delegation, On the Job, Professional Identity, Scope of Practice

Medical Assistants and Limited Scope Radiography

I receive fewer questions than I did seven or 10 years ago about the legalities of medical assistants performing limited scope radiography. However, in some states medical assistants are called upon to expose patients to ionizing radiation, as specifically directed by the overseeing/delegating provider.

The legality of this task is governed by state law. In some states unlicensed professionals such as medical assistants are forbidden from doing any limited scope radiography. Only licensed radiologic technologists are permitted to perform radiography. In other states medical assistants are required to complete a short course and pass a test in order to be delegated limited scope radiography. In other states limited scope radiography under direct/on-site provider supervision is not regulated. Physicians are permitted to delegate limited scope radiography to knowledgeable and competent employees.

On the Job, Professional Identity, Scope of Practice

Ohio Passes Senate Bill 110

I am happy to report that the Ohio Legislature has passed Senate Bill (SB) 110, which has now been signed into law by Governor John Kasich. The bill becomes effective 90 days after signing.

This bill gives nurse practitioners (NPs) and physician assistants (PAs) the ability to delegate medication administration to unlicensed allied health professionals, such as medical assistants working under their supervision in outpatient settings.

See the following relevant passages from SB 110, the first from page 20 of the attached, which is the version that has passed both Houses of the Ohio legislature:

Sec. 4723.48. (A) A clinical nurse specialist, certified nurse-midwife, or certified nurse practitioner seeking authority to prescribe drugs and therapeutic devices shall file with the board of nursing a written application for a certificate to prescribe. The board of nursing shall issue a certificate to prescribe to each applicant who meets the requirements specified in section 4723.482 or 4723.485 of the Revised Code. …

(C)(1) The holder of a certificate issued under this section may delegate to a person not otherwise authorized to administer drugs the authority to administer to a specified patient a drug, other than a controlled substance, listed in the formulary established in rules adopted under section 4723.50 of the Revised Code. The delegation shall be in accordance with division (C)(2) of this section and standards and procedures established in rules adopted under division (Q) of section 4723.07 of the Revised Code.

(2) Prior to delegating the authority, the certificate holder shall do both of the following:

(a) Assess the patient and determine that the drug is appropriate for the patient;

(b) Determine that the person to whom the authority will be delegated has met the conditions specified in division (D) of section 4723.489 of the Revised Code.

Note also the following on pages 22 and 23:

Sec. 4723.489. A person not otherwise authorized to administer drugs may administer a drug to a specified patient if all of the following conditions are met:

(A) The authority to administer the drug is delegated to the person by an advanced practice registered nurse who is a clinical nurse specialist, certified nurse-midwife, or certified nurse practitioner and holds a certificate to prescribe issued under section 4723.48 of the Revised Code.

(B) The drug is listed in the formulary established in rules adopted under section 4723.50 of the Revised Code but is not a controlled substance and is not to be administered intravenously.

(C) The drug is to be administered at a location other than a hospital inpatient care unit, as defined in section 3727.50 of the Revised Code; a hospital emergency department or a freestanding emergency department; or an ambulatory surgical facility, as defined in section 3702.30 of the Revised Code.

(D) The person has successfully completed education based on a recognized body of knowledge concerning drug administration and demonstrates to the person’s employer the knowledge, skills, and ability to administer the drug safely.

(E) The person’s employer has given the advanced practice registered nurse access to documentation, in written or electronic form, showing that the person has met the conditions specified in division (D) of this section.Sub. S. B. No. 110 131st G.A. 23

(F) The advanced practice registered nurse is physically present at the location where the drug is administered.

Note the following from pages 36 and 37:

Sec. 4730.203. (A) Acting pursuant to a supervision agreement, a physician assistant may Sub. S. B. No. 110 131st G.A. 37

delegate performance of a task to implement a patient’s plan of care or, if the conditions in division (C) of this section are met, may delegate administration of a drug. Subject to division (D) of section 4730.03 of the Revised Code, delegation may be to any person. The physician assistant must be physically present at the location where the task is performed or the drug administered.

(B) Prior to delegating a task or administration of a drug, a physician assistant shall determine that the task or drug is appropriate for the patient and the person to whom the delegation is to be made may safely perform the task or administer the drug.

(C) A physician assistant may delegate administration of a drug only if all of the following conditions are met:

(1) The physician assistant has been granted physician-delegated prescriptive authority.

(2) The drug is included in the formulary established under division (A) of section 4730.39 of the Revised Code.

(3) The drug is not a controlled substance.

(4) The drug will not be administered intravenously.

(5) The drug will not be administered in a hospital inpatient care unit, as defined in section 3727.50 of the Revised Code; a hospital emergency department; a freestanding emergency department; or an ambulatory surgical facility licensed under section 3702.30 of the Revised Code.

(D) A person not otherwise authorized to administer a drug or perform a specific task may do so in accordance with a physician assistant’s delegation under this section.

On the Job, Scope of Practice

“An Act Concerning Medical Assistants”: Raised Bill No. 459

On March 19 the Public Health Committee of the Connecticut legislature held a public hearing on General Assembly Raised Bill No. 459, “An Act Concerning Medical Assistants.”  This legislation was the result of a scope of practice request submitted by the American Association of Medical Assistants and the Connecticut Society of Medical Assistants (CSMA) on July 16, 2012, to the Connecticut Department of Public Health (as described in the March/April 2013 issue of CMA Today).

Raised Bill No. 459 would permit physicians to delegate to medical assistants who had graduated from an accredited postsecondary medical assisting program and who are certified by the Certifying Board of the AAMA “the administration of medication orally, by inhalation, or by intramuscular, intradermal, or subcutaneous injections, including, but not limited to, the administration of a vaccine.”  The bill would also require that the medication be administered “under the direct supervision, control, and responsibility of a physician who is in the outpatient clinic or office when such medication is administered.”

The AAMA and the CSMA submitted joint written testimony in support of Raised Bill No. 459, and Holly Martin, CMA (AAMA), of the CSMA, presented oral testimony at the March 19 hearing.  Legal Eye will keep readers informed about the outcome of Bill No. 459.

Scope of Practice

Q and A: Eligible Professionals and Core Objectives, Part 1 (Post 2 of 5)

Because most CMAs (AAMA) work under the direct supervision of “eligible professionals” (as defined in the rules of the Centers for Medicare and Medicaid Services [CMS]), this post focuses on some common questions surrounding the provisions of the Medicare and Medicaid Electronic Health Records (EHR) Incentive Program that are applicable to eligible professionals, not those provisions that are applicable to “eligible hospitals” and “critical access hospitals.”

Q: Are there different definitions of “eligible professionals” for the EHR incentive programs?

A: Yes. As in the previous post, an in-depth treatment is too lengthy to be presented. Physicians, osteopaths, and dentists are deemed to be eligible professionals under both programs, however.

Q: How do eligible professionals qualify for incentive payments under the programs? 

A: Eligible professionals qualify for incentive payments by demonstrating “meaningful use” of “certified EHR technology.” More specifically, meaningful use is proven (in part) by meeting minimum requirements for each Core Objective. The minimum requirements for each Core Objective are referred to in the CMS rules and publications as “measures.” The measures are sometimes quantitative in nature.

Q: Are there any exemptions for certain eligible professionals?

A: Yes. CMS has provided “exclusions” for eligible professionals who cannot meet some of the Core Objectives because of the small size of their practices, or the highly specialized nature of their practices.

Q: Are there partial payments if an eligible professional meets some, but not all, of the Core Objectives?

A: No. An eligible professional must meet all Core Objectives. Failure to meet any one Core Objective would result in no incentive payment.

Uncategorized

Favorable Report from the Connecticut Department of Public Health

In November I described the continuing scope of practice issues that exist for medical assistants in Connecticut. I also detailed my efforts in concert with the Connecticut Society of Medical Assistants (CSMA) to correct these issues and see legislation passed that allows professionally educated and suitably credentialed medical assistants to administer medication under physician supervision.

In response to our letter (the body of which will be available in the upcoming March/April issue of CMA Today), the Connecticut Department of Public Health formed a scope of practice review committee to examine the request. The committee consisted of representatives from a number of organizations—not just the AAMA and CSMA, but the Connecticut Hospital Association, the Connecticut State Medical Society, and the Connecticut Association of Optometrists, among others. All information provided in the scope of practice request was reviewed by the committee, after which a report was issued. While this report makes no recommendations as to potential legislation, there are a number of positives to be taken from it.

First, the report acknowledges the ability and education of medical assistants:

“Literature and other information reviewed and evaluated by the scope of practice review committee demonstrated that certified medical assistants are educated and trained to administer medication under the direct supervision of a licensed physician. Accredited education and training programs that lead to certification as a medical assistant … include coursework and clinical training in pharmacology and medication administration.”

The report goes on to acknowledge that certification programs like those offered by the Certifying Board of the AAMA provide powerful evidence that medical assistants possess the knowledge necessary for medication administration, and that such certification programs could potentially be used as a standard in Connecticut.

In addition, the report also states that allowing medical assistants to administer medication should allow physicians and nurses to see more patients and focus on clinical care, as our letter argues.

The report goes on to confirm that all the information provided by the AAMA and CSMA allowed the committee to thoroughly address any quality and safety risks surrounding this issue. In addition, the report recommends that a number of terms must be clarified in any proposed legislation:

  • “Physician”
  • “Certified medical assistant”
  • “Outpatient setting”
  • “Direct supervision”

In short, the report discussed necessary steps that should be taken in the event that our recommended legislation is proposed. The report itself is over 15 pages long, but nonetheless includes some very encouraging reports about the progress of our work!

As always, I will keep you informed of any further developments in this matter.