Credentialing in Pharmacy: No Simple Matter
Efforts to ensure pharmacists' competence to care for specific types of patients are now focused on credentialingthe process of demonstrating that a pharmacist has a specific set of skills.
Experts bring a variety of perspectives to the table, and their views sometimes diverge. Recently, for example, a program for certification in disease management, born in 1998 in Mississippi and then expanded nationwide, has evoked thought-provoking debate. There is growing consensus that receipt of a pharmacy degree and fulfillment of state-mandated continuing-education requirements may not be adequate in the 21st century.
This article recounts recent developments in credentialing. It describes the landmark disease-management certification program that began in Mississippi, the establishment of two national credentialing bodies, and current government efforts to establish national credentialing databanks for health professionals. Because the terms used in discussions of credentialing can be confusing, a glossary is provided.
Some pharmacists believe that interest in credentialing has been catalyzed by economic concerns; others maintain it is a natural outgrowth of pharmacists' increased involvement in patient care.
The Mississippi experiment: A new model for reimbursement
Those in the former group point to recent experience in Mississippi. Pharmacists in that state who have passed an examination in one or more of four disease areasasthma, diabetes, dyslipidemia, anticoagulation therapyand completed a one-day performance skills workshop may now, with a physician's referral, be reimbursed by Medicaid for services they provide to patients with these conditions.
The credentialing program was a joint effort of the Mississippi State Board of Pharmacy and the University of Mississippi School of Pharmacy. The National Association of Boards of Pharmacy (NABP) helped develop the competency assessment and oversaw its administration.
The first round of exams was offered in July 1998. Success with this initial administration of the exam prompted other state boards of pharmacy to sign on. As of January 2000, NABP reports that organizations in an additional 19 states have submitted letters of agreement for participation in the disease-specific certification program.
Response to expanding roles in patient care
Other pharmacists look at credentialing from a different perspective. Credentials can increase earning power; however, they also can confirm the pharmacist's knowledge base, recognize professional stature, and open the door for new patient care opportunities.
The need for credentialing is a sign of the growth of the pharmacist's clinical role and of differentiation in that role.
It was the growth of interest in specialization in pharmacy that led to the formation of Board of Pharmaceutical Specialties (BPS), whose certification remains the profession's blue-ribbon credential. Yet, only 2,940 or so
pharmacists have current certifications, the board reports. There is a need, it can be argued, for other means of recognizing clinical competence.
To voice support for credentialing does not necessarily mean that the more credentials a pharmacist has, the better. Nor does it mean that the greater array of credentialing programs from which a pharmacist has to choose, the
Credentialing programs are difficult to develop, complex to administer, and expensive to maintain. An unbridled proliferation of credentialing programs would, moreover, make it harder, rather than easier, for other professions
and payers to evaluate a pharmacist's competence. When it comes to credentialing, the major issue is not why, but how.
Years of rapid growth
The current wave of renewed interest in credentialing began in the mid-1990s. Until 1997, only one pharmacy organization, BPS, offered advanced certification in pharmacy. Formed in 1976 by the American Pharmaceutical Association (APhA), BPS certifies advanced specialty practitioners in five areas: nuclear pharmacy, nutrition support pharmacy, pharmacotherapy, psychiatric pharmacy, and oncology pharmacy.
In 1997, the Commission for Certification in Geriatric Pharmacy (CCGP) was formed. Since that time, two other national coalitions, the National Institute for Standards in Pharmacist Credentialing (NISPC) and the Council on Credentialing in Pharmacy (CCP) have been formed.
NISPC was founded in June 1998 to provide a coordinated approach to creating nationwide standards for examinations to credential pharmacists in specific disease states. It is a direct outgrowth of the disease-management
examination program in Mississippi.
NISPC has four member organizations: NABP, APhA, the National Community Pharmacists Association, and the National Association of Chain Drug Stores. The institute has two arms: a Standards Review Board, which approves standards for current exams and recommends development of new ones; and a Payer Advisory Panel, which communicates concerns of the payer community and helps NISPC ensure that its programs are nationally recognized.
As of September 1999, reports NISPC, 1,115 pharmacists had taken 1,346 disease-management examinations, and 618 had become eligible for 672 NISPC credentials, mostly in diabetes. The most recent round of exams was held Dec. 7 and 8, 1999, at a site near the ASHP Midyear Clinical Meeting and Exhibits. Through its Pharmacist and Pharmacy Achievement and Discipline database, known as PPAD, NABP maintains a searchable catalog of pharmacists who have passed the examinations and makes the information freely accessible to payers and the public.
The 11-member CCP was formed in October 1998. In addition to ASHP, CCP's membership consists of the following organizations: the American Association of Colleges of Pharmacy, the American College of Apothecaries, American College of Clinical Pharmacy, the American Council on Pharmaceutical Education, the Academy of Managed Care Pharmacy, APhA, the American Society of Consultant Pharmacists, BPS, CCGP, and the Pharmacy Technician Certification Board.
The coalition has recently been incorporated in the District of Columbia. Richard Bertin, executive director of BPS, is the group's secretary, and ASHP Executive Vice President and Chief Executive Officer Henri R. Manasse, Jr., Ph.D., Sc.D., is its chair.
The purpose of CCP is "to serve as the coordinating body charged with providing leadership and quality assurance for voluntary postlicensure certification activities." CCP will educate pharmacists and others on credentialing. It will serve as a clearinghouse for information about credentialing programs and provide tools with which to assess their validity. It will also seek to build a consensus about credentialing within the profession. Another priority of CCP is to assess the need for certification of generalist practitioners.
ASHP is a founding member of CCP. The Society is especially interested in applying its experience in one type of credentialingaccreditation of residency and technician training programsto the broader credentialing issues in pharmacy.
Wearing two hats, that of CCP chair and ASHP chief, Manasse takes a broad view of ongoing events in the credentialing arena. From his vantage point, the need for professional unity looms large. The recent developments that began in Mississippi, he says, were "born out of the need to put on the table what pharmacists can offer in a value-driven equation....It's an experiment...it's pioneering work, and we need to provide professional support for it."
Manasse is particularly enthusiastic, however, about the promise of CCP.
"We've got 11 founding organizations that feel the need to sit around the
table and think through and plan out the future. That says a lot."
This is not to say that progress will be easy. "It's a complex issue," Manasse continues. The participants, who are now meeting on a regular basis, are joined by a common sense of purpose. "We're all committed, to ensuring that credentialing will remain a credible process that will be understood and used by the payer community and the quality assurance leadership in hospitals and health systems."
Among the potential pitfalls, in Manasse's opinion, is the risk of fragmentation. "How many disease state management examinations can we support?" he asks. Disease-specific certification is impractical for that are managed by medication. In addition, an abundance of programs would be not only confusing but also impossible to support financially. Issues regarding the appropriate role of licensing boards also remain to be tackled.
A pharmacy administrator's view
Despite the complexity of these questions, a majority of health-system pharmacists might agree with Lois M. Nash, M.S., pharmacy director at The Methodist Hospital in Houston. "As we go forward and our roles become more focused on disease management and drug therapy outcomes," she says, "we need to have some sort of certification process."
A certificate, in and of itself, is not enough. As an administrator, Nash underscores the need for profession-wide standardization.
"We need something that crosses boundaries. If something works at The Methodist Hospital, it should also be good for pharmacists serving similar patients at St. Luke's or M. D. Anderson Hospital [both in Houston]. It is for this reason that Nash supports the goals of the CCP, which she describes as a "global, across-the-profession approach to [establishing direction in] credentialing."
A second challenge is developing appropriate means of evaluating the competency of pharmacists who are seeking credentialing.
"Competency is the key, and it's also the problem," says Nash. "Competency means not only being able to say something, but also being able to do it and to show outcomes from what you have done. It's more than taking a test and knowing that a certain thing should happen. It's making the right choices in a patient-care situation." This is not possible unless the program has a substantial practical component.
Federal credentialing databank: Model for the future?
Determining what types of credentialing programs are appropriate and in what areas such programs should be developed are major issues. Equally important is ensuring that the information on those hard-earned credentials is reliable and that it is readily available to those who need it.
The Federal Credentialing Program, under development by the government, may hold the answer to these concerns. Initially begun as a means for speeding up the processing of credentials for physicians and dentists who provide health care in the federal sector, the program is expanding to encompass other health professions, including nursing and pharmacy.
Rear Admiral Fred Paavola, Chief Pharmacist of the U.S. Public Health Service (PHS), is coordinating the effort to include pharmacists in the Federal Credentialing Program. "Until this began," he says, "programs among and within the services had functioned in a 'silo' atmosphere. There was no sharing of credential information between health care facilities within any service or between services."
Central to the success of the program is ready access to the information. Enter VetPro. This Internet-based credentials bank, under development for the Department of Veterans Affairs (DVA) since 1997, is scheduled for full implementation in spring 2000. At that time, it will contain data on 40,000 physicians and dentists in 172 VA medical centers. Other health care professions, including pharmacy, will gradually be added.
The first syllable of the databank's name has a dual significance, explains Kate Enchelmayer, VetPro program manager. It is indeed a shortened form of the word "veteran"; however, it is meant primarily to refer to "vetting"the process by which professional credentials are evaluated. VetPro credentials undergo verification with the primary source of the information, an enormous improvement over past practice, which often relied on secondary sources.
Negotiations are under way with more than 100 medical centers that are affiliated with DVA to also have access to VetPro data, says Enchelmayer. In the case of physicians, a group such as the Association of American Medical Colleges would coordinate this type of arrangement.
When the Federal Credentialing Program adds pharmacy to VetPro, pharmacists will be able to enter their credentials online using a pull-down menu. Requested information covers the pharmacist's backgroundeducation, residency and other training, state licensure, and certification, as well as past employment and references. Key pieces of information, such as receipt of pharmacy degrees, will be verified with the primary sources.
Paavola says that an electronic databank for federal pharmacists is "long overdue." It will have enormous value on routine basis; in emergencies, it may be crucial. Paavola pointed to recent experience when thousands of Kosovar refugees entered the United States. PHS staff had less than two weeks to assemble teams of health professionals who could meet the refugees' needs. A credentialing databank would have made the process much smoother.
A look ahead
For those who see the economic incentives of credentialing, the future may be bright. There are indications, for example, that disease-management credentialing has already piqued the interest of managed care organizations. These organizations have long been intrigued by pharmacy's potential ability to cut costs but remained unconvinced that pharmacists were up to the task.
Meanwhile, as this program and the others described here move forward, pharmacists in all practice settings. The way in which the profession deals with it will be critical to its future.
Certification is a voluntary processinstituted by a nongovernmental set of skills.
Certificate program is a structured, systematic postgraduate educational and training experience that is smaller in magnitude and shorter in time than a degree program and that imparts knowledge, skills, attitudes, and performance behaviors designed to meet specific practice-oriented objectives.
Credential is documented evidence of licensure, education, training, experience, or other qualifications to perform a task.
Credentialing is the process of obtaining, verifying, and assessing the qualifications of a health care practitioner to provide specific patient care services.
Clinical privilege is authorization, granted by an appropriate authority such as a health system, for a health care practitioner to provide specific patient care services in an organization within well-defined limits.