Many before me have said that being elected President of ACCP is a humbling experience, and it is! In fact, I hope many of you have this or a similar experience during your career, because it is so much more than humbling. It is intimidating, anxiety-provoking, and overwhelming, all at once. However, as soon as you stand back and realize how much support you receive from your colleagues, friends, family, and the staff of ACCP, you are comforted and you recognize what a gift it is to be able to serve our membership. What sets ACCP apart from other large organizations is that it is truly a member-driven, member-run organization with exceptional staff. The ACCP membership is critically important to the future of both the College and clinical pharmacy, and our future rests as much on the shoulders of our student, resident, and trainee members as it does on our more seasoned members. In ACCP, your opinions and actions really do matter.

During my brief presentation at the Opening Session in Pittsburgh, I reflected on a handful of volatile issues of the day related to health care and a number of much more global concerns. Those who attended my presentation may recall that I described the importance of keeping your eye on the ball and that, when there are many balls in the air, there is power and importance in all of us, as members of ACCP, collectively and collaboratively keeping our respective eyes on the ball for the mutual benefit of us and our patients. Let me explain. For those who have actually tried to juggle more than two balls at a time, you know how difficult it can be. We currently live in a very challenging time of change. Consider just a few of the issues frequently in the news today—the Patient Protection and Affordable Care Act, the patient-centered medical home, accountable care organizations, dwindling state budgets seriously affecting the sustainability of education and health care, potential cuts in Medicare/Medicaid coverage for vulnerable Americans, global climate change, peak oil costs as well as escalating gasoline and other transportation costs, a volatile U.S. and foreign stock market with corresponding volatility of retirement funds, worldwide economic instability—and the list goes on and on. Being aware of much more than just our focused areas of expertise will continue to be vitally important, reinforcing the importance of having a much more global perspective.

We were fortunate to have Dr. Debra Yeskey from the Office of the Assistant Secretary for Preparedness and Response as our keynote speaker. I was struck by her suggestion that the health of our nation is a matter of national security. To put her statement in context, if our citizens are not healthy, almost everything in our nation is at risk of falling apart. Imagine, for example, if the H1N1 pandemic really did become as severe as projected! If law enforcement officers, postal workers, bus drivers, nuclear plant operators, hospital workers, sanitation workers, and other key personnel became unable to work, placing our country seriously at risk. Furthermore, all too often, when we think about emergency preparedness, we think about terrorists, biological hazards, or dirty bombs, but a much more believable scenario is that our power grid will go down or that the price of gasoline and other essentials won’t be affordable for most of us and our patients. In my address, I shared that a few years ago, we surpassed “peak oil,” meaning that globally, all the liquid fossil fuels from that point on cost more per barrel, as well as require more energy, to extract. A great many ACCP members approached me during the meeting to share that they had never considered this perspective and its impact on access to and affordability of health care. The importance of this to those of us in the health care professions is that we depend on petrochemicals for many of the products we use (e.g., plastics used in hospitals; solvents, waxes, lubricants, plastics, and other products used in pharmaceutical manufacturing and packaging; and almost everything that is manufactured and transported from the site of manufacturing to the end user and the many stops along the way), and if costs rapidly escalate, the impact will be devastating. So, why all of the doom and gloom? Most of you know me as a person with a very positive outlook. My point is that as clinical pharmacists, we should be informed, looking beyond our profession-specific silos to consider the impact of the dramatic changes in our environment, which could rapidly and dramatically alter what we do in providing quality services for our patients.

Throughout my presentation, I shared with you many magazine covers with headlines from both lay and professional journals. One cover I shared described physician alignment, collaboration, and quality care; the articles within that issue further described shifting priorities as independent practitioners sell their practices and become employees of hospitals or health systems. Another story in a publication for health care leaders and administrators described innovators who are negotiating for significantly higher reimbursement by developing a new model to provide specialized treatment of high-risk and long-term-care patients often avoided by some health systems because of limited reimbursement and the risks associated with poor treatment outcomes. Some of these strategies also included changes in practitioner compensation and shifting incentives to attract and retain employees. We must understand this changing environment so that we can continue to be actively engaged in delivering quality care, with a focus on optimizing pharmacotherapeutic outcomes for our patients, as well as understand and adjust to shifts in the funding model for health care.

As clinical pharmacists, we are familiar with the importance of treatment adherence and of engaging patients in their own wellness. Together with some of the changes being considered as we witness the migration of health care toward patient-centered medical homes and accountable care organizations, it is likely that providers will be increasingly accountable for health care outcomes—in fact, we anticipate that they will be financially at risk if outcomes are not in-line with established and ever-tightening metrics. Clinical pharmacists have a long history of providing patient education and counseling as a means of improving treatment adherence and outcomes. However, we have not frequently enough documented and publicized our activities. As health care funding becomes more limited and accountability for outcomes becomes a means of clawing-back reimbursement, convincing consumers to be partners in their own wellness may be essential to optimizing both treatment outcomes and reimbursement. And who is better suited than clinical pharmacists to lead the way! Can we document our effectiveness? Of course, we can, and many of us have done so over the years. Nonetheless, it would be extraordinary and very powerful if, collectively, we could demonstrate what we as clinical pharmacists can achieve! The ACCP PBRN may be a natural place to facilitate such an effort by fostering collaboration on a large-scale demonstration project.

As I mentioned in my opening address, it is during times of crisis or volatility that we recognize the importance and power of all of us collectively and collaboratively keeping our respective eye on the ball! Collectively, we have a fund of knowledge unique from that of any other group of health professionals. A good example of keeping your eye on the ball is related to one of the current national initiatives concerning clinical decision support systems (CDSSs) that can be applied to pharmacotherapeutic decision-making. Pharmacy-based informatics systems predate many of the health information systems (HITs) developed for health systems in recent years that may affect us as well as our health professional colleagues. For example, HITs typically involve computerized physician order entry and e-prescribing, distribution (including automation), electronic medication administration records, monitoring (including laboratory and other data), and patient education and other information consistency checks and balances (medication reconciliation). Other initiatives involve the necessity for interoperability. Systems from different facilities and various modes of care must be able to effectively interface in order to provide safe and continuous patient care. A soon-to-be-published paper from the ACCP Public and Professional Relations Committee in fact addresses the clinical pharmacist’s vital role during care transitions. Throughout this process, medication-related clinical decision support is a vital and critically important component. Believe it or not, including clinical pharmacists in the development of these initiatives on a national level probably would not have occurred without the active advocacy of our exceptional Washington-based staff and the professional affairs staff of other pharmacy associations, together with some of our well-informed members. Without these key individuals keeping their eye on the ball, we would have had very limited opportunities to provide input regarding clinical decision support software. This is important because in the future, some may “suggest” that managing medication therapy can be done primarily by a CDSS without a clinical pharmacist’s input. Again, collectively, we can monitor and observe many geographic locations, different health care settings, and processes related to the delivery of health care, sharing our knowledge to help the profession navigate this volatile and rapidly changing environment.

It is also critically important to be watchful for changes and volatility peripherally associated with our professional “sphere” or domain. For example, a recent trade journal had a cover story on the potential merger of Express Scripts and Medco, asking whether such a merger could put “your business” at risk. Without making any judgment regarding this particular corporate business decision, it should be considered whether this could affect the clinical pharmacist’s ability to weigh-in regarding a patient’s drug therapy management in order to recommend the best therapeutic option to keep him or her well and able to avoid more expensive levels of care. As a clinician, have you found yourself unable to prescribe or recommend the best treatment option for one of your patients, given your knowledge of the patient’s history and other clinical factors caused by a formulary restriction? Although other agents available on the formulary may be <>i>acceptable alternatives, your knowledge of patient-specific variables might draw you to an agent that is unavailable. Sound familiar? Having served in the past as a statewide director of pharmaceutical services with responsibility for inpatient and outpatient services, I can say with confidence that, although in some instances, formulary restrictions can save money in the pharmacy budget, they may result in less-than-desirable consequences (e.g., cost shifting to other budgets) that could significantly increase total health care costs, thereby negating any net savings. Although it may be an unintended consequence, such limitations at times may also interfere with and reduce the clinical pharmacist’s ability to be effective in improving patient outcomes, an important metric in some environments, including accountable care organizations.

This week, I participated in a conference call for an editorial board with a group of psychiatrists and a primary care physician. As we discussed potential topics for upcoming issues, one of the psychiatrists raised the issue of drug interactions and spoke of being “pestered” by calls from pharmacists. The only pharmacist on the call, I quietly listened as the physicians on the call complained about these annoying calls and consults from pharmacists who “just read from their computers” and demanded that they make medication therapy changes “due to an alert that almost all of the time is irrelevant, rarely occurs, and is not a significant cause for concern.” In fact, they specifically complained about the overreaction by pharmacists because of a recent FDA alert regarding the use of citalopram (Celexa) at doses above 40 mg in patients considered at risk of QT prolongation. After politely listening, I said, “Do you really disregard communications from pharmacists and alerts and notices from the FDA? It seems to me your patient safety and quality improvement staff, and even your malpractice carriers, may have a real interest in these issues!” I was contacted a short time after the conference call by the managing editor of the journal regarding my interest in helping to develop and facilitate a roundtable discussion on the subject. We can be part of the conversation. Several of our current committees and task forces recently addressed the issue of interprofessional relationships and documenting our roles in the evolving health care delivery system. I’ll provide a progress report on these efforts in my next column.

Through ACCP, many opportunities exist to be involved in this conversation, and it has been my experience that many, if not most, ACCP members are happy to render an opinion on important issues of the day. I recently had the daunting task of making committee and task force assignments for the 2011–2012 year. I was so proud of the member response to the survey earlier this year. I spent more than 3 days reviewing the comments and interests of hundreds of qualified and motivated ACCP members interested in serving on an ACCP committee or task force. Unfortunately, there were not enough committee member slots to accommodate everyone! I filled more than 250 committee/task force openings, but I wish I could have filled more! If you or anyone you know applied to volunteer to participate and I was unable to assign him or her to a committee or task force, PLEASE complete the next annual survey and express your interest again—every effort will be made to eventually place on a committee or task force those who respond to successive surveys. We need your active involvement and welcome your opinions, so please join me as we continue to Boldly Position Clinical Pharmacy in Volatile Times.