BILL ANALYSIS C.S.S.B. 673 By: Madla (Berlanga) 05-09-95 Committee Report (Substituted) BACKGROUND In 1989, the Texas Legislature passed the Omnibus Health Care Rescue Act that 1) established the Center for Rural Health Initiatives, 2) authorized physicians to delegate the carrying out of prescription drug orders to registered nurses and physician assistants at rural health clinics and other sites serving medically underserved populations, and 3) established the Health Professions Resource Center to collect and analyze, in cooperation with the Higher Education Coordinating Board, educational and employment trends for health professions. In 1989, there were less than 10 rural health clinics and today over 300 exist. Despite this increase in numbers, there has been no comprehensive study of rural health clinics to evaluate their overall impact on rural health care or if their effectiveness can be improved. Rural areas, for example, continue to lack adequate facilities and services for the elderly and disabled. They also find it difficult to attract the numbers of health care providers needed and to provide the support health care providers need in rural practices. PURPOSE S.B. 673 provides additional support to rural areas to attract adequate health care providers to rural settings and give them the support necessary to retain them in rural practices and to increase facilities and services to the elderly and disabled populations in rural areas. It also permits a more effective utilization of advanced nurse practitioners and physicians assistants working in collaboration with physicians. RULEMAKING AUTHORITY It is the committee's opinion that this bill expressly grants additional rulemaking authority to the Texas Board of Health in Section 12 (Subsection (d)(5), Section 3.06, Medical Practice Act (Article 4495b, V.T.C.S.)); to the Texas State Board of Medical Examiners in Section 13 (Section 3.06(d), Medical Practice Act (Article 4495b, V.T.C.S.)); and to the Board of Nurse Examiners in Section 14 (Article 4514(8), Revised Statutes). SECTION BY SECTION ANALYSIS SECTION 1. Adds Section 105.007 to Chapter 105, Health and Safety Code, (a) to require the Texas Department of Health (department), as part of the comprehensive health professions resource center, to develop and establish a clearinghouse for health professionals seeking collaborative practice, and b) permits the department to set and collect a reasonable fee to offset the cost of complying with requirements of this section; solicit and receive grants, gifts and donations; and to contract with public or private entities to carry out its responsibilities under this section. SECTION 2. Adds Section 106.025(a)(8)(A) and Section 106.025(a)(15) - (17), Health and Safety Code, relating to the requirements specified for the Center for Rural Health Initiatives (Center), as follows: Subsection (a)(8)(A) requires the Center to promote telemedicine and distance learning through a transmission rate structure which accommodates rural needs and through the improvement of the telecommunications infrastructure in rural areas. Subsection (a)(15) requires the Center to develop and initiate in conjunction with specified agencies, a study to determine the efficiency and effectiveness of rural health clinics; assess the impact on access to health care; address efficiency barriers for the professional and clinical relationship of physicians, nurses, and physician assistants; assess the success of attracting primary care physicians and allied health professionals to rural areas; assess the appropriateness of the current clinic designation process. Subsection (a)(16) requires the Center to develop and initiate a quality assessment program to evaluate the health outcomes of rural patients treated in rural health clinics. Subsection (a)(17) requires the Center to encourage active participation by health-care providers in the Early and Periodic, Screening, Diagnosis and Treatment Program. SECTION 3. Amends Section 262.034, Health and Safety Code, to specify that the authority may acquire, construct, own, operate, enlarge, improve, furnish, or equip certain facilities or services, and that this section applies to municipal hospital authorities that own or operate hospitals under Chapter 241, Health and Safety Code, (regarding the licensing of hospitals), and are located in a county with less than 35,000 population or in a specified rural or nonurbanized area. SECTION 4. Adds Subchapter H, entitled "LONG TERM CARE AND RELATED FACILITIES" to Chapter 285, Health and Safety Code, as follows: (a) States that this chapter applies only to a hospital district or authority created and operated under Article IX of the Texas Constitution, a special law, or Title 4 of the Health and Safety Code and located in a county with 35,000 population or less, or in a specified rural or nonurbanized area. (b) Permits these districts or authorities to construct, acquire, own, operate, enlarge, improve, furnish, or equip one or more of the following types of facilities or services for the care of the elderly or disabled: long-term care, elderly housing, assisted living, home health, personal care, special care, continuing care, and durable medical equipment; lease or enter into an operations management agreement; close, transfer, sell, or otherwise convey all or part of a facility and discontinue service; and issue revenue bonds or other notes to acquire, construct, or improve a facility or implement the delivery of service for the elderly or disabled. (c) States that a facility or service created under Subsection (b) is considered to be a hospital project under Chapter 223, regarding hospital project financing. SECTION 5. Amends the definitions of "designated agent" and "prescription" in Section 483.001, Health and Safety Code, to reflect changes in authority of physicians to delegate the signing of prescription drug orders to advanced nurse practitioners and physician assistants under SECTION 13 of this Act. In defining prescription, Subdivision (F) of Section 483.001(13), Health and Safety Code, is deleted and Subdivision (H), Section 483.001(13), Health and Safety Code, is added. Subdivision (H) states that a prescription includes the name, address, and telephone number of the registered nurse or physician assistant, if signed by a registered nurse or physician assistant. SECTION 6. Amends Section 483.042(a), Health and Safety Code, to add language relating to the delivery of prescription drugs based on changes in authority of physicians to delegate to advanced nurse practitioners and physician assistants specified under SECTION 13 of this Act. SECTION 7. Amends Section 671.001(d), Health and Safety Code, to permit a physician assistant to pronounce death in a licensed facility, institution, or entity providing services to a patient or resident if permitted by written policies of the facility, institution or entity. Requires these policies to include physician assistants who are credentialed or otherwise permitted to practice at the facility. SECTION 8. Amends Section 671.002, Health and Safety Code, to add language extending to physician assistants who determine death the same limitation on liability currently provided physicians and registered nurses who determine death. SECTION 9. Amends Section 51.918(c), Education Code, to expand the requirement that the Center develop relief service programs for rural physicians and allied health personnel to facilitate ready access to continuing medical education to include practice coverage for purposes other than continuing medical education. SECTION 10. Amends Section 501.059(g)(4), Government Code, so that the Managed Health Care Advisory Committee to the Texas Department of Criminal Justice will include in its development of a managed health care plan for all inmates at the institutional division a provision requiring acceptance of Medicare certification of hospitals, home health and hospice providers as an alternative to accreditation by the Joint Commission on Accreditation of Healthcare Organizations. SECTION 11. Amends the definitions of "designated agent" and "prescription drug order" in Section 5(19) and (42), Texas Pharmacy Act (Article 4542-1, V.T.C.S.) based on changes in authority of physicians to delegate the signing of prescription drug orders to advanced nurse practitioners and physician assistants specified under SECTION 13 of this Act. SECTION 12. Amends Section 3.06(d)(5), Medical Practice Act (Article 4495b, V.T.C.S.), relating to physicians delegating prescriptive authority at sites serving medically underserved areas. Adds for physicians the option of permitting a physician assistant or registered nurse to utilize single-signature prescriptions at sites serving medically underserved populations as opposed to the current double-signature requirement, but limits this to dangerous drugs; adds language to clarify the specified contents required in certain protocols and other orders used by physicians to delegate to physician assistants or registered nurses; amends the definition of "carrying out or signing a prescription drug order" to reflect the delegated prescriptive authority given to a registered nurse or physician's assistant; sets forth additional information required to be provided with each prescription; establishes that the department by rule is to develop a Texas-specific designation of "medically underserved area" which is to take into account demographics, geographic factors that affect access to health care, and environmental health care factors; changes the rule governing the department regarding the requirement to publish notice of its determination from the Administrative Procedure and Texas Register Act (Article 6252 13a, V.T.C.S.) and to Chapter 2001, Government Code. Reletters the subsections throughout this section to reflect the changes made herein; SECTION 13. Adds Section 3.06(d)(6) to the Medical Practice Act as follows: (A) Allows a licensed physician, if certain supervision is provided by the physician, to delegate prescriptive authority in areas other than sites serving medically underserved populations under current Section 3.06(d)(5). States that this is limited to dangerous drugs. (B) Requires protocols and other orders to be defined to promote the exercise of professional judgment by the advanced nurse practitioner or physician's assistant commensurate with their education and experience. Sets forth the specifications of the protocols and other orders. (C) Requires the physician supervision of the carrying out and signing of prescription drug orders to conform to prudent, sound, medical judgment, but allows this to vary with the education and experience of the advanced nurse practitioner or physician's assistant. Requires a physician to provide continuous supervision, but not constant physical presence. (D) Allows an alternate physician to provide appropriate supervision on a temporary basis as defined and established by board rule. (E) Requires the carrying out and signing of prescriptive drug orders to comply with other applicable laws. (F) States that a physician's authority to delegate the carrying out and signing of prescriptive drug orders has specified limitations. (G) Sets forth the meaning of "advanced nurse practitioner," "physician assistant," primary practice site," and "carrying out or signing a prescription drug order" for the purposes of this subsection. (H) Requires a physician licensed by the board to be authorized to delegate the carrying out or signing of prescription drug orders to one or more adequately supervised physician's assistants or advanced nurse practitioner practicing in a specified facility if the physician has a certain position with regard to the facility. Sets forth the limitations on the physician's authority to delegate. (I) Allows a physician to delegate to a certified registered nurse anesthetist the ordering of drugs and devices necessary to administer anesthetic as ordered by the physician in a licensed hospital or ambulatory surgical center. States that the physician's order does not have to be specific regarding the drug, dose or administration of the anesthetic. Allows the nurse anesthetist to select, obtain, and administer those drugs and apply the appropriate medical devices necessary pursuant to and as necessary to accomplish the order and maintain the patient's good status. Requires this subsection to be liberally construed to permit the full use of safe and effective medication orders to utilize the skills and services of certified registered nurse anesthetists. (J) Allows a physician to delegate to a certified, specialized physician's assistant offering obstetrical services or an advanced nurse practitioner recognized by the Board as midwife the act or acts of administering or providing controlled substances to the clients during intra-partum and immediate post-partum care. Prohibits the physician from delegating the use or issuance of a triplicate prescription form under the triplicate prescription program in Sec. 481.075, Health and Safety Code. (ii) Requires the delegation of authority to administer or provide controlled substances to be under a physician's order, medical order, standing delegation order, or protocol which shall require adequate and documented availability for access to medical care. (iii) Requires the physician's order, medical order, standing delegation order, or protocols to provide for reporting or monitoring of clients' progress as specified in this subsection. (iv) Sets forth the limitations on the authority of the physician to delegate. (v) Requires the administering or providing of controlled substances to comply with other applicable laws. (vi) Defines "provide" for the purposes of this paragraph. (vii) Requires the controlled substance to be supplied in a labeled, suitable container in compliance with applicable drug laws, and requires it to include certain specifications. (viii) States that this paragraph does not permit the physician or nurse midwife or physician's assistant to operate a retail pharmacy as defined under the Texas Pharmacy Act (Article 4542a-1, V.T.C.S.). (ix) Requires this paragraph to be construed to provide a physician the authority to delegate the act or acts of administering or providing controlled substances to a nurse midwife or physician assistant, but not as requiring physician delegation of the administration of medications to registered nurses or physician assistants, other than as provided in this paragraph. (K) Prohibits a physician from being liable for the act or acts of a physician assistant or advanced nurse practitioner solely on the basis of having signed an order, medical order, standing delegation order, or other order or protocols authorizing certain acts unless the physician has reason to believe the physician assistant or advanced nurse practitioner lacked the competency to perform the act or acts. (L) Prohibits the authority granted to a physician to delegate from being construed as limiting the authority of a physician to delegate under any other subdivision of this subsection. SECTION 14. Adds Section 8, entitled "APPROVAL OF REGISTERED NURSE FOR ADVANCED PRACTICE," to Article 4514, Revised Statutes, as follows: (a) Requires the board to adopt rules for approval of registered nurses as advanced nurse practitioners or advanced practice nurses. Defines the terms "advanced nurse practitioner" and "advanced practice nurse." (b) Requires the board to adopt rules for the initial approval and biennial renewal of an advanced nurse practitioner to carry out or sign prescription drug orders under Section 3.06(d)(5) and (6), Medical Practice Act (Article 4495b, V.T.C.S.). Sets forth the specified required minimums for the rules. SECTION 15. Amends Section 5, Article 4518, Revised Statutes, by modifying the definition of "professional nursing" to clarify current language relating to registered nurses requesting professional drug samples, and to expand the definition to include the performing of medical acts delegated by a physician. Makes conforming changes to reflect this act. SECTION 16. Emergency clause. Effective upon passage. COMPARISON OF ORIGINAL TO SUBSTITUTE In addition to the delegation authorized in the original bill, the Committee Substitute authorizes a physician to delegate to a physician assistant certified as specializing in obstetrics or a certified nurse midwife the providing of a controlled substances to obstetrical patients during intra-partum and immediate post-partum care. The substitute includes the language relating to the content of protocols and physician orders not only in the new Section 3.06(d)(6), Medical Practice Act, but also in existing Section 3.06(d)(5) relating to sites serving medically underserved populations. The substitute makes additional conforming amendments to the Pharmacy Act and Dangerous Drugs Act to reflect the expanded authority of physicians to delegate prescriptive authority, including requiring that a prescription label include the name of the physician assistant or advanced nurse practitioner who signed the prescription. The substitute also adds "intended use of medication" to the list of items that must be on prescriptions signed by advanced nurse practitioners and physician assistants. SUMMARY OF COMMITTEE ACTION S.B. 673 was considered by the Public Health Committee in a public hearing on May 9, 1995. The committee considered a complete substitute for the bill. The substitute was adopted without objection. The bill was reported favorably as substituted, with the recommendation that it do pass and be printed, by a record vote of 7 AYES, 0 NAYS, 0 PNV, and 2 ABSENT.