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Privileging Expands Pharmacists’ Role

Pharmacist privileging at VA hospitals can extend past traditional medication management duties.

HOSPITALS THAT HAVE A STRONG CLINICAL PHARMACY PRESENCE are turning to their institutional privileging programs to expand the high-level patient care services that pharmacists can provide.

At The Johns Hopkins Hospital in Baltimore, a recently approved program will allow certain ward-based pharmacists to prescribe medications to inpatients.

“It’s about empowering some of our folks to practice at the top of their license and the top of what their knowledge base allows them to do,” said John J. Lewin III, division director of critical care and surgery pharmacy at Johns Hopkins. “That’s going to be good for patients in terms of efficiency, and accuracy, and care, and medication safety and its related outcomes.”

Lewin expects the pilot program to begin this summer in the hospital’s surgical ICU, where clinical pharmacists are fully integrated into the multiprofessional team and work there daily.

Writing Medication Orders

Under Maryland law, pharmacists can manage medication therapy by protocol, under the terms of a drug therapy management agreement between pharmacists and physicians.

“Our pharmacists do make the interventions now, but they’re not allowed to write medication orders,” Lewin said. Under the current system, any changes to the medication regimen must be performed by a resident, attending physician, or other prescriber.

John J. Lewin III

“What we really heard from our physicians was, basically, ‘Why can’t you write the orders for this? You guys are the medication experts, and it would be good for patient care,” Lewin said.

He said allowing pharmacists to enter medication orders into the computer system will decrease the administrative burden on physicians and allow them to make better use of their time.

Ultimately, he said, about 20–30 unit-based pharmacists are expected to be granted prescribing authority. He said the expanded scope of practice will be available to clinical pharmacy specialists who have a Pharm.D. degree and postgraduate year 2 (PGY2) residency training or equivalent experience.

Lewin said hospital decision-makers concluded that modifying drug therapy is akin to prescribing, and that the hospital’s governing board should be responsible for assigning privileges to clinical pharmacists to encompass this work. The same process is used to permit physicians, nurse practitioners, and other qualified health care providers to order medications.

Lewin expects the pilot program to focus on renal dosage-adjustment protocols.

He said the protocols are designed to comply with state law and will allow pharmacists to use their professional judgment to make clinical decisions about drug therapy. He noted that different units will use different protocols that take into account the individual needs of the entire health care team and its patients.

Mirroring Physician Privileging

A similar privileging process is used at Fort Belvoir Community Hospital in Virginia, said U.S. Army Lieutenant Colonel Eric Maroyka, director of pharmacy for the joint services military treatment facility.

U.S. Army Lt. Col. Eric Maroyka

Maroyka said all hospital pharmacists are “core privileged” to perform routine tasks at the hospital. But about a dozen clinical pharmacy specialists with advanced training have been granted additional privileges that include the ability to prescribe medications in specific settings.

“We’re really mirroring what physicians and other midlevel practitioner providers do for their privileging,” Maroyka said.

For example, he said, one pharmacist in a patient-centered medical home setting specializes in diabetes care and is able to prescribe medications, monitor patients, and educate them about their drug therapy.

“She handles newly diagnosed diabetics and type 2 diabetics without complications,” Maroyka said. “If it’s more complex, like they need to be set up on [an insulin] pump or some other advanced regimen, then they would see the endocrinologist.”

Maroyka said credentials for supplemental privileges may include PGY2 residency training or the completion of a fellowship or other recognized educational activity.

For one pharmacist, he said, completion of the ASHP Research and Education Foundation’s three-part traineeship program in pain management and palliative care supported the attainment of advanced privileges to treat patients in need of such services.

The Council on Credentialing in Pharmacy, a coalition consisting of ASHP and nine other national pharmacy organizations, recognizes several groups that may credential or certify pharmacists in advanced practice areas. These include the Board of Pharmacy Specialties, the National Asthma Educator Certification Board, the American Heart Association, the National Certification Board for Diabetes Educators, the Commission for Certification in Geriatric Pharmacy, the American Academy of HIV Medicine, and the American Board of Applied Toxicology.

Click here to find resources that describe credentialing opportunities and related documentation.

Flexibility to Perform Advanced Functions

William Greene, chief pharmaceutical officer at St. Jude Children’s Research Hospital in Memphis, Tennessee, said 11 clinical pharmacists have been granted advanced privileges by the St. Jude governing board.

“These individuals have the authority to order and monitor laboratory tests and other items related to medication therapy and to adjust medication therapy [for] a broad number of medications,” Greene said.

He said most pharmacists practicing at this level have completed a PGY2 residency program and are board certified in oncology pharmacy. But he said the system includes enough flexibility to allow some highly qualified, experienced pharmacists who lack those credentials to perform advanced functions.

William Greene

Greene said the decision to privilege pharmacists through the medical staffing process grew out of his concern that an auditor could potentially decide that clinical pharmacists were providing medication therapy services without a valid medication order.

The problem, he said, is that although Tennessee’s pharmacy practice act allows pharmacists and physicians to establish patient care relationships, the act doesn’t define collaborative drug therapy management.

Greene said that the hospital’s medical executive committee determined that clinical pharmacists are functioning as “midlevel practitioners” and should be credentialed and privileged as such. He noted that the determination coincided with the Centers for Medicare and Medicaid Services 2012 revision of its conditions of participation that allowed pharmacists to be considered part of a hospital’s medical staff.

“It was perfect timing,” Greene said.

ASHP’s Council on Education and Workforce Development recently recommended that the Society support the use of postlicensure credentialing, privileging, and competency assessment to establish qualifications for providing direct care to patients. The council agreed that credentialing programs should meet guiding principles established by the Council on Credentialing in Pharmacy.

ASHP’s House of Delegates, when it meets June 1 and 3 in Las Vegas, will consider these positions for adoption as an official ASHP policy.

–By Kate Traynor, reprinted with permission from AJHP
(volume 71, pages 686-687).