Credentialing and the Role of the Hematology/Oncology Clinical Pharmacy Specialist within the US Department of Veterans Affairs

Andrea (Annie) Bailey, PharmD, BCOP
Clinical Pharmacy Specialist – Hematology/Oncology
Phoenix VA Health Care System
Phoenix, AZ

Julia M. Hammond, PharmD, BCOP
Clinical Pharmacy Specialist – Hematology/Oncology
Durham VA Health Care System
Durham, NC

The Veterans Health Administration (VA) is the country’s largest integrated health care system with 9 million veterans receiving care each year. One of the core values of the VA is to strive for the highest quality of health care.¹ Clinical Pharmacy Specialists (CPS) play an integral role in providing high quality care to veterans including in the hematology/oncology practice setting. Hematology/oncology CPSs practice at the height of their license through comprehensive medication management (CMM) services. The hematology/oncology CPS team works autonomously and alongside the care team to provide direct patient care and improve clinical outcomes.

Scope of Practice and Ongoing Professional Practice Evaluation
The Clinical Pharmacy Practice Office (CPPO) was created in 2010 within the Pharmacy Benefit Management (PBM) service to advance and support the role of the CPS. CPPO’s role is to optimize clinical pharmacy across the VA, provide cost-effective care, and improve both patient access and care. In the VA, CPSs operate under a scope of practice, or credentialing, which is like a collaborative practice agreement that is used outside the VA. However, the scope of practice is between the CPS and the individual VA facility and does not reside with an individual physician. With a scope of practice, CPSs have the authority to modify, initiate, or discontinue medications, order labs and imaging, and manage medication toxicities^.2,3

The credentialing process to obtain an initial scope of practice requires the pharmacist meet competency criteria as determined by the Executive Committee Medical staff (ECMS) or Professional Standards Board (PSB) and chief of pharmacy. This may include an individualized mentorship training in which the pharmacist seeking scope of practice approval is assigned a pharmacy specialist mentor. The mentorship period includes observation of a minimum number of patient care cases and chart review. The assigned mentor provides recommendations for the appropriateness for scope of practice approval.

After ECMS or PSB review of the individual pharmacist’s competencies and approval for credentialing process, critical duties outlined in the scope must be assessed. This includes a Focused Professional Practice Evaluation (FPPE) in which competencies are assessed relating to the duties and functions that are outlined in the scope of practice. The FPPE process allows the pharmacist to function autonomously to demonstrate knowledge, skill, and competence required for the requested scope of practice. The results of the FPPE are provided to ECMS for final approval of the scope of practice.4

After approval of the initial scope of practice, CPSs are required to undergo Ongoing Professional Practice Evaluations (OPPE). This process includes peer reviews to ensure quality care and re-assess CPS knowledge and competence. The OPPE process is locally defined by each VA facility but should be performed at minimum, biannually. Results of OPPE are utilized during re-credentialing and renewal of the CPS scope of practice, which occurs approximately every 2 years.^4,5

As of February 2021, there were over 130 hematology/oncology CPSs within the VA. Hematology/oncology CPSs are highly trained with many completing both general PGY1 and PGY2 oncology residency training. In addition, many have obtained Board Certification in Oncology Pharmacy (BCOP). Hematology/oncology CPSs provide care in both the inpatient and outpatient settings providing expertise in antineoplastic medication selection, medication monitoring, preparation/dispensing, antineoplastic toxicity management, patient education, and cost savings considerations.⁶

Advanced Practice Providers within the VA
Within the VA, hematology/oncology CPSs are essential to the care team. Through utilization of the scope of practice, hematology/oncology CPSs serve as advanced practice providers. Hematology/oncology CPSs have prescriptive authority, allowing them to practice at the height of their license. The primary role of the hematology/ oncology CPS is CMM focusing on antineoplastic treatment. Their expertise focuses on treatment appropriateness and selection, safety, and patient/staff education. The CPS works closely with the care team to provide patient-centered care to the veteran including collaboration with the hematology/oncology provider for management beyond the CPS scope of practice.

Furthermore, hematology/oncology CPSs have an important role in supportive care considerations. The CPS ensures appropriate anti-emetics are ordered to prevent chemotherapy induced nausea and vomiting. This includes being involved in the process of ensuring appropriate order sets and utilizing their scope of practice to order anti-emetics, as necessary. In addition, many hematology/ oncology CPSs within the VA utilize their scope to order appropriate agents for the prevention of cancer-related infections, prevention of hypersensitivity reactions, and other supportive care agents.

By ordering appropriate lab tests and providing patient monitoring, hematology/oncology CPSs play a key role in identifying anti-neoplastic toxicities including immune-mediated adverse effects and anti-neoplastic adverse effects. CPSs are able to identify toxicity early in treatment which can help prevent more severe toxicity as well as assisting in anti-neoplastic dose adjustments and discontinuation. CPSs can utilize a scope of practice to manage adverse effects. Examples include refractory nausea/vomiting, diarrhea, constipation, dermatological toxicities, and myelosuppression.

In addition, hematology/oncology CPSs play an important role in education and training. The VA provides training opportunities for medical students and residents, hematology/oncology fellows, pharmacy residents and students. The hematology/oncology CPS provides educational services and assistance to trainees. Further, the hematology/oncology CPS is often responsible for providing in-service education to the care team regarding treatment updates, new drug information, and appropriate administration of antineoplastic agents.

Although the practice of the hematology/oncology CPS depends on the specific VA facility, hematology/oncology CPSs are important in the management, monitoring, and follow-up of oral antineoplastic agents. This can include utilization of telehealth services through an oral antineoplastic clinic. The hematology/ oncology CPSs use their scope of practice to order lab results to ensure appropriate monitoring. Further, prescriptive authority is used to renew oral antineoplastic orders and manage toxicities. Regular follow up between the patient and the hematology/oncology CPS allows for assessment of adherence and toxicity of oral antineoplastic medications and ensures appropriate monitoring per FDA labeling/Guideline recommendations.

Ultimately, hematology/oncology CPSs play an integral role in the care of hematology/oncology patients within the VA Health Care System. They are highly trained advanced practice practitioners who help guide the selection, management, and monitoring of antineoplastic agents. The care team relies on the CPS to provide patient and staff training as well as ensure appropriate supportive care efforts are achieved with hematology/oncology patients. The hematology/oncology CPS utilizes a scope of practice that allows them to function independently with prescriptive authority. The VA gives hematology/oncology CPSs the opportunity to practice at the height of their license and professional training to ensure positive outcomes in the care of hematology/oncology patients.

REFERENCES

1. US Department of Veterans Affairs. About VA. Available at https://www.va.gov/about_va/Accessed October 16, 2021.
2. Pharmacy Benefit Management. Pharmacy Benefits Management Services. Clinical Pharmacy Practice Office. Available at https://www.pbm.va.gov/PBM/CPPO/Clinical_Pharmacy_Practice_Office_Home.asp. Accessed October 16, 2021.
3. McFarland, Groppi, Jorgenson, et al. 2020. Role of the US Veterans Health Administration Clinical Pharmacy Specialist Provider: Shaping the Future of Comprehensive Medication Management. Can J Hosp Pharm. 73(2): 152–158.
4. VHA handbook 110811: Clinical pharmacy services. US Department of Veterans Affairs, Veterans Health Administration; 2017. [cited 2017 Dec 12]. Available at www.va.gov/vhapublications/ViewPublication.asp?pub_ID=3120. Accessed October 16, 2021.
5. Pharmacy Benefit Management Guidance. Professional Practice Evaluations for VHA Pharmacists with a Scope of Practice; 2021. Accessed October 16, 2021.
6. Clinical Pharmacy Specialist Role in Oncology Depart of Veterans Affairs Fact Sheet; 2021. Accessed October 16, 2021