and Patient Care: Specific Practice Areas–Statements 385 ASHP Statement on the Role of -System in

Position One concept underlying many public health activities is prevention, which is commonly categorized into three Pharmacists who practice in and health systems types: primary prevention (reducing the actual incidence (health-system pharmacists) play a vital role in maintain- and occurrence of diseases, injuries, and disability), second- ing and promoting public health. The American Society of ary prevention (decreasing the severity or progression of Health-System Pharmacists (ASHP) believes that all health- the disease, injury, and disability), and tertiary prevention system pharmacists have a responsibility to participate in (treatment or rehabilitation to return the disease, injury, or 5 global, national, state, regional, and institutional efforts to disability to the initial or baseline state). Public health ef- promote public health and to integrate the goals of those forts on the macro and micro levels can fall anywhere along initiatives into their practices. Furthermore, health-system the prevention spectrum and can reinforce each other. For pharmacists have a responsibility to work with public health example, Healthy People 2010 (a macro-level public health planners to ensure their involvement in public policy) aims to reduce the number of admissions decision-making and in the planning, development, and im- attributable to therapy management problems (primary 6 plementation of public health efforts. prevention). Policies implemented by hospitals The primary objectives of this statement are to (1) (on the micro level) will allow clinicians to quickly identify increase awareness of health-system pharmacists’ contribu- such adverse drug events (ADEs) and prevent them from tions to public health, (2) describe the role of health-system worsening (secondary prevention), as well as treat the af- pharmacists in public health planning and promotion, and fected patients (tertiary prevention). Pooling and evaluat- (3) identify new opportunities for health-system pharma- ing these clinical experiences can to the development cists’ involvement in future public health initiatives. This of dispensing guidelines or utilization studies that could be statement does not provide an exhaustive review of health- used as a primary prevention tool on the macro level. system pharmacists’ public health activities. Its intent is to The health-system ’s role in public health, stimulate dialogue about the role that health-system phar- and the distinction between individualized patient care and macists can play in providing care that improves public public health efforts, can be illustrated by several examples. health in the . Providing optimal to a single patient has great value. Nonetheless, lessons learned from the manage- ment of individual patients can have an even greater impact Background when they result in practice guidelines or health policies that affect the larger population. Such policy development Public health has been defined simply as “what we as a requires careful evaluation and synthesis of health informa- society do to assure the conditions in which people can be 1 tion using epidemiologic principles. Similarly, identification healthy.” In contrast to , public health initiatives of a specific ADE is an important patient care service rou- “emphasize the prevention of disease and the health needs 2 tinely performed by health-system pharmacists. The phar- of the population as a whole.” macoepidemiologic study of ADEs across a population, cou- Public health services have been characterized as oc- pled with action to prevent or mitigate such events, can have curring on two levels: the planning (“macro”) level and the 3 a significant impact on public health. Counseling a patient implementation (“micro” or “provider”) level. Macro-level on the proper use of a medication helps that patient. When public health services focus on the well-being of the popula- that knowledge is systematically evaluated and used to de- tion as a whole and emphasize the assessment and prioritiza- velop better behavioral outcomes, general public health can tion of a community’s health-related needs as well as plan- be improved. Finally, a health-system pharmacist who dis- ning to address those needs. Such services include working penses as a member of an emergency-response with community representatives in identifying health-related team has a limited impact on public health. However, the community problems; setting community health priorities; same health-system pharmacist working with emergency- formulating community health programs and policies; man- preparedness planners to develop policies and programs that aging, administering, and evaluating community health- ensure proper utilization of the full range of ser- promotion programs; educating the community in ways vices during a disaster can have an enormous effect on the that promote public health; and researching, presenting, and health of the affected population. publishing information about public health activities.3 These macro-level activities are carried out by public health pro- fessionals with varying backgrounds, degrees, and interests. Public Health Activities of Micro-level public health services include all the ac- Health-System Pharmacists tivities required to implement public health initiatives. Many of these services are performed on a provider-to-patient or a In 1981, the American Public Health Association (APHA) program-to-population basis, usually with a specific health- outlined the public health role of the pharmacist in a pio- related outcome in mind.4 Examples of such services include neering statement.7 This succinct policy position, building disease screening, immunization, counseling for at-risk pop- on a previous APHA publication,8 declared that pharmacists ulations, and tobacco-cessation programs. were an underutilized resource in promoting public health 386 Medication Therapy and Patient Care: Specific Practice Areas–Statements and described an array of functions that could be performed Over the past two decades, the expanding role of by pharmacists, from providing direct personal health-system pharmacists in patient care has allowed them services to planning for health care for communities or to support public health efforts by designing and providing wider geographic areas. In 2004, the American Association disease management programs. ASHP urges health-system of Colleges of Pharmacy recognized the important role phar- pharmacists to build on this foundation by leading their macists can play in public health by including population- institutions’ efforts to provide population-based care. By based care and public health in its Center for Advancement in working with their health care colleagues through such insti- 9 Pharmaceutical Education (CAPE) Educational Outcomes. tutional mechanisms as the pharmacy and therapeutics com- These outcomes also emphasized the pharmacist’s role in mittee and using tools such as medication-use evaluation, the public health components of “health improvement, well- health-system pharmacists can contribute to population- ness, and disease prevention” and the need for pharmacist specific, evidence-based disease management programs tai- involvement to ensure the “availability of effective, quality lored to fit the needs of the institutions and communities they health and disease prevention services,” as well as the ur- serve. Health-system pharmacists can participate in quality 9 gency to “develop public health policy.” reviews and ensure that evidence-based treatments are used The public health duties that an individual health- for all patients to help alleviate health care disparities. system pharmacist performs will vary, based on the individ- ual’s experience, abilities, training, and work setting. ASHP Disease Prevention and Medication Safety. Health-system believes that all health-system pharmacists, working alone pharmacists can be involved in disease prevention and con- or in collaboration with health care colleagues and admin- trol in many ways. For example, they can help develop insti- istrators, can contribute to the promotion of public health. tutional screening programs to check immunization status and ASHP believes that health-system pharmacists have specific identify undiagnosed medical conditions (e.g., hypertension, public-health-related responsibilities in control10; 11 diabetes, hyperlipidemia, depression). The health-system substance abuse prevention, education, and treatment ; im- pharmacist’s role in medication safety and error prevention munization12; tobacco cessation13; and emergency prepared- is in keeping with the national public health goals outlined ness and response.14 The following are examples of other in the federal government’s Healthy People 2010 initiative, activities that health-system pharmacists can engage in to which include reducing the number of hospital admissions re- promote public health: sulting from drug therapy mismanagement and fostering pro- grams to intercept counterfeit medications.6 Medication rec- Providing population-based care. • onciliation programs are one example of the tools pharmacists Developing disease prevention and control programs • can encourage their facilities to use to achieve these goals. (including medication safety programs) in their insti- tutions and communities. Health Education. Health-system pharmacists can promote Developing health-education policies and programs • public health by developing patient education programs within their institutions that address the needs of pa- 17 tients, other health care professionals, community on safe and effective medication use and other public leaders, and the public. health-related topics, such as tobacco cessation, exercise, • Collaborating with state and local authorities, includ- and healthy . Pharmacists should support the edu- ing local and state health departments and boards of cation and training of the population at an early age, such health, to address local and regional health care needs as through school health programs, to help children develop (including environmental hazard and emergency- good health behaviors that can continue into adulthood. preparedness programs). Furthermore, health-system pharmacists can improve so- • Advocating for sound legislation, regulations, and ciety’s use of medications by educating their health care public policy regarding disease prevention and man- colleagues about safe and effective medication use. Health- agement. system pharmacists can also use their knowledge and exper- • Engaging in population-based research and initiating tise to educate community leaders (e.g., legislators, regula- campaigns to disseminate new knowledge. tors, public officeholders, school officials, religious leaders) about and involve them in public health initiatives. Population-Based Care. The Institute of Medicine, in Cross- ing the Quality Chasm: A New for the 21st Public Health Policy. Health-system pharmacists should Century, presented the problems of health care quality in the be encouraged to participate in public health policy devel- United States and provided recommendations for change.15 opment, from local boards of health to national programs. Subsequent follow-up reports, including Priority Areas for By linking disease prevalence, drug utilization, and the de- National Action: Transforming Health Care Quality, have terminants of disease, health-system pharmacists can place provided additional direction related to population-based prevention within a larger context. play a central care.16 The CAPE Educational Outcomes recommended that role in health, and health policy, especially policy directed pharmacists engage in both patient-centered and population- at chronic disease, must be formulated with a better under- based care, suggesting that a core competency of pharma- standing of the relationship of drug therapy to the many cists is the ability to develop “population-specific, evidence- other factors that affect disease outcomes. Since medication based disease management programs and protocols based use increases as patients age, health-system pharmacists will upon analysis of epidemiologic and pharmacoeconomic face increasing responsibilities to ensure appropriate and data, medication use criteria, medication use review and risk cost-effective medication use as the average age of the U.S. reduction strategies.”9 population rises. Medication Therapy and Patient Care: Specific Practice Areas–Statements 387

Health-system pharmacist participation in emergency serve on institutional review boards, data monitoring and planning and service delivery is critical. Requirements for safety committees, and expert medication advisory commit- new and enlarged inventories of specialized pharmaceuti- tees. Experiential and didactic training for practicing health- cals to provide prophylaxis and treatment to communities system pharmacists, students, residents, and research fellows during emergencies are growing. The Centers for Disease should include exposure to research in public health policy, Control and Prevention’s Strategic National Stockpile (SNS) pharmacoepidemiology, pharmacoeconomics, health-related program, for example, includes 12-hour push packages, ven- quality of life, and evidence-based medicine. Health-system dor-managed inventory, “chempacks,” vaccines, and medi- pharmacists should also work directly with public health cal supplies.18 Hospital and health-system are policymakers and other key stakeholders, such as profes- essential in planning for accommodation of supplies, such sional , medical centers, academic institutions, as antibiotics and antidotes needed in the initial 24 hours governmental agencies, and third-party payers, to promote following a crisis, before state and federal assets become optimal pharmacotherapy. available. Community-based planning efforts for mass im- munization, prophylaxis, and treatment, including pandemic Future Roles response to biological, chemical, radiological, or explosive agents, are an ongoing process, as is planning for utilization Revolutionary progress in basic , in- of the SNS. Medication management is a critical component cluding , stem-cell , , of all these contingencies, yet many of the plans do not ad- , and , has provided dress pharmacy participation. Involvement of health-system an unprecedented supply of information for improving hu- pharmacists is critically important to reliably address medi- man health. The rapidly emerging fields of population ge- cation issues. netics and highlight the significance of ASHP encourages pharmacists to serve on National molecular techniques in the clinical diagnostic laboratory Disaster Medical System assistance teams (http://ndms.dhhs. and the potential for application in patient-directed pharma- gov), the National Pharmacy Response Team (www.ndms. cotherapy. Medication-prescribing decisions will increas- dhhs.gov/nprt.html), or local units of the Medical Reserve ingly rely on the results of genotyping of drug-metabolizing Corps (www.medicalreservecorps.gov) to assist in distribut- enzymes. New technology and practices will allow health- ing emergency supplies of pharmaceuticals, dispensing and system pharmacists to reduce treatment failures and pre- administering medications and immunizations, and manag- 14 vent adverse drug reactions through the proper application ing the drug therapy of individual victims. The develop- of pharmacogenetic principles.19 Advances in informatics ment, implementation, and revision of local emergency op- will permit aggregation and application of population- and erations plans, which include public health management of patient-specific clinical data in ways that will encourage de- emergencies, require pharmacist input. Health-system phar- velopment of population-specific, evidence-based disease macists need to be actively involved in planning for procure- management programs. As medication-use experts, health- ment, distribution, and dispensing of medications, as well as system pharmacists will need to apply these new tools not ongoing management of patient medication issues. simply to improve patient-specific pharmacotherapy but to Pharmacists should also work with health-system ad- advance public health. Similarly, innovations in medication ministrators to develop policies and initiatives that heighten delivery technology will allow more complex to awareness of the applicable laws and best management be administered outside institutional settings. Patients, care- practices in the proper handling and disposal of hazardous givers, and health professionals will require education about drugs. the safe use of such technologies, as will the legislators and As medication-use experts and experienced health- other officials responsible for regulating their use. system administrators, health-system pharmacists can and should contribute to the development of public-health- related legislation and regulation and should be involved in Conclusion public program oversight and administration. Legislators, regulators, and program managers at all levels of govern- Health-system pharmacists play a vital role in maintain- ment should be educated to utilize this expertise. Health- ing and promoting public health. ASHP believes that all system pharmacists, as and through their profes- health-system pharmacists have a responsibility to partici- sional associations, state and local boards of health, and state pate in global, national, state, regional, and institutional ef- boards of pharmacy, are encouraged to participate in legisla- forts to promote public health and to integrate them into tive, regulatory, and oversight processes. their practices and that health-system pharmacists should be involved in public health policy decision-making and in the planning, development, and implementation of pub- Research and Training. To assume a greater responsibil- lic health efforts. Health-system pharmacists can improve ity in public health, health-system pharmacists must receive public health by providing population-based care; devel- adequate education and training. Pharmacy curricula should oping disease prevention and control programs; providing include advanced coursework in public health and research health education; collaborating with state and local author- design. Health-system pharmacists need to be proficient in ities to address local and regional health care needs, includ- research methodology, pharmacoepidemiology, and bio- ing emergency preparedness and response; advocating for and their applications to public health decision- sound legislation, regulations, and public policy regarding making. Knowledge and experience in the design, conduct, disease prevention and management; and engaging in pub- and interpretation of clinical studies (both observational and lic health research. experimental) are essential. Health-system pharmacists have the opportunity to participate in collaborative research and 388 Medication Therapy and Patient Care: Specific Practice Areas–Statements References 19. Spear BB, Health-Chiozzi M, Huff J. Clinical appli- cations of pharmacogenetics. Trends Mol Med. 2001; 1. Committee for the Study of the Future of Public 7:201–4. Health. The future of public health. Washington, DC: National Academies Press; 1988:1. Other Resources 2. for public health. New York: Milbank Memorial Fund; 1976. Pharmacists looking for further involvement in public health 3. Bush PJ, Johnson KW. Where is the public health have many options. First, training and competence in public pharmacist? Am J Pharm Educ. 1979; 43:249–53. health disciplines are invaluable in understanding the field 4. Bush PJ, ed. The pharmacist role in disease prevention of public health and its applications to pharmacy practice. and health promotion. Bethesda, MD: ASHP Research Accredited schools of public health offer traditional didac- and Education Foundation; 1983:3. tic classes, and some have courses or continuing educa- 5. Ives TJ, DerMarderosian AH. Pharmacists and public tion available on-line that will give the beginner a clearer health. In: Hendrickson R, Beringer P, DerMarderosian understanding of the four traditional areas of public health AH, et al., eds. Remington: the science and practice of practice: health administration and policy, health educa- pharmacy. 21st ed. Philadelphia: Lippincott Williams tion, , and . Pharmacists who & Wilkins; 2006:51. wish to pursue a degree in public health can also do so on- 6. Office of Disease Prevention and Health Promotion. line at a growing number of schools of public health (www. Healthy People 2010. www.healthypeople.gov/docu- asph.org/document.cfm?page=718). ment/HTML/Volume2/17Medical.htm (accessed 2007 Pharmacists with an interest in federal public health Dec 27). initiatives can start with one of three main points of access. 7. American Public Health Association. APHA policy The first is the Centers for Disease Control and Prevention 8024: the role of the pharmacist in public health. Am J (www.cdc.gov), the largest repository of documents, pro- Public Health. 1981; 71:213–6. gram descriptions, and contacts in the realm of prevention. 8. Cain RM, Kahn JS. The pharmacist as a member of the Major efforts aimed at disease surveillance, infectious dis- health team. Am J Public Health. 1971; 61:2223–8. ease control, immunization, health education, chronic dis- 9. Center for Advancement in Pharmaceutical Education ease maintenance, and disease-related data management (CAPE) Educational Outcomes 2004. www.aacp.org/ provide an ample and readily available source of informa- Docs/MainNavigation/Resources/6075_CAPE2004. tion. The second major source of information is the Office pdf (accessed 2007 Nov 27). of Disease Prevention and Health Promotion (http://odphp. 10. American Society of Health-System Pharmacists. osophs.dhhs.gov), which provides access to Healthy People ASHP statement on the pharmacist’s role in infection 2010, a health information clearinghouse, national dietary control. Am J Health-Syst Pharm. 1998; 55:1724–6. guidelines, and information about health observances. 11. American Society of Health-System Pharmacists. Finally, the Agency for Healthcare Research and Quality ASHP statement on the pharmacist’s role in substance (www.ahrq.gov) provides information on evidence-based abuse prevention, education, and assistance. Am J clinical practice, the Guide to Clinical Preventive Services Health-Syst Pharm. 2003; 60:1995–8. (www.ahrq.gov/clinic/pocketgd.htm), and quality measure- 12. American Society of Health-System Pharmacists. ment of health care. Virtually the entire realm of public ASHP guidelines on the pharmacist’s role in immuni- health within the U.S. Public Health Service can be accessed zation. Am J Health-Syst Pharm. 2003; 60:1371–7. or linked via these three websites. 13. American Society of Health-System Pharmacists. State government websites provide public health in- ASHP therapeutic position statement on smoking ces- formation for their respective states. State entities serve as sation. Am J Health-Syst Pharm. 1999; 56:460–4. the main policymaking entity for public health priorities and 14. American Society of Health-System Pharmacists. strategies, provide a conduit for federal public health dol- ASHP statement on the role of health-system phar- lars, and are the main repository of health information and macists in emergency preparedness. Am J Health-Syst data for the state. States often organize a range of advisory Pharm. 2003; 60:1993–5. groups, task forces, and planning committees whose output 15. Committee on Quality of Health Care in America. shapes their public health agenda. These entities also pro- Crossing the quality chasm: a new health system for vide input and direction for state legislative bodies to ad- the 21st century. Washington, DC: National Academy dress, legislate, and fund. Press; 2001. On the local level, boards of health serve as the main 16. Adams K, Corrigan JM, eds. Priority areas for national government entities involved in public health. Aside from action: transforming health care quality. Washington, their usual routine of immunizations and restaurant inspec- DC: National Academies Press; 2003. tions, these boards serve as the policymakers for disaster re- 17. American Society of Health-System Pharmacists. sponse and provision of to underserved popula- ASHP guidelines on pharmacist-conducted patient tions. They receive federal and state dollars that are used to education and counseling. Am J Health-Syst Pharm. fund public health efforts. They are closest to the general pop- 1997; 54:431–4. ulation both in their makeup and in their efforts at improving 18. Centers for Disease Control and Prevention. Strategic the public’s health. Pharmacists interested in learning more National Stockpile. www.bt.cdc.gov/stockpile/ (ac- about public health and the types of activities that community cessed 2007 Nov 20). public health agencies are involved in can register for a free interactive tutorial at www.nynj-phtc.org/orientation. Medication Therapy and Patient Care: Specific Practice Areas–Statements 389

Below is a list of websites that provide information • Food and Drug Administration (www.fda.gov) related to public health. • Health Resources and Services Administration (www. hrsa.gov) Public Health Organizations • National Institutes of Health (www.nih.gov) • Agency for Healthcare Research and Quality (www. • World Health (www.who.int) ahrq.gov) • Pan American Health Organization (www.paho.org) • Environmental Protection Agency (www.epa.gov) • American Public Health Association (www.apha.org) • Association of State and Territorial Health Officials (www.astho.org) This statement was reviewed in 2011 by the Council on Pharmacy • National Association of County and City Health Practice and by the Board of Directors and was found to still be Officials (www.naccho.org) appropriate. • Public Health Foundation (www.phf.org) • Association of Schools of Public Health (www.asph. Developed through the ASHP Council on Pharmacy Practice and org) approved by the ASHP Board of Directors on January 12, 2007, and by the ASHP House of Delegates on June 24, 2007. Federal Health Agencies Copyright © 2008, American Society of Health-System Pharma- • U.S. Department of Health and Human Services cists, Inc. All rights reserved. (www.dhhs.gov) • Office of the Surgeon General, Public Health Priorities The bibliographic citation for this document is as follows: Ameri- (www.surgeongeneral.gov/publichealthpriorities. can Society of Health-System Pharmacists. ASHP statement on the html) role of health-system pharmacists in public health. Am J Health-Syst • Centers for Disease Control and Prevention (www. Pharm. 2008; 65:462–7. cdc.gov)