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Specialization Key to Evolving Health Care Environment

Kate Traynor

As health care models evolve, so do pharmacy practices, and the profession's increased emphasis on specialized training has a vital role to play in the process.

"We're in what I believe is the era of accountability for health care . . . and that has demanded the expansion of clinical knowledge and competence of all pharmacists," said William Ellis, executive director of the Board of Pharmacy Specialties (BPS). "We're truly moving beyond a distribution model to being directly involved in affecting patient outcomes."

William Ellis

John Clark, director of pharmacy services at the University of Michigan Hospitals and Health Centers, said that from his perspective as an employer, specialized training helps guide hiring decisions.

"One of the things that specialization and board certification allows us is an opportunity to look at practitioners that are beyond residency-trained individuals," Clark said. "There are fewer positions available than there were a few years ago. And this allows us to be more selective as employers."

John Clark

And from the profession's standpoint, specialization and credentialing are viewed as keystones of so-called provider status—the recognition of the pharmacy profession as health care providers under Medicare.

"While we believe that all pharmacists should be recognized as providers, we also realize that . . . decision-makers will want to know that the pharmacists who are providing care possess the requisite knowledge and skills to provide that care competently," said ASHP Chief Operating Officer David Witmer.

David Witmer

Witmer said that through its work with the Council on Credentialing in Pharmacy, a collaborative effort involving 10 national pharmacy organizations, ASHP "strives to create a framework for credentialing and privileging that empowers pharmacists to assume a more significant role in patient care."

Specialization today. BPS today awards credentials in six specialty areas and next year will allow pharmacists to take examinations for two additional areas—pediatric pharmacy and critical care pharmacy.

But that's a tiny fraction of the more than 150 specialty and subspecialty areas in which physicians can be credentialed through the Board of Medical Specialties.

"Pharmacy is probably behind the curve in specialization," Ellis said. "Our colleagues in medicine and nursing have had board certifications and specialties for probably a good 30 or 40 years prior to pharmacy."

Ellis said the needs of patients and the health care system will ultimately determine the appropriate number of specialty areas for the pharmacy profession—presumably, a much smaller number than for physicians.

He said one reason fewer specialty areas are needed is that pharmacists' knowledge encompasses a broad range of patient care situations, whereas physicians, especially those who are board certified, tend to have a narrow practice focus.

"Pharmacists . . . understand overall medication therapy beyond a specialty area. And that can be a very valuable addition to the health care team," Ellis said.

Witmer noted that hospitals and payers expect physicians to undergo credentialing and privileging in order to care for patients, and he said pharmacists should be subject to the same process.

"A license provides a very broad assurance that a health care professional is adequately prepared to function as a professional, but [licensing] does not assure competence in the provision of specific patient care services," Witmer said.

Clark likewise said it makes sense for the pharmacy profession to align with the certification model used by physicians. He said physicians with whom he has spoken appreciate the credibility that comes with board certification of their pharmacy colleagues.

Ellis said the number of BPS-certified pharmacists doubles about every five years, and 19,000 pharmacists currently hold board-certification credentials. He said BPS has set a goal of certifying 30,000 pharmacists by 2017.

Care settings. Health care reform efforts that emphasize pay for performance, medical homes, and accountable care organizations have put pressure on health care providers to deliver high-quality care.

One way to accomplish this is by relying on credentialed health care professionals in team-based environments to deliver that care, Ellis said.

He said such care is increasingly being demanded in outpatient settings, and pharmacists appear to be aware of this trend.

"We're seeing the biggest growth area come in one of the newer board-certified specialties, and that's ambulatory care," Ellis said. "Currently, ambulatory care is the third-largest BPS specialty, even though we've only offered the examination for three years."

He said that ambulatory care "is really where the patients are," including people transitioning from hospital care and those who need help managing chronic conditions.

"The pharmacist is in an ideal position to provide those services," Ellis said.

Provider status. Clark said that from the time he started practicing pharmacy 14 years ago, he has expected the profession to attain provider status. And he believes that residency training and board certification will be important criteria on which to ultimately base provider-status decisions.

Kasey Thompson, vice president of ASHP's office of policy, planning and communications, said that the goal of provider status is not limited to pharmacists with specialized credentials. But, he noted, "it is safe to assume that many residency trained and BPS-certified pharmacists are and will be well positioned to take advantage of provider recognition as a means to support the team and care for their patients."

Kasey K. Thompson

Pharmacists in California were recently granted provider status by the state, and regulations governing the state's advanced-practice pharmacist designation are under development. North Carolina and New Mexico likewise allow qualified clinicians to be designated as advanced-practice pharmacists.

"Provider status may happen first at a state-by-state level before it happens nationally. It's hard to say," Ellis said. He noted that he expects California to recognize BPS certification as a foundation for attaining the advance-practice pharmacist designation.

Attaining provider status for pharmacists is one of ASHP's stated advocacy priorities, and the organization has been working with other pharmacy groups to move the issue forward at the federal and state levels.

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