ACCP White Paper - Pharmacy's Future Roles ... · A Vision of Pharmacy’s Future Roles, Responsibilities, and ... This White Paper examines the pharmacy ... pharmacist’s responsibilities

PHARMACOTHERAPY_The Journal of Human Pharmacology and Drug Therapy

ISSN 0277-0008

The OfficialJournal of the

AmericanCollege of

Clinical Pharmacy

A VISION OF PHARMACY’S FUTURE ROLES, RESPONSIBILITIES, AND MANPOWER NEEDS

IN THE UNITED STATES

American College of Clinical Pharmacy

Volume 20Number 8A u g u s t2 0 0 0

A Vision of Pharmacy’s Future Roles, Responsibilities, andManpower Needs in the United States

American College of Clinical Pharmacy

(Pharmacotherapy 2000;20(8)991–1022)

Executive Summary

Purpose

This White Paper examines the pharmacyprofession’s future. It discusses pharmacy’schanging philosophy of practice, factorsinfluencing the evolution of professional rolesand responsibilities, preparation for future roles,future leadership and management needs,workforce manpower projections, and qualifi-cations for practice. The paper projects a visionfor this future and provides recommendations tothe profession and to the American College ofClinical Pharmacy (ACCP).

Toward a Unified Philosophy of Practice

The time has come to unify the profession inpursuit of its patient care mission. Pharmacy ismaturing as a clinical profession and presently iswell positioned to transform itself from aproduct-oriented to a patient-oriented profession.At the root of this change is a movement torevisit the true focus of the profession—namely,the patient. The profession as a whole now mustunequivocally dedicate itself to a philosophy ofpractice that clearly identifies the patient as itsprimary beneficiary. We suggest that inculcation

of this new philosophy will require a rational,practical, and inclusive approach that engages allsegments of the profession.

Issues Influencing Change in Pharmacist Rolesand Responsibilities

Pharmacists gradually are embracing changingprofessional roles. However, several factors mayserve to impair the adoption of new roles,including lack of consensus regarding theprofession’s goals, resistance to broadening thepharmacist’s responsibilities beyond dispensingfunctions, lack of professional competenceand/or self-confidence, the false impression thatmanaged care invariably will decrease pharmacistdemand, dissension surrounding adoption of thedoctor of pharmacy as the sole professionaldegree, work environments that provide little orno opportunity for patient-centered practice, lackof reimbursement for pharmacists’ clinicalservices, and underdevelopment of practitioners’interpersonal skills. Factors that appear likely topromote changing professional roles includeopportunities to positively impact patients’ drugtherapy outcomes through disease statemanagement, expanded use of technology andtechnicians in the dispensing process, increaseddemand for drug information among healthprofessionals and consumers, new opportunitiesfor creating tailored drug therapy as the field ofpharmacogenomics is better understood, andexpanded practice roles in community,ambulatory, long-term care, and home caresettings. Regardless of the issues confrontingfuture practitioners, it is clear that we will becalled upon to provide evidence that justifiesthese new professional roles.

This paper was prepared by the 1997–1999 ACCPClinical Practice Affairs Subcommittee A: Michael S.Maddux, Pharm.D., FCCP, Chair; Betty J. Dong, Pharm.D.;William A. Miller, Pharm.D., FCCP; Kent M. Nelson,Pharm.D., BCPS; Marsha A. Raebel, Pharm.D., FCCP, BCPS;Cynthia L. Raehl, Pharm.D.; and William E. Smith,Pharm.D., Ph.D. Endorsed by the ACCP Board of Regentson May 26, 2000.

Address reprint requests to the American College ofClinical Pharmacy, 3101 Broadway, Suite 380, Kansas City,MO 64111; e-mail: [email protected]; or download fromhttp://www.accp.com.

A C C P W H I T E P A P E R

PHARMACOTHERAPY Volume 20, Number 8, 2000

Preparing for Future Pharmacist Roles

A number of steps should be considered aspharmacy prepares to shift toward a profession-wide, patient-centered practice model. Moreeffective collaboration between pharmacyeducators and the profession will be necessary toimprove experiential education, develop newpatient-centered practice models, and increasestudent professionalization. Pharmacy practicesystems must be revised to support a level ofpatient care that genuinely impacts healthoutcomes. The time has come to accept theproven health care benefits of pharmacists’clinical activities and move forward toconfidently promote these patient care roles topatients, payers, health care systemadministrators, and politicians. A broad-based,inclusive planning process involving allpharmacy organizations and associations will benecessary to address the profession’s vastretraining needs. In this regard, pharmacyfaculty and clinical practitioners must make thecommitment to provide the expertise andcooperation necessary to develop efficaciouseducation and training programs that canenhance the clinical practice abilities ofcommunity pharmacists. There is a need forcommunity and institutional pharmacy leadersand managers to commit themselves topharmacy’s patient-centered philosophy ofpractice as they address the challenges associatedwith establishing new patient care roles.Increasing the recruitment and utilization ofwell-trained pharmacy technicians to carry outappropriate dispensing functions underpharmacist supervision will be critical to thesuccessful development of new pharmacistpractice roles. Clinical pharmacy would benefitfrom increased involvement in political advocacyat the state and national levels; this might beaccomplished best by working synergisticallywith those national pharmacy organizations andassociations that have well-established politicallinks to important decision-makers. Pharmacyeducators can strengthen their efforts to developstudents’ abilities to collaborate with other healthcare professionals, function in a teamenvironment, and supervise technical personnel.Continued expansion of residency programs inall sectors of practice will be necessary to meetfuture needs for clinically trained pharmacists.Flexible and innovative approaches to residencytraining may provide practical and cost-effectivemechanisms for some experienced baccalaureate-

educated pharmacists who seek retraining.Schools and colleges of pharmacy have done agood job in effecting broad-based curricularrevision but have not yet focused on optimizingthe integration of general and professionaleducation to better prepare patient-centeredpharmacists.

Providing Necessary Leadership andManagement for the Future

The future health care environment may holdmany opportunities for pharmacists if theleadership and management of the profession canrespond quickly to focus the profession’s effortson improving patients’ drug therapy outcomes.The role of future pharmacy leaders will be toestablish innovative working environments byprojecting a unifying vision for the professionand providing mentoring to pharmacy managersand staff. All pharmacists must become agents ofchange. Pharmacy managers who have assembledsuccessful pharmacy teams will be better able toproduce data that justify current and futurepharmacist roles. All future pharmacists willrequire greater leadership and managementabilities.

Forecasting Manpower Needs

Future demand for pharmacists remains anunresolved issue for the profession. Both futuresurpluses and shortages of pharmacists have beenpredicted. Once technology, new centralizeddispensing systems, and technicians are widelyutilized to increase drug distribution efficiencies,it is likely that the need for pharmacists engagedsolely in distribution will decrease. Thereafter,future manpower needs no doubt will be affectedby the profession’s success in redefining andtransforming itself into a discipline that providescare and impacts patient outcomes. If a majorityof pharmacists become involved in collaborativedrug therapy (both patient-specific andpopulation-based), disease management, andother evolving areas of practice, then manpowerdemands likely will increase. If pharmacists’professional roles remain unchanged, manpowerrequirements will be determined primarily bycost-driven changes in drug distributionmanagement. These changes eventually couldproduce an environment that requires fewerpharmacists to support the future health caresystem successfully. To address academicpharmacy’s manpower problem, there is a needfor the academy to recruit new graduates into

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PHARMACY ROLES AND MANPOWER ACCP

academic career tracks more effectively, promoteexpansion of residency and fellowship programs,place increased emphasis on the mentoring ofnew faculty, and incorporate formal pedagogicalinstruction into postgraduate training programs.

Qualifications for Pharmacy Practice

The requisite education and credentialing ofpharmacists will be important issues as theprofession pursues patient-centered practiceroles. We believe that the credentialing issue—inparticular the controversy associated withcertification—has the potential to spark the samelevel of discussion that occurred during the “B.S.versus Pharm.D.” controversy. Certainly onemust hope that the credentialing/certificationissue will not result in the marked polarizationthat was spawned by the entry-level degreecontroversy. However, there is still confusionwithin the profession concerning contemporaryeducation and credentialing. A coordinatednational strategy to clarify pharmacistcredentialing clearly is needed. The currentproliferation of credentialing processes andcertification programs that do not undergorigorous review and assessment has the potentialto undermine pharmacists’ credibility withproviders, the public, and payers. We believethat credentialing within the pharmacyprofession should meet rigorous nationalstandards. Pharmacist certification would beadministered best through a coordinated nationalcertification board that assures assessment ofknowledge and skills while also validating theappropriate level of training or experience. Wefurther suggest that the entire voluntarypharmacist credentialing process (includingcertification and perhaps postgraduate training)should be coordinated by a national, broad-basedcredentialing coalition or governing body.Finally, the profession is encouraged to study andassess the value of certification.

A Vision for the Future

The White Paper authors were asked todevelop a vision of pharmacy as it might exist atthe conclusion of the first decade of the 21stcentury. Like all visioning efforts, much of whatwe expect may not come to pass; new, unforeseendevelopments may profoundly influence thefuture of the pharmacy profession. However, weoffer the following predictions of how eventsaffecting pharmacy may unfold during the nextdecade:

• Health care will place increasing emphasison drug therapy to improve patient outcomesand quality of life. Prescription drug use willcontinue to rise, creating greater risk of drug-related morbidity.

• Society will become increasingly technologyliterate and technology driven. Technologywill be deployed fully to dispense mostprescriptions, provide drug information topatients, and facilitate the exchange ofpatient-specific data among and withinhealth care systems.

• Pharmacy will transform itself from aprimarily product-centered profession to apatient care-oriented profession.

• Patient care rendered by pharmacists,including those not directly involved withdrug product distribution, will be reimbursedby payers.

• Corporate pharmacy and independentpharmacy owners will find pharmacists’patient care services to be profitable and willcommit resources to this market, includingenhanced use of technology and technicians.

• State boards of pharmacy and governmentallegislation will enable and facilitatepharmacists’ patient care activities, bothindividually and in collaboration with otherhealth care professionals.

• Technician certification will be mandated toprotect the public.

• Pharmacy education will prepare graduatesfor increasingly complex patient andpopulation drug therapy management andproblem-solving, and supervision ofprescription dispensing and processing bytechnicians and automated technology.

• Pharmacy schools will experience anunprecedented increase in graduates due to acontinued rise in demand for pharmacists,popularity of health care careers, and anincreased visibility of pharmacists’ patientcare roles in the 21st century.

• Appropriate credentials that documentclinical practice abilities will be aprerequisite for all pharmacists that providepatient care services. Eventually, residencytraining will be an expectation of mostentry-level pharmacists.

Recommendations

The White Paper recommendations have beendivided into two categories: (1) recommendedactions for the entire profession, and (2)

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recommendations for ACCP and its membership.The recommendations reflect the analyses,forecasts, assessments, and opinions offered inthe body of the paper.

Recommendations for the Pharmacy Profession

1. Adopt a unifying philosophy of practice thatestablishes the patient as the primarybeneficiary of the profession, with thepharmacist accepting shared responsibilitywith other health care professionals forpatient care.

2. Capitalizing on the collective strengths ofnational pharmacy organizations, develop acoordinated strategy to secure financialcompensation for pharmacists’ patient careservices that are not directly related to drugdistribution.

3. Create a profession-wide strategy for boththe development and use of technology.This strategy should engage pharmacyeducation and all venues of pharmacypractice to enhance pharmacists’ training in,and use of, technology in prescription pro-cessing and distribution, drug information,and drug therapy management.

4. Work with professional regulators and statelegislators to revise pharmacy practice actsto enable shared responsibility for directpatient care, use of appropriate technologyand technical support personnel, andcollaborative drug therapy management.

5. Develop credible, coordinated certificationand credentialing processes whereby allqualified pharmacists can demonstratepatient care competence.

6. In academia, focus not only on manpower,but also (perhaps even more) on profes-sional empowerment. Pharmacy educatorsmust maintain high expectations for per-formance of both general and professionaleducational outcomes; contribute to thedevelopment of new post-licensureeducation and training programs that helpexisting practitioners “retool”; promotecontinued expansion of residency programs,including nontraditional programs (mini-residencies); and assume leadership roles intechnician training and certification.

7. Foster collaborative efforts by professionalorganizations, academia, and health caresystems to develop new models of pharmacypractice in the community practice setting.

Recommendations for ACCP

1. Collaborate closely with other nationalpharmacy organizations and assume aleadership role in the profession’s adoptionof a unifying philosophy of practice.

2. Place increased emphasis on thedevelopment of leadership abilities amongthe rank-and-file membership.

3. Embrace community pharmacy and seek toassist community practitioners in acquiringadditional knowledge, skills, and attitudesthat can expand pharmacists’ impact onpatient outcomes.

4. Encourage colleges and schools of pharmacyto explore how current doctor of pharmacyprograms can better prepare graduates forcontemporary generalist practice.

5. Encourage the National Association ofBoards of Pharmacy (NABP) and individualstate boards of pharmacy to continue theirefforts toward creating licensure exams thatare more reflective of pharmacists’ patientcare responsibilities.

6. Support, and assist in the development of,certificate programs and certificationprocesses that provide for appropriateassessment of knowledge and skills whilealso validating adequate levels of experience.

7. Oppose pharmacist certification that lacksunique (differentiating) and definableknowledge domains, or adequate assessmentof clinical training or experience.

8. Work inclusively with other pharmacyorganizations/associations and the Councilon Credentialing in Pharmacy to establish acohesive and coherent plan for pharmacistcredentialing.

9. Explore the feasibility of engaging incooperative political advocacy efforts withcommunity pharmacy organizations andtrade associations for the purpose ofpursuing agendas of mutual professionalinterest (e.g., reimbursement for pharmacists’clinical activities that improve patientoutcomes).

OUTLINE

Introduction and PurposeToward a Unified Philosophy of PracticeIssues Influencing Change in Pharmacist Roles and

ResponsibilitiesFactors that Oppose Changing Pharmacist RolesFactors that Promote Changing Pharmacist RolesJustifications for Changing Pharmacist Roles


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Providing Necessary Leadership and Management forthe FutureLeadershipManagementMeeting the Leadership and Management

Challenges of the FutureForecasting Manpower NeedsQualifications for Pharmacy Practice

Curricular Preparation and LicensureCurriculum Standards and GuidelinesLicensure

Post-Licensure CredentialingCredentialing OptionsGeneral Elements of Post-Licensure Certification

Specialist Pharmacist CertificationAdded Qualification within a Recognized

Pharmacy SpecialtyGeneralist Pharmacist CertificationInterdisciplinary Certification

Disease-Specific CredentialingCertificate Programs

Council on Credentialing in PharmacyViews on Credentialing

A Vision for the FutureRecommendations

Recommendations for the pharmacy professionRecommendations for ACCP

References

Introduction and Purpose

… the great need is to look at pharmacy from thepoint of view of the patient—that is, unless we comeup with something which deals with people, notpharmacists, not research laboratories, notphysicians, not nurses, not drug store proprietors,not the system, et cetera, we really have not addedmuch…”

Millis, summarizing the first day of the MillisCommission’s deliberations in September, 19731

It’s deja vu all over again!Yogi Berra, circa 19602

As these quotations suggest, the issuescurrently confronting the pharmacy professionare not new. Despite a vivid realization that itmust redefine itself as a patient-centeredprofession, pharmacy’s longstanding focus onproduct has continued throughout the lastquarter of the 20th century. However, it isapparent that the changes in United States healthcare delivery, financing, education, andmanagement systems that transpired during the1990s have now finally set the stage for

meaningful transformation of the profession.This paper presents a vision for the future in anattempt to facilitate that transformation.

In the fall of 1997, ACCP President JerryBauman charged a subcommittee of the ACCPClinical Practice Affairs Committee withdeveloping a White Paper on pharmacymanpower for the future that would “considersuch things as likely future roles andresponsibilities of pharmacists; the number ofpractitioners required to fulfill these roles andresponsibilities; requisite education and training,and continuing education and training; types andnumbers of supportive personnel required; andother issues identified by the committee.”President Bauman’s intent was to provide forACCP and the profession an analytical andpotentially provocative vision of pharmacy’sfuture as it enters the new millennium. Thepurpose of this document is not only to provideleadership within the profession, but also to lendguidance to ACCP as it pursues in the future avariety of issues with other organizations. Whatfollows is the subcommittee’s best effort toaddress its task, relying on analyses ofinformation available during its 2-yeardeliberations.

It is interesting to note that evolvingcontroversies surrounding manpower availabilityhave served as a primary stimulus for much ofpharmacy’s recent widespread dialogueconcerning the future of the profession. Indeed,manpower issues were a major driving forcebehind ACCP’s development of this White Paper,and we devote a section of the paper to this issuealone. This is certainly not a new phenomenon;past manpower problems have promptedsegments of the profession to take pause and givedue consideration to the future scope ofpharmacy’s role in health care.3, 4 And, thereinlies the most important principle in addressingpharmacy manpower: although quantitativemanpower availability is a critical issue thatinexorably gains the entire profession’s attention,it is only a symptom of more substantiveproblems that lie at the heart of the issue. In ourestimation, quantitative manpower dilemmas canbe addressed only through serious efforts thatachieve commitment to the qualitativecomponents of pharmacy’s professional mission.Once this is accomplished, solutions to themanpower problem can be sought throughappropriate strategic planning to operationalizethe mission. Whereas in the past suchdetermining and planning of mission may have

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been optional for many segments of pharmacy,the unfolding economic and political health careenvironment of the 21st century has positionedthe entire profession at a crossroads. Previouspublished exhortations notwithstanding,5–7 thetime has come for concerted, unified action by allstakeholders. It is in this context that the WhitePaper’s observations, analyses, and recommendationshave been developed.

Toward a Unified Philosophy of Practice

The pharmacist has lost his professional standingprimarily because the patient cannot visualize himas a tradesman and a professional simultaneously.

The Dichter Report, 19738

The most truthful thing I can say about pharmacypractice is this: it is an occupation psychicallybound to the act of providing medications topatients, but which knows that it must find a newreason for being.

Zellmer, 19969

Thus, we see today a major proportion ofpharmacists in both community and health-systemsettings who perform solely or primarilydistributive functions, the uneven adoption since the1970s of clinical tasks, and much talk about, butscant performance of, pharmaceutical care functionsby either health-system or community pharmacists.

Holland and Nimmo, 199910

Throughout its modern history, pharmacy hasstruggled to balance the profession’s seeminglydual mercantile and professional missions. TheDichter report, commissioned by the AmericanPharmaceutical Association (APhA) in 1972 toanalyze consumers’ perceptions of pharmacists,noted that this model of merchant-professionalwas in agreement with no other profession’scredo and therefore was potentiallydysfunctional.8 Pharmacy is the only health careprofession that is reimbursed primarily throughsale of a product rather than for provision ofpatient-specific service.11 The profession’smovement toward patient-centered practice inthe 1960s, 1970s, and 1980s resulted inpromulgation of the principles of clinicalpharmacy practice, drug information services,and eventually, pharmaceutical care.12 In theearly 1990s, the provision of pharmaceutical carewas endorsed broadly by the profession,including pharmacy educators, as its newprofessional mission.13 However, continued high

demand for product-oriented practitioners,combined with the absence of viablereimbursement systems for nondistributivepatient care services, made the implementation ofpatient-centered practice impractical for theprofession as a whole…until now.

Today, it is apparent that technology-driven,cost-effective systems for managing the drugdistribution process are a reality, and thesesystems will be refined and widely implementedin the near future.5 Technical support personnelare becoming more extensively deployed inpharmacies, and the involvement of pharmacytechnicians in the drug distribution process willbe increased if the steps necessary to assurepublic safety are accomplished.14 Thesedevelopments gradually will relieve the demandon pharmacists to dedicate the majority of theirtime solely to distributive functions. Reimburse-ment of pharmacists for direct patient careservices unrelated to the distribution of a productis now occurring, and concerted efforts toincrease the number of pharmacists able tosuccessfully secure this compensation are underway. 14–16 Although admittedly slow to evolve,reimbursement for pharmacists’ patient careservices most likely will have unprecedentedimpact on the profession during the 21st century.As suggested by Sleath and Campbell in theirprovocative essay on the sweeping changes inpharmacy, “If large [retail pharmacy]corporations…perceive pharmaceutical care as aprofitable market and commit resources toexpand the area, the practice of pharmacy couldbe changed almost overnight.”17

With this backdrop, we believe that the time isat hand to unify the profession in pursuit of itspatient care mission. Further suggesting that aprofession-wide dialogue regarding pharmacy’smission is appropriate at this time, recentlypublished papers from diverse segments of theprofession have focused on the need toimplement broad changes in practice.10, 14, 18–21

The divisiveness that resulted from pharmacy’spursuit of patient-centered practice wasnonproductive for the profession as a whole.17

One source of this divisiveness was thecontroversy surrounding adoption of a singleprofessional practice model and the monikerassigned to that model. Nimmo and Hollandconcisely summarize the major practice modelsthat have engaged the profession for the past fourdecades, namely (1) the drug informationpractice model, (2) the self-care practice model,(3) the clinical pharmacy practice model, (4) the

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pharmaceutical care practice model, and (5) thedistributive practice model.18 These authors alsopoint out that pharmacy’s transition to a newpatient-centered role “will not be instantaneousbut will continue for an indefinite period toinclude a shifting balance of the five practicemodels.”20 The 1999 White Paper from theNational Association of Chain Drugstores(NACDS), APhA, and the National CommunityPharmacists Association (NCPA) echoes thisview: “While some say that the pharmacist’s rolehas been ‘redefined’ from medication dispenser topatient care provider, it is more accurate to saythe role has been expanded.”14 Hence, it appearsthat the transformation of pharmacy from aproduct-oriented to a patient-oriented professionshould necessitate the coexistence of severalconcurrent practice models during this period oftransition. Nonetheless, we believe that thisevolutionary process probably will resulteventually in the emergence of a single practicemodel, although one that may be actualizeddifferently within a variety of settings.

Given this likelihood, there is clearly nopurpose in continuing to debate the terminologythat should be properly applied to this evolvingpatient-oriented practice while we still findourselves in a transitional period. Be it “clinicalpharmacy,” “pharmaceutical care,” “disease statemanagement,” “total pharmacy care,” or any ofthe myriad of other descriptors, what remainmost important are the purpose and end result ofpharmacy’s professional activities. Weaver andcolleagues captured this idea well in a recentreview by stating, “…clinical pharmacy was ameans, rather than the end, to achieve theprofessional shift that was needed.”22 And,unfortunately, many members of the professioninvolved in the clinical pharmacy andpharmaceutical care movements have failed toappreciate this seminal principle—it is not reallyabout what we do, but rather, about why we do it.

Based on the foregoing, we propose that theprofession’s leading organizations and tradeassociations come together to redefine, and reachconsensus on, a unifying philosophy of practicefor the pharmacy profession. Cipolle, Strand,and Morley23 offer the following characterizationof practice philosophy:

A philosophy of practice is a set of valuesthat guides behaviors associated with certainacts. …A philosophy defines the rules, roles,relationships, and responsibilities of thepractitioner. Any philosophy of practice that isto be taken seriously must reflect the functions

and activities of the practitioner—both esotericand common, appropriate and questionable—and also critically provide direction toward theformation of a consistent practice. How apractitioner practices from day to day shouldreflect a philosophy of practice. A philosophyof practice helps a practitioner make decisions,determine what is important, and set prioritiesover the course of the day. Ethical dilemmas,management issues, and clinical judgementsare all resolved with the assistance of apractitioner’s philosophy of practice. This iswhy the philosophy of practice must be wellunderstood and clearly articulated, so it isexplicit and relied on in the face of difficultproblems.

In our estimation, the pharmacy profession hasno such consensus philosophy of practice.Although pharmaceutical care was adopted bythe profession as pharmacy’s practice mission, thephilosophy behind this practice has not beenembraced by the profession as a whole.Common misconceptions exist amongpractitioners, including the all-too-often-heardproclamation that “all pharmacists practicepharmaceutical care.” Obviously, as noted byHolland and Nimmo, this is not the case. Datarecently gathered by Arthur Andersen, LLP, forNACDS indicate that community chainpharmacists are spending more than two-thirds(68%) of their time engaged in processing ordersand prescriptions, managing inventory, andperforming administrative activities.24 This studyfound that only 2% of community chain phar-macists’ time was devoted to activities involvingdisease management. Sleath and Campbellobserve that “the profession has a long way to goin its efforts to convince the public (or itself) thatthe patient rather than the drug product is thesocial object of the profession.”17

It is noteworthy that the NACDS-APhA-NCPAWhite Paper on implementing change incommunity pharmacy practice [emphasis is ours]never employs the term “pharmaceutical care,”opting instead to use the terms “patient care,”“direct patient care,” and “patient care services.”Nonetheless, the NACDS-APhA-NCPA WhitePaper supports the vision of patient-orientedpractice, indicating that the “concept of thepharmacist as a patient care provider is gainingacceptance in the health care community.”14 TheWhite Paper emphasizes the continued dual roleof pharmacists as managers of both dispensingand patient care, and suggests that if pharmacy isto succeed in this capacity, the profession must

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become united by establishing common goalsthat meet public need. We agree.

Whereas adoption of the pharmaceutical caremission was a laudable step for pharmacy, thisalone has not transformed professional practice.Ironically, the tenet of pharmaceutical care maybe experiencing significant erosion due to itsimplementation because this implementation hasbeen inconsistent. When most practicingpharmacists are unable to achieve the mission setforth for pharmacy as a whole, one must questionthe profession’s credibility. Despite the fact thatmeaningful, patient-centered care that impactspatient outcomes is performed by pharmacists ina variety of settings today, we still fall short ofimplementing this practice model to the fullbenefit of society. Indeed, to the majority ofconsumers, pharmaceutical care is at bestimperceptible, and at worst nonexistent.23 This isparticularly significant in the community hospitaland community pharmacy sectors wherepressures of manpower shortages, inadequatetechnological resources and support personnel,diminished financial support due to managedcare policies and inefficient third party benefitdesigns, and the mismatch between practiceregulations and needed practice empowermenthave made the implementation of pharmaceuticalcare impractical.14 The landmark MillisCommission Report, perhaps the most holisticand comprehensive study of pharmacy to date,implored the profession to redefine itself toimprove patient care, “Eventually, perhaps thedefinition will describe the practice of the vastmajority of pharmacists who should be deeplyinvolved with people and their health as they aremet through drugs.”25 But try as we might, it willnot be possible to meet society’s drug therapyneeds without engaging all sectors of theprofession and mounting the support necessaryto involve the “vast majority” of pharmacists, asthe Commission suggested. At present, mostpharmacists not only are prevented fromrendering pharmaceutical care, but have adopteda jaundiced view of the profession’s ability toachieve this vision. We no longer can accept themismatch between what we espouse and what weare able to accomplish.

Pharmacy’s leadership must rally the professionto revisit, and forever affirm, its philosophy ofpractice. That is, the profession as a whole mustdedicate itself unequivocally to a philosophy ofpractice that clearly identifies the patient as theprimary beneficiary of the profession. Once thisphilosophy is embraced wholeheartedly by the

profession’s respective organizational leaders,each sector of the profession should participatecollaboratively to plan both strategically andrealistically to promote the evolution of practicemodels that consistently will support thisphilosophy. This cannot be a “revolutionary” orexclusionary process. Rather, the currentenvironment demands a rational, practical, andinclusive approach that will engage all segmentsof the profession. Whether consideringinstitutional, community, managed care, or othersectors of the pharmacy profession, an unevencommitment to the transformation andimplementation of patient-centered practicemodels is not acceptable. However, as thesepractice models evolve, it must be realized thatdifferent segments of the profession will progressat different rates and perhaps along differentpaths. Whether practitioners choose to labeltheir activities as clinical pharmacy, pharma-ceutical care, or disease management should beimmaterial to the success of this endeavor.Pharmacy’s leadership will be confronted withthe challenge of valuing the initial differencesamong various approaches that may be necessaryto implement patient-centered care in diversepractice settings while at the same time seekingto achieve solidarity through a shared philosophyof practice.

Issues Influencing Change in Pharmacist Rolesand Responsibilities

The future will not permit use of the full-trained[sic] pharmacist in procedures and tasks that do notrequire the level of his knowledge and skill.

The Millis Commission, 197525

…much of what pharmacists will do or not doduring a workday is driven by their professionalvalues—by what is important and what obligationsare to be met—rather than by some carefullydefined list of tasks.

Nimmo and Holland, 200021

Numerous factors will influence the pharmacyprofession’s ability to accomplish the changesnecessary to implement a profession-wide shift inpractice philosophy and activities. Concertedand unified efforts from within the profession area definite prerequisite to change, as has beennoted. However, forces external to the professionalso will have profound influence on pharmacy’sfuture.

Fortunately, pharmacists gradually are

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embracing changing definitions of theirprofessional roles. All segments of the pharmacyprofession—practice, research, industry, andacademia—are welcoming and accepting change.An underlying premise of this White Paper is thatpharmacists’ roles and responsibilities shouldchange and that the result of appropriate,ongoing change will determine pharmacistmanpower needs over the next decade.

Factors that Oppose Changing Pharmacist Roles

Multiple factors are perceived to be barriers toany change in pharmacists’ professional identity.Some of these also have been delineated in anearlier ACCP White Paper, “Clinical PharmacyPractice in the Noninstitutional Setting.”26

Although it is not the intent of this paper toreiterate all barriers to changing professionalroles for pharmacists, several key points deservediscussion.

First, the many differing attitudes and goals ofindividual pharmacists often contribute to a lackof professional cohesiveness. In fact, the goals ofdifferent pharmacists and pharmacy organizationsare often at odds with one another. Examplesinclude past debates concerning the entry-levelPharm.D. degree and current controversiessurrounding certification and credentialing. Lackof consensus on goals, and the lack of a clear,focused definition of “who we are and where weare headed,” are strong forces that can impaireffective change.

Second, Donald Brodie observed the followingin 1981:

“...we must remember that our professionlends itself exceptionally well to the practice oftechnique. Some would say that we are victimsof our own technique. Consumers often seeonly a bottle of pills. Many of our practitionerssee the boundaries of their professionalresponsibility circumscribed by the practice oftechnique—the dispensing of medicine.”27

Through much of the 20th century the professionwas served well by its strong identification withproduct dispensing, but at this point an exclusiveemphasis on dispensing is detrimental to theefforts to change pharmacists’ roles. Theboundaries of the profession are not static andcircumscribed but dynamic and ever evolving.This is disconcerting to some members of theprofession, for with a dynamic boundary we arenever in complete command of the knowledgenecessary to practice with optimal effectivenessand therefore must commit ourselves to lifelong

learning. This is not to say that the accuratedispensing of drugs and devices should be theresponsibility of some other profession, but thatthe responsibilities of the profession must expandbeyond an exclusive identification withdispensing. Indeed, the recent report released bythe National Academy of Science’s Institute ofMedicine (IOM) should serve as impetus for allsectors of the profession to take action towardreducing medical errors.28 The IOM reportestimates that approximately 7,000 patients dieeach year from medication errors. As has beennoted by others, preventable drug-relatedmorbidity can be reduced by involvingpharmacists in the provision of direct patientcare.29

Third, the competence and confidence levels ofsome segments of the pharmacy workforce arefactors opposing pharmacist role redefinition.For example, when Knapp and colleaguesevaluated prescription intervention rates amongcommunity pharmacies, intervention ratesranged from 0–4.1% of prescriptions.30 Thisvariability may have been due to insufficient self-confidence among the community pharmacists inthe study, or it could reflect that thosepharmacists who accomplished no interventionslacked the clinical competence to conduct suchinterventions. Alternatively, it could indicate thatprescription interventions were not a highpriority in the practice settings included in theevaluation. Unfortunately, if any of thesesuppositions are true, they suggest that thelargest segment of our profession (communitypharmacists) is not consistently and effectivelymaking professional interventions a coreprofessional value. Stated another way, the lackof prescription interventions may be a significantobstacle if community pharmacists are to play amajor role in improving drug-related outcomes.Confidence level and self-image are importantprerequisites for pharmacists who seek toperform health care functions that traditionallyhave been carried out by other healthprofessionals. However, many pharmacistschoose not to intervene in a patient’s drugtherapy because they do not believe that theyhave a role in disease prevention and healthpromotion initiatives, such as immunizations andsmoking cessation; they feel incompetent tomonitor the necessary clinical or laboratoryparameters pertinent to drug therapy; theypossess unfounded fear that there is increasedrisk of professional liability associated withprescription interventions; or they believe that

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their duty to counsel is completed after askingthe patient, “Did your physician tell you how totake this medicine?”

Fourth, some assert that corporate or managedhealth care is associated with a decrease innumber of pharmacy positions. When therelationship between staff size and full-timeequivalent (FTE) changes was evaluated in thePharmacy Manpower Project under thehypothesis that increased managed carepenetration was associated with decreasedpharmacy staff size and job loss, the hypothesiswas rejected.31 Managed health care systemshave increased demand for pharmacists byproviding more jobs in areas such as dataanalysis, pharmacy benefit management,formulary construction and maintenance,development of system-wide clinical pathways,drug information, disease-specific clinics,prevention services, and automation.32 Managedcare systems typically utilize sophisticatedinformation technology and possess greateraccess to patient-specific data to supportexpanded pharmacist roles.33

Fifth, dissension about whether or not toimplement the entry-level Pharm.D. degreeoccupied pharmacy organizations andpharmacists for too long. Regardless of the prosand cons of the ultimate decision, one thingseems evident: the all-Pharm.D. controversyoccupied the pharmacy profession’s intellectualand political energies for so long that somemembers of the profession “took their eyes off”other issues that were critical to the survival andadvancement of the profession.

Sixth, business interests (i.e., the bottom line)often are cited as factors opposing professionaladvancement of pharmacists. Pharmacistscomplain that the volume and time demands ofdispensing prescriptions preclude using drugtherapy knowledge to help patients. However,pharmacists have options with respect to thesetting in which they choose to practice theirprofession. Perhaps the current shortage ofpharmacists in high-volume, chain drug storesettings is an indication that pharmacists are notamenable to the requirement of high-volumedrug dispensing at the expense of time spentusing professional knowledge to help patients.Further exacerbating this situation is the currentlow-unemployment economic environment thathas created a concomitant shortage of availablepharmacy technicians. Should it persist, thistechnician shortage might drive more phar-macists away from some community pharmacy

settings.Seventh, lack of reimbursement for pharmacists’

patient care services is impeding development ofnew, expanded practice roles. Most prescriptionbenefit programs are designed to providereimbursement only for the provision and cost ofprescription drugs. Pharmacist activities thathave been shown to improve patient outcomesand/or lower health care costs in most cases areexcluded from patients’ health care benefits.14

Without remuneration for both product andservice, the majority of pharmacists have focusedtheir efforts on distribution of product. This isclearly a major impediment in the communitypharmacy setting, where marginal reimbursementsfor dispensing have necessitated continuedincreases in prescription volume. In addition,although a majority of recently surveyed health-system pharmacists indicated that they areinvolved in provision of pharmaceutical care,only 16% said that they are reimbursed for suchservices.34

Finally, the interpersonal skills of pharmacistsperhaps are underdeveloped and undervalued.These skills are crucial to success in manyinteractions with patients and other health careprofessionals. Pharmacy education in someinstances may have neglected the link betweencommunication ability, human relations skills,and effective professional practice. Fortunately,this is changing. Pharmacy schools increasinglyare using personal interviews in selectingcandidates; mandating course work incommunications, negotiation, persuasion, andteamwork; and requiring team projects andverbal presentations throughout the professionalcurriculum.5

Factors that Promote Changing Pharmacist Roles

Multiple factors can prompt changes inprofessional roles. The anticipated growth in thenumber of drugs prescribed is arguably a factorthat should stimulate increased future demandfor pharmacists. Also, with increased prescribingcomes more frequent medication-relatedproblems, a major area of need for pharmacistintervention.35 Throughout the past 30 years,numerous publications have detailed thesignificant health care problems associated withdrug-related morbidity and mortality.36–47 Foreach $1 spent on medications in nursing homes,$1.33 is expended for drug-related problems.48

More than 70% of medication expenditures occurin the ambulatory setting where, coincidentally,

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about 60% of pharmacists practice.49 Acommunity pharmacy study described theanalysis of more than 600 interventions frommore than 93,000 prescriptions obtained under acapitated, managed care Medicaid contract.31 Inthis study, product selection interventionsresulted in a $20.17 reduction in cost/prescription,whereas interventions directed toward clinicalproblem resolution resulted in a range of savingsfrom $1188–$1755/intervention. Opportunitiesfor medication interventions exist in virtually allpractice settings. Pharmacists routinely mustconduct patient counseling, become moreactively involved in patient drug therapydecision-making, and consistently intervene toprevent and resolve drug-related problems.

Second, a small percentage of patients (e.g.,patients with chronic diseases, such as diabetesor asthma) account for a high percentage ofhealth care costs. Disease state management(DSM) for patients with chronic medicalconditions that contribute to high resourceutilization increasingly is being conductedthrough an interdisciplinary collaboration ofhealth care professionals including nurses,primary care physicians, specialist physicians,and pharmacists. Disease state management canoccur in either the inpatient or ambulatory careenvironment. Additionally, patients with chronicdiseases visit pharmacies often for prescriptionand over-the-counter medications. Communitypharmacies—and pharmacists—can serve aspotential “ambulatory clinic sites” wherepharmacy professionals assess and monitorpatients with chronic diseases during theirpharmacy visits.

A third factor promoting changes inpharmacists’ professional roles is the increasingrecognition of the need to impact clinical,economic, and humanistic patient outcomes.Assessment of these patient outcomes requiresdata collection and analysis. As key collaboratorsin the DSM process, pharmacists are wellpositioned to apply the scientific methodeffectively to outcomes analysis. Accreditationprocesses for hospitals and health plans (e.g., theNational Council on Quality Assurance [NCQA]and the Joint Commission on Accreditation ofHealthcare Organizations [JCAHO]) require datacollection and analysis in areas such as careprocesses and outcomes. Typically, data must beintegrated from several sources to document theperformance of the organization. Again,pharmacists are well positioned to provide andanalyze the data critical to this documentation.

Fourth, the expanding use of automation andinformation technologies, and the use of supportpersonnel, allow pharmacists to shift focus fromthe drug product (and the knowledge and skillthat its compounding and/or dispensing requires)to drug-related problems, care processes,outcomes, and so forth. Although somepharmacists fear increased use of technology andsupport personnel, this assistance can promotechange by allowing pharmacists to focus on thepatient.

Fifth, the ability to retrieve, analyze, and applypublished literature to medication-relatedproblems can create expanded roles forpharmacists. Health care professionals alwayswill need current information about new drugs,devices, and medical advances, particularly inview of the rapid pace of new drug development.Likewise, increasingly sophisticated consumersnow are seeking more information about theirdrugs and expect to participate in their own care.Roles exist for pharmacists in Internet-basedprofessional and consumer education, and inhealth professional continuing education.Pharmacist roles also are expanding to includedirect delivery of patient-focused informationand education.

Pharmacogenomics—the application ofprinciples of pharmacogenetics to thedevelopment of optimal regimens for treatmentor prevention of disease—also may result in newpharmacist roles.50, 51 It is likely that knowledgeof a particular patient’s genetic profile will beused in the future to individualize drug selectionand dosing, or to predict adverse effects.Pharmacists may be required to assist in theinterpretation of diagnostic genetic tests and touse their knowledge of pharmacokinetics andpharmacodynamics to optimize drug therapy fora specific patient. The greater degree ofcomplexity associated with this mode of drugselection may further increase pharmacists’ roleson the patient care team. In addition, one wouldexpect that the evolution of pharmacogenomicswill increase the need for patient and health careprovider education regarding drug therapy.51, 52

For the past several years, pharmacists’ practicesettings have been shifting away from the acutecare and traditional community practiceenvironment toward long-term, ambulatory, andhome care settings. Changing models ofpharmacy practice in these settings are providingnew, expanded opportunities for pharmacists inthe areas of continuity of care, disease statemanagement, and preventive care.

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Other issues also may influence both currentand potential roles of pharmacists in the future.It is important to note that some issues have thepotential either to impair or promote redefinitionof the pharmacist’s professional role, dependingon the perspective from which the individualmay choose to view a given issue.

Justifications for Changing Pharmacist Roles

Patient outcomes are frequently suboptimalbecause of drug-related problems. Pharmacistsare often the health care professionals who havethe greatest knowledge and skills to prevent,detect, monitor, and resolve drug-relatedproblems. Pharmacists remain highly trustedand readily accessible to the public.Furthermore, as costs of drug therapy increase atan untoward rate, health care delivery systemsand technology continue to evolve, andinterdisciplinary practice becomes morecommon, many pharmacists likely will findthemselves engaged in direct patient care.

Expanding and retaining desirable roles (i.e.,those that are useful to both patients and to thehealth care system) will require proactivedevelopment and implementation. Pharmacistsmust continue to justify their positions throughdocumentation of clinical interventions andpatient outcomes; education of patients, healthprofessionals, and payers; collaboration withother health providers; and dissemination ofprofessional accomplishments throughpublication. Pharmacists also must seek tohighlight best practices, thereby establishingquality performance expectations and increasingthe practice levels of pharmacy generalists andspecialists.

Can pharmacists change? We believe they can.A growing number of pharmacists are proactivelychanging their practices, participating inresearch, and educating students and other healthcare professionals. Clinical pharmacy remains atthe forefront of these initiatives. But, how willthe profession prepare for this change? Weconsider some possibilities.


[We must] work to solve the challenges ofattaining adequate numbers of pharmacists tomanage the increasing prescription volume, andadequate support help for dispensing functions, sopharmacists may devote an appropriate amount oftime to direct patient care.

NACDS-APhA-NCPA White Paper, 199914

…the continued requirement for pharmacists tomaintain ownership and oversight of drugdistribution requires that we re-think the linkage ofthe systems of pharmaceutical care and dispensing.”

Cohen, 199953

Pharmacy education has a responsibility ofpreparing not only for the present but also for thefuture, even innovating for the future and guidingthe course of the profession.

Alan Brands, 196954

Whereas forecasting the future may beimpossible, preparing for the future is possible ifone gathers and analyzes information based onknowledge of past and present trends. Germaneto the themes of this White Paper are someimportant observations that should be consideredas pharmacy prepares to shift toward aprofession-wide, patient-centered practice model.

Observation No. 1

Revising the goals, content, and processes ofpharmacy education will not in and of itselfchange practice.7 Although pharmacy educatorshave a responsibility to prepare their graduatesfor evolving professional roles, academia alonecannot create these roles in sufficient number toimpact broadly on the practice of pharmacy.Academia can help to innovate, but anysustainable change in pharmacy practiceultimately must be driven and maintained by thepractice community. Indeed, past efforts toeducate and prepare graduates better for newprofessional activities have, ironically, distancedacademia from the profession it serves.17 In theabsence of an empowering practice environment,new graduates eventually become disenchantedby the mismatch between what they are “taught”and what they actually “do”; and more maturemembers of the profession grow increasinglyconvinced that the academy has lost touch withthe real world. “Overeducated and underutilized”has served at times as a mantra for the profession.

Implications

Pharmacy educators must work more closelywith the profession, particularly in the areas ofexperiential education, development of newpatient-centered practice models, and studentprofessionalization. Likewise, involvingpharmacist leaders from the community who arewilling to serve as adjunct faculty can promoteleadership development and enhance profes-

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sionalization among the student body. Collegesalso must seek to collaborate with health systemsand organizations to finance and developdemonstration projects that explore new,evolving models of pharmacy practice. Exposingstudents to these practices may foster furtherdevelopment and propagation of successfulmodels in years to come. However, it isimportant that academia recognize that asubstantial period of time may be required todevelop empowering practice environments thatglobally impact the profession. In the interim,pharmacy school faculty and administratorsshould make every attempt to ease studentfrustrations with the mismatch betweeneducation and practice, while still maintainingtheir resolve to prepare graduates for futurepatient care roles.

Observation No. 2

A revolutionary practice mission will notrevolutionize practice if it cannot be implemented.As noted previously, since the profession-wideendorsement of the pharmaceutical care mission,the vast majority of pharmacists’ practices haveundergone little change.7, 14, 24

Implications

Practitioners should recognize that new rolescan be achieved only if a new practice model isestablished that is aligned with the newprofessional mission. This requires investment inthe new mission by all segments of theprofession. As a reality check, pharmacists andpharmacy students must be made aware of thefact that traditional pharmacist activities,including patient education and counseling, donot alone constitute pharmaceutical care.Professionals must work together patiently,honestly, and meaningfully to revise pharmacy’spractice systems to support a level of patient carethat genuinely affects patients’ drug therapyoutcomes.

Observation No. 3

Patient-centered, clinical services have apositive impact on patient outcomes and healthcare costs.55–61 The efficacy of the clinical patientcare activities provided by pharmacists has beendemonstrated convincingly in institutional,ambulatory, and community pharmacy settings(Table 1). These data provide ample evidencethat pharmacists’ patient care activities can be

fiscally and medically prudent, regardless ofpractice setting.

Implications

The time has come to accept that adequate datahave been generated to validate the benefits ofpharmacists’ clinical activities. All sectors of theprofession (academia, clinical, community,institutional) now must move forward in aunified fashion to confidently advocate andmarket pharmacy’s patient care roles to patients,payers, health care system administrators, andpoliticians. Meanwhile, additional randomized,controlled studies are needed to rigorouslyanalyze the true costs of pharmacists’ clinicalpatient care activities and to document therelative outcomes produced by these activitiescompared to those of traditional medical care.62

These data will be invaluable to the profession asit seeks to establish its place in our increasinglycompetitive health care environment.

Observation No. 4

Approximately 90% of practicing pharmacistshold the baccalaureate pharmacy diploma as theirsole degree and have been involved primarily indispensing prescriptions.63 Inadequate mechanismsare currently available to accomplish the retrainingnecessary for these practitioners to fulfill newclinical practice roles.

Implications

This observation leads us to the undeniableconclusion that profession-wide retraining willbe needed for pharmacists to assume true patientcare roles. We believe that some segments of theprofession may have underestimated theimportance and enormity of this task. A broad-based, inclusive planning process involving allpharmacy organizations and associations must beinitiated to address this issue.

Observation No. 5

Collectively, the clinical pharmacy practicecommunity (including ACCP) and pharmacyeducation possess the expertise necessary tocreate new, practical, and valid means ofretraining pharmacists for emerging patient careroles.64 However, these sectors of the professionhave not yet fully committed to partnering withcommunity pharmacy to create effective,appropriately rigorous retraining mechanisms.

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Table 1. Selected peer-review publications that document the benefits of pharmacists’ clinical practice activities.

Category Publication SummaryAmbulatory Care McKenney JM, Slining JM, Henderson HR, Important publication of an early, controlled

Devins D, Barr M. The effect of clinical clinical study demonstrating ability of clinicalpharmacy services on patients with essential pharmacy services to effect significanthypertension. Circulation 1973;48:1104–11. improvement in patients’ knowledge of

hypertension, number of normotensivepatients, and compliance with prescribedtherapy.

Chiquette E, Amato MG, Bussey HI. Comparison Comparative trial showing that a clinicalof an anticoagulation clinic with usual medical pharmacist-run anticoagulation cliniccare. Arch Intern Med 1998;158:1641–7. improved anticoagulation control, reduced

bleeding and thromboembolic event rates,and saved $162,058/100 patients annuallythrough reduced hospitalizations andemergency room visits.

Community Pharmacy Munroe WP, Kunz K, Dlamady-Israel C, Potter L, Controlled study showing that pharmacistSchonfeld WH. Economic evaluation of intervention in the community pharmacypharmacist involvement in disease management setting reduced substantially monthly healthin a community pharmacy setting. Clin Ther 1997; care costs in patients with hypertension,19:113–23. hypercholesterolemia, diabetes, and asthma.

Savings ranged from $143.95/patient/monthto $293.39/patient/month.

Bluml BM, McKenney JM, Cziraky MJ. Multi-site observational study demonstratingPharmaceutical care services and results in project pharmacists’ abilities to promote patientImPACT: hyperlipidemia. J Am Pharm Assoc 2000; persistence (93.6%) and compliance (90.1%)40:157–65. with dyslipidemic therapy. Among 397

evaluable patients followed for a mean of 24.6months, 62.5% reached and were maintainedat their NCEP lipid goal by the end of thestudy.

Cipolle RJ, Strand LM, Morley PC, ed. Outcomes of Observational study involving provision ofpharmaceutical care practice. In: Pharmaceutical pharmaceutical care to 5480 patients duringcare practice. New York: McGraw-Hill, 1998: a 12-month period. The authors found205–35. significant improvement in attaining

therapeutic goals and reducing the level ofpatient complexity due to resolution of drugtherapy problems. Among a cohort of 249patients aged > 65 years, every dollar investedin providing pharmaceutical care produceda potential savings to the health care systemof over $11.

Inpatient Care Bond CA, Raehl CL, Franke T. Clinical pharmacy Evaluation of the association between clinicalservices and hospital mortality rates. pharmacy services and mortality ratesPharmacotherapy 1999;19:556–64. (adjusted for severity of illness) for Medicare

patients in 1029 U.S. hospitals. Servicessignificantly associated with lower mortalityrates were clinical research, drug information,drug admission histories, and participation ona cardiopulmonary resuscitation team.

Leape LL, Cullen DJ, Clapp MD, et al. Pharmacist Controlled study showing that pharmacistparticipation on physician rounds and adverse drug participation in physician rounds in a medicalevents in the intensive care unit. J Am Med Assoc ICU decreased the rate of preventable adverse1999;282:267–70. drug effects due to ordering errors by 66%.

The pharmacist’s prospective interventionsconsisted primarily of order correction/clarification, provision of drug information atthe time of therapeutic decision-making, andrecommendation of alternative therapy.Nearly all recommendations (99%) wereaccepted by physicians.


Implications

Pharmacy faculty and clinical practitionersmust make the commitment to provide theexpertise and cooperation necessary to developefficacious education and training programs thatcan enhance the clinical practice abilities ofcommunity pharmacists. The ACCP’s involve-ment in community pharmacy training andcertification is essential. We believe that theclinical pharmacy community, working collabo-ratively with academia, is both ready and able tobegin this task.

Observation No. 6

Community pharmacy, and to some extentinstitutional pharmacy, face serious challenges inestablishing patient care practice roles. Barriersto change include rapidly increasing prescriptionvolume; limited opportunity to appropriatelydeploy pharmacy technicians in the drugdistribution process due to legal prohibitions;inability to fully employ technology due to itsexpense; lack of access to patient-specific data;inefficient and restrictive pharmacy benefitprograms; lack of reimbursement for non-

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Table 1. (continued)

Category Publication SummaryMcMullin ST, Hennenfent JA, Ritchie DJ, et al. Prospective study demonstrating that patientsA prospective, randomized trial to assess the cost randomized to receive clinical pharmacistimpact of pharmacist-initiated interventions. intervention had drug costs that were 41%Arch Intern Med 1999;159:2306–9. lower than those in the control group.

Interventions typically involved streamliningtherapy to less expensive drugs, discontinuingunnecessary agents, and modifying route ofadministration. This extrapolated to an annual saving for this 1200-bed teachinghospital of approximately $394,000.

Managed Care Borgsdorf LR, Miano JS, Knapp KK. Pharmacist- Retrospective study of a pharmacist-managedmanaged medication review in a managed care medication review clinic in a staff modelsystem. Am J Hosp Pharm 1994;51:772–7. HMO. Analysis of patients referred to the

pharmacist for this service revealedreductions in the number of unscheduledphysician visits, urgent care visits, emergencyroom visits, and hospital days. Savingsassociated with this service were calculatedto be $644/patient/year.

Economic Impact Schumock GT, Meek PD, Ploetz PA, et al. Literature review of economic assessmentsEconomic evaluations of clinical pharmacy of clinical pharmacy services publishedservices—1988–1995. Pharmacotherapy 1996; between 1988 and 1995 found that 89% of16:1188–1208. the 104 studies reviewed described positive

economic impact of the clinical servicesevaluated. Among those studies analyzingcost versus benefit, the mean benefit:costratio was 16.70:1.

Bond CA, Raehl CL, Franke T. Clinical pharmacy Study examining the relationships andservices, pharmacist staffing, and drug costs in associations among clinical pharmacyUnited States hospitals. Pharmacotherapy 1999; services, pharmacist staffing, and drug costs19:1354–62. in 934 U.S. hospitals. Based on multiple

regression analysis, increased clinicalpharmacy staff levels were associated withdecreased drug costs. Specific clinicalpharmacy services associated with lowerdrug costs were in-service education, druginformation services, drug protocolmanagement, and admission drug histories.For each dollar spent on clinical pharmacistsalaries, drug costs were reduced by $23.80–$83.23, depending on the services provided.


distributive services; workforce dissatisfaction; arelative paucity of clinical education and practicemodels in community pharmacies; and shortagesof both traditionally prepared practitioners andclinical pharmacists.14, 56

Implications

We believe that it is essential that academiaand clinical pharmacy recognize the significantchallenges facing community and institutionalpharmacy. It is equally important thatcommunity and institutional pharmacy leaderscommit themselves to pharmacy’s patient-centered philosophy of practice as they addressthese challenges. Finally, pharmacy educatorsand clinicians should begin immediately to workcooperatively with community and institutionalpharmacy to assist in development of neweducation and practice models, share data on thecost-effectiveness of clinical pharmacy services,and develop new types of training programs.

Observation No. 7

Pharmacy technician training is notstandardized and remains inconsistent across theprofession.14, 25, 65 Given this potentially unevenpreparation of technicians, a valid certificationprocess is necessary to ensure that technicianspossess the knowledge and skills required toperform competently. Although more than54,000 pharmacy technicians currently arecertified by the Pharmacy TechnicianCertification Board (PTCB), this represents asignificant minority of the total workforce ofmore than 150,000 pharmacy techniciansemployed in the community or institutionalsetting.66–68 Even if it were universally permittedby law, many pharmacists would hesitate todelegate distributive functions to technicians dueto a lack of confidence in the competence ofsome support personnel.

Implications

Pharmacists must advocate the recruitmentand utilization of well-trained, nationallycertified pharmacy technicians who can bedeployed in appropriate dispensing roles, underpharmacist supervision. The term “pharmacytechnician” should be applied only to thoseindividuals who have completed minimumtraining requirements and who are certified bythe PTCB.69 Standardized training of pharmacytechnicians should be a high priority for the

profession to ensure public safety, and pharmacyemployers must be encouraged to employ onlynationally-certified technicians.65 Pharmacyeducation should consider expanding its role inthe standardization and validation of techniciantraining. We agree with the Millis Commission’sassertion:

“The definition of that [technician] trainingwill be the joint responsibility of the pharmacyprofession, pharmacy education, and the stateboards of pharmacy. The general supervisionof training, however, should be the responsibilityof the colleges of pharmacy… the pharmacycolleges must play a significant and active rolein the curriculum design, in the setting ofstandards, and in supervising the teaching ofpharmacy technicians.”25

Observation No. 8

Despite its position as a highly trustedprofession, pharmacy has been unable toadvocate its patient care role effectively withpolitical decision-makers.7 In particular, webelieve that the clinical pharmacy communityhas maintained a relatively low degree ofvisibility on state and national politicallandscapes. This observation notwithstanding,national community pharmacy organizations andtrade associations appear to possess greaterstrength in these arenas.70

Implications

We suggest that this is an opportunity forpharmacy organizations to work togethersynergistically on state and national politicaladvocacy efforts that both strengthen and unifythe profession’s message regarding pharmacists’contributions to patient care.

Observation No. 9

Although attempting to prepare graduates forthe collaborative roles necessary to shareresponsibility for drug therapy with other healthcare professionals, the vast majority of pharmacyschools are not yet delivering interdisciplinarydidactic course work.63 There is also a relativeunderemphasis on team-building and inter-disciplinary health management skills in thetypical pharmacy curriculum. Similarly,acquisition of the abilities necessary tocollaborate with and manage pharmacytechnicians is not a component of most currentprogram curricula.

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Implications

If pharmacists are to be skilled in workingcollaboratively with other health careprofessionals, then a portion of their educationalexperience, including didactic learning, shouldbe conducted in interdisciplinary settings.Whereas most experiential rotations today areinterdisciplinary, this could change in the futureif increasing numbers of pharmacy practiceexperiences are conducted in the communitypharmacy and managed care settings. The MillisCommission made the following recommendation:“Because pharmacists must practice inassociation with other health workers, pharmacyeducation demands an environment in whichother health professionals are being educated andother health professions are being practiced.”25

Similarly, if students will be expected to superviseand manage pharmacy technicians, then learningto work with them also should be an objective ofthe pharmacy curriculum.

Observation No. 10

Current residency training opportunities areinadequate to meet both contemporaryquantitative and qualitative needs. Although thepast 20 years have produced significant progressin the development of postgraduate clinicaltraining programs, the vast majority of theseprograms are restricted to institutional and clinicpractice settings. It has been estimated thatapproximately 5% of the pharmacy workforce hascompleted residency training.71

Implications

Clearly, there is currently an inadequate supplyof clinically trained pharmacists to deliverwidespread patient care. As pharmacy’sprofessional roles change, there will be both anenhanced need within the profession, and anacute demand among graduates, for residencytraining. Academia and practitioners mustcontinue to place high priority on thedevelopment and expansion of pharmacyresidency training. We agree with Ray’srecommendation that every effort should bemade to preserve the current levels of pharmacyresidency reimbursement that are securedthrough Medicare.71 In addition, expansion ofresidency training in the community pharmacysetting should be pursued aggressively throughpartnerships among community pharmacy,clinical pharmacy, and academia. Flexible and

innovative approaches to the development ofresidency programs in the community pharmacysetting (e.g., mini-residencies) may providepractical and cost-effective alternatives for thoseexperienced baccalaureate-educated pharmacistswho seek retraining.

Observation No. 11

Pharmacy education has engaged inwidespread curricular change to better preparegraduates to assume increased responsibility forpatient care.7 Whereas considerable emphasishas been placed on expanding and integratingcourse work in the basic and applied sciences,information technology, literature evaluation, andpopulation-based management, less attention hasbeen devoted to the development and growth ofpharmacists as professionals.55

Implications

Pharmacy education should seriously considerplacing renewed emphasis on the integration ofgeneral education outcomes (e.g., criticalthinking, decision-making, valuing and ethics,communication, social interaction andcitizenship, self-learning) with professionaloutcomes to prepare truly patient-centered,caring pharmacy professionals.72 By integratingand building on the perspectives and skillsobtained from the liberal arts, the pharmacycurriculum will produce graduates able tofunction as professionals and informed citizens ina changing society and health care system.73

The foregoing observations are not intended tooffer a comprehensive list of all factors that willimpact the preparation of pharmacists for futureprofessional roles. However, they do provideopportunities for increased thought and dialogueamong the profession as it seeks to plan strategicaction for the future.

Providing Necessary Leadership andManagement for the Future

…one gets the feeling that everything has alreadybeen said, and I can well imagine a pharmacist backin 1776, or even Galen before that, arguing aboutthe need for change in pharmacy. We constantlyseem to be wandering in the wilderness seeking ourtrue identity.

William Kinnard, 197674

Let’s dedicate ourselves to remaking thisoccupation of ours into a profession that gives

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people what they want and need. This is not anagenda that we can assign to someone else. Each ofus must take personal responsibility for making thishappen.

Zellmer, 19969

As we noted earlier in this paper, pharmacy hassuffered from a fractionated vision of theprofession due to the conflicting perspectives ofdifferent practitioner groups. Although a unifiedvision for all segments of the profession likelywill occur with time, the changes inpharmaceutical education and in the health careand pharmaceutical industries are focusingpharmacists’ efforts on utilizing their advancedpharmacologic knowledge to improve patientoutcomes. The implementation of entry-levelPharm.D. programs has provided an opportunityto increase the consistency of pharmacists’abilities, regardless of their practice setting. Theexpansion of pharmacists’ outpatient roles toinclude collaboration with other health careprofessionals in disease state management is aneffort to improve patient outcomes and to controlspiraling pharmaceutical and health care costs.The increased use of automation and theemphasis on the value of the pharmacist’s uniqueknowledge and skills are other factors that mayresult in expansion of pharmacists’ roles. Thefuture health care environment may hold manyopportunities for pharmacists if the leadershipand management of the profession can respondquickly to focus the profession’s efforts onimproving patients’ drug therapy outcomes.

Leadership

The role of future pharmacy leaders will be toestablish an innovative working environment byprojecting a unifying vision for the professionand providing mentoring to pharmacy managersand staff. Pharmacy leaders must emphasize theresponsibilities of the pharmacist to ensure thesafe use of drugs by demonstrating a commitmentto serving the drug-related needs of patients andother health care professionals.75 Pharmacyleaders can provide direction to all healthprofessions in improving drug-related outcomes.If future pharmacy leaders can embrace theobjectives of health care reform (i.e., improvedpatient outcomes at an affordable cost to thepatient and society) and proactively directpharmacists’ efforts to improve the medicationuse system, the profession will be well-positionedto adapt to future challenges.76 Pharmacy does

not require visionary “giants.” In fact, futurechallenges will require that pharmacy leaderscapitalize on the diversity of the pharmacyprofession and accept responsibility fordeveloping leaders from within its organizations.Pharmacy should attempt to foster an organi-zational and professional culture characterized bycollaboration, teamwork, and empowerment.77

Accomplishing the necessary transformation inprofessional philosophy and roles will requirethat pharmacy’s leadership engage in eightcritical processes. First, pharmacy leaders mustestablish a sense of urgency to identify and seizemajor opportunities for the profession. Second,leaders must form a coalition to lead the change.Third, they must create a vision and developstrategies to achieve it. Fourth, they mustcommunicate the vision and use examples fromearly coalitions that engage other pharmacists inachieving the vision. Next, they need toempower others to act on the vision by removingobstacles, encouraging risk-taking andnontraditional ideas, and changing systems thatundermine the vision. Sixth, pharmacy leadersmust plan for and create visible short-termaccomplishments, and then recognize and rewardpharmacists who are involved in achieving theseinitial outcomes. Seventh, leaders will need toconsolidate improvements and produce morechange by utilizing their increased credibility inthe system. Even small improvements that occurwith change will encourage pharmacists to followleaders who want to make a difference.Sustaining the process by hiring, promoting, anddeveloping pharmacists who can implement thevision will also be important. Finally, effectivenew behaviors must be institutionalized andpromoted. It is important that pharmacistsrealize that new behaviors can be instrumental inachieving success.78

Management

Future pharmacy management training mustbe experience-based, rather than conceptual orglobal.79 Due to the rapid pace of change inhealth care, pharmacy managers must act withboth speed and effectiveness. The professioncannot afford untapped resources. Allpharmacists must become agents of change.79 Asingle pharmacy manager in a complexdepartment is wholly inadequate to implementall of the changes necessary. Although themanager must be in charge (e.g., providingguidance for multiple initiatives), he or she also

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must exhibit trust, encourage new ideas, anddelegate responsibilities to achieve the vision.75

Frequent, sincere reinforcement and recognitionwill encourage excellent performance. Pharmacymanagers must develop collaborative teams toachieve optimal outcomes.79

A team’s performance is a function of teammember abilities and motivations.80 Pharmacymanagers can create a stimulating workenvironment by providing good clinical practiceopportunities, productive pharmacistrelationships with physicians and nurses,competitive compensation and benefits, andprofessional opportunities, such as teachingstudents or residents and attending professionalmeetings.80 Managers should attempt to hirepersonnel who share the vision of thedepartment’s leaders. Although a pharmacymanager can provide support for the team’sactivities, team members must sometimes stretchtheir capacity in order to achieve extraordinaryresults.75

Pharmacy managers who have assembled ahigh-performing pharmacy team with clear goalscan work with the team to produce data thatjustify current and future pharmacist roles. Byworking with leaders in the department andorganization, effective pharmacy managersdevelop an understanding of the information thatkey decision-makers need to approve futureprojects. Managers who communicate effectivelywith all team members can focus their energiestoward achieving the identified goals.

Meeting the Leadership and ManagementChallenges of the Future

Whereas pharmacists are among America’smost trusted professionals due to their ability todevelop effective relationships with theirpatients, pharmacists have not routinelydisplayed the leadership abilities necessary toestablish effective interprofessional relationshipsand assume positions as full-fledged members ofthe health care team. Although not allpharmacists will find themselves in formalleadership positions, they should possessleadership skills. Pharmacists of the future musteffectively demonstrate their value in reducingdrug-related morbidity and mortality, and inimproving drug-related patient outcomes. Thiswill require leadership abilities that may not havebeen well-honed in most traditional, noninter-disciplinary pharmacy practice environments.Hence, future pharmacists will require increased

mentoring to develop the leadership andmanagement skills necessary to successfullydemonstrate pharmacists’ value in theinterdisciplinary health care environment. Ablepharmacy leaders and managers increasingly willbecome responsible for assembling pharmacistteams and providing them with the necessarydirection to achieve these goals.

Forecasting Manpower Needs

Manpower demand studies have a long history ofinaccuracy, especially at times when the workforceand nature of the work are undergoing rapidchange.

Wells, 199981

No one understands why we have these swings indemand and supply. Since 1990, we’ve gone througha shortage, a slight surplus, and now it appearswe’re back in an era of shortage.

Knapp, 199982

Future demand for pharmacists remains anunresolved issue for the profession. Both futuresurpluses83 and shortages6 of pharmacists havebeen predicted. The most controversial of thesepredictions was rendered in a 1995 report of thePew Health Commissions that projected asurplus of 40,000 pharmacists by the year 2005.83

This report generated widespread dialogueconcerning manpower throughout the professionand among pharmacy academicians.

Recent pharmacy workforce statistics49 indicatethat pharmacists held approximately 185,000jobs in 1998. About 60% worked in communitypharmacies that were either independentlyowned or part of a drug store chain, a grocerystore, department store, or mass merchandiser.Most community pharmacists were salariedemployees, but some were self-employed owners.About 25% worked in hospitals, and theremaining 15% worked in clinics, managed careorganizations (MCOs), mail-order pharmacies,long-term care, pharmaceutical wholesalers andmanufacturers, home health care agencies,academic institutions, the federal government, orother pharmacy-related environments. About20% of the pharmacy workforce is engaged inpart-time employment.

Future manpower needs will undoubtedly beinfluenced by a variety of developments, severalof which are likely to increase the demand forpharmacists. The continued rise in America’sprescription drug use is projected to result in the

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dispensing of 3.5–4 billion prescriptions annuallyby the year 2005, an increase of as much as 44%from the estimated 2.8 billion prescriptions thatwere dispensed in 1999.14, 82 If Medicare offers anoutpatient prescription drug benefit, this wouldimprove access to prescription drugs for the one-third of beneficiaries who currently lackcoverage, further fueling the increase in futureprescriptions.84 To accommodate risingprescription demand and to enhance marketshare, chain pharmacies are increasing thenumber of chain outlets and expanding storeoperating hours.85 As we enter a newmillennium, women will outnumber men amongthe pharmacist workforce, primarily as aconsequence of the increased number of femalepharmacy graduates and the retirement or deathof the relatively large cohort of post-World War IImale pharmacists. The U.S. Bureau of HealthProfessions projects that by the year 2003 themajority of pharmacists will be women.82 Aswomen traditionally have been more likely toengage in part-time employment during theirprofessional careers, it is anticipated that thisgender shift will contribute further to an increasein pharmacist demand. Although there are dataindicating that the impact of the increased part-time force has been counterbalanced by a sizablecadre of moonlighting pharmacists,86, 87 it seemsunlikely that the number of moonlighters willkeep pace with the expected growth of the part-time female pharmacy workforce. In addition,relative job dissatisfaction and decreasedemployee retention may contribute to a shortageof pharmacists in selected areas of practice,particularly in the chain pharmacy sector.85

Other factors likely to drive an increased demandfor pharmacists during the next 5 years includeevolving roles for pharmacists in MCOs, wherepharmacists are participating in management ofdrug utilization among “high utilizer”populations and analyzing data that addressspecific MCO performance outcomes31, 88;increasing employment of pharmacists by thepharmaceutical industry to pursue researchinvolving drug development, diseasemanagement, outcomes measurement, andpharmacoeconomics49; increasing jobopportunities in long-term, ambulatory, andhome care settings, as pharmacy servicescontinue to shift toward these sectors89, 90; andcreation of new roles for pharmacists in theonline telehealth environment, includingInternet-based drug purchasing and onlinepatient counseling, a heretofore uncharted

landscape for pharmacy practice.91

Factors that may contribute to future decreasesin pharmacist demand include an anticipatedincrease in number of pharmacy schoolgraduates; expanded use of automated dispensingsystems, mail-order prescription services andpharmacy technicians; and an eventualdownsizing of the dispensing pharmacyworkforce due to increased managed carepenetration.5, 49 However, recent data suggestthat the short-term effect of managed care on theinstitutional pharmacy workforce has beennegligible.31 Whereas the influence of expandedmanaged care penetration on the pharmacyworkforce as a whole is controversial, it appearsthat the number of pharmacists required tomanage the drug distribution process willdecrease in the long term.5

Taking the foregoing trends into account,short-term predictions for pharmacist demandhave been published. The U.S. Bureau of LaborStatistics (BLS) estimates that employment ofpharmacists will increase 0–9% between 1998and 2008, a rate slower than the average for alloccupations in the U.S.49 The BLS predicts thatduring this period automated drug dispensingand increased use of technicians will helppharmacists fill prescriptions. It also notes thatgrowth of pharmacist employment in hospitals isexpected to be slow, reflecting continuedreduction in hospital stays, downsizing, andconsolidation of departments. On the otherhand, the BLS suggests that the increased numberof prescription drugs used by middle aged andelderly people could increase demand forpharmacists in all practice settings. The BLS alsoacknowledges that cost-conscious insurers andhealth systems will continue to explore the rolesof pharmacists in primary and preventive healthservices. This is based on their realization thatthe expense of using drug therapy to treatdiseases and conditions is often considerably lessthan the potential costs for patients whoseconditions go untreated, and that pharmacistscan play an important role in reducing theexpenses resulting from unexpected complicationsdue to adverse drug events or drug interactions.

Based on a study of the pharmacy manpowerissue conducted by the Pharmacy ManpowerProject, Knapp recently analyzed the impact ofmanaged care on future demand for pharmacistsand pharmacy services.31 Unlike the BLSoutlook, this analysis predicts that there will be asteadily increasing demand for pharmacists andtheir services. Although unable to validate the

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downsizing of the pharmacy workforce predictedby the 1995 Pew Health Professions Commission’sreport,83 Knapp calls for pharmacists to continuedocumenting their value to the health caresystem and participating in activities thatimprove patient outcomes.31

From a manpower perspective, is pharmacy“short-handed” or just “short-sighted”? A federalstudy is under way to address this question. TheHealthcare Research and Quality Act of 1999requires the Health and Human ServicesDepartment to study the pharmacist workforcesupply and report its findings to Congress inDecember 2000. Meanwhile, we believe that theprojections of the BLS, the Pharmacy ManpowerProject, and the Pew Commission are notnecessarily at odds with one another. While wehave long been disturbed by the relative lack ofdata to support the Pew Commission’s manpowerforecast, we recognize that pharmacy has beenrelatively slow to embrace new technologies inthe areas of information, communications, androbotics that were anticipated by the Pewreport.91 The profession also continues tostruggle with developing expanded roles fortechnicians in the drug distribution system.14

However, once technology, new centralizeddispensing systems, and technicians are widelyutilized to increase drug distribution efficiencies,it is probable that the need for pharmacistsengaged solely in distribution will decrease. Thewisdom of Pew’s suggested downsizing ofpharmacy school classes by 2005 has been calledinto question by current manpower trends.Nonetheless, it is not impossible that Pew’spredictions might yet coincide with theemergence of a new era of decreased pharmacistdemand—a trend that would be consistent withthe slower-than-normal growth in pharmacistjobs through 2008 that recently was forecast bythe BLS. Thereafter, future manpower needs nodoubt would be affected by the profession’ssuccess in redefining and transforming itself intoa discipline that provides care and impactspatient outcomes.

Recent demonstration projects, including theMississippi Medicaid Disease State ManagementProgram, may be instrumental in providingnecessary documentation of the contributionsthat pharmacists can make toward more effectiveand cost-efficient care.14, 15 In addition, recentlypublished data indicate that pharmacists inmanaged care and integrated health systems havebroadly expanded their ambulatory carefunctions, including using pharmacoeconomic

data to make formulary decisions, conductingmedication management programs, trackingadverse drug reactions, providing writteninformation with each new prescription,monitoring patient outcomes, and monitoringcompliance with medication use.92 Suchcontinued expansion of pharmacist responsi-bilities could produce a demand for “nondispensing”pharmacists that would seriously challenge theprofession’s manpower resources for theforeseeable future6, 56 (though this possibleincrease in demand may be mitigated somewhatby enhanced clinical efficiencies enabled by newtechnologies such as artificial intelligenceapplications for streamlining and monitoringdrug therapy). Regardless, if pharmacists’current professional roles remain unchanged,manpower requirements will be determinedprimarily by cost-driven changes in drugdistribution management. Such changeseventually could produce an environment thatrequires fewer pharmacists to successfullysupport the future health care system. In view ofthese uncertainties, it seems to us that academiashould carefully assess the nation’s futurepharmacy manpower needs before seeking toadjust pharmacy school enrollments. Clearly,these potential manpower trends should serve asa wake-up call for the entire profession.

Finally, academic pharmacy is facing its ownmanpower problem.93 Expanding pharmacyworkforce needs, increasing numbers ofpharmacy schools, rising numbers of doctor ofpharmacy students, and relatively static supply offaculty training programs (Ph.D. programs,residencies, and fellowships) are contributing toan inadequate supply of faculty to meet thecurrent demand. The number of facultydeparting academia to pursue careers in thepharmaceutical industry appears to be increasing,at least in the short term.93 It has beenrecommended that the academy increase effortsto recruit new graduates and experiencedpractitioners into academic career tracks, supportthe growth of clinical residency programs to meetthe rapidly increasing need for clinicalpractitioner faculty, promote expansion offellowship programs to increase the supply ofacademic clinical scientists, and establisheffective mentoring processes for new faculty.64, 93

In addition, we suggest that formal instruction indidactic and experiential teaching be incorporatedinto clinical residency and fellowship training,particularly in those programs that are affiliatedwith schools of pharmacy.

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Qualifications for Pharmacy Practice

Students prepared at the entry level are generalpractitioners who coordinate and renderpharmaceutical care. A system of pharmaceuticalcare requires the participation of both generalistsand specialists.

The Commission to Implement Change inPharmaceutical Education, 199194

The issue of credentialing in pharmacy is ofcritical importance because it has the potential toelevate the profession to new levels or to mire it indivisiveness.

Bertin, 199995

Any system that assesses and recognizespractitioner competence must be based on a validand reliable method of assessing capability. Thatsuch systems are possible is verified by the existenceof specialty certification mechanisms which useexperience and examinations as assessment tools.

The Commission to Implement Change inPharmaceutical Education, 199396

Requisite education and credentialing ofpharmacists will be important issues as theprofession pursues patient-centered practiceroles. As recounted earlier, the debatesurrounding the most appropriate degree forentry into the profession has been resolved as webegin a new century. However, emergingcontroversies surrounding postgraduatecredentialing processes now threaten to embroilthe profession in renewed debate. We believethat the credentialing issue—in particular thecontroversy associated with certification—hasthe potential to spark the same level ofdiscussion that occurred during the “B.S. versusPharm.D.” controversy. Certainly one must hopethat the credentialing/certification issue will notresult in the marked polarization that wasspawned by the entry-level degree controversy.Because there is still confusion within theprofession concerning contemporary educationand credentialing, we have taken the liberty ofsummarizing the current status of each below(Figure 1) and then concluding with an editorialviewpoint on credentialing.

Curricular Preparation and Licensure

Curriculum Standards and Guidelines

“Accreditation Standards and Guidelines forthe Professional Program in Pharmacy Leading to

the Doctor of Pharmacy Degree” (Standards2000) were adopted by the American Council onPharmaceutical Education (ACPE) in 1997,setting the stage for the final steps of a 10-yearaccreditation revision process that resulted inimplementation of the doctor of pharmacy as thesole professional degree.97 Standards 2000 stateas follows:

“The professional program in pharmacyshould promote the knowledge, skills, abilities,attitudes, and values necessary to the provisionof pharmaceutical care for the general practiceof pharmacy in any setting.”97

Colleges of pharmacy are expected to preparegeneralist practitioners of pharmacy for bothcontemporary practice and for emerging practiceroles. The ACPE standards acknowledge thatcolleges should educate and train pharmacists forboth patient-specific and population-basedpharmaceutical care. Contained withinStandards 2000 are 18 professional competenciesthat graduates should achieve through theprofessional curriculum. Outcome expectationsfor student performance in these professionalcompetencies are expected to be determined andassessed by each institution.

Disease state management is one of theprofessional practice competencies included inStandards 2000, although no specific diseasestates are required for inclusion in thecurriculum. With respect to experientialeducation, introductory practice experiences areto be offered to all students during the “earlysequencing” of the curriculum. This expansionof the experiential curricula will provide studentswith an early exposure to practice environmentsthat is likely to reinforce the relevance of didacticcontent and also to set the stage for earlyprofessionalization. Institutions also areexpected to provide advanced pharmacy practiceexperiences in both ambulatory and inpatientsettings including primary, acute, chronic, andpreventative care among patients of all ages. Theguidelines further call for core (required)advanced practice experiences that providesubstantial experience in the communitypharmacy setting, hospital/institutional practice,and acute care of general medicine patients.

Licensure

Licensure is the national, uniform, mandatoryprocess whereby regulatory and governmentalbodies (the National Association of Boards ofPharmacy [NABP] and the respective individual

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state boards of pharmacy) determine byexamination (e.g., NAPLEX) whether anindividual has the required education and skill topractice pharmacy. The boards of pharmacy inturn rely on ACPE to review and accredit thecurricula offered by schools and colleges ofpharmacy. The professional degree programs inpharmacy provide sufficient knowledge, skills,and practice experience for graduates to fulfillthe professional competencies required of generalpractice.94 Thus, these professional curriculasatisfy the educational requirements for licensureof pharmacists. Professional degree programs, bythemselves, do not provide graduates with theskills and experience needed to deliver specialtypractice-based care, thus creating a need for post-licensure credentialing options.94 In addition, itappears to us that current licensure examinationsare not adequately directed toward the clinicalcompetencies needed to provide care andconduct collaborative drug therapy management.98

Hence, continued revision and updating oflicensure examinations will be necessary toensure that future graduates are sufficientlycompetent to fulfill evolving practice roles. Asthe profession examines future means to ensure

professional competence in evolving clinicalroles, it also should assess the need for periodicre-licensure.

Post-Licensure Credentialing

Lack of understanding of the terminologyassociated with the credentialing process hascontributed to significant confusion regardingcredentialing.95 A credential is evidence of anachievement, including documentation oflicensure to practice; residency or fellowshiptraining; or completion of specific trainingcourses. Credentialing commonly refers to thereview of an individual’s credentials, often for thepurpose of determining practice privileges; thisterm also may be used to describe simply theprocess of awarding a credential. Licensure is aform of mandatory credentialing. Certification isa voluntary process, usually established by aprofessional, nongovernmental agency, that isdesigned to evaluate an individual’s training,experience, knowledge, and skill level beyondthat required for licensure. Certification usuallyis focused in an area of practice that is definedmore narrowly than the domain(s) tested during

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Education and Training Governmental Licensing Professional Certification

Educational Program Credential Accrediting Agency Credential LicensingAgency

Credential Certifying Agency

Entry-Level Pharmacy Education

B.S.Pharm.D.

ACPE RegisteredPharmacist

State Boardof Pharmacy

BCNP—Board Certified NuclearPharmacist

BPS

Continuing ProfessionalEducation

Certificate ofAttendance

ACPE BCNSP—Board Certified NutritionSupport Pharmacist

BPS

Certificate Program Certificate ofCompletion

ACPE BCOP—Board Certified OncologyPharmacist

BPS

Residency ResidencyCertificate

ASHP BCPS—Board CertifiedPharmacotherapy Specialist

BPS

BCPP—Board Certified PsychiatricPharmacist

BPSFellowship FellowshipCertificate

ACCP Peer ReviewProgram

SP

EC

IAL

TY

PR

AC

TIC

E

BCPS with added qualifications inInfectious Diseases, Cardiology

BPS

CGP—Certified GeriatricPharmacist

CCGP

DSM—Anticoagulation NISPC

DSM—Asthma NISPC

DSM—Diabetes NISPC

GE

NE

RA

L P

RA

CT

ICE

DSM—Dyslipidemia NISPC

SU

PP

OR

TP

ER

SO

NN

EL

CPhT—Certified PharmacyTechnician

PTCB

Figure 1. Summary of current education/training, licensing, and certification credentialing processes in pharmacy.Interdisciplinary certification is not included here. ACPE = American Council on Pharmaceutical Education; ASHP = AmericanSociety of Health-System Pharmacists; ACCP = American College of Clinical Pharmacy; BPS = Board of PharmaceuticalSpecialties; CCGP = Commission for Certification in Geriatric Pharmacy; DSM = Disease State Management; NISPC = NationalInstitute for Standards in Pharmacist Credentialing; PTCB = Pharmacy Technician Certification Board.


initial licensure. Certificate programs are definedby ACPE as “…structured and systematicpostgraduate continuing education experiencesfor pharmacists that are generally smaller inmagnitude and shorter in time than degreeprograms, and that impart knowledge, skills,attitudes, and performance behaviors designed tomeet specific pharmacy practice objectives.”99

Credentialing Options

Excluding pharmacist licensure, postgraduatecredentials are obtained on a strictly voluntarybasis. Pharmacists may elect to obtaincredentials at the disease, generalist, or specialistlevels. Post-licensure credentialing programsshould be subject to national standards. Trainingprograms also may be guided by nationalstandards, such as those used in the accreditationof residency programs. Although pharmacy has anational accrediting body for pharmacyresidencies (The Commission on Credentialingwithin the American Society of Health-SystemPharmacists [ASHP]), many pharmacy residencytraining programs are not accredited; therefore,they do not undergo national peer review.100, 101

Whereas some pharmacy fellowship programs aresubjected to voluntary peer review throughACCP, most pharmacy fellowship programs donot undergo national peer review.101 The recentproliferation of post-licensure disease-specificcredentialing programs, often not subject tonational standards, has created concern aboutprogram quality, consistency, and value.Confusion is rampant, as neither pharmacists northe public clearly can define the minimalstandards for these programs.

General Elements of Post-Licensure Certification

Voluntary certification has emerged as thehighest demonstrated professional level ofachievement in pharmacy practice. Certificationprovides public identity for those pharmacistswho have demonstrated knowledge deemedimportant by professional peers. Pharmacy, likeall professions, endorses certification as a meansof elevating professional standards. Certificationcan be used both to expand the professionalinfluence of pharmacy within health care systemsand to protect professional boundaries.Certification of licensed pharmacists may be ameans of verifying advanced professionalknowledge and skills. Certification processesusually are established by professional,nongovernmental agencies.99 In addition to

evaluating an individual’s knowledge, thecertification process also should document theindividual’s formal training, professionalexperience, and clinical skills. The individualseeking certification usually is assessed using anational standard that is more rigorous than thatrequired for entry into the profession bylicensure. Certification bodies should notprovide the training or education required forcertification examinations. Instead, independentprofessional, academic, or corporate entities arebest suited to provide preparatory materials andcourses.

Specialist Pharmacist Certification. In 1976,the APhA established the Board of Pharma-ceutical Specialties (BPS) to recognize specialtypractice areas, define knowledge and skillstandards for recognized specialties, evaluate theknowledge and skills of individual pharmacistspecialists, and serve as a source of informationand coordination for pharmacy specialties.102

The BPS has recognized five specialty practiceareas: nuclear pharmacy, nutrition supportpharmacy, oncology pharmacy, pharmacotherapy,and psychiatric pharmacy. Board certification bythe BPS indicates that a pharmacist hasdemonstrated an advanced level of education,experience, knowledge, and skills—beyond thatrequired for licensure—in a specialty practicearea. Board of Pharmaceutical Specialtiescertification is the only such designation withinpharmacy that recognizes advanced, specializedskills and knowledge against an establishednational standard. Four eligibility criteria aredefined for BPS recognized specialties: an entry-level pharmacy degree, an active pharmacylicense, additional training within the respectivespecialty area, and successful completion of thespecialty certification examination.102 Whereasthe specialized education or experience requiredfor certification varies among the BPS specialties,all require either several years of prior specialtypractice experience or completion of specialtyresidency or fellowship training. The BPSrequires recertification every 7 years, with eachspecialty having separate requirements for therecertification process. As of January 2000, morethan 2900 pharmacists have been certified by theBPS.102

Added Qualifications within a RecognizedPharmacy Specialty. The BPS also recognizesfocused areas within established pharmacyspecialties. Demonstration of enhanced training

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and experience within one segment of a BPS-sanctioned specialty practice area is recognizedby the designation “Added Qualifications.”102

This designation denotes further differentiationwithin a specialty. Unlike the medical profession,pharmacy does not require such subspecialtydifferentiation through separate boardexaminations. To establish a new area of AddedQualifications, a group first must petition the BPSto recognize the desired subspecialty. If thispetition is approved, individuals wishing to beconsidered for Added Qualifications must submita portfolio that documents their enhancedexperience and training. If the committee of theSpecialty Council believes the portfolio meetsestablished requirements, individuals receive anew BPS Certificate recognizing their status as“Board Certified with Added Qualifications.”The Added Qualifications practice area firstrecognized by the BPS was Infectious Diseaseswithin the specialty of Pharmacotherapy,approved by the Board in 1999.

Generalist Pharmacist Certification. The APhAproposed a certification program in “pharmaceuticalcare” in the late 1990s, although the program hasnot yet been developed. This was intended to bean advanced generalist designation but not asintensive as the pharmacotherapy specialty orother specialty certification processes performedby the BPS. Another generalist certificationprogram was developed for pharmacists ingeriatric pharmacy practice. The Commission forCertification in Geriatric Pharmacy (CCGP) wasestablished by the American Society ofConsultant Pharmacists (ASCP) in 1997.103 Thisnational voluntary certification program requiressuccessful completion of a written examination.To be eligible to take the CCGP certificationexamination, the pharmacist must hold a currentlicense and possess a minimum of 2 years ofpractice experience. According to CCGP, nospecial training or clinical experience ingeriatrics is required, although a review course isavailable on the ASCP Web site, and numerouscontinuing education programs can helppharmacists prepare for the exam.103, 104 Domainsincluded in the geriatric pharmacy practice examare patient-specific activities, disease-specificactivities, and quality improvement andutilization management activities.103

Interdisciplinary Certification. Most certificationprocesses in health care emerged withinindividual health care disciplines. This is also

true for pharmacy. During the past 2 decades,however, interdisciplinary certification involvingtwo or more health care disciplines emerged.The American Academy of Pain Managementprovides voluntary certification for inter-disciplinary pain practitioners.105 Practitionersfrom medicine, pharmacy, nursing, psychology,counseling, physical therapy, chiropractic, andsocial work have been accorded voluntarycertification as interdisciplinary pain managers.The National Certification Board for DiabetesEducators designates qualifying health carepractitioners as Certified Diabetes Educators(CDE).106 The CDE designation assures thepublic that the individual demonstratedexcellence in diabetes education. The AmericanBoard of Applied Toxicology (ABAT) providesvoluntary certification of nonphysician specialistsin applied clinical toxicology.107 Certifiedindividuals are designated as ABAT Diplomates(DBAT). The American Board of ClinicalPharmacology (ABCP) provides voluntarycertification for nonphysicians in appliedpharmacology.108 On successful completion ofprofessional requirements and certificationexams, the ABCP issues a certificate thatdesignates the individual as “Accredited inApplied Pharmacology.”

Disease-Specific Credentialing

Disease-specific credentialing is designed todocument a pharmacist’s ability to providedisease-specific care beyond the dispensing ofmedications.109 The National Institute forStandards in Pharmacist Credentialing (NISPC)serves as the credentialing body for this process.The NISPC was formed by NABP, NCPA, andNACDS in June 1998; the APhA joined the groupin 1999. Pharmacists who desire to becredentialed voluntarily in one of four diseasestates must pass an NABP disease statemanagement exam. Currently, disease statemanagement exams are available for anti-coagulation, asthma, diabetes, and dyslipidemia.The exams are designed to serve as standardizedassessment tools that measure the application ofknowledge and judgment of pharmacistsproviding disease state management. The NABPcreates and administers the disease statemanagement exams, which were offered in morethan 20 states in 1999. Pharmacists may elect tobecome credentialed in more than one diseasestate and combine disease-specific credentialingwith other continuing education activities.

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Whereas disease state management exams assessknowledge and skills related to management ofeach respective disease state, they cannot assessclinical training or experience. Because trainingand experience are certainly importantprerequisites for the provision of patient care,other certification processes (e.g., BPScertification) require validation of theseprerequisites. The NABP maintains a database onits Web site that allows the public and third-partypayers to verify pharmacists’ disease-specificcredentials obtained through NISPC.110

Successful completion of a disease statemanagement exam qualifies the pharmacist toapply for a provider number and receive paymentfor disease-specific clinical services in a pilotMedicaid waiver program in Mississippi.Eligibility to sit for any of the disease statemanagement examinations is limited topossession of an active license issued by a boardof pharmacy in a jurisdiction that administers theexam; no prior clinical experience is required.The NABP disease state management examqualifications do not require additionalpreparation beyond the education required forlicensure; although, review courses are offered byprofessional organizations and schools andcolleges of pharmacy. The disease statemanagement objectives and standards, availableon the NABP Web site, include collection ofpatient data and documentation of care.110

To obtain input on disease managementcertification value and process, NISPC convenesa Payer Advisory Panel and a Standards Board.110

According to the NISPC, both advisory groupshave affirmed the value of pharmacistcredentialing in “high-cost clinical conditions.”The Payer Panel recognized the importance ofoutcomes assessment and the need for a clearlydefined menu of services to be provided bycredentialed pharmacists. They also recom-mended creation of a credentials databaseaccessible to payers, physicians, and othercollaborating health care providers as previouslydescribed.

Certificate Programs

In late 1998, national professional organizationsand the NABP asked the ACPE to assume overallresponsibility for developing guidelines forcertificate programs and their providers. The“Standards and Quality Assurance Procedure forACPE-Approved Providers of ContinuingPharmaceutical Education Offering Certificate

Programs in Pharmacy” were adopted by theACPE Board of Directors in June 1999 andbecame effective in January 2000, following animplementation/transition period.99 Thus, theACPE extended its purview to include oversightof providers of all voluntary pharmacy certificateprograms in addition to providers of generalpharmacy continuing education programs. Thesenew ACPE standards provide a list of 24professional competencies that may be used forguiding the organization and for development ofcertificate program content. The standards alsorequire the certificate program to include practiceexperiences, simulations, and/or innovativeactivities to ensure demonstration of the statedprofessional competencies. Unlike traditionalcontinuing education provider standards, ACPEcertificate program provider standards require thatproviders of certificate programs conductsummative evaluations of participant learning.Generally, certificate programs are expected torequire a minimum program length of 15 contacthours or 1.5 CEUs. A special ACPE certificateprogram logo identifies certificate programs thatare delivered by ACPE-approved providers.Because ACPE approves the provider of theprogram and not individual participants, eachparticipant is awarded a certificate of completion.The certificate of program completion does notimply certification of the individual. This isanalogous to the recognition of residencyprogram graduates; residents are awardedcertificates of completion, but the individualresident practitioner is not certified.

Council on Credentialing in Pharmacy

The Council on Credentialing in Pharmacy(CCP) was formed in 1998 by a consortium oforganizations dedicated to providing leadership,standards, public information, and coordinationof voluntary pharmacy credentialing programs.111

The CCP was established by 11 foundingmember organizations: the Academy of ManagedCare Pharmacy, the American Association ofColleges of Pharmacy, the American College ofApothecaries, ACCP, ACPE, APhA, ASCP, ASHP,BPS, CCGP, and the Pharmacy TechnicianCertification Board. The Council is dedicated toensuring that pharmacist credentialing is acredible process that is understood by allstakeholders, including patients, payers, otherhealth professionals, and the quality assuranceleadership in hospitals and health systems.112

The CCP is attempting to establish a more

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coordinated approach to guide the professionthrough the development of new, voluntary, post-licensure certification processes. The Councilalso hopes to determine and clarify therelationships among the profession’s variouscredentialing activities.111

Views on Credentialing

A coordinated national strategy to clarifypharmacist credentialing processes clearly isneeded. The proliferation of credentialingprocesses and certification programs that do notundergo rigorous review and assessment and thatmay not require prior training or experiencecould undermine pharmacists’ credibility withproviders, the public, and payers. We stronglysupport the continued evolution of post-licensurepharmacist credentialing. However, we believethat credentialing within the pharmacyprofession should meet rigorous nationalstandards. Therefore, pharmacist certificationwould be administered best through acoordinated national certification board thatassures assessment of knowledge and skills whilealso validating the appropriate level of training orexperience. Logically, this certification boardwould include BPS to conduct specialistcertification and an analogous body to carry outnonspecialist certification. We further suggestthat the entire voluntary pharmacist credentialingprocess (including certification and perhapspostgraduate training) should be coordinated bya national, broad-based credentialing coalition,such as the CCP (should it choose to assume thisrole) or an alternate governing body as depictedin Figure 2. We recommend that this proposedmodel for pharmacist credentialing be exploredfurther in a future ACCP thought paper. Finally,the subcommittee also endorses pharmacistparticipation in national interdisciplinarycertification processes as previously described(e.g., CDE).

It is important to recognize that many of thenewly emerging credentialing mechanisms areintended to serve primarily as a temporary“bridge” to the future. That is, effectiveretraining processes will be required by many oftoday’s pharmacists as they prepare to “retool” toassume new patient care roles. However, it isreasonable to expect that future doctor ofpharmacy graduates will possess the abilitiesnecessary to enter the profession as effectivegeneralist practitioners and should not requireretooling. The profession should be prudent in

its approach to developing and managing theseretraining processes; creating a plethora of“extra” postgraduate certificates that allpharmacists would be required to complete toengage in clinical practice should be avoided.Structured and systematic postgraduateeducation experiences (i.e., certificate programs)should provide much of the retraining that willbe needed by the current pharmacist workforce.Therefore, we favor development of well-designed certificate programs that pharmacistscan complete as part of a nonspecialistcertification process (as discussed previously).Such nonspecialist certification could serve as abasis for the credentialing of today’s nonspecialistpharmacists who desire access to particularpractice privileges or reimbursement. Moreimportantly, we hope that this process might helpthe profession to establish new and moreappropriate domains of the professionalknowledge, skill, and experience to be tested infuture licensing exams.

We view disease-specific credentialingprocesses (such as those administered byNISPC), as currently constituted, in a mixedlight. On the positive side, such programs canimprove the practitioner’s knowledge base, mayallow pharmacists to have increased impact onpatient care outcomes, and may provide a basison which to qualify for reimbursement from

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ACPE CCP• Entry-level Pharmacy Education

• Certificate Programs

• Continuing Professional Education

Board ofPharmaceutical

Specialties

Cer

tific

atio

n

Board ofPharmaceuticalNon-SpecialtyCertification

Board ofPharmaceuticalResidencies &

Fellowships

• BCNP• BCNSP• BCOP• BCPS• BCPP

• DSM Certification

• Residencies

• Fellowships

• CGP

• CPhT

Trai

ning

Edu

catio

n

Figure 2. Proposed model for coordination of pharmacycredentialing. ACPE = American Council onPharmaceutical Education; CCP = Council on Credentialingin Pharmacy; BCNP = Board Certified Nuclear Pharmacist;BCNSP = Board Certified Nutrition Support Pharmacist;BCOP = Board Certified Oncology Pharmacist; BCPS =Board Certified Pharmacotherapy Specialist; BCPP = BoardCertified Psychiatric Pharmacist; DSM = Disease StateManagement; CGP = Certified Geriatric Pharmacist; CPhT =Certified Pharmacy Technician.


some payers. On the negative side, theseprograms are limited in scope, require no clinicaltraining or clinical experience, and may fragmentpatient care. Furthermore, if a pharmacist’sdisease management abilities are limited to onlyselected diseases, he or she may not be able toimpact fully the number of patients that healthcare payers expect. We also are concerned that apharmacy practitioner could be credentialed inan area of disease management without havingacquired any prior clinical patient careexperience. In our view, this could compromisepatient care.

The role of generalist pharmacist certificationremains to be determined. As it has not yet beendeveloped, a pharmaceutical care certificationcannot be evaluated. However, pharmaceuticalcare is a philosophy of practice that theCommission to Implement Change inPharmaceutical Education characterized asfollows:

“Pharmaceutical care focuses pharmacists’attitudes, behaviors, commitments, concerns,ethics, functions, knowledge, responsibilities,and skills on the provision of drug therapywith the goal of achieving definite outcomestoward the improvement of a patient’s qualityof life. These outcomes of drug use are: (1)cure of a disease; (2) elimination or reductionof symptoms; (3) arresting or slowing a diseaseprocess, (4) prevention of disease; and (5)desired alterations in physiological processes,all with minimum risk to patients. Just as it isgenerally assumed that physicians are primarilyinvolved in medical care and nurses in nursingcare, pharmacists are the primary providers ofpharmaceutical care.”13

It appears that it would be virtually impossibleto describe a unique set of knowledge and skillsthat would encompass the domains forcertification of pharmaceutical care. Even if sucha set of domains were defined, the breadth ofsuch a certification program would be enormous,presumably approaching the outcomeexpectations for the doctor of pharmacy degree.Furthermore, it is inconceivable to us that theprofession or public would find value incertifying a philosophy of practice—to follow theanalogies from the previous quotation, medicinehas no “medical care” certification and nursingdoes not certify “nursing care.” On the otherhand, if it is clinical skills and selected drug- anddisease-specific knowledge that are desired, it isconceivable that appropriately focused and

standardized certificate or training programscould be designed to meet practitioner needseffectively.

Our impression is that the CCGP certificationprocess involves pharmacists actively practicingin geriatric and long-term care settings.However, we still view the absence of any explicitrequirement for prior clinical training or clinicalpractice experience as a potential weakness ofthis certification process, as noted for the disease-specific programs.

As a final caveat, we encourage those involvedin current and future pharmacy certificationprocesses to study and assess the value ofcertification. While acknowledging the potentialbenefits of certification, we are aware of nopublished data that have examined the effects ofany pharmacy certification process on patientoutcomes, including technician certification,specialist pharmacist certification, or generalistpharmacist certification. Until such data areavailable, it may be difficult to convincepharmacists, other health professionals, payers,or the public of the benefits of certification. Inthis regard, we believe that mechanisms shouldbe explored to include BPS-certified clinicalspecialists in the national NABP database (oranalogous credentialing directory) that currentlycatalogs pharmacists who have been credentialedin disease management. This would allow readyidentification of those specialty-certified anddisease-certified practitioners who could beavailable to participate in patient outcomesstudies or pilot reimbursement programs (e.g.,Mississippi Medicaid waiver program).

A Vision for the Future

The future ain’t what it used to be.Yogi Berra, 19742

Our subcommittee was charged to address themany factors likely to impact future qualitativeand quantitative manpower needs, and todevelop a vision of pharmacy as it might exist atthe conclusion of the first decade of the 21stcentury. The list below, to a great extent, is basedon the information, analyses, and forecasts statedin this paper. As is the case in all visioningefforts, much of what we expect may not come topass; new, unforeseen developments mayinfluence profoundly the future of the pharmacyprofession. However, we offer the followingpredictions of how events affecting pharmacymay unfold during the next decade:

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1. Health care will place increasing emphasison drug therapy to improve patientoutcomes and quality of life. Prescriptiondrug use will continue to rise, creatinggreater risk of drug-related morbidity.

2. Society will become increasingly technologyliterate and technology driven. Technologywill be deployed fully to dispense mostprescriptions, provide drug information topatients, and facilitate the exchange ofpatient-specific data among and withinhealth care systems.

3. Pharmacy will transform itself from aprimarily product-centered profession to apatient care-oriented profession.

4. Patient care rendered by pharmacists,including those not directly involved withdrug product distribution, will bereimbursed by payers.

5. Corporate pharmacy and independentpharmacy owners will find pharmacists’patient care services to be profitable and willcommit resources to this market, includingenhanced use of technology and technicians.

6. State boards of pharmacy and governmentallegislation will enable and facilitatepharmacists’ patient care activities, bothindividually and in collaboration with otherhealth care professionals.

7. Technician certification will be mandated toprotect the public.

8. Pharmacy education will prepare graduatesfor increasingly complex patient andpopulation drug therapy management andproblem-solving, and supervision ofprescription dispensing and processing bytechnicians and automated technology.

9. Pharmacy schools will experience anunprecedented increase in graduates due toa continued rise in demand for pharmacists,popularity of health care careers, and anincreased visibility of pharmacists’ patientcare roles in the 21st century.

10. Appropriate credentials that documentclinical practice abilities will be aprerequisite for all pharmacists who providepatient care services. Eventually, residencytraining will be an expectation of mostentry-level pharmacists.

Recommendations

Put as much energy into long-term planning forpharmacy as is put into short-term strategizing.Let’s begin to outline, through our professional

organizations, what we can achieve over ageneration or two, not just within the next 12months. Let’s see if we can coordinate the planningefforts of national and state practitionerorganizations and the academic community.

Zellmer, 19969

In developing this White Paper, our sub-committee was asked to provide recommen-dations for action by the profession. Theserecommendations have been divided into twocategories: (1) recommended actions for theentire profession, and (2) recommendations forACCP and its membership. The recommendationsreflect the analyses, forecasts, assessments, andopinions offered in the body of the paper. Weexpect that not all of the suggested actions willbe deemed possible, or in some cases, evenappropriate. However, we do hope that therecommendations herein will promote furtherthought and dialogue among the profession ingeneral, and the clinical pharmacy community inparticular.

Recommendations for the Pharmacy Profession

1. Adopt a unifying philosophy of practice thatestablishes the patient as the primarybeneficiary of the profession, with thepharmacist accepting shared responsibilitywith other health care professionals forpatient care.

2. Develop a coordinated strategy bycapitalizing on the collective strengths ofnational pharmacy organizations to securefinancial compensation for pharmacists’patient care services that are not directlyrelated to drug distribution.

3. Create a profession-wide strategy for boththe development and use of technology.This strategy should engage pharmacyeducation and all venues of pharmacypractice to enhance pharmacists’ training in,and use of, technology in prescriptionprocessing and distribution, drug information,and drug therapy management.

4. Work with professional regulators and statelegislators to revise pharmacy practice actsto enable shared responsibility for directpatient care, use of appropriate technologyand technical support personnel, andcollaborative drug therapy management.

5. Develop credible, coordinated certificationand credentialing processes whereby allqualified pharmacists can demonstrate

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patient care competence.6. Focus, in academia, not only on manpower,

but also (perhaps even more) on professionalempowerment. Pharmacy educators mustmaintain high expectations for performanceof both general and professional educationaloutcomes; contribute to the development ofnew post-licensure education and trainingprograms that help existing practitioners“retool”; promote continued expansion ofresidency programs, including nontraditionalprograms (mini-residencies); and assumeleadership roles in technician training andcertification.

7. Foster collaborative efforts by professionalorganizations, academia, and health caresystems to develop new models of pharmacypractice in the community practice setting.

Recommendations for ACCP

1. Collaborate closely with other nationalpharmacy organizations and assume aleadership role in the profession’s adoptionof a unifying philosophy of practice.

2. Place increased emphasis on the developmentof leadership abilities among the rank-and-file membership.

3. Embrace community pharmacy and seek toassist community practitioners in acquiringadditional knowledge, skills, and attitudesthat can expand pharmacists’ impact onpatient outcomes.

4. Encourage colleges and schools of pharmacyto explore how current doctor of pharmacyprograms can prepare graduates better forcontemporary generalist practice.

5. Encourage NABP and state boards ofpharmacy to continue their efforts towardcreating licensure exams that are morereflective of pharmacists’ patient careresponsibilities.

6. Support, and assist in the development of,certificate programs and certificationprocesses that provide for appropriateassessment of knowledge and skills whilealso validating adequate levels of experience.

7. Oppose pharmacist certification that lacksunique (differentiating) and definableknowledge domains, or adequate assessmentof clinical training or experience.

8. Work inclusively with other pharmacyorganizations, associations, and CCP toestablish a cohesive and coherent plan forpharmacist credentialing.

9. Explore the feasibility of engaging incooperative political advocacy efforts withcommunity pharmacy organizations andtrade associations to pursue agendas ofmutual professional interest (e.g., reimburse-ment for pharmacists’ clinical activities thatimprove patient outcomes).

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