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Ohio legislators recently passed statute allowing pharmacists a greater scope of practice under a consult agreement with licensed Ohio physicians. Changes for pharmacists consist of adding, modifying and discontinuing drugs and ordering blood and urine testing to assess the effectiveness of the collaboratively managed drug therapy.   Also included in this statute and within State Board of Pharmacy issued consult agreement rules is the requirement that consult agreement policies and procedures establish "training and experience criteria for pharmacists to manage drug therapy pursuant to the consult agreement. These criteria may include privileging or credentialing, board certification, continuing education or any other training requirements. The agreement shall include a process to verify that the pharmacists participating in the agreement meet the specified criteria". These credentialing and continuous quality improvement mandates have been legislated and issued by a number of states permitting collaborative drug therapy management in order to evaluate effectiveness of patient care and ensure safe patient outcomes. So what does this really mean to the pharmacist practicing collaborative drug therapy management? How does the referring physician or payer know that the pharmacist possesses appropriate knowledge and skills beyond obtaining licensure?  

The Council on Credentialing in Pharmacy defines credentialing as the documentation and demonstration that the healthcare professional has attained the credentials and qualifications to provide the scope of care expected. Privileging assures the stakeholders that the healthcare professional has specific demonstrable competencies and experience for specific services. These processes facilitate the framework for continuous quality improvement.

The process of pharmacist credentialing often starts within the health system's human resources department. At MetroHealth, a safety-net health system located in Cleveland, Ohio, credentials established for the ambulatory care pharmacist specialist are:

• Ohio licensed pharmacist in good standing and employed by MetroHealth
• PharmD or BS Pharm degree awarded from an ACPE accredited School/College of Pharmacy
• ASHP-accredited PGY1 pharmacy residency or 3 years of clinically related pharmacy experience
• Board Certified Pharmacotherapy Specialist (BCPS) or by BPS in the respective field of practice OR BPS certification within 36 months of hire date
• Valid National Provider Identifier (NPI) number

With the expansion of pharmacy practice in Ohio and the implementation of facility-based outpatient clinic pharmacy specialists at MetroHealth, the privileging process required the involvement of key stakeholders including medical, legal and pharmacy leadership. Pharmacy leadership jointly with MetroHealth's legal support created consult agreement policies and procedures for the ambulatory care pharmacist to ensure that statute requirements and health system policy and procedures were met. Medical leadership reviewed these to establish and safely support the expanded scope of the pharmacist. Privileges such as ordering drugs identified within the American Diabetes Association and the American Association of Clinical Endocrinologists diabetes management algorithms, or the American Heart Association dyslipidemia guidelines were established, as were lab tests which would aid patient safety and drug efficacy. These include point of care glucose testing and lab monitoring such as that for renal function, hemoglobin A1c and fasting lipid panels as examples. Ordering of specialty drugs or devices such as PCSK9 inhibitors or insulin pumps are specifically excluded from the MetroHealth consult agreements as their initiation warrants clinical pharmacist supervision by the appropriate specialist according to regulations established by the Centers for Medicare and Medicaid. Prescribing tests that are diagnostic in nature (e.g., pulmonary function tests) are also excluded although it is possible that with more advanced specialization by the pharmacist, these types of tests could be seen as necessary in managing drug therapy. Both focused (when there is no clinical evidence of competency) and ongoing (review and analysis at regular intervals) professional practice evaluation by pharmacy and medical leadership becomes the basis for pharmacy specialist performance evaluation. MetroHealth has defined this as 10 medical record reviews biannually for each pharmacist completed by a quality improvement coordinator (physician or designee) with the intent of determining if the scope of practice was met and if medication ordering and testing was consistent with accepted practice or guidelines identified in the consult agreement. The privileging process also supports reimbursement for pharmacist services.

As pharmacist medical provider status pushes forward, pharmacists in physician-based outpatient clinics will likely be more commonplace. How do these pharmacists not associated with a health system establish credentialing and privileging? Pharmacist credentialing which includes residency training, board certification and additional training such as certified diabetes education or certification as an anticoagulation care provider may be sufficient to establish privileges such as clinic-based medical history and decision-making documentation. Health plan credentialing and privileging of pharmacists for billing purposes may require inclusion of pharmacists within existing health plan professional credentialing agreements, or the pharmacist may pursue direct credentialing by each health plan under which he/she is seeing patients. More information around this topic is likely to surface as pharmacist medical provider status is achieved.

As pharmacists' roles change and levels of responsibility expand, privileging becomes integral to the practice as it demonstrates the value of the pharmacist, improves quality of care, supports the pharmacist as an integral member of the healthcare team and justifies payment to the pharmacist as a medical provider of healthcare.

References:

1. LA Writer Ohio Laws and Rules. Ohio Revised Code. 4729.39 Consult agreement with physicians. http://codes.ohio.gov/orc/4729.39. Accessed 3.18.17.
2. LA Writer Ohio Laws and Rules. Ohio Administrative Code. 4729-29-02 Consult agreements. http://codes.ohio.gov/oac/4729-29-02. Accessed 3.18.17.
3. American Pharmacists Association. The rise of credentialing and privileging in all settings:
Kaiser’s Price meets criteria, patients. www.pharmacist.com/rise-credentialing-and-privileging-all-settings-kaiser-s-price-meets-criteria-patients. Accessed 3.17.17.
4. Council on Credentialing in Pharmacy. Credentialing and privileging of pharmacists: a resource paper from the Council on Credentialing in Pharmacy. AJHP 2014;71:1891-1900.
5. Lee M, Badowski ME, Acquisto NM, et al. ACCP Template for Evaluating a Clinical Pharmacist. www.accp.com/docs/positions/guidelines/Template%20PrePub%20Final_3.6.17.pdf. Accessed 3.17.17.
6. Jordan TA, Hennefent JA, Lewin JJ III, et al. Elevating pharmacists' scope of practice through a health system clinical privileging process. AJHP 2016:73;1395-1405.

Mary Ann R. Dzurec, PharmD, BCACP

Member ASHP SAG Compensation and Practice Sustainability

Pharmacy Specialist, Ambulatory Care, MetroHealth

Cleveland, OH

Christina Wadsworth, PharmD, BCPS, BCGP

Manager, Clinical Pharmacy Services, MetroHealth

Cleveland, OH