ARIZONA
MEDICAL BOARD ADOPTS GUIDELINES ON SCOPE OF PRACTICE
At its February 2008 meeting, the Arizona Medical Board adopted the following guidelines to assist physicians who were considering changing their practice:
Introduction:
Medical boards make basic assumptions when resolving scope of practice issues for physicians. Paramount among those assumptions is that the public must be protected from poorly trained or unqualified physicians.
The Arizona Medical Board developed these scope of practice guidelines to assist physicians in assessing their specific qualifications when they make the decision to undertake new procedures, employ new technologies or migrate into new areas of medical practice for which they have not received formal post graduate/residency training.
Preamble:
The Arizona Medical Board (board) recognizes that the practice of medicine is dynamic with respect to scientific and technological advancements.
Physician practice patterns are changing with evolving medical knowledge and treatment modalities, new technologies and fluctuations within health care specialties and the health care workforce. Consumer demand has contributed to changes in practice patterns as well. Laws defining the practice of medicine, in Arizona and nationwide, are broadly defined and do not restrict a licensee from adopting new technologies, employing new procedures, broadening one's scope of practice or even entering into a different area of practice from which he or she was formally trained. While the law may not restrict these changes in practice patterns, the board does have the obligation to ensure patient safety through the competent practice of medicine.
Prior to licensure, physicians must graduate from an approved medical school, complete an approved residency program and pass standardized tests. Physicians who complete these necessary requirements are presumed competent to practice within the field in which they received their formal training. Formal training requirements must meet national standards and are heavily regulated and scrutinized. A physician who meets the qualifications for licensure has an unlimited scope of practice.
The standard of care, however, requires physicians to be trained, qualified and competent to perform medical procedures before engaging in a particular practice or field of medicine. Post-formal training and continuing medical education does not receive the same level of scrutiny. While, it is critical for physicians to remain competent and current in the practice of medicine, this training may not be adequate for physicians trying to practice specialty care far afield from their formal post graduate/residency training.
Physicians who practice in specialty areas, whether or not they received formal training, must be competent in all procedures they perform regardless of where they received their training.
For example, internists, who also perform dermatological procedures, must be competent in all procedures that they perform. Likewise, a radiologist practicing radiology for many years may require additional training before being competent to practice emergency department medicine or urgent care medicine. Areas in which the board has recently seen physicians expand their scopes of practice include:
Pain management
Cosmetic surgery
Treatment of erectile dysfunction
While these areas are not inclusive of all the areas in which physicians have expanded their scopes of practice, they represent areas in which physicians have found themselves outside their training and skill levels – at times, to the detriment of their patients. Physicians must be aware of any complications that can arise during the course of a procedure and be prepared to adequately address them. Physicians administering anesthesia during office based surgery must also be aware of the board's Office Based Surgery Rules, specifically R4-16-702(A)(3)(d), which requires “… the physician and health care professional administering the sedation to rescue a patient after sedation is administered and the patient enters into a deeper state of sedation than what was intended by the physician.”
Obtaining Practice Area Expertise and Considerations for an Expanded Scope of Practice:
Practice area expertise can be obtained in a number of ways, including: mini-residency programs, informal training by a hospital or group practice, seminars prepared by private organizations, and direct training by medical equipment manufacturers and pharmaceutical companies. Regardless of how expertise is obtained, physicians should consider the following factors before engaging in an expanded practice:
What competencies (clinical knowledge, judgment and skills) are required in order to provide services safely and competently?
What are the prerequisites and the core education needed in terms of undergraduate and postgraduate education and clinical experience?
Will the education received meet the standards and be recognized by an independent and formally accredited educational organization or institution?
Is the expanded scope of practice appropriate for the education and training received?
How does that education compare to that of other practitioners providing the same service?
What goals must be established for attaining and retaining competence in that specialty area?
Competence Self-Assessment:
Once additional training is complete, and prior to beginning an expanded practice, physicians may elect to obtain an assessment of their skills. Assessment and evaluation programs are available through institutions such as the University of California San Diego Physician Assessment and Clinical Evaluation (PACE) program or the Colorado Center for Personalized Education for Physicians (CPEP). Additional assessment tools may be available through specialty medical societies or through county and state medical associations.
Summary:
These guidelines were developed to assist physicians in their understanding of the Arizona Medical Board's position on scope of practice issues and the board's obligation to protect the public through the competent practice of medicine. The board expects physicians to maintain their educational and technical competencies for their current practices. The board strongly recommends that these scope of practice guidelines be carefully reviewed by all physicians holding current licenses to practice medicine in Arizona.
PRESCRIPTION MONITORING PROGRAM BEGINS IN FALL 2008
The director of the Prescription Monitoring Program (PMP) says he hopes to begin collecting data from Arizona pharmacies in September of this year. But Dean Wright says the program probably will not be fully functional until March 2009.
The Arizona Legislature approved a bill creating the PMP, and Gov. Janet Napolitano signed it into law in early July 2007. A 2005 survey by the federal Substance Abuse and Mental Health Services Administration (SAMHSA) shows that 17 percent of substance abusers obtained drugs by presenting pain complaints to multiple physicians. The aim of the secure electronic database is to identify patients who may be “doctor shopping” for controlled substances and to notify their physicians. Substance abusers often seek prescriptions from more than one doctor. By filling the prescriptions at different pharmacies, they are able to avoid notice by the Arizona Pharmacy Board.
A Pharmacy Board Task Force has held meetings to establish guidelines for trend markers and to set parameters for how the Arizona program will utilize data. In April, the task force awarded a contract to a vendor for the necessary hardware and software. When the task force met again in May, the vendor demonstrated some program screens. The task force has yet to establish the number of doctors and pharmacies a patient would have to see in a month's time in order to trip an alert. Wright says members of the task force appear to be leaning toward five doctors and five pharmacies, which mirrors the Nevada prescription monitoring program.
Once a patient has seen five doctors and filled prescriptions at five pharmacies within a one month period, the PMP would notify the physicians who wrote the prescriptions about the situation. Late last year, the Pharmacy Board sent forms to physicians telling them that state law requires them to register with the PMP. Some of the notices came back undelivered. Physicians who haven't received the notice should either go to the Pharmacy Board website at www.pharmacy.state.az.us, where the form is available, or call the board at (602) 771-2727. Only physicians who stock and dispense Schedule II, III and IV drugs (not samples) to their patients for take home use from their offices will have to provide the PMP with data.
Once the program is underway, a physician will gain access to the PMP database with a username and a password. A doctor could then query the PMP to find out whether a patient is seeing other physicians and, if so, what they've prescribed.
Reprinted from volume 3, issue 1, online version of Primum, published by the Arizona Medical Board and Arizona Regulatory Board of Physician Assistants.
CONNECTICUT
CONNECTICUT RECEIVES CENTERS FOR DISEASE CONTROL AND PREVENTION GRANT ADDRESSES THE HEALTH AND EDUCATIONAL OUTCOMES FOR CHILDREN AND YOUTH
The Connecticut State Department of Education (CSDE) in partnership with the Department of Public Health (DPH) has secured a grant of approximately $3 million over the next five years to address health and educational issues in Connecticut public schools.
The Cooperative Agreement, Improving the Health and Educational Outcomes for Young People, is funded through a grant from the Centers for Disease Control and Prevention's Division of Adolescent and School Health (CDC/DASH). It will support implementation of Coordinated School Health (CSH), Promotion of Physical Activity, Nutrition, and Tobacco-Use Prevention (PANT), HIV prevention education and the Youth Risk Behavior Survey also known as the Connecticut School Health Survey (CSHS).
State Education Commissioner Mark K. McQuillan noted that this is the first time Connecticut has received federal support to implement Coordinated School Health, adding that only 22 states were awarded funding in the competitive national application process.
“This Cooperative Agreement will help to address prominent health concerns that are contributing factors to loss of instructional time including absenteeism, dropout rates and chronic illness,” said Comm. McQuillan. “Coordinated School Health addresses the needs of the whole child by effectively connecting health with education programs, policies and services at the local school level. This coordinated approach provides the framework for families, communities and schools to work together to improve students' health and capacity to learn.”
Specifically, this funding will:
Increase effectiveness of policies, practices and services to promote physical activity, improve nutrition, reduce tobacco use and increase health-enhancing behaviors among children and youth;
Strengthen statewide partnerships to effectively implement CSH and disease prevention education programs in Connecticut;
Administer the Connecticut School Health Survey, a health behavior surveillance system to students in Grades 9–12;
Support the development of a leadership institute to work with 20 school districts demonstrating health and educational disparities; and
Assist in aligning and enhancing existing local school district wellness policies and school improvement plans to address students' physical, social, emotional and behavioral health needs.
Reducing the disparities in educational, child and adolescent health indicators remains one of the major challenges facing the education and public health communities in Connecticut. This Cooperative Agreement will assist Connecticut in addressing these challenges and opportunities.
Reprinted from the Connecticut Medical Examining Board website.
GEORGIA
PAIN MANAGEMENT GUIDELINES
Effective Jan. 11, 2008, the Georgia Composite State Board of Medical Examiners adopted new pain management guidelines. Please visit the board website at www.medicalboard.georgia.gov to review these important guidelines.
Reprinted from the April 2008 issue of the Georgia Composite State Board of Medical Examiners Newsletter, published by the Georgia Composite State Board of Medical Examiners.
HAWAII
IMPORTANT INFORMATION 2010 RENEWAL AND CONTINUING MEDICAL EDUCATION (CME) REQUIREMENT FOR OSTEOPATHIC PHYSICIANS (D.O.)
Please be advised that a new law has been enacted which repeals the current law regarding osteopathic physicians (D.O.s) and puts them under chapter 453, relating to medicine and surgery. This now means that M.D.s and D.O.s are regulated under the same law.
The biggest impact to D.O.s is in the area of license renewal. Like M.D.s, D.O.s are now expected to obtain continuing medical education (CME) as a requirement for renewal, effective with the 2010 renewal. Among other things, CME requirements for 2010 renewal may be met by:
Completing, in the year 2008 or 2009, an accredited residency or fellowship program;
Completing, in the year 2008 or 2009, a full academic year of education in a medically related field leading to an advanced degree other than D.O.;
Meeting the CME requirements of a medical society to which the D.O. belongs;
Meeting the CME requirements of an American Board of Medical Specialties (ABMS) specialty board with which the D.O. is certified; or
Obtaining 40 or 20 category 1 or 1A CME hours between July 1, 2008–June 30, 2010.
Category 1 CME hours
D.O.s fulfilling the CME requirement through number 5 above would need to obtain:
40 hours if they received their license in Hawaii prior to 7/11/08; or 20 hours if they received their license in Hawaii between 7/1/08-6/30/09. Only 20 hours are required for the initial renewal. Beginning with the 2012 renewal and thereafter, 40 hours will be required.
Random audit
The Hawaii Medical Board will conduct a random audit to determine whether the CME requirement has been met. As such, D.O.s will not need to submit their documentation of CME unless they have been randomly selected.
A letter to this effect will be sent in April 2010 to advise and provide instructions for those who have been selected.
Reprinted from the Hawaii Department of Commerce and Consumer Affairs website.
ILLINOIS
NEW PHYSICIAN PROFILE WEBSITE WILL HELP HEALTH CARE CONSUMERS SELECT PROVIDERS
As part of his efforts to improve Illinois families' access to quality health care, Gov. Rod R. Blagojevich today announced the launch of a new physician profile feature available to the public at www.IDFPR.com, the Department of Financial and Professional Regulation's website. The new feature allows health care consumers to review important information about the professional and disciplinary background of 44,000 physicians and surgeons licensed to practice in Illinois.
“It is not enough to make sure every Illinois family has access to health care,” said Gov. Blagojevich. “We need to make sure that people have enough information to make informed decisions about the doctors who treat them. This new online tool will provide valuable assistance for patients as they choose their health care providers.”
The search engine is easy to use and allows health care consumers to search by the physician's name, specialty, geographic region or hospital affiliation. The program also allows consumers to compare several doctors with similar specialties. State Rep. Mary Flowers (D-Chicago) has been a leading advocate of the creation of the physician profile search tool.
“This physician profile search engine is exactly what I had hoped we could provide for Illinois consumers,” said Rep. Flowers. “With these tools, each of us will be able to learn about our doctors' education, training and any disciplines or judgments against them – all of which can help us make the best possible choice when deciding who should provide our health care.”
More than 85 percent of all licensed physicians and surgeons have provided the information necessary to create their profile in categories that include: the location and scope of practice, the type of insurance the physician accepts, specialties and certifications, legal and disciplinary actions taken against the physician, his or her educational background and any professional activities or honors the physician would like to add. Physicians' licenses are subject to renewal in July 2008. Before a license is renewed, physicians must provide the information for their profiles.
Reprinted from the Illinois Department of Financial and Professional Regulation website.
NEW YORK
STATE TESTS EMERGENCY RESPONSE TO INFLUENZA PANDEMIC
Called NYFLEx for New York Full Scale Logistics Exercise, the drill tested the state's ability to effectively implement its Pandemic Influenza Emergency Response Plan during a practice scenario in which an outbreak of a highly contagious H5N1 influenza virus spreads from China to New York.
In particular, the exercise focused on the state's ability to mobilize and distribute resources including antiviral medications, respirators, masks and ventilators to the hardest hit counties and hospitals. As part of the exercise, the state will transport supplies from its Medical Emergency Response Cache (MERC) and request additional supplies from the federal Strategic National Stockpile.
The exercise will also focus on assessing high-level decision- making by New York State Department of Health (Department) senior staff in allocating limited resources, including antiviral medications and ventilators, when there aren't sufficient resources to meet the need.
Led by the Department, “players” in the exercise included 62 hospitals and 28 county health departments, as well as emergency management agencies in Suffolk and Onondaga counties and other local agencies in the Capital Region and Central New York counties; the State Emergency Management Office (SEMO); the State Office of Homeland Security, the State Police, the State Division of Military and Naval Affairs; the State Office of General Services; and the State Department of Correctional Services.
“New Yorkers can be assured there is no immediate threat of an influenza pandemic,” said State Health Commissioner Richard F. Daines, M.D. “But public health experts around the world believe it is not a question of if, but when, a pandemic will occur, and New York wants to be as ready as possible. This exercise is one of many drills we have been conducting around the state to practice and test our response.”
“State agencies are continually working to protect New Yorkers and ensure the strongest response possible to many potential threats,” said John R. Gibb, director of SEMO. “Earlier this month we conducted a hurricane exercise to test our preparedness and response capabilities. Now we will test our ability to respond to pandemic flu.”
“An effective response to an influenza pandemic requires strong collaboration and coordination among New York's public health agencies and health care facilities, as well as federal and state agencies,” said Robert L. Burhans, director of the State Health Department's Office of Emergency Preparedness. “This exercise allows us to practice that coordination, increasing our readiness for a real public health emergency.”
During a severe pandemic, in addition to antiviral medications, there will be tremendous need for mechanical ventilators to provide breathing support to large numbers of critically ill people. Although the state continues to purchase and stockpile ventilators as part of pandemic preparedness, shortages of ventilators are inevitable and rationing will be required.
During the exercise, Department senior staff and clinicians in participating hospitals referred to the Department's “Guidelines on the Allocation of Ventilators in an Influenza Pandemic,” currently the only planning document of its kind in the nation developed to help guide difficult clinical and ethical decisions about the allocation of scare ventilators during a severe pandemic.
To assess available resources at health care facilities during the exercise, the Department will use a statewide electronic web-based system known as HERDS for Health Emergency Response Data System, which provides an emergency communication link to all health care facilities through a secure Internet site. HERDS provides real time data visualization, including GIS mapping of data, to track laboratory-confirmed influenza hospitalizations, inpatient bed capacity, available ventilators, isolation room capacity, staff resources and the availability of drugs and supplies by facility, county and region.
The Department activated its Public Information/Crisis Emergency Risk Communication Plan and used a secure Health Alert Notification (HAN) system that provided fast and reliable communication with local health officials, health care facilities and clinicians during the practice drill.
Reprinted from the New York State Department of Health website.
TEXAS
TEXAS MEDICAL BOARD IMPLEMENTS LICENSURE INQUIRY SYSTEM
It just got a little easier for a doctor to be licensed in Texas. On June 1, 2008, the Texas Medical Board implemented the Licensure Inquiry System of Texas (LIST), an online license application tracking system that promises to reduce the time required to process and issue physician licenses in Texas. A public/private partnership, LIST was funded by a grant from the Texas Hospital Association.
The LIST application uses existing technology in an innovative manner, and is designed for ease of use by applicants and board staff alike. It allows applicants to track the status of their physician licensure applications online 24 hours a day without requiring the assistance of board staff, including providing detailed explanations of any missing items needed to process the application. LIST allows applicants to communicate with the board from anywhere in the world with Internet access. The system also creates an easily accessible archive of all such communication between the board and the applicant. LIST also allows the board to broadcast to all applicants in the event that changes in statute or board rules modify requirements for licensure.
Prior to the implementation of LIST, an applicant was required to contact the board to determine the status of their application, confirm receipt of submitted materials or determine what might still be needed to complete their application.
“The fact that it is available 24 hours a day from anywhere in the world is very significant,” said Dr. Roberta M. Kalafut, board president. “Doctors may work challenging hours, and contacting the board during regular business hours may be difficult. Also, doctors who want to practice in Texas come from all over the world. Business hours here might be the middle of the night where the applicant resides.”
The new system is expected to reduce the time required to license a physician in Texas by adding efficiencies, not only for board staff, but also for the applicants, who will have real-time access to all the materials they submitted. “There is a great need in Texas for additional doctors, particularly in rural and border areas where Texans' medical needs are underserved,” said Dan Stultz, M.D., F.A.C.P., F.A.C.H.E., president and CEO of Texas Hospital Association. “This system will streamline the application process, putting more doctors in the field. We immediately saw the potential when the board approached us about funding this project and we are very pleased to be involved.”
Reprinted from the Texas Medical Board website.
LET US HEAR FROM YOU
Would you like for information from your board to be considered for publication in the Journal? If so, e-mail your articles and news releases to Edward Pittman at [email protected] or send via fax to (817) 868-4098.
- Copyright 2008 Federation of State Medical Boards. All Rights Reserved.
