|
|
|
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. |