A Vision of Pharmacy's Future Roles, Responsibilities, and Manpower Needs in the United States

This paper was prepared by the 1997-1999 ACCP Clinical Practice Affairs Subcommittee A: Michael S. Maddux, PharmD, FCCP, Chair; Betty J. Dong, PharmD; William A. Miller, PharmD, FCCP; Kent M. Nelson, PharmD, BCPS; Marsha A. Raebel, PharmD, FCCP, BCPS; Cynthia L. Raehl, PharmD; and William E. Smith, PharmD, PhD

Pharmacotherapy. 2000;20(8) 

In This Article

Issues Influencing Change in Pharmacist Roles and Responsibilities

The future will not permit use of the full-trained [sic] pharmacist in procedures and tasks that do not require the level of his knowledge and skill.
The Millis Commission, 1975 [25]

...much of what pharmacists will do or not do during a workday is driven by their professional values -- by what is important and what obligations are to be met -- rather than by some carefully defined list of tasks.
Nimmo and Holland, 2000 [21]

Numerous factors will influence the pharmacy profession's ability to accomplish the changes necessary to implement a profession-wide shift in practice philosophy and activities. Concerted and unified efforts from within the profession are a definite prerequisite to change, as has been noted. However, forces external to the profession also will have profound influence on pharmacy's future.

Fortunately, pharmacists gradually are embracing changing definitions of their professional roles. All segments of the pharmacy profession -- practice, research, industry, and academia -- are welcoming and accepting change. An underlying premise of this White Paper is that pharmacists' roles and responsibilities should change and that the result of appropriate, ongoing change will determine pharmacist manpower needs over the next decade.

Multiple factors are perceived to be barriers to any change in pharmacists' professional identity. Some of these also have been delineated in an earlier ACCP White Paper, "Clinical Pharmacy Practice in the Noninstitutional Setting."[26] Although it is not the intent of this paper to reiterate all barriers to changing professional roles for pharmacists, several key points deserve discussion.

First, the many differing attitudes and goals of individual pharmacists often contribute to a lack of professional cohesiveness. In fact, the goals of different pharmacists and pharmacy organizations are often at odds with one another. Examples include past debates concerning the entry-level Pharm.D. degree and current controversies surrounding certification and credentialing. Lack of consensus on goals, and the lack of a clear, focused definition of "who we are and where we are headed," are strong forces that can impair effective change.

Second, Donald Brodie observed the following in 1981:

"...we must remember that our profession lends itself exceptionally well to the practice of technique. Some would say that we are victims of our own technique. Consumers often see only a bottle of pills. Many of our practitioners see the boundaries of their professional responsibility circumscribed by the practice of technique -- the dispensing of medicine." [27]

Through much of the 20th century the profession was served well by its strong identification with product dispensing, but at this point an exclusive emphasis on dispensing is detrimental to the efforts to change pharmacists' roles. The boundaries of the profession are not static and circumscribed but dynamic and ever evolving. This is disconcerting to some members of the profession, for with a dynamic boundary we are never in complete command of the knowledge necessary to practice with optimal effectiveness and therefore must commit ourselves to lifelong learning. This is

not

to say that the accurate dispensing of drugs and devices should be the responsibility of some other profession, but that the responsibilities of the profession must expand beyond an exclusive identification with dispensing. Indeed, the recent report released by the National Academy of Science's Institute of Medicine (IOM) should serve as impetus for all sectors of the profession to take action toward reducing medical errors.

[28]

The IOM report estimates that approximately 7,000 patients die each year from medication errors. As has been noted by others, preventable drug-related morbidity can be reduced by involving pharmacists in the provision of direct patient care.

[29]

Third, the competence and confidence levels of some segments of the pharmacy workforce are factors opposing pharmacist role redefinition. For example, when Knapp and colleagues evaluated prescription intervention rates among community pharmacies, intervention rates ranged from 0-4.1% of prescriptions.[30] This variability may have been due to insufficient self-confidence among the community pharmacists in the study, or it could reflect that those pharmacists who accomplished no interventions lacked the clinical competence to conduct such interventions. Alternatively, it could indicate that prescription interventions were not a high priority in the practice settings included in the evaluation. Unfortunately, if any of these suppositions are true, they suggest that the largest segment of our profession (community pharmacists) is not consistently and effectively making professional interventions a core professional value. Stated another way, the lack of prescription interventions may be a significant obstacle if community pharmacists are to play a major role in improving drug-related outcomes. Confidence level and self-image are important prerequisites for pharmacists who seek to perform health care functions that traditionally have been carried out by other health professionals. However, many pharmacists choose not to intervene in a patient's drug therapy because they do not believe that they have a role in disease prevention and health promotion initiatives, such as immunizations and smoking cessation; they feel incompetent to monitor the necessary clinical or laboratory parameters pertinent to drug therapy; they possess unfounded fear that there is increased risk of professional liability associated with prescription interventions; or they believe that their duty to counsel is completed after asking the patient, "Did your physician tell you how to take this medicine?"

Fourth, some assert that corporate or managed health care is associated with a decrease in number of pharmacy positions. When the relationship between staff size and full-time equivalent (FTE) changes was evaluated in the Pharmacy Manpower Project under the hypothesis that increased managed care penetration was associated with decreased pharmacy staff size and job loss, the hypothesis was rejected.[31] Managed health care systems have increased demand for pharmacists by providing more jobs in areas such as data analysis, pharmacy benefit management, formulary construction and maintenance, development of system-wide clinical pathways, drug information, disease-specific clinics, prevention services, and automation.[32] Managed care systems typically utilize sophisticated information technology and possess greater access to patient-specific data to support expanded pharmacist roles.[33]

Fifth, dissension about whether or not to implement the entry-level Pharm.D. degree occupied pharmacy organizations and pharmacists for too long. Regardless of the pros and cons of the ultimate decision, one thing seems evident: the all-Pharm.D. controversy occupied the pharmacy profession's intellectual and political energies for so long that some members of the profession "took their eyes off" other issues that were critical to the survival and advancement of the profession.

Sixth, business interests (i.e., the bottom line) often are cited as factors opposing professional advancement of pharmacists. Pharmacists complain that the volume and time demands of dispensing prescriptions preclude using drug therapy knowledge to help patients. However, pharmacists have options with respect to the setting in which they choose to practice their profession. Perhaps the current shortage of pharmacists in high-volume, chain drug store settings is an indication that pharmacists are not amenable to the requirement of high-volume drug dispensing at the expense of time spent using professional knowledge to help patients. Further exacerbating this situation is the current low-unemployment economic environment that has created a concomitant shortage of available pharmacy technicians. Should it persist, this technician shortage might drive more phar-macists away from some community pharmacy settings.

Seventh, lack of reimbursement for pharmacists' patient care services is impeding development of new, expanded practice roles. Most prescription benefit programs are designed to provide reimbursement only for the provision and cost of prescription drugs. Pharmacist activities that have been shown to improve patient outcomes and/or lower health care costs in most cases are excluded from patients' health care benefits.[14] Without remuneration for both product and service, the majority of pharmacists have focused their efforts on distribution of product. This is clearly a major impediment in the community pharmacy setting, where marginal reimbursements for dispensing have necessitated continued increases in prescription volume. In addition, although a majority of recently surveyed health-system pharmacists indicated that they are involved in provision of pharmaceutical care, only 16% said that they are reimbursed for such services.[34]

Finally, the interpersonal skills of pharmacists perhaps are underdeveloped and undervalued. These skills are crucial to success in many interactions with patients and other health care professionals. Pharmacy education in some instances may have neglected the link between communication ability, human relations skills, and effective professional practice. Fortunately, this is changing. Pharmacy schools increasingly are using personal interviews in selecting candidates; mandating course work in communications, negotiation, persuasion, and teamwork; and requiring team projects and verbal presentations throughout the professional curriculum.[5]

Multiple factors can prompt changes in professional roles. The anticipated growth in the number of drugs prescribed is arguably a factor that should stimulate increased future demand for pharmacists. Also, with increased prescribing comes more frequent medication-related problems, a major area of need for pharmacist intervention.[35] Throughout the past 30 years, numerous publications have detailed the significant health care problems associated with drug-related morbidity and mortality.[36,37,38,39,40,41,42,43,44,45,46,47] For each $1 spent on medications in nursing homes, $1.33 is expended for drug-related problems.[48] More than 70% of medication expenditures occur in the ambulatory setting where, coincidentally, about 60% of pharmacists practice.[49] A community pharmacy study described the analysis of more than 600 interventions from more than 93,000 prescriptions obtained under a capitated, managed care Medicaid contract.[31] In this study, product selection interventions resulted in a $20.17 reduction in cost/prescription, whereas interventions directed toward clinical problem resolution resulted in a range of savings from $1188-$1755/intervention. Opportunities for medication interventions exist in virtually all practice settings. Pharmacists routinely must conduct patient counseling, become more actively involved in patient drug therapy decision-making, and consistently intervene to prevent and resolve drug-related problems.

Second, a small percentage of patients (e.g., patients with chronic diseases, such as diabetes or asthma) account for a high percentage of health care costs. Disease state management (DSM) for patients with chronic medical conditions that contribute to high resource utilization increasingly is being conducted through an interdisciplinary collaboration of health care professionals including nurses, primary care physicians, specialist physicians, and pharmacists. Disease state management can occur in either the inpatient or ambulatory care environment. Additionally, patients with chronic diseases visit pharmacies often for prescription and over-the-counter medications. Community pharmacies -- and pharmacists -- can serve as potential "ambulatory clinic sites" where pharmacy professionals assess and monitor patients with chronic diseases during their pharmacy visits.

A third factor promoting changes in pharmacists' professional roles is the increasing recognition of the need to impact clinical, economic, and humanistic patient outcomes. Assessment of these patient outcomes requires data collection and analysis. As key collaborators in the DSM process, pharmacists are well positioned to apply the scientific method effectively to outcomes analysis. Accreditation processes for hospitals and health plans (e.g., the National Council on Quality Assurance [NCQA] and the Joint Commission on Accreditation of Healthcare Organizations [JCAHO]) require data collection and analysis in areas such as care processes and outcomes. Typically, data must be integrated from several sources to document the performance of the organization. Again, pharmacists are well positioned to provide and analyze the data critical to this documentation.

Fourth, the expanding use of automation and information technologies, and the use of support personnel, allow pharmacists to shift focus from the drug product (and the knowledge and skill that its compounding and/or dispensing requires) to drug-related problems, care processes, outcomes, and so forth. Although some pharmacists fear increased use of technology and support personnel, this assistance can promote change by allowing pharmacists to focus on the patient.

Fifth, the ability to retrieve, analyze, and apply published literature to medication-related problems can create expanded roles for pharmacists. Health care professionals always will need current information about new drugs, devices, and medical advances, particularly in view of the rapid pace of new drug development. Likewise, increasingly sophisticated consumers now are seeking more information about their drugs and expect to participate in their own care. Roles exist for pharmacists in Internet-based professional and consumer education, and in health professional continuing education. Pharmacist roles also are expanding to include direct delivery of patient-focused information and education.

Pharmacogenomics -- the application of principles of pharmacogenetics to the development of optimal regimens for treatment or prevention of disease -- also may result in new pharmacist roles.[50,51] It is likely that knowledge of a particular patient's genetic profile will be used in the future to individualize drug selection and dosing, or to predict adverse effects. Pharmacists may be required to assist in the interpretation of diagnostic genetic tests and to use their knowledge of pharmacokinetics and pharmacodynamics to optimize drug therapy for a specific patient. The greater degree of complexity associated with this mode of drug selection may further increase pharmacists' roles on the patient care team. In addition, one would expect that the evolution of pharmacogenomics will increase the need for patient and health care provider education regarding drug therapy.[51,52]

For the past several years, pharmacists' practice settings have been shifting away from the acute care and traditional community practice environment toward long-term, ambulatory, and home care settings. Changing models of pharmacy practice in these settings are providing new, expanded opportunities for pharmacists in the areas of continuity of care, disease state management, and preventive care.

Other issues also may influence both current and potential roles of pharmacists in the future. It is important to note that some issues have the potential either to impair or promote redefinition of the pharmacist's professional role, depending on the perspective from which the individual may choose to view a given issue.

Patient outcomes are frequently suboptimal because of drug-related problems. Pharmacists are often the health care professionals who have the greatest knowledge and skills to prevent, detect, monitor, and resolve drug-related problems. Pharmacists remain highly trusted and readily accessible to the public. Furthermore, as costs of drug therapy increase at an untoward rate, health care delivery systems and technology continue to evolve, and interdisciplinary practice becomes more common, many pharmacists likely will find themselves engaged in direct patient care.

Expanding and retaining desirable roles (i.e., those that are useful to both patients and to the health care system) will require proactive development and implementation. Pharmacists must continue to justify their positions through documentation of clinical interventions and patient outcomes; education of patients, health professionals, and payers; collaboration with other health providers; and dissemination of professional accomplishments through publication. Pharmacists also must seek to highlight best practices, thereby establishing quality performance expectations and increasing the practice levels of pharmacy generalists and specialists.

Can pharmacists change? We believe they can. A growing number of pharmacists are proactively changing their practices, participating in research, and educating students and other health care professionals. Clinical pharmacy remains at the forefront of these initiatives. But, how will the profession prepare for this change? We consider some possibilities.

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