S.B. 104 (S-3): FIRST ANALYSIS - RPN: PRESCRIBER

Senate Bill 104 (Substitute S-3 as reported)

Sponsor: Senator John J.H. Schwarz, M.D.

Committee: Health Policy and Senior Citizens

Date Completed: 1-13-98

RATIONALE

An issue that has been discussed in recent years concerns the authority of nurses to prescribe medication. Part 72 of the Public Health Code governs the scope of practice of nurses, including registered professional nurses (RPNs). Registered professional nurses are authorized to teach, direct, and supervise less skilled personnel in the performance of nursing activities. In addition, the Board of Nursing may issue a specialty certification to an RPN who has advanced training, has demonstrated competency, and practices as a nurse midwife, nurse anesthetist, or nurse practitioner. These nurses sometimes are referred to as advanced registered nurse practitioners or advanced professional nurses.

The Code does not specifically authorize nurses to issue prescriptions, except in regard to complimentary starter dose drugs. Under general provisions of the Code, a licensed health professional may delegate functions that will be performed under his or her supervision; also, the definition of "prescriber" includes a licensed health professional acting under the delegation of a physician. In addition, a 1980 Opinion of the Attorney General (No. 5630) held that physicians may delegate to nurses the authority to prescribe drugs. Thus, nurses may write prescriptions under certain circumstances.

Despite these provisions, many people believe that some RPNs should have broader authority to prescribe medication. In situations in which a nurse does not have delegated authority, either the patient must see the physician separately or the physician must actually write or sign a prescription. In addition, the authority to prescribe controlled substances cannot be delegated. According to some people, this system can delay the health care delivery process, and may result in illness or death. Thus, it has been suggested that certain RPNs with specialty certification and advanced training should be permitted under the law to write prescriptions without authority from a physician.

CONTENT

The bill would amend the Public Health Code to include in the definition of "prescriber" a licensed registered professional nurse with specialty certification who was a nurse midwife or a nurse practitioner and who met the bill's requirements. An RPN who specialized in psychiatric nursing would not be eligible to become a prescriber. An RPN with specialty certification could not order magnetic resonance imaging or computerized tomography scanner tests and could not prescribe antineoplastic chemotherapy drugs. An RPN who was a prescriber under the bill biennially would have to complete at least 20 hours of continuing education in pharmacology.

To be a prescriber, an RPN with a specialty certification would have to file with the Department of Consumer and Industry Services both an emergency plan for the management and referral to appropriate medical services of a patient who experienced an adverse drug reaction, and a collaborative agreement between the RPN and one or more physicians or health facilities. The collaborative agreement would have to specify that the physician or health facility would be available for the referral and treatment of patients referred by the RPN for a specific period of time, not exceeding the two years immediately following the date the agreement was executed. The agreement would not prohibit the RPN from consulting with or referring to other physicians and/or other facilities.

If an RPN's specialty certification were issued after January 1, 1993, he or she would have to possess a master's degree in advanced practice nursing from an accredited college or university approved by the Board of Nursing, to be a prescriber. The RPN also would have to have completed at least a one-year prescribing internship with a licensed physician or with an RPN with specialty certification who was a prescriber. During the internship, the RPN could prescribe only under the delegated authority of the physician or RPN prescriber. The prescribing internship would have to involve a significant and ongoing experience with prescribing the full range of prescription drugs related to health conditions that could be treated and treatments that were allowed under the RPN's specialty certification. The RPN would have to complete the internship within 12 months before becoming a prescriber.

If an RPN who was a prescriber determined from interviewing or examining a patient, using judgment and the degree of skill, care, knowledge, and attention ordinarily possessed and exercised by RPNs with specialty certifications in good standing under like circumstances, that the patient required medical care that was outside of the RPN's scope of practice, the RPN promptly would have to advise the patient to seek evaluation by an appropriate physician for diagnosis and possible treatment and could not attempt to provide the medical care that was outside his or her scope of practice.

An RPN who was a nurse midwife could prescribe a Schedule 2 controlled substance only if he or she determined that the prescription was necessary, the prescription was written during the patient's intrapartum or immediate postpartum period, and the patient was in a licensed hospital or in a birthing center at the time the prescription was written. An RPN who was a nurse practitioner could prescribe a Schedule 2 controlled substance only if the patient were suffering from a terminal illness and the RPN determined that the prescription was necessary.

MCL 333.17708

ARGUMENTS

(Please note: The arguments contained in this analysis originate from sources outside the Senate Fiscal Agency. The Senate Fiscal Agency neither supports nor opposes legislation.)

Supporting Argument

Currently, RPNs may prescribe medication only under a physician's delegation. The bill would recognize that qualified RPNs are highly trained and competent to prescribe medication within their field of expertise without first consulting a physician. All nurses undergo a continuous educational process and rigorous training program to ensure the safety of patients, and RPNs with a specialty certification are subject to even more demanding requirements. The bill would require, among other things, that an RPN with a specialty certification possess a master's degree in advanced practice nursing, undergo a one-year prescribing internship, and complete at least 20 hours of continuing education in pharmacology every two years. The bill also would limit the circumstances under which RPNs could prescribe controlled substances. In addition, RPNs still would not be permitted to order magnetic resonance imaging or computerized tomography scanner tests and could not prescribe antineoplastic chemotherapy drugs.

Supporting Argument

The bill would improve patients' access to health care and reduce the cost of meeting medical needs. The bill would eliminate unnecessary duplication of services and would assure timely and appropriate care for patients. Currently, if a nurse does not have delegated authority to prescribe, or if a controlled substance is needed, patients either need to wait for a physician's signature for a prescription or need to make a separate appointment with a physician to obtain a prescription. This results in further delay for the patient to obtain medication and, in some instances, could result in harmful or fatal consequences. The present system is cumbersome and potentially dangerous to patients who need immediate medication. The time currently wasted by doctors, nurses, and patients, when nurses must obtain a physician's signature on their prescription orders, could be used more efficiently. Further, a physician's help could be costly or unavailable, while most qualified RPN services are less expensive and readily available, especially in poor urban areas.

Response: Health care costs would not necessarily be lowered because, as a result of the bill, qualified nurses could seek increased pay for their ability to prescribe medication.

Supporting Argument

By allowing RPNs with a specialty certification to prescribe medication, the bill would help provide medical care in remote or underserved areas. These RPNs provide services to children, families, adults, and elderly in rural and poor urban areas of the State. Further, their wide availability would allow these patients easy access to necessary medical care.

Response: Most RPNs with a specialty certification who would be eligible to prescribe medication under the bill have already established their practice in certain areas throughout the State. There is no indication that RPNs with a specialty certification who were allowed to prescribe would relocate to other underserved areas.

Opposing Argument

Life-threatening diseases and complex problems often require a physician's in-depth education and extensive clinical training to determine what medication is best for the patient. The bill would jeopardize patients by exposing them to prescriptions written by underqualified individuals with insufficient training. Even with the required training and educational programs, an RPN with a speciality certification still would lack the necessary education and experience to prescribe drugs. Compared with RPNs with a specialty certification, physicians must have four years of graduate-level medical school courses and two years of residency training even before being eligible for a medical license application. Further, the bill would set no uniform criteria for nurses' credentials.

Response: Michigan Administrative Rules contain explicit requirements for nurses' specialty certification (R 338.10401 et seq.). Among other things, nurses must meet national standards for certification and must renew their certification every two years. The bill's requirement of 20 hours of continuing education in pharmacology every two years would be in addition to the continuing education required under the rules. Moreover, the bill would mandate a prescribing internship of at least one year, which is not presently required for nurses to receive delegated authority to prescribe.

Opposing Argument

The bill would undermine the team approach to health care delivery, in which nurses and physicians consult with each other in regard to patients under their care. Even though nurses currently may receive delegated authority to write prescriptions, it is up to the physician to decide whether to delegate and to what extent prescribing authority is delegated. A physician may delegate the authority to prescribe only certain drugs, or may retain the ultimate authority to sign prescriptions.

Response: The bill actually could strengthen the team approach by requiring a prescribing nurse to enter into a collaborative agreement with a physician or health facility for referral and treatment of patients.

Furthermore, under the present system, for basic diagnoses, physicians reportedly will often presign prescription pads, telephone orders to pharmacists upon qualified RPNs' request, and countersign prescriptions after medication was administered to speed up the prescription process for patients and nurses. These tactics would not be necessary under the bill.

- Legislative Analyst: N. Nagata

FISCAL IMPACT

The bill would have no fiscal impact on State or local government. If one assumes that a patient actually needs a given drug so prescribed, then the "type" of prescriber should have no effect on overall costs.

- Fiscal Analyst: J. Walker

A9798\S104A

This analysis was prepared by nonpartisan Senate staff for use by the Senate in its deliberations and does not constitute an official statement of legislative intent.