Texas 2009 - 81st Regular

Texas House Bill HB696 Compare Versions

Only one version of the bill is available at this time.

Old	New	Differences
1	1	81R4694 YDB-F
2	2	By: Orr H.B. No. 696
3	3
4	4
5	5	A BILL TO BE ENTITLED
6	6	AN ACT
7	7	relating to a physician's authority to delegate prescribing acts to
8	8	advanced practice nurses or physician assistants.
9	9	BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
10	10	SECTION 1. The heading to Subchapter B, Chapter 157,
11	11	Occupations Code, is amended to read as follows:
12	12	SUBCHAPTER B. PRESCRIPTIVE AUTHORITY AGREEMENTS WITH [DELEGATION
13	13	TO] ADVANCED PRACTICE NURSES AND PHYSICIAN ASSISTANTS
14	14	SECTION 2. Section 157.051, Occupations Code, is amended by
15	15	adding Subdivisions (2-c) and (4) to read as follows:
16	16	(2-c) "Medication order" has the meaning assigned by
17	17	Section 551.003.
18	18	(4) "Prescription drug order" means an order from a
19	19	physician or a physician's designated agent to a pharmacist for a
20	20	drug or device to be dispensed.
21	21	SECTION 3. Section 157.0511, Occupations Code, is amended
22	22	to read as follows:
23	23	Sec. 157.0511. PHYSICIAN AUTHORITY [PRESCRIPTION DRUG
24	24	ORDERS]. (a) In a prescriptive authority agreement executed
25	25	under Section 157.052, a physician may provide an advanced practice
26	26	nurse or physician assistant authority to prescribe or order a
27	27	dangerous drug or controlled substance, including authority to sign
28	28	a prescription drug order or medication order. [A physician's
29	29	authority to delegate the carrying out or signing of a prescription
30	30	drug order under this subchapter is limited to:
31	31	[(1) dangerous drugs; and
32	32	[(2) controlled substances to the extent provided by
33	33	Subsection (b).]
34	34	(b) [A physician may delegate the carrying out or signing of
35	35	a prescription drug order for a controlled substance only if:
36	36	[(1) the prescription is for a controlled substance
37	37	listed in Schedules III, IV, or V as established by the commissioner
38	38	of public health under Chapter 481, Health and Safety Code;
39	39	[(2) the prescription is for a period not to exceed 30
40	40	days;
41	41	[(3) with regard to the refill of a prescription, the
42	42	refill is authorized after consultation with the delegating
43	43	physician and the consultation is noted in the patient's chart; and
44	44	[(4) with regard to a prescription for a child less
45	45	than two years of age, the prescription is made after consultation
46	46	with the delegating physician and the consultation is noted in the
47	47	patient's chart.
48	48	[(b-1) The board shall adopt rules that require a physician
49	49	who delegates the carrying out or signing of a prescription drug
50	50	order under this subchapter to maintain records that show when and
51	51	to whom a delegation is made. The board may access the physician's
52	52	records under this subsection as necessary for an investigation.
53	53	[(c)] This subchapter does not modify the authority granted
54	54	by law for an advanced practice [a licensed registered] nurse or
55	55	physician assistant to administer or provide a medication,
56	56	including a controlled substance listed in Schedule II as
57	57	established by the commissioner of state [public] health services
58	58	under Chapter 481, Health and Safety Code, that is authorized by a
59	59	physician under a physician's order, standing medical order,
60	60	standing delegation order, or protocol.
61	61	SECTION 4. Section 157.052, Occupations Code, is amended to
62	62	read as follows:
63	63	Sec. 157.052. PRESCRIPTIVE AUTHORITY AGREEMENT
64	64	[PRESCRIBING AT SITES SERVING CERTAIN MEDICALLY UNDERSERVED
65	65	POPULATIONS]. (a) A physician may enter into a prescriptive
66	66	authority agreement with an advanced practice nurse or physician
67	67	assistant. The prescriptive authority agreement must:
68	68	(1) identify the physician's and the advanced practice
69	69	nurse's or physician assistant's areas of practice and any
70	70	specialties;
71	71	(2) describe any limitations on the advanced practice
72	72	nurse's or physician assistant's authority to prescribe or order
73	73	dangerous drugs, controlled substances, or medical devices in
74	74	accordance with Section 157.055;
75	75	(3) describe a prescriptive authority quality
76	76	evaluation and improvement plan and specify methods for documenting
77	77	the implementation of the plan; and
78	78	(4) specify a process to ensure collaboration between
79	79	the physician and the advanced practice nurse or physician
80	80	assistant.
81	81	(b) The physician and the advanced practice nurse or
82	82	physician assistant may specialize in different practice areas and
83	83	enter into a prescriptive authority agreement if the prescriptive
84	84	authority agreement demonstrates an appropriate link between the
85	85	specialty practice area of the physician and the specialty practice
86	86	area of the advanced practice nurse or physician assistant.
87	87	(c) The degree of collaboration between the physician and
88	88	the advanced practice nurse or physician assistant specified in the
89	89	prescriptive authority agreement may vary based on the advanced
90	90	practice nurse's or physician assistant's education, experience,
91	91	and skill in treating patients.
92	92	(d) Except as provided by Subsection (e), a physician may
93	93	enter into prescriptive authority agreements with not more than
94	94	eight advanced practice nurses and physician assistants or their
95	95	full-time equivalents, unless a reasonably prudent physician would
96	96	consider agreements with more than eight advanced practice nurses
97	97	and physician assistants to be safe based on:
98	98	(1) the advanced practice nurses' and physician
99	99	assistants' education, experience, knowledge, skills, and
100	100	abilities; and
101	101	(2) either:
102	102	(A) the type of patients served; or
103	103	(B) the extent to which access to care by a
104	104	medically underserved population is improved.
105	105	(e) The limitation on the number of prescriptive authority
106	106	agreements under Subsection (d) does not apply to an agreement at a
107	107	hospital licensed under Chapter 241, Health and Safety Code, or
108	108	owned or operated by this state, in which the physician and the
109	109	advanced practice nurses and physician assistants who are parties
110	110	to the agreement are authorized to practice.
111	111	(f) The board shall cooperate with the Texas Board of
112	112	Nursing in adopting rules under this subchapter to eliminate, to
113	113	the extent possible, conflicts between the rules adopted by each
114	114	board.
115	115	(g) This section shall be liberally construed to allow the
116	116	use of prescriptive authority agreements to safely and effectively
117	117	utilize the skills and services of advanced practice nurses and
118	118	physician assistants. [In this section:
119	119	[(1) "Health manpower shortage area" means:
120	120	[(A) an urban or rural area of this state that:
121	121	[(i) is not required to conform to the
122	122	geographic boundaries of a political subdivision but is a rational
123	123	area for the delivery of health service;
124	124	[(ii) the secretary of health and human
125	125	services determines has a health manpower shortage; and
126	126	[(iii) is not reasonably accessible to an
127	127	adequately served area;
128	128	[(B) a population group that the secretary of
129	129	health and human services determines has a health manpower
130	130	shortage; or
131	131	[(C) a public or nonprofit private medical
132	132	facility or other facility that the secretary of health and human
133	133	services determines has a health manpower shortage, as described by
134	134	42 U.S.C. Section 254e(a)(1).
135	135	[(2) "Medically underserved area" means:
136	136	[(A) an area in this state with a medically
137	137	underserved population;
138	138	[(B) an urban or rural area designated by the
139	139	secretary of health and human services as an area in this state with
140	140	a shortage of personal health services or a population group
141	141	designated by the secretary as having a shortage of those services,
142	142	as described by 42 U.S.C. Section 300e-1(7); or
143	143	[(C) an area defined as medically underserved by
144	144	rules adopted by the Texas Board of Health based on:
145	145	[(i) demographics specific to this state;
146	146	[(ii) geographic factors that affect access
147	147	to health care; and
148	148	[(iii) environmental health factors.
149	149	[(3) "Registered nurse" means a registered nurse
150	150	recognized by the Texas Board of Nursing as having the specialized
151	151	education and training required under Section 301.152.
152	152	[(4) "Site serving a medically underserved
153	153	population" means:
154	154	[(A) a site located in a medically underserved
155	155	area;
156	156	[(B) a site located in a health manpower shortage
157	157	area;
158	158	[(C) a clinic designated as a rural health clinic
159	159	under 42 U.S.C. Section 1395x(aa);
160	160	[(D) a public health clinic or a family planning
161	161	clinic under contract with the Texas Department of Human Services
162	162	or the Texas Department of Health;
163	163	[(E) a site located in an area in which the Texas
164	164	Department of Health determines there is an insufficient number of
165	165	physicians providing services to eligible clients of federal,
166	166	state, or locally funded health care programs; or
167	167	[(F) a site that the Texas Department of Health
168	168	determines serves a disproportionate number of clients eligible to
169	169	participate in federal, state, or locally funded health care
170	170	programs.
171	171	[(b) After making a determination under this section that a
172	172	site serves a medically underserved population, the Texas
173	173	Department of Health shall publish notice of its determination in
174	174	the Texas Register and provide an opportunity for public comment in
175	175	the manner provided for a proposed rule under Chapter 2001,
176	176	Government Code.
177	177	[(c) At a site serving a medically underserved population, a
178	178	physician licensed by the board may delegate to a registered nurse
179	179	or physician assistant acting under adequate physician supervision
180	180	the act of administering, providing, or carrying out or signing a
181	181	prescription drug order, as authorized by the physician through a
182	182	physician's order, a standing medical order, a standing delegation
183	183	order, or another order or protocol as defined by the board.
184	184	[(d) An advertisement for a site serving a medically
185	185	underserved population must include the name and business address
186	186	of the supervising physician for the site.
187	187	[(e) Physician supervision is adequate for the purposes of
188	188	this section if a delegating physician:
189	189	[(1) is responsible for the formulation or approval of
190	190	the physician's order, standing medical order, standing delegation
191	191	order, or other order or protocol, and periodically reviews the
192	192	order and the services provided patients under the order;
193	193	[(2) is on-site to provide medical direction and
194	194	consultation at least once every 10 business days during which the
195	195	advanced practice nurse or physician assistant is on-site providing
196	196	care;
197	197	[(3) receives a daily status report from the advanced
198	198	practice nurse or physician assistant on any problem or
199	199	complication encountered; and
200	200	[(4) is available through direct telecommunication
201	201	for consultation, patient referral, or assistance with a medical
202	202	emergency.]
203	203	SECTION 5. Section 157.055, Occupations Code, is amended to
204	204	read as follows:
205	205	Sec. 157.055. ORDERS AND PRESCRIPTIVE AUTHORITY AGREEMENTS
206	206	[PROTOCOLS]. (a) A prescriptive authority agreement [protocol]
207	207	or other order shall be defined in a manner that promotes the
208	208	exercise of professional judgment by the advanced practice nurse
209	209	and physician assistant commensurate with the education and
210	210	experience of that person. Under this section, a prescriptive
211	211	authority agreement or [an] order [or protocol] used by a
212	212	reasonable and prudent physician exercising sound medical judgment
213	213	[:
214	214	[(1)] is not required to:
215	215	(1) describe the exact steps that an advanced practice
216	216	nurse or a physician assistant must take with respect to each
217	217	specific condition, disease, or symptom; or [and]
218	218	(2) [may] state the specific drugs, medical devices,
219	219	or types or categories of drugs [medications] that may be
220	220	prescribed or the specific drugs, medical devices, or types or
221	221	categories of drugs [medications] that may not be prescribed.
222	222	(b) A prescriptive authority agreement is considered a
223	223	protocol for the purpose of fulfilling any requirement for a
224	224	protocol imposed under any other law.
225	225	SECTION 6. Section 157.056, Occupations Code, is amended to
226	226	read as follows:
227	227	Sec. 157.056. PRESCRIPTION INFORMATION. The following
228	228	information must be provided on each prescription subject to this
229	229	subchapter:
230	230	(1) the patient's name and address;
231	231	(2) the drug to be dispensed;
232	232	(3) directions to the patient regarding the taking of
233	233	the drug and the dosage;
234	234	(4) the intended use of the drug, if appropriate;
235	235	(5) the name, address, and telephone number of the
236	236	physician;
237	237	(6) the name, address, telephone number, and
238	238	identification number of the advanced practice [registered] nurse
239	239	or physician assistant [completing or] signing the prescription
240	240	drug order;
241	241	(7) the date; and
242	242	(8) the number of refills permitted.
243	243	SECTION 7. Section 157.057, Occupations Code, is amended to
244	244	read as follows:
245	245	Sec. 157.057. ADDITIONAL IMPLEMENTATION METHODS. The
246	246	board may adopt additional methods to implement:
247	247	(1) a physician's prescription; or
248	248	(2) the delegation of the signing of a prescription
249	249	under a physician's order, standing medical order, standing
250	250	delegation order, or other order [or protocol].
251	251	SECTION 8. Sections 157.059(d), (e), (f), (i), and (j),
252	252	Occupations Code, are amended to read as follows:
253	253	(d) The delegation of authority to administer or provide
254	254	controlled substances under Subsection (b) must be under a
255	255	physician's order, medical order, standing delegation order, or
256	256	prescriptive authority agreement [protocol] that requires adequate
257	257	and documented availability for access to medical care.
258	258	(e) The physician's orders, medical orders, standing
259	259	delegation orders, or prescriptive authority agreements
260	260	[protocols] must require the reporting of or monitoring of each
261	261	client's progress, including complications of pregnancy and
262	262	delivery and the administration and provision of controlled
263	263	substances by the nurse midwife or physician assistant to the
264	264	clients of the nurse midwife or physician assistant.
265	265	(f) The authority of a physician to delegate under this
266	266	section is limited to:
267	267	(1) eight [three] nurse midwives or physician
268	268	assistants or their full-time equivalents; and
269	269	(2) the designated facility at which the nurse midwife
270	270	or physician assistant provides care.
271	271	(i) This section authorizes a physician to delegate the act
272	272	of administering or providing a controlled substance to a nurse
273	273	midwife or physician assistant but does not require physician
274	274	delegation of:
275	275	(1) further acts to a nurse midwife; or
276	276	(2) the administration of medications by a physician
277	277	assistant or advanced practice [registered] nurse other than as
278	278	provided by this section.
279	279	(j) This section does not limit the authority of a physician
280	280	to delegate the [carrying out or] signing of a prescription drug
281	281	order involving a controlled substance under this subchapter.
282	282	SECTION 9. Section 157.060, Occupations Code, is amended to
283	283	read as follows:
284	284	Sec. 157.060. PHYSICIAN LIABILITY FOR DELEGATED ACT. Unless
285	285	the physician has reason to believe the physician assistant or
286	286	advanced practice nurse lacked the competency to perform the act, a
287	287	physician is not liable for an act of a physician assistant or
288	288	advanced practice nurse solely because the physician signed a
289	289	prescriptive authority agreement, a standing medical order, a
290	290	standing delegation order, or another order [or protocol]
291	291	authorizing the physician assistant or advanced practice nurse to
292	292	administer, provide, [carry out,] or sign a prescription drug
293	293	order.
294	294	SECTION 10. The following statutes are repealed:
295	295	(1) Section 157.051(2), Occupations Code;
296	296	(2) Section 157.053, Occupations Code;
297	297	(3) Section 157.054, Occupations Code;
298	298	(4) Section 157.0541, Occupations Code; and
299	299	(5) Section 157.0542, Occupations Code.
300	300	SECTION 11. The changes in law made by this Act apply only
301	301	to a delegation by a physician to an advanced practice nurse or
302	302	physician assistant under Subchapter B, Chapter 157, Occupations
303	303	Code, on or after the effective date of this Act.
304	304	SECTION 12. This Act takes effect September 1, 2009.