Clinical Pharmacy: Definition, Development, Scope, and Objectives

1. Definition

• American College of Clinical Pharmacy (ACCP): "A health science discipline in which pharmacists provide patient care that optimizes medication therapy and promotes health, wellness, and disease prevention."
• European Society of Clinical Pharmacy (ESCP, 2022): "Activities and services focused on the optimisation of medicines use through practice and research to achieve person-centred and public health goals."
• Expanded ESCP definition: Clinical pharmacy encompasses cognitive, managerial, and interpersonal activities targeting all stages of the medicines use process. As a research field, it generates knowledge that informs clinical decision-making, healthcare organisations, and policy.

2. Historical Development

Early Origins (Pre-1960s)

Birth of the Clinical Pharmacy Movement (1960s - USA)

• A dramatic increase in the number, complexity, and potency of available drugs
• Recognition that medication errors and adverse drug events were causing significant patient harm
• The growth of hospital pharmacy services and the emergence of drug information centres
• Academic leaders at the University of California, San Francisco (UCSF) and the University of Kentucky began developing clinical pharmacy education and residency training programmes in the mid-1960s
• The concept of "unit-dose dispensing" placed pharmacists closer to the patient care unit, facilitating clinical involvement

Pharmaceutical Care Era (1970s-1990s)

• The 1970s saw increasing integration of pharmacists into ICUs, oncology wards, and specialty clinics
• The ACCP was founded in 1979, bringing formal structure to the clinical pharmacy profession
• The ESCP was also founded in 1979, extending the movement internationally
• In 1990, Hepler and Strand published the landmark concept of "pharmaceutical care" - defined as the responsible provision of drug therapy for the purpose of achieving definite outcomes that improve or maintain a patient's quality of life. This became the philosophical backbone of clinical pharmacy
• The Omnibus Budget Reconciliation Act (OBRA '90) in the USA mandated pharmacist counselling for Medicaid patients, formalising the patient-counselling role

Modern Era (2000s-Present)

• Expansion of prescribing authority for pharmacists in the UK (independent prescribing, 2003) and in various US states under collaborative practice agreements
• Growth of Comprehensive Medication Management (CMM) as the clinical standard of care
• Integration of clinical pharmacists into primary care, ambulatory clinics, emergency departments, and community settings
• Pharmacist-led clinics for anticoagulation, diabetes, hypertension, and antimicrobial stewardship are now standard
• In the emergency department, clinical pharmacists now intercept medication errors, identify adverse drug event-related admissions, and apply criteria such as Beers, START, and STOPP to optimise therapy - particularly in older adults (Rosen's Emergency Medicine)

3. Scope of Clinical Pharmacy

A. Medication Therapy Management (MTM)

• Review and assessment of all medications (prescription, OTC, supplements, herbals)
• Identification and resolution of drug therapy problems
• Dose optimisation based on patient-specific factors (renal/hepatic function, age, weight, genetics)

B. Pharmaceutical Care and Comprehensive Medication Management (CMM)

• Individual assessment to determine if each medication is appropriate, effective, and safe
• Follow-up evaluation to ensure therapeutic goals are met
• CMM is considered the standard of care for clinical pharmacists

C. Drug Information and Evidence-Based Practice

• Serving as the primary expert resource for scientifically valid drug information
• Evaluating and applying clinical evidence to patient care
• Developing and contributing to drug therapy guidelines and formularies

D. Monitoring and Safety

• Therapeutic drug monitoring (TDM) for narrow therapeutic index drugs
• Adverse drug reaction (ADR) detection, reporting, and prevention
• Identifying and preventing drug-drug, drug-disease, and drug-food interactions
• Applying evidence-based criteria (Beers Criteria, STOPP/START) to reduce inappropriate prescribing

E. Patient and Caregiver Education

• Counselling patients on correct medication use, adherence, and side effects
• Explaining the importance of completing prescribed courses
• Educating caregivers about medication administration

F. Interprofessional Collaboration

• Functioning as an active member of the multidisciplinary healthcare team (with physicians, nurses, PAs, NPs)
• Participating in ward rounds, case conferences, and clinical decisions
• Entering formal collaborative practice agreements

G. Prescribing Authority

• In the UK: independent prescribing authority for clinical pharmacists
• In the USA: prescriptive authority under protocol/collaborative drug therapy management (CDTM) in many states

H. Specialised Clinical Services

• Antimicrobial stewardship - optimising antibiotic selection, dose, and duration
• Anticoagulation clinics - warfarin/DOAC management
• Oncology/haematology pharmacy - chemotherapy dosing, toxicity management
• Transplant pharmacy - immunosuppressant drug monitoring
• Critical care pharmacy - sedation, nutrition, vasopressor management
• Geriatric pharmacy - polypharmacy reduction, fall risk assessment
• Ambulatory care - chronic disease management (diabetes, hypertension, dyslipidaemia, asthma)

I. Research and Education

• Conducting and publishing clinical pharmacy research
• Teaching pharmacy students, residents, and other health professionals
• Contributing to national and international drug policy

4. Objectives of Clinical Pharmacy

A. Patient-Centred Objectives

1. Optimise medication therapy - ensure the right drug, right dose, right route, right frequency, and right duration for each individual patient
2. Prevent and minimise drug-related problems - including adverse effects, toxicity, under-treatment, and non-adherence
3. Improve patient outcomes - reduce morbidity, mortality, hospital readmissions, and complications related to medications
4. Promote health and wellness - through disease prevention, health education, and patient empowerment
5. Ensure patient safety - act as a medication safety expert and safety net in the prescribing chain

B. Professional and System Objectives

1. Integrate pharmacists into the clinical care team - as accountable, collaborative practitioners
2. Develop clinical pharmacy services - in hospitals, community, primary care, and specialised settings
3. Advance pharmacy education and training - through residency programmes, fellowships, and continuing professional development
4. Establish evidence-based practice standards - by generating and applying research to clinical decision-making
5. Develop drug policies and formularies - contributing to cost-effective, evidence-based drug selection

C. Public Health Objectives

1. Promote rational drug use - at individual and population levels
2. Combat antimicrobial resistance - through stewardship programmes
3. Reduce healthcare costs - by preventing costly medication errors, ADRs, and hospital admissions attributable to drug therapy problems
4. Advocate for access to quality pharmaceutical care - particularly in underserved and low-resource settings

Summary Table

• ESCP position paper and definition (2022)
• ACCP definition via Elsevier/Revista Medica
• Rosen's Emergency Medicine, 9th Ed. - Clinical Pharmacy Services in Emergency Departments
• Wikipedia - Clinical Pharmacy