October 27,
2006
GNA has responded to the second
draft of proposed Board of medicine rules. Below are the
highlights from the response.
**Please
note that this is directly from GNA’s official letter to the
Composite State Board of Medical Examiners for your reference
only. Please do not resend this to the Board. If you are writing
a letter, you may use this as a reference tool ONLY.
GNA has respectfully requested
that the Composite State Board of Medical Examiners consider the
comments below regarding the Nurse Protocol Agreement between
APRNs and physicians, and asks that the Board incorporate
modifications to the following sections of the newly proposed
rules:
1. Additional Requirements
Regarding Physician Delegation to an APRN.
“Delegating
physician shall spend at least four hours per month at each
location where the APRN is providing medical services and shall
monitor the quality of medical care provided by the APRN.”
A universal,
statewide rule regulating every single practice setting by
mandating a specific on-site inspection ignores the statutory
guidance found in the underlying statute. By going beyond the
statutory language to require on-site visits, the Board is
adding an unnecessary, costly, and inefficient element to the
delivery of services. The Board would find that the language
set out in O.C.G.A. § 43-34-26.3 offers a less costly and less
burdensome alternative to what the Board proposes in this rule.
Under the statute, the physician controls what acts may be
delegated to the APRN. In fact, the physician has the authority
to NOT delegate any medical act. By following the directions of
the GAPA – that is, looking to language in the statute and not
adding its own additional language – the Board could achieve its
goal without overstepping its authority. That goal could be met
by following the statutory language to allow the physician the
discretion on how to interact with the APRN on this subject
matter.
2. Physician Signing of
Record and Review of Records
“that the
delegated physician sign 100% of the patient records for the
patients receiving prescriptions for controlled substances and
100% of the patient records in which an adverse outcome has
occurred, and 100% of the patient records where patients
receiving prescriptions for chronic illnesses, and 25% of all
other patient records; and
That such
review occur no more than 30 days after the issuance of the
controlled substance prescription no more than 30 days after the
discovery of an adverse outcome, and no less than once every 12
months for patients receiving prescriptions for chronic
illnesses, and that such review of 25% of all other patient
records occur no less than once every 30 days.”
Simply put, this
newly proposed requirement greatly exceeds the statutory
guidance for nurse protocol agreements and, in turn, adds
unnecessary costs and restrictive barriers to health delivery.
Specifically, the Official Code of Georgia Annotated states:
The nurse protocol agreement
shall include a schedule for periodic review by the delegated
physician of patient records. Such patient records review may
be achieved with a sampling of such records as determined by the
delegating physician.” O.C.G.A. § 43-34-26(c)(5).
Again reminding the
Board of the directive in the GAPA, the statutory authority
gives the delegating physician the right to determine an
appropriate sample and a time frame for reviewing charts. And
the statute, unlike what the Board is proposing, does not
require “signing” the charts. This signing requirement in the
proposed rules is not supported by the statute and, in turn, is
repugnant to the rule-making standards the Board should follow
as set out in the GAPA. The result is an unnecessary cost to
the delivery of health care in the state.
The Board’s
standard of requiring a specific percentage for review also
exceeds what is found in the statute. Requiring 100% of all
patients receiving controlled substances would be an
administrative nightmare and financial burden for an institution
which treats a large number of patients. If this standard were
enacted, any benefit legislators may have anticipated with
passage of SB 480 would evaporate against the fiscal heat of
requiring the physician to review and sign 100% of the charts.
Even the 25% review standard for other situations results in an
arbitrary level which adds costs to the system and limits
access, as physicians’ time is drawn to such administrative
duties. The statute expects the physician to perform some level
of review and allows a “sampling of such records” based on the
physician’s relationship with the APRN; hence, the Board’s 100%
standard for some situations and 25% standard for others is not
supported by the language in the law. The result is an
unnecessary requirement which is exacerbated by the cost
attendant to such a standard.
3.
Pharmacology Education of APRN
The statute
recognizes an APRN to be a registered nurse licensed by the
State of Georgia and who is credentialed as an APRN by the Board
of Nursing. The statute is silent on the pharmacology education
and training of the APRN, as the Legislature recognizes the
Board of Nursing as the state agency to set such standards in
its rules and regulations for the APRN.
The Board again
exceeds its regulatory role by proposing a rule which attempts
to govern the credentials of an APRN by adding a pharmacology
test to the list of what a physician is to supply to the Board.
Other than the requirement regarding a similar field of practice
to that of the delegating physician, the statute does not
dictate what level of training, experience, or education an APRN
must have in order to be a party to a nurse protocol agreement.
The Board, however, has decided it must go beyond the statute to
place this requirement on its physicians. The result, again, is
an unnecessary rule which only adds to the administrative duties
of a physician who chooses to work with an APRN.
4. Filing of Nurse Protocol
Agreements with the Board.
“The
delegating physician shall file the nurse protocol agreement and
a board approved application form with the Board for review and
submit the requisite fee for review establishing the Board’s fee
schedule.”
The Board has added
a new step in this process which is not supported by the
statutory language. The statute allows for the board to
“require that a nurse protocol agreement shall be filed by the
delegating physician with the board within a reasonable time
from the date of execution.” O.C.G.A. §43-34-26.3(m)(1). The
statute does not contain any authority for the Board to require
a fee. And the creation of a new requirement of submitting an
“application form” begs the question: what is the physician
applying for? Certainly the Board is not suggesting that a
physician must apply to the Board for the authority to practice
under this law when the law itself grants that authority. This
proposed rule is yet another example of a requirement going
beyond not just the law but legislative and statutory intent.
Moreover, the Board
has not revealed the amount of this fee. Even if the Board has
sound authority to impose a fee, the Board has so many filing
requirements (original agreement, amendments to the agreement,
supplemental agreements, renewal of agreements, etc.) that there
is a real risk these fees could create financial difficulties
for many clinics and facilities that provide services to the
community, especially those on strict budgets which serve the
indigent, homeless, and uninsured. It is perhaps for that
reason the Board recognized the impact of these fees and added
language in this second draft exempting government facilities
from such fees. The Board should make this exemption universal
by removing it altogether.
5. Personal Re-Evaluation by Physician of Patients
“Provide
the delegating physician shall personally re-evaluate a patient,
at least every three (3) months if the patient receives
controlled substances and, provide that the delegating physician
shall personally re-evaluate all other patients at a frequency
consistent with minimum acceptable standards of practice of
medicine in the State of Georgia.”
With this proposed
rule, the Board has rewritten part of the statute. True, the
statute requires an evaluation or examination of a patient
receiving controlled substances every three months for patient
who received a controlled substance prescription order. In
fact, the statute allows the Board to set a more frequent
evaluation or examination schedule for such patients. However,
requiring personal re-evaluation extends beyond the
statutory guidance. The statute does not stipulate
“re-evaluation” or that there be a “personal evaluation.”
Following the statutory language, the decision should remain
with the physician; that is, whether to evaluate a patient’s
medical chart or personally examine the patient.
While a patient who
receives a controlled substance may fall into a more evaluative
category, the same is not the case for other patients. Yet, the
Board insists on requiring personal re-evaluation of all other
patients – a standard which is not necessary and creates
additional costs to the healthcare system. The statutory
obligations are “to provide for patient evaluation or follow-up
examination by the delegating physician or other physician
designated by a delegating physician pursuant to O.C.G.A.
§43-34-26.3(c)(2)” which requires for the physician to be
available for immediate consultation. The statute does not
require “personal re-evaluation of all other patients.” In
fact, the statute clearly allows for the physician to evaluate
or examine the patient as needed upon consultation. The
evaluation or examination should follow the language of the
statute; that it, such acts should be determined by the
delegating physician in accordance with the nature, extent, and
scope of the delegated act or acts – and all within the
framework of the nurse protocol agreement. It then follows
that not every patient needs to be seen, evaluated, or examined
by the physician after receiving care from the APRN.
6. Language on Prescription
Drug Form
“1. The name, address and telephone number of the delegating
physician, the name of the APRN, the APRN’s DEA number, if
applicable, and the name and address of the patient, the drug or
device prescribed, the number of refills and directions to the
patient with regard to taking and dosage of the drug; and
2. The form/prescription shall be signed by the APRN shall
utilize the following language:
“This
prescription authorized through (delegating physician name),
(M.D. or D.O.) by (APRN’s name), APRN.”
The statute clearly
states what is to be on a prescription drug order and the Board
followed the statute with what is listed in (1) above in the
Boards’s proposed rule. Not content with meeting the statutory
language, the Board proceeds to add an unnecessary requirement
which has no legitimate practice, legal, or medical benefit to
the delivery of health services. The continuation of the rules
to require a specific type of language and form on each
prescription is unduly burdensome and unnecessary. There is
adequate protection for the patients and for the pharmacies to
determine the source of a particular prescription form by
requiring what is found in (1) above and not adding another
layer to the process.
