ACCP Report | Vol. 27, No. 5; May 2008

The chief force reshaping manufacturing today, according to David Brooks of the New York Times—technological change—may also be one of the driving forces behind the transformation of pharmacy in the 21st century. Brooks contends that the central process driving this change is not globalization but rather a skills revolution.¹ Pharmacy is clearly at this crossroad; we are faced with the dilemma that pharmacists in this demanding age—all pharmacists but especially those who provide direct patient care—will need to rely on their evolving set of cognitive skills to be relevant in the future and receive compensation for clinical services not linked to the provision of a product. The globalization paradigm emphasizes that information can now travel around the world in an instant. Indeed, products can be dispensed from anywhere in the world, but the most important part of this “dispensing” is the provision of the initial consultation (i.e., the information that makes use of the product relevant to the individual patient). This may include the coaching necessary to stimulate the patient to take the medication correctly as well as the monitoring plan—a plan that works best when the patient is engaged in his/her own care through the establishment of an ongoing relationship with the pharmacist.

Unfortunately, the future of pharmacy lacks a clear focus for many in the profession, and it is certainly an unclear landscape for other health professionals, insurers, regulators, and legislators, as well as the public. Among the key issues are the hopes that, someday soon, pharmacists will routinely use the patient-oriented cognitive skill set that academicians have been instilling in graduates for years and that the public will recognize what it can and should expect when patients interact with the pharmacist. These related issues are currently being addressed by the College’s Clinical Practice Affairs and Public and Professional Affairs committees. The commentaries they are now preparing will be significant steps toward building a broader awareness of the skills pharmacists have and where, when, and how patients should expect to benefit from these skills. Such efforts are aligned with the 2015 Vision for Pharmacy Practice released by the Joint Commission of Pharmacy Practitioners in 2005.²

JCPP’s Vision of How Pharmacists Will Practice in 2015

(Excerpted from ref 2)

Pharmacists will have the authority and autonomy to manage medication therapy and will be accountable for patients’ therapeutic outcomes. In doing so, they will communicate and collaborate with patients, caregivers, health care professionals, and qualified support personnel. As experts regarding medication use, pharmacists will be responsible for:

Rational use of medications, including the measurement and assurance of medication therapy outcomes.
Promotion of wellness, health improvement, and disease prevention.
Design and oversight of safe, accurate, and timely medication distribution systems.

Working cooperatively with practitioners of other disciplines to care for patients, pharmacists will be:

The most trusted and accessible source of medications and related devices and supplies.
The primary resource for unbiased information and advice regarding the safe, appropriate, and cost-effective use of medications.
Valued patient care providers whom health care systems and payers recognize as having responsibility for assuring the desired outcomes of medication use.

The recently announced revolutionary model of change for community pharmacy practice, “Project Destiny,” which was developed through a collaboration between the American Pharmacists Association (APhA), the National Association of Chain Drug Stores (NACDS), and the National Community Pharmacists Association (NCPA), is complementary to the direction in which ACCP is heading. Project Destiny is intended to shape the future of community pharmacy practice through a multistep process of recognition and acceptance within the profession, together with efforts to change the public’s perception of pharmacists, their skills, and the services they provide:³

"The concept of a primary care pharmacist is a fundamental component of the transformation strategy. In order for this model of practice to be successful primary care pharmacists, the community pharmacists of the present, will have to demonstrate their value by assisting patients and their providers in the overall management of medications and specific conditions."

Pharmacists of the future will have to use their cognitive skills to affect overall patient care, with a specific focus on the management of multiple conditions, including the use of medications prescribed by multiple providers. The authors of this statement suggest that the time to initiate change is now. Furthermore, they project that pharmacy will either “survive under protection of legislation or flourish under a market oriented model that yields improved patient outcomes and better economic sustainability.”³

Project Destiny’s Vision for Community Pharmacy³

Community pharmacists will fulfill the role of a primary care pharmacist, serving as a trusted and effective resource that is valued by consumers, prescribers, health care funders, and payers for their clinical and medical management expertise.
The primary care pharmacist will demonstrate value by working with consumers to navigate throughout the health care delivery system and improve health outcomes through better medication and condition management.
Working collaboratively with the health care delivery and financing systems, the primary care community pharmacist will focus on managing medications, positively impacting health outcomes, reducing overall health care system costs, and empowering consumers to actively manage their health.

So what can we learn from the global pharmacy community regarding the process of transformation of pharmacy practice? For decades, the clinical pharmacy movement has been pioneered and led by research and practice innovations that have largely emanated from the United States. However, as we enter the 21st century, many other countries have begun to redefine the roles and expectations of pharmacists. None has given pharmacists as much power as Great Britain.^4–6 Pharmacists began training to be supplementary prescribers in 2003, and more than 900 pharmacists in England are now qualified to prescribe in collaboration with a physician. This is analogous to the United States’ collaborative drug therapy management (CDTM) partnerships now authorized in 44 states.⁵

In 2006, Great Britain expanded the scope of pharmacy practice to include treating patients once pharmacists completed appropriate training. To qualify as an “independently prescribing pharmacist,” pharmacists must take a 9-week course and document at least 30 hours of experience treating patients under a physician’s supervision.⁴ Although the number of non-physician prescribers remains small, their ranks are growing, and the government hopes they will someday become the norm. More than 300 pharmacists are now qualified and registered as independent prescribers in England.⁵ Pharmacists who have met the standards may prescribe any licensed medicine for any medical condition they are competent to treat. In addition, changes to regulations will soon enable pharmacist prescribers to prescribe controlled drugs independently. Independent pharmacist prescribing is an important step toward increasing patient access to medications, making better use of pharmacist skills, and improving patient outcomes.

The leadership of the United Kingdom’s National Health Service has stated that for pharmacy to take its rightful place as a clinical profession that fully contributes to the care of the public, individual pharmacists will have to assume greater clinical responsibilities and meet greater expectations with regard to ensuring patient safety, delivering quality care, and being accountable for patient outcomes. This futuristic vision from the governmental health care establishment has contributed to radical change within the pharmacy profession in the United Kingdom—pharmacy practice has indeed entered a new era there. In addition to the developments stated, the United Kingdom has established recognition of new roles and responsibilities:

While the United Kingdom has moved aggressively in support of broadened pharmacist responsibilities, the free market system of health care in the United States has not endorsed this concept, despite a decade of emerging evidence that documents the benefits of clinical pharmacy services.^7,8 The FDA recently entertained the possibility of implementing a third class of drugs that would be available through a pharmacist’s “prescription.”⁹ The ultimate benefits of this approach will only be achieved if there is an expectation of, and policy support for, active patient-centered interaction between pharmacists and consumers that enhances patients’ understanding and appropriate use of such “third-class” medications. Evidence from other countries using pharmacist-only systems for access to designated medications suggests that these benefits are substantial and that they are valued by consumers.¹⁰

Finally, there are at least two other initiatives on the horizon that may move the U.S. pharmacy community closer to the reality of pharmacy practice that is emerging in England. First, the clinical pharmacy demonstration projects, which were funded by the Health Research and Services Administration from 2000 to 2002, were undertaken to ascertain if access to medications, when delivered as part of comprehensive pharmacy services, makes a substantial and affordable contribution to improvements in the health status of the predominantly low-income populations served by community health centers (CHCs). Data from these demonstration projects have spawned a new wave of funding for the expansion of pharmacy practice models in CHCs. The provision of disease state management services by clinical pharmacists, which “appeared to add value to the CHCs and … suggested that … further research should evaluate patient outcomes,” will now be rigorously assessed in 40 centers across the country. If these data are conclusive and positive, perhaps then Medicare and other providers will consider changing their payment policies to recognize clinical pharmacy services as a legitimate approach to care. Second, progress on the legislative front is also moving forward with the introduction last month of H.R. 5780 – The Medicare Clinical Pharmacist Practitioner Services Coverage Act by Representative Heather Wilson (R-NM).¹¹ This legislation proposes the provision of payment under Medicare Part B for “pharmacist clinicians” and “clinical pharmacist practitioners” who have been granted “prescriptive authority … by New Mexico and North Carolina state statute(s).” These new terms define pharmacists who meet the unique “advanced credential” standards of each respective state, and thus, as the bill is currently written, only these select individuals would be eligible to receive payment from Medicare. At least in theory, by changing state practice acts to amend CDTM rules and regulations to mirror those in New Mexico and North Carolina, other pharmacists could also become eligible for Medicare Part B payment for pharmacist services.

Many exciting opportunities lie ahead for the pharmacy profession. Expansion of the scope and responsibilities of pharmacists and pharmacy technicians in all practice settings (community, institutional, and other environments) is on the horizon. Now is clearly a time to actively speak out to all who will listen so that we can express with a unified voice our willingness to accept greater clinical responsibilities and deliver the level of care that the public deserves. This is not only the challenge for a few key leaders, but rather for all pharmacists. Will you accept this challenge?




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