81R4694 YDB-F

By: Orr H.B. No. 696

A BILL TO BE ENTITLED

AN ACT

relating to a physician's authority to delegate prescribing acts to advanced practice nurses or physician assistants.

BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:

SECTION 1. The heading to Subchapter B, Chapter 157, Occupations Code, is amended to read as follows:

SUBCHAPTER B. PRESCRIPTIVE AUTHORITY AGREEMENTS WITH [DELEGATION

TO] ADVANCED PRACTICE NURSES AND PHYSICIAN ASSISTANTS

SECTION 2. Section 157.051, Occupations Code, is amended by adding Subdivisions (2-c) and (4) to read as follows:

(2-c) "Medication order" has the meaning assigned by Section 551.003.

(4) "Prescription drug order" means an order from a physician or a physician's designated agent to a pharmacist for a drug or device to be dispensed.

SECTION 3. Section 157.0511, Occupations Code, is amended to read as follows:

Sec. 157.0511. PHYSICIAN AUTHORITY [PRESCRIPTION DRUG ORDERS]. (a) In a prescriptive authority agreement executed under Section 157.052, a physician may provide an advanced practice nurse or physician assistant authority to prescribe or order a dangerous drug or controlled substance, including authority to sign a prescription drug order or medication order. [A physician's authority to delegate the carrying out or signing of a prescription drug order under this subchapter is limited to:

[(1) dangerous drugs; and

[(2) controlled substances to the extent provided by Subsection (b).]

(b) [A physician may delegate the carrying out or signing of a prescription drug order for a controlled substance only if:

[(1) the prescription is for a controlled substance listed in Schedules III, IV, or V as established by the commissioner of public health under Chapter 481, Health and Safety Code;

[(2) the prescription is for a period not to exceed 30 days;

[(3) with regard to the refill of a prescription, the refill is authorized after consultation with the delegating physician and the consultation is noted in the patient's chart; and

[(4) with regard to a prescription for a child less than two years of age, the prescription is made after consultation with the delegating physician and the consultation is noted in the patient's chart.

[(b-1) The board shall adopt rules that require a physician who delegates the carrying out or signing of a prescription drug order under this subchapter to maintain records that show when and to whom a delegation is made. The board may access the physician's records under this subsection as necessary for an investigation.

[(c)] This subchapter does not modify the authority granted by law for an advanced practice [a licensed registered] nurse or physician assistant to administer or provide a medication, including a controlled substance listed in Schedule II as established by the commissioner of state [public] health services under Chapter 481, Health and Safety Code, that is authorized by a physician under a physician's order, standing medical order, standing delegation order, or protocol.

SECTION 4. Section 157.052, Occupations Code, is amended to read as follows:

Sec. 157.052. PRESCRIPTIVE AUTHORITY AGREEMENT [PRESCRIBING AT SITES SERVING CERTAIN MEDICALLY UNDERSERVED POPULATIONS]. (a) A physician may enter into a prescriptive authority agreement with an advanced practice nurse or physician assistant. The prescriptive authority agreement must:

(1) identify the physician's and the advanced practice nurse's or physician assistant's areas of practice and any specialties;

(2) describe any limitations on the advanced practice nurse's or physician assistant's authority to prescribe or order dangerous drugs, controlled substances, or medical devices in accordance with Section 157.055;

(3) describe a prescriptive authority quality evaluation and improvement plan and specify methods for documenting the implementation of the plan; and

(4) specify a process to ensure collaboration between the physician and the advanced practice nurse or physician assistant.

(b) The physician and the advanced practice nurse or physician assistant may specialize in different practice areas and enter into a prescriptive authority agreement if the prescriptive authority agreement demonstrates an appropriate link between the specialty practice area of the physician and the specialty practice area of the advanced practice nurse or physician assistant.

(c) The degree of collaboration between the physician and the advanced practice nurse or physician assistant specified in the prescriptive authority agreement may vary based on the advanced practice nurse's or physician assistant's education, experience, and skill in treating patients.

(d) Except as provided by Subsection (e), a physician may enter into prescriptive authority agreements with not more than eight advanced practice nurses and physician assistants or their full-time equivalents, unless a reasonably prudent physician would consider agreements with more than eight advanced practice nurses and physician assistants to be safe based on:

(1) the advanced practice nurses' and physician assistants' education, experience, knowledge, skills, and abilities; and

(2) either:

(A) the type of patients served; or

(B) the extent to which access to care by a medically underserved population is improved.

(e) The limitation on the number of prescriptive authority agreements under Subsection (d) does not apply to an agreement at a hospital licensed under Chapter 241, Health and Safety Code, or owned or operated by this state, in which the physician and the advanced practice nurses and physician assistants who are parties to the agreement are authorized to practice.

(f) The board shall cooperate with the Texas Board of Nursing in adopting rules under this subchapter to eliminate, to the extent possible, conflicts between the rules adopted by each board.

(g) This section shall be liberally construed to allow the use of prescriptive authority agreements to safely and effectively utilize the skills and services of advanced practice nurses and physician assistants. [In this section:

[(1) "Health manpower shortage area" means:

[(A) an urban or rural area of this state that:

[(i) is not required to conform to the geographic boundaries of a political subdivision but is a rational area for the delivery of health service;

[(ii) the secretary of health and human services determines has a health manpower shortage; and

[(iii) is not reasonably accessible to an adequately served area;

[(B) a population group that the secretary of health and human services determines has a health manpower shortage; or

[(C) a public or nonprofit private medical facility or other facility that the secretary of health and human services determines has a health manpower shortage, as described by 42 U.S.C. Section 254e(a)(1).

[(2) "Medically underserved area" means:

[(A) an area in this state with a medically underserved population;

[(B) an urban or rural area designated by the secretary of health and human services as an area in this state with a shortage of personal health services or a population group designated by the secretary as having a shortage of those services, as described by 42 U.S.C. Section 300e-1(7); or

[(C) an area defined as medically underserved by rules adopted by the Texas Board of Health based on:

[(i) demographics specific to this state;

[(ii) geographic factors that affect access to health care; and

[(iii) environmental health factors.

[(3) "Registered nurse" means a registered nurse recognized by the Texas Board of Nursing as having the specialized education and training required under Section 301.152.

[(4) "Site serving a medically underserved population" means:

[(A) a site located in a medically underserved area;

[(B) a site located in a health manpower shortage area;

[(C) a clinic designated as a rural health clinic under 42 U.S.C. Section 1395x(aa);

[(D) a public health clinic or a family planning clinic under contract with the Texas Department of Human Services or the Texas Department of Health;

[(E) a site located in an area in which the Texas Department of Health determines there is an insufficient number of physicians providing services to eligible clients of federal, state, or locally funded health care programs; or

[(F) a site that the Texas Department of Health determines serves a disproportionate number of clients eligible to participate in federal, state, or locally funded health care programs.

[(b) After making a determination under this section that a site serves a medically underserved population, the Texas Department of Health shall publish notice of its determination in the Texas Register and provide an opportunity for public comment in the manner provided for a proposed rule under Chapter 2001, Government Code.

[(c) At a site serving a medically underserved population, a physician licensed by the board may delegate to a registered nurse or physician assistant acting under adequate physician supervision the act of administering, providing, or carrying out or signing a prescription drug order, as authorized by the physician through a physician's order, a standing medical order, a standing delegation order, or another order or protocol as defined by the board.

[(d) An advertisement for a site serving a medically underserved population must include the name and business address of the supervising physician for the site.

[(e) Physician supervision is adequate for the purposes of this section if a delegating physician:

[(1) is responsible for the formulation or approval of the physician's order, standing medical order, standing delegation order, or other order or protocol, and periodically reviews the order and the services provided patients under the order;

[(2) is on-site to provide medical direction and consultation at least once every 10 business days during which the advanced practice nurse or physician assistant is on-site providing care;

[(3) receives a daily status report from the advanced practice nurse or physician assistant on any problem or complication encountered; and

[(4) is available through direct telecommunication for consultation, patient referral, or assistance with a medical emergency.]

SECTION 5. Section 157.055, Occupations Code, is amended to read as follows:

Sec. 157.055. ORDERS AND PRESCRIPTIVE AUTHORITY AGREEMENTS [PROTOCOLS]. (a) A prescriptive authority agreement [protocol] or other order shall be defined in a manner that promotes the exercise of professional judgment by the advanced practice nurse and physician assistant commensurate with the education and experience of that person. Under this section, a prescriptive authority agreement or [an] order [or protocol] used by a reasonable and prudent physician exercising sound medical judgment [:

[(1)] is not required to:

(1) describe the exact steps that an advanced practice nurse or a physician assistant must take with respect to each specific condition, disease, or symptom; or [and]

(2) [may] state the specific drugs, medical devices, or types or categories of drugs [medications] that may be prescribed or the specific drugs, medical devices, or types or categories of drugs [medications] that may not be prescribed.

(b) A prescriptive authority agreement is considered a protocol for the purpose of fulfilling any requirement for a protocol imposed under any other law.

SECTION 6. Section 157.056, Occupations Code, is amended to read as follows:

Sec. 157.056. PRESCRIPTION INFORMATION. The following information must be provided on each prescription subject to this subchapter:

(1) the patient's name and address;

(2) the drug to be dispensed;

(3) directions to the patient regarding the taking of the drug and the dosage;

(4) the intended use of the drug, if appropriate;

(5) the name, address, and telephone number of the physician;

(6) the name, address, telephone number, and identification number of the advanced practice [registered] nurse or physician assistant [completing or] signing the prescription drug order;

(7) the date; and

(8) the number of refills permitted.

SECTION 7. Section 157.057, Occupations Code, is amended to read as follows:

Sec. 157.057. ADDITIONAL IMPLEMENTATION METHODS. The board may adopt additional methods to implement:

(1) a physician's prescription; or

(2) the delegation of the signing of a prescription under a physician's order, standing medical order, standing delegation order, or other order [or protocol].

SECTION 8. Sections 157.059(d), (e), (f), (i), and (j), Occupations Code, are amended to read as follows:

(d) The delegation of authority to administer or provide controlled substances under Subsection (b) must be under a physician's order, medical order, standing delegation order, or prescriptive authority agreement [protocol] that requires adequate and documented availability for access to medical care.

(e) The physician's orders, medical orders, standing delegation orders, or prescriptive authority agreements [protocols] must require the reporting of or monitoring of each client's progress, including complications of pregnancy and delivery and the administration and provision of controlled substances by the nurse midwife or physician assistant to the clients of the nurse midwife or physician assistant.

(f) The authority of a physician to delegate under this section is limited to:

(1) eight [three] nurse midwives or physician assistants or their full-time equivalents; and

(2) the designated facility at which the nurse midwife or physician assistant provides care.

(i) This section authorizes a physician to delegate the act of administering or providing a controlled substance to a nurse midwife or physician assistant but does not require physician delegation of:

(1) further acts to a nurse midwife; or

(2) the administration of medications by a physician assistant or advanced practice [registered] nurse other than as provided by this section.

(j) This section does not limit the authority of a physician to delegate the [carrying out or] signing of a prescription drug order involving a controlled substance under this subchapter.

SECTION 9. Section 157.060, Occupations Code, is amended to read as follows:

Sec. 157.060. PHYSICIAN LIABILITY FOR DELEGATED ACT. Unless the physician has reason to believe the physician assistant or advanced practice nurse lacked the competency to perform the act, a physician is not liable for an act of a physician assistant or advanced practice nurse solely because the physician signed a prescriptive authority agreement, a standing medical order, a standing delegation order, or another order [or protocol] authorizing the physician assistant or advanced practice nurse to administer, provide, [carry out,] or sign a prescription drug order.

SECTION 10. The following statutes are repealed:

(1) Section 157.051(2), Occupations Code;

(2) Section 157.053, Occupations Code;

(3) Section 157.054, Occupations Code;

(4) Section 157.0541, Occupations Code; and

(5) Section 157.0542, Occupations Code.

SECTION 11. The changes in law made by this Act apply only to a delegation by a physician to an advanced practice nurse or physician assistant under Subchapter B, Chapter 157, Occupations Code, on or after the effective date of this Act.

SECTION 12. This Act takes effect September 1, 2009.