Regular readers of the ACCP Report are aware that since May 2012, the Public and Professional Relations Committee has published a series of commentaries regarding the need for clinical pharmacy to define a consistent, direct patient care process—the so-called what of our clinical pharmacy discipline. The Annual Meeting keynote address featured a provocative presentation by Dr. Linda Strand citing the importance of the clinical pharmacy discipline’s conforming to the “rules” or standards established for the provision of direct patient care and arguing that the failure to do so might prevent clinical pharmacists from becoming essential members of the patient care team of the future. She also stressed that these rules are nonnegotiable. The late afternoon town hall meeting that followed the morning keynote session provided an opportunity for discussion by ACCP members and invited guests of the what and its significance.

Given the importance of this issue for the continued growth and recognition of clinical pharmacy in a reformed health care system, my ACCP presidential theme for this year is, “Advancing a comprehensive and consistent direct patient care practice for clinical pharmacists – the future is now.” I believe it essential that ACCP remain focused on this issue, a sentiment strongly supported by the ACCP member survey conducted in September 2012 by the Public and Professional Relations Committee, in which 78% of respondents affirmed that a consistent process of care is an important issue to our members.

The wording of my theme has several key components. First, the use of “a” assumes the position that a solitary patient care practice be embraced by clinical pharmacy. The intentional use of “’direct patient care” reinforces prior ACCP positions that clinical pharmacists providing direct patient care (as defined by ACCP and the Council on Credentialing in Pharmacy [CCP] and endorsed by CCP’s member organizations¹) should be residency-trained and board-certified (or equivalent).^2,3 Finally, “the future is now” challenges us to realize that great opportunity exists for clinical pharmacists to be central to achieving improved patient medication outcomes in a reformed health care delivery system. However, it also emphasizes that we must take definitive action now to maximize that opportunity.

Listening to the keynote presentations, discussions that ensued during the town hall meeting, and conversations that occurred during the more informal gatherings of members, it became evident to me that we must get the terminology correct so that we are using common terms. We often incorrectly interchange the terms practice, patient care process, clinical service, and practice model freely. This imprecise use of terms contributes to confusion and to the concern among some members that there cannot be a single direct patient care practice across the heterogeneous environments where clinical pharmacists practice. However, there must be one professional practice of clinical pharmacy for meaningful and sustained progress to be made. A professional practice has three required elements: (1) a philosophy of practice; (2) a specific, well-defined process of care; and (3) a practice management system. The process of care for the clinical pharmacist’s practice has been defined using several steps, but the main categories or components of these steps are (1) identifying patient-specific needs, (2) establishing a plan of care, and (3) completing a follow-up to adjust/revise the plan and ensure the best possible outcome. The process of care is an integral part of one’s professional practice, but it is not the entire practice.

For example, the Medication Management Task Force of the Patient-Centered Primary Care Collaborative has published a resource guide that defines a patient care process referred to as comprehensive medication management (CMM).⁴ This document describes a care process intended for application in the patient-centered medical home (PCMH) team-based practice environment. Although this patient care process could be provided by other members of the PCMH team, the resource guide makes a compelling argument for why the clinical pharmacist is the most qualified member of the team to provide this type of care.

A clinical service results from applying a professional practice to a specific patient care setting. The nature and delivery of the clinical service may vary in different practice settings. In medicine, how a clinical service is provided by a cardiologist will differ from how that service is provided by an endocrinologist. However, what each specialist does from a professional practice perspective is standardized and common across practice settings. In this example, the common and standardized approach constitutes the professional practice of medicine. So, for the professional practice of clinical pharmacy, a consistent, direct patient care practice that can be applied to the various settings where clinical pharmacists practice is what our discipline must seek to adopt. Indeed, without such a consistent practice, it’s unlikely that clinical pharmacists will ever be credible, fully-recognized patient care providers. We must also realize that for many years, we have used the term clinical service so nonspecifically that it has grown to include many different activities of clinical pharmacists that do not consistently meet the definition of a clinical service. We should be careful to differentiate “clinical services” from these other activities.

Finally, I must admit I am often confused by the many ways we refer to practice models. Recently, when we considered the need to define and/or agree on a clinical pharmacy practice model, we should have recognized that we are really seeking to define a consistent, direct patient care process. Instead, when referring to a given clinical practice model, we have used examples of different clinical pharmacy services that can vary, depending on the practice environment, and that probably won’t (or shouldn’t) conform to a single practice model. The Pharmacy Practice Model Initiative (PPMI) advanced by the American Society of Health-System Pharmacists (ASHP) uses the term pharmacy practice model in a much broader context. That is, through PPMI, ASHP is engaged in a comprehensive reengineering of health systems pharmacy broadly (i.e., with respect to administrative, technological, operational, as well as direct patient care activities), which laudably includes the goals of positioning the pharmacist closer to the patient and redefining and/or reengineering the provision of clinical services, including direct patient care. Although a very important and worthwhile initiative for health systems pharmacy departments, this effort represents one particular use of the term practice model. To minimize confusion with PPMI and other applications of the term practice model, it is probably best for us to avoid the use of this term altogether as we attempt to define and agree on a consistent direct patient care process for clinical pharmacy.

So, I’ve compiled below my own brief glossary of these terms to assist in their application by ACCP as we proceed to reach our own definition of the what:

Clinical service. Application of professional practice to a specific patient care setting or clinical problem area. Nature and delivery of the clinical service may vary in different patient care settings (e.g., management of patient-specific anticoagulation therapy).

Philosophy of practice. The philosophic foundation of one’s practice. Includes fundamental guiding professional principles (e.g., ethical values, fiduciary relationship with patients, patient-centeredness, and accountability for patient outcomes).

Practice management system. The system that supports the clinical pharmacist’s delivery and documentation of patient care activities, scheduling of patient visits and/or patient care activities, communication with patients and health care professionals, measurement of patient outcomes, and submission of charges, claims, or bills, as appropriate.

Practice model. For health care disciplines, a practice model typically describes a (1) process of care and (2) practice management system. Therefore, this is part of the practitioner’s professional practice, but it doesn’t constitute all components of the practice (see also Professional practice below).

Process of care. The specific steps used by clinical pharmacists in providing care to patients that contribute to optimizing patient outcomes (e.g., CMM).

Professional practice. Composed of three distinct components: (1) a philosophy of practice; (2) a specific, well-defined process of care; and (3) a practice management system.

The what. The direct patient care practice process used by clinical pharmacists. This has yet to be specifically delineated by the clinical pharmacy discipline.

In conclusion, I believe it imperative that we use common terminology as the clinical pharmacy discipline attempts to reach consensus on a consistent and comprehensive process of care. And I remain hopeful that we will come together during my presidential year to reach this consensus.

References

1. Council on Credentialing in Pharmacy. Scope of Contemporary Pharmacy Practice: Roles, Responsibilities, and Functions of Pharmacists and Pharmacy Technicians. 2009. Available at http://www.pharmacycredentialing.org/Contemporary_Pharmacy_Practice.pdf. Accessed November 8, 2012.
2. Murphy JE, Nappi JM, Bosso JA, et al. American College of Clinical Pharmacy’s vision of the future: postgraduate pharmacy residency training as a prerequisite for direct patient care practice. Pharmacotherapy 2006;26:722-33.
3. American College of Clinical Pharmacy. Board certification of pharmacist specialists. Pharmacotherapy 2011;31:1146-9.
4. Patient-Centered Primary Care Collaborative. The Patient-Centered Medical Home: Integrating Comprehensive Medication Management to Optimize Patient Outcomes. Resource Guide, 2nd ed. 2012. Available at http://www.pcpcc.net/guide/medication-management. Accessed November 8, 2012.