Buried in Paperwork

Improvements in Team-Based Care Help Doctors Delegate 

Texas Medicine Logo 

Cover Story – May 2013 

Tex Med. 2013;109(5):14-20.

By Amy Lynn Sorrel 
Associate Editor 

The litany of regulations can be staggering. Reviewing and cosigning at least 10 percent of charts every 10 days for patients cared for by physician-supervised midlevel practitioners. Keeping track of which advanced practice registered nurse (APRN) or physician assistant (PA) has the delegated authority to prescribe medications, which physician oversees each practitioner, and whether the doctor is on site. Spending at least 10 percent of practice time alongside midlevel practitioners at alternate sites, often miles apart in rural areas, and calculating the mileage allowed between locations.

As former medical director of a federally qualified health center in Conroe and past regional clinic director for quality and safety at Scott & White Memorial Hospital and Clinic in Temple, family physician Troy Fiesinger, MD, is all too familiar with those kinds of rules. He says they make care often inefficient, sometimes inaccessible.

Yet the decades-old regulations – based in a world of paper charts and no cell phones or electronic health records – still govern the team-based care model in Texas today.

"Reviewing charts can be done, but we would be much better off having a regulatory mechanism that reflects best practices. Instead of counting charts and initialing them, let's look at quality of care – that's what we are after," Dr. Fiesinger said. "If Dr. X is out one day, and Dr. Y is on site but he's not the supervising physician, all of a sudden [a clinic] is out of compliance, not because anyone is doing anything wrong or unsupervised, but because that physician is not the name on paper. And we don't want to say [to patients], 'sorry we can't see you today' because that doctor is on vacation."

What if instead of counting charts, hours, and miles, physicians could meet monthly or quarterly to go over quality assurance with the APRNs and PAs they supervise? What if multiple physicians and midlevel practitioners in the practice could sign on to a single prescriptive authority delegation agreement for all to refer to? What if they could devise a plan that fits the geographic and access needs of the practice?

"If I started over and designed the rules to handle oversight, this is how I would set it up. These kinds of rules reflect the spirit of how doctors, nurses, and PAs already practice team-based care and would trade technical oversight requirements for a more practical and relevant system," Dr. Fiesinger said.

Such improvements are close to becoming reality under Senate Bill 406, spearheaded by Sen. Jane Nelson (R-Flower Mound), chair of the Senate Health and Human Services Committee. The bill unanimously cleared the committee in February and won full Senate approval in early March.

Senator Nelson sees the measure as part of a larger strategy to improve access to care and says she is "confident this bill will advance all the way through the legislative process."

If passed and the governor signs it, the legislation takes effect Sept. 1.

The measure would replace what physicians, nurse practitioners, and PAs agree is an outdated system of site-based regulations for delegating and supervising prescribing authority with one that reflects a more cooperative, efficient, and quality-based approach to team care. Supporters say the changes also add needed flexibility, particularly for rural areas.

But Texas Medical Association leaders emphasize the bill maintains the current physician-led team model, which, along with other safeguards, would still apply to a new provision allowing doctors to delegate prescriptive authority for Schedule II drugs only in hospitals and hospice care.

Despite the changes reflected in the legislation, one thing remains the same, says Fort Worth pediatrician Gary Floyd, MD, a consultant to the TMA Council on Legislation and a former chair.

"Medical practice is medical practice. Physicians are still the ones who are trained to diagnose and treat, and the statute still places physicians in a supervisory role to ensure patients get adequate, evidenced-based care. That fundamental principle hasn't changed. All we are changing is how we supervise it," he said.

At the same time, the bill recognizes the important role allied practitioners play as partners in care delivery. "This creates a vehicle to develop that team-based approach and develop trust in each other," Dr. Floyd added.

Coming to the Table 

Equally significant is the fact that after years of feuding over scope-of-practice issues, a bill on the topic garnered support from the various professionals involved, all of whom endorsed it.   Supporters include TMA, the Texas Academy of Family Physicians (TAFP), the Texas Nurses Association (TNA), the Coalition for Nurses in Advanced Practice, Texas Nurse Practitioners, the Texas Association of Nurse Anesthetists, and the Texas Academy of Physician Assistants (TAPA).

Nurse groups, for example, argued over the years that their level of education and training prepared them to safely and effectively care for patients without restrictive physician oversight. They point to other states allowing expanded or independent practice as examples. Freeing them up could help mitigate access-to-care shortages, they say.

But TMA data shows only 12,000 APRNs and 7,500 PAs work in Texas, compared with more than 60,000 physicians. Those professionals are not concentrated in underserved areas, and only half or fewer serve in primary care.

TMA leaders maintain that physicians, because of their extensive medical training, are uniquely qualified to diagnose and treat patients. That's reflected by the fact the legislature set up the Texas Medical Board (TMB) to oversee medical practice. Without a physician to guide the health care team, patient safety is at risk and utilization is likely to increase unnecessarily.

The agreed-to legislation, SB 406, not only represents a significant step forward from the old site-based care model, but also sets a cooperative standard for addressing future scope-of-practice issues, Dr. Floyd says.

Key Senate and House leaders provided the impetus for the legislation partially with that goal in mind.

Rather than battling one another, Senator Nelson asked the physician, nurse, and PA groups to come together and work on a mutually agreeable solution.

"The agreement to move forward in a collaborative way, allowing each highly skilled professional to maximize his or her abilities to contribute to patient care, was significant," and will help make primary care more accessible, she said.

The legislation was the culmination of nearly two years of negotiations.

The House Committee on Public Health explored the issue in a May 2012 hearing. Testimony by TMB reinforced physicians' concerns that the inconsistencies in the various prescriptive delegation statutes and rules – which vary by site and practitioner type – make it difficult for doctors to comply.

A subsequent report by the committee urged the legislature to work with physicians, nurses, and PAs to revise and replace the current "opaque" prescriptive delegation scheme with a "simpler regulatory framework based upon physician-led collaboration … to allow more flexibility and increase patient access to primary care and address geographic disparities."

Rep. Lois Kolkhorst (R-Brenham), House Public Health Committee chair, sponsors the companion legislation to SB 406, House Bill 1055.

"Members of the House and Senate sat down with stakeholders at all levels to find a workable solution. Hopefully, we'll see a policy shift that expands care to more Texans in a way that's both safe and sensible," she said.

The legislation also is the result of TMA's persistence in warding off attempts by nursing groups to achieve full independent practice, says TMA Director of Legislative Affairs Dan Finch. "Diagnosing and prescribing is the practice of medicine. We never wavered from that core principle."

Nurses acknowledged at the February Senate committee hearing that "we did not obtain everything we wanted in this bill," said Jean Gisler, a nurse practitioner representing TNA and other nursing groups.

But TNA told Texas Medicine the collaborative effort to date has been productive in addressing the acknowledged deficiencies in Texas's current site-based delegation model.

The measure "will facilitate better utilization of APRNs in meeting Texas' health care needs, and TNA is pleased that nursing was able to reach agreement with medicine on this bill," the organization said. "Only by permitting APRNs and also physicians to practice to the full extent of their licenses will Texas begin to address its shortage of health care providers, and SB 406 is a step forward."

Todd Pickard, a PA at The University of Texas MD Anderson Cancer Center in Houston, called the bill "a gift from heaven," for two reasons.

First, the negotiations brought together the three professions he says are at the heart of providing primary care.

"Any time we can get together and agree on how to serve our patients in safe teams is a tremendous asset for any community, state, hospital, or practice," said Mr. Pickard, chair of TAPA's Legislative Affairs Committee.

Second, the measure does away with regulatory barriers he says keep cancer patients waiting for pain medications because a doctor is unavailable to come to the bedside. The bill also removes rules that have physicians and PAs in rural areas, in particular, spending hours in their cars or filling out chart logs when they could be treating patients.

"When people are in pain, you don't want to keep them waiting. Nowadays, the reality is, we [physicians, nurses, and PAs] talk all the time in person or through electronic records, Skype, and cell phones. How else do you practice team care?"

A Better System 

Key features of the legislation would: 

  • Replace site-based requirements, such as mileage limitations and percentage of chart reviews, with a prescriptive authority agreement;
  • Establish minimum standards for prescriptive authority agreements, such as face-to-face quality assurance meetings, while giving physicians and other practitioners flexibility to determine the specifics, such as where the meetings occur and the percentage of charts that must be reviewed;
  • Allow hospital-based practices and practices serving medically underserved populations to remain unlimited in the number of APRNs and PAs to which a physician may delegate prescriptive authority;
  • Increase the number of APRNs and PAs to whom a physician may delegate prescriptive authority from four to seven at any other practice sites;
  • Ensure patient safety by improving communication and coordination between TMB, the Texas Board of Nursing (BON), and the Texas Physician Assistant Board (PAB) regarding those who have entered into prescriptive authority agreements; and 
  • Allow physicians to delegate prescriptive authority for Schedule II controlled substances to APRNs and PAs in hospitals and hospices only.  

Dr. Floyd says the changes help streamline the myriad of current requirements for practice protocols through the use of an overarching prescriptive authority agreement.

Physicians and the APRNs and PAs they supervise would have to sign on to the document, which, among other requirements, must detail the types of drugs or medical devices midlevel practitioners may prescribe upon delegation by a physician, and must identify any alternate supervising physicians who may oversee those and other activities.

The bill also requires that the agreement outline a quality assurance plan that specifies, for example, a level of chart review determined by the team and periodic face-to-face meetings wherever they choose.

While there are minimum requirements for implementing the agreement, physicians and their teams also can tailor other agreed-upon provisions as they see fit, Dr. Floyd says. "This allows the team to develop a quality assurance plan within the environment they work in" while maintaining a regulatory mechanism.

Dr. Fiesinger also emphasized what the bill does not change.

For example, it preserves exceptions to the cap on the number of APRNs and PAs a physician can supervise in rural and facility-based settings. And, prescriptive authority agreements still must be registered with the state medical board.

On the other hand, the biggest shift under the legislation is permitting the prescription delegation of Schedule II medications to APRNs and PAs in hospitals and hospice care. But it does not introduce controlled substances into settings where they are not prescribed today, Senator Nelson emphasizes.

And physicians still must supervise, says Dr. Fiesinger, TAFP president.

The provision's intent, he says, is to strike a balance between the need for adequate safety controls of these high-risk narcotics and for certain patients to get access to the drugs in critical situations, for example, those facing chronic pain or end-of-life situations, or children with attention deficit/hyperactivity disorder in rural areas.

"The thought was to do this in facilities that are already highly regulated," and where teams tend to work closely together, said Dr. Fiesinger. "And we wanted to make sure we weren't impairing good care for patients with those needs."

In addition to physician supervision, hospitals and hospices have additional oversight by The Joint Commission, and APRNs and PAs practicing there are subject to those facilities' credentialing policies, he says. Such delegation must comply with hospital medical staff bylaws, providing another avenue for physician oversight.

Facilities may have additional controls, Mr. Pickard added. At MD Anderson, for example, PAs involved in ordering any medication sets, which could include Schedule II drugs, must complete a 12-hour internal education program that includes a comprehensive review of pain management and drug side effects.

Referring back to the prescriptive authority agreement, however, Dr. Fiesinger reiterated: "If physicians don't want to delegate prescribing of Schedule II drugs, they don't have to."

The bill also increases monitoring of this new activity by the various licensing boards involved, which must gather and share information relating to those entering into prescriptive authority agreements. The medical, nursing, and physician assistant boards also must develop ways to notify one another when their respective licensees become the subject of an investigation involving such agreements.

The boards would have to adopt the necessary rules to implement those processes by Dec. 31.

Patient Safety Paramount 

Sen. Charles Schwertner, MD (R-Georgetown), however, raised some doubts at the Senate committee hearing in February about whether the bill could be construed to allow APRNs and PAs to prescribe Schedule II drugs in outpatient hospital clinics that may not have the same safeguards as those within hospital walls.

He also questioned whether BON is equipped to oversee those expanded activities by APRNs and whether nurse practitioners are adequately trained to handle the new role. TMB and PAB jointly handle prescription delegation for PAs.

"This is a dangerous, potent, and addictive class of drugs," said Senator Schwertner, an orthopedic surgeon. "My concern is regarding the oversight of individuals with the authority to prescribe these dangerous drugs when the [nursing] board doesn't have the expertise. … And what will the board do differently to ensure those nurses have the appropriate training, education, credentials, and discipline?"

Senator Nelson said at the hearing that the bill is not intended to apply to hospital-based clinics, and, if necessary, she will clarify that language.

BON Executive Director Katherine A. Thomas told Texas Medicine the board has regulated APRNs since 1980 and prescriptive authority since 1989. As those and other changes occurred, the board reviewed and changed its curricular and continuing education requirements as needed to ensure safety in practice, and would do so again if the bill is implemented. In fact, the bill requires it.

"We have a lot of experience on staff, and we will continue to rely heavily on our outside advisory committee in setting regulations. We also use physicians as experts in our cases, and we will continue to do that, perhaps even more so," Ms. Thomas said.

She added that BON and TMB already have a referral processes for when an investigation implicates another licensee, and the nursing board has educated APRNs about the existing requirement for physicians to register their agreement with the medical board.

"That communication is already there informally, and we would just formalize it," Ms. Thomas said. "As always, we would take on this new responsibility seriously, and the board will do what it has always done, which is to make sure the public is protected."

Dr. Fiesinger says the bill alone won't fix access-to-care shortages in Texas, but it could be a piece of the solution.

"Access is about getting boots on the ground," he said. Simplifying the rules for physician oversight could, for example, make it easier for rural clinics to hire nurse practitioners and PAs to take care of more patients and still supervise them in a safe and legal manner.

That will certainly benefit physicians and their teams in conducting more efficient care, Dr. Floyd says. More importantly, "the ones who really ought to win are the patients because this ensures safety."

 Amy Lynn Sorrel can be reached by telephone at (800) 880-1300, ext. 1392, or (512) 370-1392; by fax at (512) 370-1629; or by email. 

 SIDEBAR 

Prescription for Collaboration 

Instead of following a web of inconsistent rules, Senate Bill 406 allows physicians to use a single prescriptive authority agreement to delegate their prescribing authority to qualified advanced practice registered nurses (APRNs) and physician assistants (PAs) under their supervision. At minimum, the agreement must: 

  • Be in writing and signed and dated by the parties to the agreement;
  • State the name, address, and all professional license numbers of the parties to the agreement;
  • State the nature of the practice, practice locations, or practice settings;
  • Identify the types or categories of drugs or devices that may be prescribed or the types of categories of drugs or devices that may not be prescribed;
  • Describe a prescriptive authority quality assurance plan, and specify methods for documenting the implementation of the plan that includes chart review and periodic face-to-face meetings that occur monthly or quarterly;
  • Provide a general plan for addressing consultation and referral;
  • Provide a plan for addressing patient emergencies;
  • State the general process for communication and information sharing between the physician and APRN or PA to whom the physician has delegated prescriptive authority related to the care and treatment of patients; and
  • Designate one or more alternate physician who may provide appropriate supervision temporarily if alternate physician supervision is to be used. 

SIDEBAR 

TMA Legislative News Hotline Keeps You Informed 

Keep up-to-date with Senate Bill 406 and other legislation important to medicine through the TMA Legislative News Hotline.

The electronic newsletter delivers news on the Texas Legislature's latest actions on bills affecting you, your practice, and your patients. A weekly recap is also available each Friday.

This year, the hotline includes weekly video updates from TMA lobbyists, health care experts, and even state legislators.

To sign up and stay informed, email Hotline Editor Pam Udall or contact the TMA Knowledge Center at (800) 880-7955 or by email


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