Health-system pharmacists empower the team

The role of health-system pharmacists has evolved considerably over the last half century. No longer responsible only for compounding drugs and dispensing prescriptions, today's health-system pharmacists are an integral part of an enterprise-wide healthcare team.

See also: Five top trends for health-system pharmacists in 2016

Many-sided expertise

As they participate in rounding teams, develop pharmaceutical care plans, and create medication therapy management (MTM) strategies, health-system pharmacists are involved in patient care and interact regularly with physicians, nurses, and other caregivers.

See also: Some hospital pharmacy leaders who have made a difference

With the establishment of residency programs, antimicrobial stewardship programs, specialties in emergency medicine and ambulatory care, and board certification, health-system pharmacists have established themselves as essential healthcare professionals.

They evaluate trends in medication use and physician prescribing, develop guidelines for medication use, educate patients and healthcare professionals, and implement and maintain drug distribution systems. In some hospitals, they provide specialized services in areas such as pediatrics, oncology, infectious diseases, nutrition support, and drug information.

As patient safety experts, they are responsible for the automation systems that control drug distribution. In collaboration with nursing, they help to ensure that patients receive the right medication, in the correct form and dosage, at the right time, in order to prevent adverse events.

Standards and certification

Kasey Thompson"Hospital pharmacists have long embraced the roles that practice standards, residency training, credentialing and privileging, and specialty certification play in achieving optimal patient care outcomes," said Kasey K. Thompson, PharmD, MS, MBA, vice president, ASHP Office of Policy, Planning, and Communications.

Thompson noted that pharmacy technician education, training, and certification, along with the enhanced use of information technology, have also played important roles.

"These advancements and others in hospitals have served as examples for other practice settings, many of which are now seeking to adopt similar pharmacy practice models," Thompson said.  

Residency programs

According to the American Society of Health-System Pharmacists (ASHP), pharmacy residencies date back to the early 1930s. Originally referred to as internships, the main goal of residencies was to train pharmacists in hospital pharmacy management.

ASHP got involved in 1948 with the development of standards for pharmacy internships. In 1962, ASHP established an accreditation process and accreditation standards for residencies in hospital pharmacy.

Fast forward to the 1970s. Residencies in clinical practice increased, which led to the establishment of accreditation standards for clinical pharmacy and specialized residency training. According to ASHP, at that juncture, most programs were conducted in colleges of pharmacy, and general and clinical residencies were recognized separately.

By the early 1990s, the two types of programs were replaced by pharmacy practice residencies that placed a greater focus on pharmaceutical care. By the late 1990s, ASHP had developed accreditation standards that recognized 15 specialized areas of practice.

Partnerships

Recently, ASHP has forged partnerships with other pharmacy associations, including the Academy of Managed Care Pharmacy (AMCP), the American College of Clinical Pharmacy (ACCP), and the American Pharmacists Association (APhA), for accreditation of residencies. 

In 2005, ASHP established new residency accreditation standards that replace pharmacy practice residencies with postgraduate year one (PGY1) pharmacy residencies and specialized residencies with postgraduate year two (PGY2) pharmacy residencies. 

Health-system pharmacists, according to ASHP, can achieve board certification in a variety of specialty areas: ambulatory care, critical care, nuclear pharmacy, nutrition support pharmacy, oncology, pediatrics, pharmacotherapy, and psychiatric pharmacy.

Numerous studies have indicated that expanding the role of pharmacists in the hospital setting can have a positive impact on the quality of patient care and can provide cost savings.

Board certification

Established in 1976, the Board of Pharmacy Specialties (BPS) was created as an independent division of APhA.

The goals of BPS certification aim to:

• Grant recognition of appropriate pharmacy practice specialties on the basis of criteria established by BPS

• Establish standards for certification and recertification of pharmacists in recognized pharmacy practice specialties

• Grant to qualified pharmacists certification and recertification in recognized pharmacy practice specialties

• Serve as a coordinating agency and information clearinghouse for organizations and pharmacists in recognized pharmacy practice specialties

• Enhance public/consumer protection by developing effective certification programs for specialty practices in pharmacy

More than 20,000 pharmacists worldwide are board-certified by BPS in the eight specialties already mentioned. Data have shown that when specialty-trained pharmacists are part of the collaborative care team, patient satisfaction is enhanced, with fewer complications in drug treatment; laboratory monitoring improves; use of unnecessary medications is reduced; and hospital stays are shorter, resulting in lower treatment costs.

Emergency medicine

It wasn't until the early 1970s that hospital pharmacists were involved in emergency departments (ED). In those early years, they dealt mostly with cost containment, inventory control, and dispensing.

In the December 1, 2015 issue of the American Journal of Health-System Pharmacy (AJHP), "Emergency medicine pharmacy: Still a new clinical frontier," an article by co-authors Nicole M. Aquisto, PharmD, and Daniel P. Hays, PharmD, noted: "As hospital distribution practices changed, the role of the pharmacist developed into one that was more clinically focused."

The development of emergency medicine (EM) pharmacy services was sluggish in the early years, according to Aquisto and Hays, until the Institute of Medicine's landmark 1999 report on medical errors revealed that EDs had high rates of preventable adverse drug events. Then it was recognized that the inclusion of pharmacists in the ED setting could help reduce error rates.

But to achieve that goal, Aquisto and Hays noted that this new area of practice for pharmacists would require validation, accreditation, and new practice guidelines.

Initially, clinical pharmacy services focused on drug procurement during cardiac arrest, adverse drug event surveillance, and identification of medication-related ADEs in the ED.

Clinical pharmacy services in the ED began to escalate in the early 2000s. ASHP has been instrumental in supporting the growth of EM pharmacy practice. 

EM physicians and nurses value the pharmacists' role in the ED. In 2014, pharmacists involved with ASHP's Section Advisory Group on Emergency Care drafted a resolution document asking that the American College of Emergency Physicians (ACEP) create a policy statement to support clinical pharmacy services in the ED.  In 2015, ACEP adopted the resolution, and the American Academy of Emergency Medicine (AAEM) accepted pharmacists as members of the organization's Allied Health Professionals membership category.

Ambulatory care

Throughout the 1960s and 1970s, ambulatory care pharmacy practice in the United States was the domain of stand-alone independent community pharmacists.

In "Evolution of ambulatory care pharmacy practice in the past 50 years," an article published in the December 1, 2015 issue of AJHP, co-authors Jannet M. Carmichael, PharmD, and Deanne L. Hall, PharmD, noted that while hospitals and clinics operated outpatient pharmacies that allowed patients to fill prescriptions before being discharged from the hospital, those facilities were not intended to fill prescriptions for medications used for chronic conditions.

In the early 1950s, APhA prohibited pharmacists from discussing therapeutic effects of a prescription drug with a patient. That counseling prohibition was removed in 1969. The policy shift, according to Carmichael and Hall, enabled pharmacists to begin offering patients verbal consultations.

During the 1970s and 1980s, pharmacists started getting involved with clinical ambulatory care pharmacy. In 1972, the Indian Health Service developed the Pharmacy Practitioner Training Program, which was designed to position ambulatory care pharmacists as patient care providers in the area of chronic disease management.

Carmichael and Hall reported that in the 1990s, the Department of Veterans Affairs (VA) established guidelines for deployment of "clinical pharmacy specialists" within the ambulatory care environment, which paved the way for the use of pharmacists to provide direct patient care in the management of anticoagulation therapy and chronic diseases. 

According to the authors, in the years between 1990 and 2000, increased "focus on chronic disease state management and disease prevention positioned the ambulatory care pharmacist to become a vital member of the healthcare team by improving patient outcomes."

In 1990, ASHP created an accreditation standard for residencies in primary care that was revised as a standard for PGY2 residencies in ambulatory care pharmacy in 2006.

Critical care

Critical care pharmacy has been in existence only for about 35 years. Clinically oriented pharmacy practice came about as a result of changes in industry processes, education standards, laws, and coordination of views through professional organizations, according to Neal Benedict, PharmD, and Mary M. Hess, PharmD. In their article "History and future of critical care pharmacy practice," published in the December, 2015 issue of AJHP, the notion of moving pharmacists into patient care areas began in the mid-1960s.

In the "Ninth-Floor Pharmacy Project" at the University of California, San Francisco (UCSF), pharmacists were responsible for distributing drugs and gathering drug histories from patients at Moffitt Hospital. Ultimately, according to Benedict and Hess, the pharmacist's role expanded to include participation on resuscitation teams and responsibility for parenteral nutrition calculations.

In 1962, ASHP developed formal pharmacy post-graduate training program standards that focused on hospital pharmacy administration. This evolved into a greater emphasis on hospital and clinical pharmacy standards, and on specialized residency standards, in the 1980s.

The Ninth-Floor Pharmacy Project paved the way for pharmacists to engage directly with physicians in the management of patients. Benedict and Hess cite a landmark 1999 study by Leape and colleagues "describing the major impact pharmacists can have on ICU patient safety through the reduction of preventable adverse events."

Antimicrobial stewardship

An ASHP position paper promoting the pharmacist's role in antimicrobial stewardship and infection control states, "Pharmacists have a responsibility to take prominent roles in antimicrobial stewardship and infection prevention and control programs in health systems."

The association contends that pharmacists should participate in antimicrobial stewardship and infection prevention and control efforts through clinical endeavors that concentrate on correct antimicrobial use and membership on appropriate multidisciplinary work groups and committees in health systems.

According to ASHP, antimicrobial stewardship is employed in practice settings of health systems to improve patient outcomes and minimize the unintended consequences of antimicrobial use. The goals of antimicrobial stewardship programs include attenuating or reversing antimicrobial resistance, preventing antimicrobial-related toxicity, and reducing the costs resulting from inappropriate antimicrobial use and healthcare-associated infections.

Paul AbramowitzAt an antimicrobial stewardship forum convened by the White House in June 2015, a top official at the Department of Health and Human Services (HHS) suggested that hospitals would eventually be required to improve the way they use antimicrobial drugs.

Paul W. Abramowitz, ASHP's executive vice president and CEO, applauded the Obama Administration's initiative in making antibiotic stewardship a national priority and in recognizing the vital roles that pharmacists play in improving stewardship and antibiotic use.

Chief pharmacy officer

As the role of the health-system pharmacist continues to expand beyond clinical duties, the pharmacy executive, a relatively new position, is also gaining ground.

According to ASHP, it behooves hospitals and health systems to have a pharmacy executive responsible for the strategic planning, design, operation, and improvement of the organization’s medication management system.

Widespread use of the title “chief pharmacy officer” was first proposed in 2000 in an effort to enhance the contribution of pharmacy by creating organizational parity between the pharmacy executive and other C-suite executives, including chief nursing, medical, and information officers.

In its position statement on the "Roles and Responsibilities of the Pharmacy Executive," ASHP asserted that "when the pharmacy executive works collaboratively with others at this executive level, the pharmacy department is better positioned to effectively contribute to the organization’s strategic initiatives and address system-wide issues regarding medications and medication management."
 

The future

Going forward, how will the evolving role of the health-system pharmacist continue to benefit the patient?

For some industry experts, the answer to that question is clear.

"Pharmacists improve patient outcomes as members of interprofessional teams," said ASHP's Thompson. When a pharmacist is on the team, patients are safer, medication therapy is optimized, and healthcare costs are lower, he said.

"As healthcare, science, and pharmacy practice continue to evolve, pharmacists will continue to take on enhanced roles in areas such as pharmacogenomics, personalized medicine, and many others," said Thompson. "It’s really wonderful to see how much the medical community, patients, and other providers have embraced the vital roles pharmacists play as direct patient care providers."

The clear benefits shown by team-based practice models have demonstrated the important and necessary roles pharmacists already play for patients and will continue to play in the future, said Thompson.

Anthony Vecchioneis a healthcare journalist based in New Jersey.