/s authorized to prescribe or write a prescription (physician, dentist, optometrist, podiatrist, veterinarian, naturopathic doctors, certified nurse midwife, NP, or PA); b) person/s with whom those specified in 9)a) above share a community or other financial interest in the permit sought; or, c) any corporation that is controlled by, or in which 10% or more of the stock is owned by a person prohibited from pharmacy ownership pursuant to 9)a) or b) above. 10)Prohibits a person from conducting a pharmacy unless he or she has obtained a licensed from the BOP. Requires a license for each pharmacy owned or operated by a specific person. FISCAL EFFECT : According to the Senate Appropriations Committee: 1)One-time costs of about $200,000 to adopt new regulations and upgrade the existing system for processing license applications (Pharmacy Board Contingent Fund). 2)Ongoing costs of about $300,000 per year for licensing and enforcement (Pharmacy Board Contingent Fund). 3)Indeterminate impact on state health care programs, such as the California Public Employees' Retirement System and Medi-Cal. COMMENTS : SB 493 Page 8 1)PURPOSE OF THIS BILL . According to the author, as a result of the implementation of the Patient Protection and Affordable Care Act, about 4.7 million more Californians will be eligible for health insurance starting in 2014. The newly insured will increase demand for healthcare services and will create more pressure on an already strained health care system, particularly in medically underserved areas. This bill will allow for better utilization of the existing infrastructure of trained medical providers to bridge the provider gap through expanded practice. Californians deserve access to high quality primary care offered by a range of safe, efficient, and regulated providers. PAs, NPs, pharmacists and optometrists all have significantly advanced degrees and an upgraded program accreditation process. Other states have recognized these advances with practice acts that align with professional competence and advanced education. But California's practice acts have not kept pace. We can no longer afford to get by on a fraction of our professional capacity. California has a robust network of providers who are well-trained, evenly distributed throughout the state, and well positioned to pay particular attention to currently underserved areas. Deploying these professionals in a team-based delivery model where they work collaboratively with physicians will allow California to meet the demands placed on the healthcare systems. 2)BACKGROUND . a) The Practice of Pharmacy . Current law authorizes pharmacists to furnish compounded drug products, transmit a valid prescription to another pharmacist, administer, orally or topically, drugs and biologicals pursuant to a prescriber's order, perform procedures or functions in a licensed health care facility, licensed home health agency, manufacture, measure, fit to the patient or sell and repair dangerous devices or furnish instructions to the patient regarding the use of such devices, furnish emergency contraception drug therapy, and provide consultation and professional information, including clinical or pharmacological information to patients, advice, or consultation to other health care professionals, and administer immunizations pursuant to a protocol with a prescriber. SB 493 Page 9 In a licensed health care facility, a home health agency, a licensed clinic in which there is physician oversight, a provider who contracts with a licensed health plan for the provision of services to enrollees of the health care service plan or a physician, and pursuant to policies, procedures, or protocols developed by health professionals, a pharmacist could perform additional functions, including: i) ordering or performing routine drug therapy-related patient assessment procedures including temperature, pulse, and respiration; ii) ordering drug therapy-related laboratory tests; iii) administering drugs and biologicals by injection pursuant to a prescriber's order; iv) initiating or adjusting the drug regimen of a patient pursuant to an order or authorization made by the patient's prescriber. It should be noted that many of the functions that this bill authorizes for APPs are functions that are already performed by pharmacists in the above settings. b) Education and Training of Pharmacists . According to the BOP, there are approximately 40,000 licensed pharmacists in California, and eight pharmacy schools based in the state. The Pharmacy Act requires that pharmacists, to obtain licensure, must have graduated from a college of pharmacy or department of pharmacy of a university recognized by the BOP; have completed at least 150 semester units of collegiate study in the United States, or the equivalent thereof in a foreign country, and no less than 90 of those units must be completed while in resident attendance at a school or college of pharmacy; have earned at least a baccalaureate degree in a course of study devoted to the practice of pharmacy; have completed 1,500 hours of pharmacy practice or experience; and, have passed the North American Pharmacist Licensure Examination and the California Practice Standards and Jurisprudence Examination for Pharmacists. For purposes of the 1,500 hours of pharmacy practice experience, the BOP requires the following: i) a minimum of 900 hours must be obtained in a pharmacy; ii) a maximum of 600 hours may be granted at the discretion of the BOP for other experience substantially related to the practice of pharmacy; iii) experience in both community pharmacy and institutional pharmacy settings; and, iv) pharmacy experience that satisfies the requirements for both introductory and advanced pharmacy practice experiences established by the ACPE. The BOP also requires pharmacists to complete 30 hours of CE every two SB 493 Page 10 years for purposes of license renewal. The ACPE is the national agency for the accreditation of professional degree programs in pharmacy and providers of pharmacy CE. All pharmacy schools in the country and California are ACPE-accredited. ACPE initially established standards for the baccalaureate degree in pharmacy, then added the doctor of pharmacy standards as an alternative, and in 2000 announced the conversion to the doctor of pharmacy (PharmD) as the sole entry-level degree for the profession of pharmacy. c) Vaccines . This bill authorizes a pharmacist to independently administer vaccines listed on the routine immunization schedules recommended by ACIP. According to the CDC, vaccines are responsible for the control of many infectious diseases that were once common in this country and around the world, including polio, measles, diphtheria, pertussis (whooping cough), rubella (German measles), mumps, tetanus, and Haemophilus influenzae type b (Hib). Vaccine-preventable diseases have a costly impact, resulting in doctor's visits, hospitalizations, and premature deaths. Sick children can also cause parents to lose time from work. Vaccines contain the same antigens or parts of antigens that cause diseases, but the antigens in vaccines are either killed or greatly weakened. Vaccine antigens are not strong enough to cause disease but they are strong enough to make the immune system produce antibodies against them. Federal law requires ACIP to provide advice and guidance to the Secretary of the U.S. Department of Health and Human Services (HHS), the Assistant Secretary for Health, and the CDC on the most effective means to prevent vaccine-preventable diseases. Another goal of ACIP is to increase the safe usage of vaccines and related biological products. ACIP consists of 15 experts in fields associated with immunization who have been selected by the HHS Secretary, and is the only entity in the federal government which develops recommendations for the routine administration of vaccines to children and adults, along with schedules regarding the age for vaccine administration, appropriate dosage, dosing intervals, precautions, and contraindications applicable to the vaccines SB 493 Page 11 d) Healthcare Workforce Shortage . On March 23, 2010, President Obama signed the ACA (Public Law (PL) 111-148), as amended by the Health Care and Education Reconciliation Act of 2010 (PL 111-152). Among other provisions, the new law requires most U.S. citizens and legal residents to have health insurance; creates state-based American Health Benefit Exchanges through which individuals can purchase coverage, with premium and cost sharing credits, and creates separate exchanges through which small businesses can purchase coverage. A 2011 study by the Center for the Health Professions of the University of California, San Francisco entitled "California's Health Care Workforce: Readiness for the ACA Era" indicates that with California's implementation of the ACA, 4-6 million Californians will obtain coverage. As such, there is a need not only for a sufficient number of providers but also providers who can meet the needs of a diverse and changing public. Specifically, the study points out that primary care will be the area most immediately affected because preventive care and chronic disease management become increasingly important. In March 2012 and March 2013, the Senate Health Committee conducted informational hearings relating to healthcare workforce and the ACA. The hearings explored the supply, and expected demand, for various healing arts practitioners as part of ACA implementation. Additionally, several options were discussed to address workforce needs. 3)SUPPORT . The University of California states that full and consistent recognition of scope of practice and provider status by health care payers for California pharmacists would enable the pharmacy profession to make significant strides forward. In this era of limited resources, the changes proposed by this bill would help increase workforce capacity, improve access to care, more fully integrate the pharmacy profession into the health care team, and potentially offer much-needed costs savings to California. Pharmacy schools such as Touro University state that this bill allows more pharmacists to practice to their level of education. It states that graduates are trained to manage chronic diseases such as hypertension, diabetes, and hyperlipidemia. SB 493 Page 12 The California Chronic Care Coalition states that pharmacists are highly-trained health care workers, who can provide some preventative health care measures and medications in very safe conditions to people who would otherwise go without health care. Blue Shield of California indicates that this bill will help alleviate the healthcare access challenge, help control costs, and reduce the strain in our overburdened healthcare system. The California Retailers Association indicates that pharmacists are one of the most underutilized healthcare professionals within the healthcare system and historically their role in providing direct patient care has been fairly limited. However, pharmacists are well- equipped with the clinical and professional experience to do much more and are uniquely and conveniently situated within communities to help patients optimize medication use, prevent medication-related problems, and improve health outcomes through the delivery of direct and frequent patient care services such as Medication Therapy Management, health promotion and education among other functions. The California Board of Pharmacy states that the functions and services that an APP may perform under this bill are not new and pharmacists can currently perform these types of functions and services in certain settings under certain conditions. Pharmacists are highly educated, with extensive training in patient care and disease prevention and management, and are one of the most accessible health care providers to patients. 4)OPPOSITION . The California Chapter of the American College of Emergency Physicians opposes a previous version of this bill and states that "pharmacists have no education training to perform physical examinations nor do they have any training to diagnose medical conditions. As physicians educated and trained in the complexities of human physiology and epidemiology, we cannot imagine how someone without adequate education or training could safely perform physical exams or render diagnosis. Additionally, the bill introduces potential conflicts of interest and undermines the corporate ban on the practice of medicine because pharmacists are not covered by the ban. It is foreseeable that a pharmacist working for a retail chain could be paid to prescribe a drug by the company SB 493 Page 13 profiting from the prescription. The California Psychiatric Association opposes the APP provisions of this bill because of the potential risks to the health and safety of patients of psychiatrists or other physicians who are taking powerful, sometimes dangerous psychotropic medications which often have serious side effects. 5)OPPOSE UNLESS AMENDED . The California Academy of Family Physicians has an oppose unless amended position on a prior version of this bill and states that the single training course required for pharmacists to administer vaccines puts patients at risk; smoking cessation drugs and devices should only be used under close medical supervision; fragmented primary care received in a pharmacy may not be an appropriate venue in which to monitor patients using these medications; and, the authority of an APP to adjust drug therapy should be contingent upon notice to the prescriber. The Osteopathic Physicians and Surgeons of California (OPS) also has an oppose unless amended position on a prior version of this bill and indicates concerns regarding giving authority to pharmacists to furnish self-administered hormonal contraception, prescription smoking-cessation drugs, and medications required for international travelers. OPS states that unlike physicians, pharmacists do not conduct full patient assessments in the course of their practice that would identify potential contraindications from these medications. 6)NEUTRAL . The California Medical Association (CMA) has taken a neutral position on this bill and indicates that this bill, as amended, enables pharmacists, with the appropriate training and education, to attain the APP designation and this would help improve the communication and coordination between the patient, the physician, and their pharmacists. CMA also points out that the amendments have the potential to improve access to vaccines for children and access to nicotine based smoking cessation products for adults seeking to end their addiction to tobacco products. 7)RELATED LEGISLATION . a) SB 491(Ed Hernandez), among other provisions, authorizes a NP to practice independently if the NP meets specified SB 493 Page 14 experience and certification requirements. SB 491 is pending in the Assembly Business, Professions and Consumer Protection Committee. b) SB 492 (Ed Hernandez), among other provisions, expands the scope of practice of optometrists, as specified, and states the Legislature's intent that the Office of Statewide Health Planning and Development, under the Health Workforce Pilot Projects Program, designate a pilot project intended to test, demonstrate, and evaluate expanded roles for optometrists in the performance of management and treatment of diabetes mellitus, hypertension, and hypercholesterolemia. SB 492 is pending in the Assembly Business, Professions and Consumer Protection Committee. 8)PREVIOUS LEGISLATION . a) AB 2408 (Negrete McLeod), Chapter 777, Statutes of 2006, among various provisions, authorizes a pharmacist to perform certain procedures or functions in specified facilities, including a health care facility, home health agency, or licensed clinic. b) AB 1711 (Strickland), Chapter 58, Statutes of 2005, authorizes a registered nurse or licensed pharmacist to administer in skilled nursing facilities influenza and pneumococcal immunizations to patients over 50 years of age, as specified. c) SB 490 (Alpert), Chapter 651, Statutes of 2003, authorizes a licensed pharmacist to initiate emergency contraceptives in accordance with standardized procedure approved by BOP and MBC. 9)DOUBLE-REFERRAL . This bill is double referred, it was heard in the Assembly Business, Professions and Consumer Protection Committee on August 6, 2013, and passed out on a 14-0 vote. 10)POLICY CONCERNS . a) Patient Assessments . This bill authorizes an APP to perform patient assessments. However, it is unclear whether patient assessments include conducting full or partial physical examinations. Under existing law, a SB 493 Page 15 pharmacist in a health care facility could order and perform routine drug therapy-related patient assessment procedures including temperature, pulse, and respiration. The Chair recommends that the performance of patient assessments should only be for purposes of drug therapy, as in existing law for pharmacists in a health care facility. b) Vaccines . This bill authorizes a pharmacist to independently initiate and administer vaccines listed on the routine immunization schedules recommended by ACIP for persons three years of age and older and requires a pharmacist to complete an immunization training program, as specified. The Chair recommends that the training required in this bill specifically include demonstrated proficiency annually in the application of ACIP's recommended immunization schedules. c) Order and Interpret Tests . Provisions relating to the ordering and interpreting of tests are contained in two different sections of this bill. First, Section 4052 (a) (12) authorizes a pharmacist to order and interpret tests for the purpose of monitoring and managing the efficacy and toxicity of drug therapies. According to the author, this authority is limited to monitoring the efficacy and toxicity of drug therapies, and does not allow the pharmacist to take any action/s based on the results of the test. On the other hand, Section 4052.6 authorizes an APP to order and interpret drug therapy-related test which is broader and aligns with an APP's additional authority to adjust, initiate, or discontinue drug therapy pursuant to a protocol, as specified. The Chair is concerned that these provisions provide no parameters on how these functions could be accomplished. For example, this bill provides no practice guidelines for ordering and interpreting these tests, the need to evaluate the test results in the context of a patient's full medical history, which a pharmacist may not have access to, the handling of abnormal test results that require discussion or consultation with a physician, and the need for additional patient assessments. As such, the Chair recommends that a pharmacist orders and interprets these tests under the direction of a physician who is actively involved in the direct care of the patient, such as the prescribing physician. This recommendation would correspond to current practice by health system pharmacists who are members of the patient care team. SB 493 Page 16 Additionally, there is nothing in this bill that requires a pharmacist to provide a copy of the test results to the patient or the physician who is actively involved in the direct care of the patient, which is required under this bill when drugs and devices are furnished to the patient, and also when a pharmacist initiates, adjusts, or discontinues drug therapy. To be consistent and facilitate communication with the physician, the Chair recommends that a pharmacist who orders and interprets tests must provide a copy of the test results to the patient or the physician who is actively involved in the direct care of the patient. d) Corporate Influence . This bill expands the role of pharmacists by, among other functions, authorizing them to independently administer vaccines, order and interpret tests, and initiate a prescription (APP). In those instances that a corporation employs these pharmacists, the Chair is concerned that that the financial goals of a corporation may conflict with the professional goals of a pharmacist. The Chair recommends including a provision in this bill to make it unprofessional conduct for a person (defined in the Pharmacy Act to include a firm, association, partnership, corporation, limited liability company, state governmental agency, or political subdivision) who conducts a pharmacy to exert undue influence on a pharmacist to commit any act or omission with the primary purpose of increasing revenue, sales, or other financial influence. REGISTERED SUPPORT / OPPOSITION : Support Adventist Health American Society of Health-System Pharmacists Bay Area Council Blue Shield of California California Association for Nurse Practitioners California Association of Physician Groups California Association of Public Hospitals and Health Systems California Chronic Care Coalition California Hospital Association California Immunization Coalition California Korean American Pharmacists Association SB 493 Page 17 California Medical Board California Northstate University, College of Pharmacy California Optometric Association California Pharmacists Association California Primary Care Association California Retailers Association California Society of Health-System Pharmacists California State Board of Pharmacy Californians for Patient Care Cedars-Sinai Medical Center Dignity Health Indian Pharmacists Association of California Kaiser Permanente Loma Linda University National Asian American Coalition National Association of Chain Drug Stores Pharmacy Choice and Access Now Private Essential Access Community Hospitals Safeway St. Elizabeth Community Hospital Touro University-California, College of Pharmacy United Nurses Association of California/Union of Health Care Professionals University of California University of California, San Diego, Skaggs School of Pharmacy and Pharmaceutical Sciences University of California, San Francisco Western University of Health Sciences Numerous pharmacy students Opposition American College of Emergency Physicians, California Chapter Blind Children's Center California Academy of Eye Physicians and Surgeons California Academy of Family Physicians California Psychiatric Association California Right to Life Committee, Inc. California Society of Anesthesiologists California Society of Plastic Surgeons Canvasback Missions, Inc. Dream Machine Foundation Here for Them, Inc. Let's Face It Together Foundation Lighthouse for Christ Mission and Eye Center SB 493 Page 18 Osteopathic Physicians and Surgeons of California Sansum Diabetes Research Institute Time for Change Foundation Union of American Physicians and Dentists Ventura County American Chinese Medical Dental Association Analysis Prepared by : Rosielyn Pulmano / HEALTH / (916) 319-2097