ADVANCED PRACTICE REGISTERED NURSES

January 2014

PE 13-18-554

AUDIT OVERVIEW

The Legislative Auditor Recommends Revising the Written Collaborative

Agreement Requirement for Advanced Practice Registered Nurses and

Allowing Removal When Certain Conditions Are Met

The Requirement for a Collaborative Relationship Between Certied

Nurse Midwives and Physicians Should Remain

The Legislative Auditor Recommends Retaining Limitations on Advanced

Practice Registered Nurse Prescriptive Authority by Retaining the Current

Restricted Drug Formulary

The Request for the Addition of the Same Signatory Authority as Physicians

on All Health Care Documents Is Too Broad and Non-Specic to Be

Evaluated by the Legislative Auditor

WEST VIRGINIA LEGISLATIVE AUDITOR

PERFORMANCE EVALUATION & RESEARCH DIVISION

JOINT COMMITTEE ON GOVERNMENT OPERATIONS

JOINT COMMITTEE ON GOVERNMENT ORGANIZATION

Senate

Herb Snyder, Chair

Ronald F. Miller, Vice-Chair

Sam Cann

Donald Cookman

Rocky Fitzsimmons

Mike Green

Art Kirkendoll

Ronald Stollings

Bob Williams

Jack Yost

Craig Blair

Donna J. Boley

Evan H. Jenkins

Dave Sypolt

House of Delegates

Jim Morgan, Chair

Dale Stephens, Vice-Chair

Gary G. Howell, Minority Chair

Tom Azinger

Joshua J. Barker

Mike Caputo

Phil Diserio

Je Eldridge

Ryan Ferns

William G. Hartman

Ronnie D. Jones

Timothy Kinsey

Brady Paxton

Margaret D. Smith

Margaret A. Staggers

Randy Swartzmiller

Karen Arvon

Anna Border

Scott Cadle

Larry Faircloth

Michael Folk

Larry D. Kump

Joshua Nelson

William Romine

Randy Smith

Building 1, Room W-314

State Capitol Complex

Charleston, West Virginia 25305

(304) 347-4890

WEST VIRGINIA LEGISLATIVE AUDITOR

PERFORMANCE EVALUATION & RESEARCH DIVISION

Senate

Herb Snyder, Chair

Mike Green, Vice-Chair

Sam Cann

Rocky Fitzsimmons

Craig Blair

Evan H. Jenkins

House of Delegates

Jim Morgan, Chair

Dale Stephens, Vice-Chair

Brent Boggs

Eric Nelson

Ruth Rowan

Agency/ Citizen Members

John A. Caneld

W. Joseph McCoy

Kenneth Queen

Vacancy

Aaron Allred

Legislative Auditor

John Sylvia

Director

Michael Midki

Research Manager

Performance Evaluation & Research Division | pg. 3

Janaury 2014

CONTENTS

Finding 1: The Legislative Auditor Recommends Revising the Written Collaborative Agreement

Requirement for Advanced Practice Registered Nurses and Allowing Removal When

Certain Conditions Are Met ................................................................................................................................... 5

Finding 2: The Requirement for a Collaborative Relationship Between Certied Nurse Midwives and

Physicians Should Remain ...................................................................................................................................33

Finding 3: The Legislative Auditor Recommends Retaining Limitations on Advanced Practice

Registered Nurse Prescriptive Authority by Retaining the Current Restricted Drug

Formulary ..................................................................................................................................................................35

Finding 4: The Request for the Addition of the Same Signatory Authority as Physicians on All

Health Care Documents Is Too Broad and Non-Specic to Be Evaluated by the

Legislative Auditor ..................................................................................................................................................41

List of Maps

Map 1: Primary Care Health Professional Shortage Areas ............................................................................................. 8

List of Tables

Table 1: Numbers of Separate APRN Collaborative Agreements Held by Physicians ........................................16

Table 2: West Virginia Healthcare Practitioner Requirements for Education, License, and Scope of

Prescriptive Authority...............................................................................................................................................22

Table 3: Adverse Actions Against Mid-Level Medical Practitioners in Independent Practice States

Compared to West Virginia .....................................................................................................................................23

Table 4: West Virginia Advanced Practice Registered Nurses .....................................................................................24

Table 5: West Virginia Medical Malpractice Claims Paid CY 2002-2012 ..................................................................30

Table 6: West Virginia Medical Malpractice Claims Paid in CY 2012 .........................................................................31

Table 7: West Virginia Healthcare Practitioners Pharmacology Specic Education Requirements ..............38

List of Appendices

Appendix A: States That Allow APRNs to Practice and Prescribe Independently .................................................43

Appendix B: Legislative Rule 19CSR8 - Limited Prescriptive Authority for Nurses in Advanced

Practice ...................................................................................................................................................................45

Appendix C: West Virginia Stakeholder Comments .........................................................................................................53

pg. 4 | West Virginia Legislative Auditor

Advanced Practice Registered Nurses

Performance Evaluation & Research Division | pg. 5

Janaury 2014

FINDING 1

The Legislative Auditor’s review

does not find any apparent public

safety issues with the prescribing

and clinical practice of experienced

APRNs, although the literature review

does not include research created by

independent sources focused on the

quality of APRNs in autonomous

practice.

The Legislative Auditor Recommends Revising the Written

Collaborative Agreement Requirement for Advanced

Practice Registered Nurses and Allowing Removal When

Certain Conditions Are Met.

Summary

In accordance with West Virginia Code §30-1A-1 et seq., an

application was submitted seeking an expanded scope of practice for

Advanced Practice Registered Nurses. The Applicant argues that by

virtue of education, training, national certification and regulation by state

licensure APRNs are prepared to practice as autonomous professionals,

and that restrictions to their practice exist in West Virginia Code.

Currently APRNs can diagnose and treat patients but must have a written

collaborative agreement with a physician in order to prescribe medication

from a limited drug formulary. In addition, certified nurse midwives

must establish a collaborative relationship with a physician practicing in

obstetrical and gynecological patient care.

In Finding 1, the Legislative Auditor considered the request to

remove the written collaborative agreement. The Legislative Auditor’s

review does not find any apparent public safety issues with the

prescribing and clinical practice of experienced APRNs, although the

literature review does not include research created by independent

sources focused on the quality of APRNs in autonomous practice.

However, there are oversight issues with the written collaborative

agreement that need to be addressed legislatively. The Legislative

Auditor is concerned about the impact of the collaborative agreement

requirement on access to crucial primary and preventive health care for

rural West Virginians. While the lack of standardization and absence of

any official review process reinforces the Applicant’s argument that the

collaborative agreement is unnecessary, the Legislative Auditor finds that

some degree of clinical supervision and collaboration is appropriate for

inexperienced APRNs. In addressing the Applicant’s request to eliminate

the written collaborative agreement requirement as a prerequisite to the

APRN obtaining limited prescriptive authority, the Legislative Auditor

finds that the written collaborative agreement requirement for advanced

practice registered nurses should be revised in code and rule, and may be

removed when certain conditions are met.

Required Analysis

The West Virginia Nurses Association (Applicant) submitted an

application on May 31, 2013 in accordance with West Virginia Code §30-

1A-1 et seq. seeking an expansion of the professional scope of practice

pg. 6 | West Virginia Legislative Auditor

Advanced Practice Registered Nurses

of Advanced Practice Registered Nurses (APRNs) in West Virginia

requesting the following changes to West Virginia Code:

• removal of the requirement of a written collaborative agreement

between a physician and APRN as a prerequisite to prescriptive

authority;

• removal of the required collaborative relationship between nurse

midwives and physicians;

• removal of all restrictions to prescribing medications, both

controlled and legend drugs; and

• addition of the same signature authority as physicians on all health

care documents.

APRNs are licensed and regulated in West Virginia by the Board

of Examiners for Registered Professional Nurses (Nursing Board).

Currently APRNs are allowed to diagnose and treat patients without

physician involvement but must have a written collaborative agreement

with an allopathic (MD) or osteopathic (DO) physician before receiving

authority from the Nursing Board to prescribe medications from a

restricted formulary set in West Virginia code.

For applications proposing an expansion of the scope of practice,

West Virginia Code §30-1A-3 requires the Legislative Auditor’s Office to

evaluate the application and make a clear recommendation as to whether

the scope of practice should be expanded as proposed. Six months was

available to evaluate the application. Upon review, the Legislative Auditor

requested an extension of an additional month from the Joint Standing

Committee on Government Organization. Even with the extension, it

is the opinion of the Legislative Auditor that the short time frame has

impacted the quality of advice and the recommendations in Finding 1 that

are required for the Legislature.

Background

An APRN in West Virginia is a licensed registered nurse who has

acquired advanced clinical knowledge and skills, completed a Nursing

Board approved graduate-level education program and passed a Nursing

Board approved national certification examination. APRNs are trained in

one of four roles: Certified Registered Nurse Anesthetist, Certified Nurse-

Midwife, Certified Nurse Practitioner and Clinical Nurse Specialist.

APRNs have limited prescribing authority. APRNs are considered mid-

level medical practitioners as are Physician Assistants (PA). However,

APRNs are trained and licensed to function autonomously, while PAs

are trained and licensed to function under the supervision and control

of an employing physician. APRNs usually provide primary health care

services, although some specialize. Nationally, 87.2 percent of APRNs are

Performance Evaluation & Research Division | pg. 7

Janaury 2014

Of the West Virginia APRNs, 956 pres-

ently have collaborative agreements

with physicians and have received

limited prescriptive authority from the

Nursing Board.

trained in primary care, and 75.6 percent practice in at least one primary

care site. As of November 2013 there are 171,000 APRNs nationally, with

2,149 APRNs licensed in West Virginia. Of the West Virginia APRNs,

956 presently have collaborative agreements with physicians and have

received limited prescriptive authority from the Nursing Board. There

are currently about 21 APRNs practicing as self-employed independent

primary care practitioners in West Virginia.

The request to expand the West Virginia APRN scope of

practice comes at a time when states are anticipating a greater demand

for primary health care services. The federal Health Resources and

Services Administration (HRSA) projects that the demand for primary

care services will increase through 2020 and demand for primary care

physicians will grow more rapidly than the physician supply, resulting

in a projected national shortage of approximately 20,400 primary care

physicians. Consequently, states are looking for ways to increase the

number of primary care providers in rural areas, and exploring whether

to allow mid-level medical practitioners to furnish more services to

patients.

West Virginia has estimated that 137,000 patients will be added to

Medicaid coverage by 2016 due to the Medicaid expansion for the Patient

Protection and Affordable Care Act (ACA). However, by December

2013 the State had received Medicaid enrollments for 82,981 consumers

which is substantially higher than the original projections for 2014. West

Virginia is considered the third most rural state in the nation,

and 50 of

its 55 counties are designated, in part or full, as either Health Professional

Shortage Areas (HPSA) for primary healthcare, or Medically Underserved

Areas by the United States Department of Health and Human Services.

There are 48 counties that have facilities, population groups or the entire

county meeting the HPSA designation. See Map 1 for a view of these

counties. The seven counties with no HPSAs are: Brooke, Hampshire,

Harrison, Lewis, Mingo, Wayne and Wood.

This designation is based on the percentage of residents living in non-metropolitan

areas with populations less than 2,500 people.

pg. 8 | West Virginia Legislative Auditor

Advanced Practice Registered Nurses

West Virginia also ranked 46

out of the 50 states in overall health

status in 2013, indicating a prevalence of preventable chronic conditions

which require treatment and monitoring.

The Public Policy Debate on APRN Scope of Practice

The Legislative Auditor conducted an extensive literature review

in its examination of the policy issues posed by the Nursing Board’s

application. Although numerous position papers and articles exist, the

Legislative Auditor based the following summary on reputable and

Map 1

Primary Care Health Professional Shortage Areas

Source: Health Resources and Services Administration

Performance Evaluation & Research Division | pg. 9

Janaury 2014

In all the literature reviewed,The vast

majority of organizations support an

expanded scope of practice APRNs,

with the important and notable excep-

tion of the American Medical Associa-

tion (AMA) and the American Osteo-

pathic Association (AOA).

established organizations. In all the literature reviewed, the vast majority

of organizations support an expanded scope of practice APRNs, with the

important and notable exception of the American Medical Association

(AMA) and the American Osteopathic Association (AOA).

In 2010 a 586 page report titled The Future of Nursing: Leading

Change, Advancing Health (Future of Nursing) was released by the

Institute of Medicine (IOM).

This report examined the critical role

that nurses, the largest segment of healthcare professionals, will play in

responding to demands on the healthcare system that are expected to result

from the passage of the ACA, and also from other forces such as the aging

population of the United States. The Future of Nursing addresses the role

that states and the federal government can play in reform. In addressing

state reform, this report identified APRNs and noted that in many states,

state laws prevent APRNs from practicing to the full extent of their

education and training. The report notes that what APRNs are allowed to

do after graduation varies widely across the country for reasons that are

not related to their ability, education or training, but rather the political

decisions of the state in which they work. Further, the states with broader

nursing scopes of practice have experienced no deterioration of patient

care. The report concludes that all nurses should be playing a larger

role in the health care system, both in delivering care and in decision-

making about care.

In addition, in 2008 the National Council of State Boards of

Nursing’s APRN Advisory Committee and the APRN Consensus

Work Group issued the APRN Consensus Model in an effort to present

standards that would modernize state regulations to allow for the

consistent practice of APRNs from state to state. The Consensus Model

also describes the standards for licensure, accreditation, certification

and educational requirements across states. The current application

references the Consensus Model. The Applicant asserts that it is

requesting a retirement of outdated codes and regulations that limit

practitioners from practicing to their full scope, and that none of the

requested changes to West Virginia code allows any practice outside

the current professional educational scope and standards for APRNs.

Opposition to the expansion of the APRN scope of practice is

expressed in the positions of two national physicians’ organizations,

the American Medical Association (AMA) and the American

Osteopathic Association (AOA). Both have positions that oppose the

The Institute of Medicine is one of four national private non-profit academies cre-

ated by Congressional charter, to provide independent expert advice on the sciences,

engineering and medicine. The other three are the National Academy of Sciences, the

National Academy of Engineering, and the National Research Council.

pg. 10 | West Virginia Legislative Auditor

Advanced Practice Registered Nurses

It is important to note that a recent

analysis shows no variation in physi-

cian earnings between states that have

expanded APRN scope of practice

laws and states that have not.

independent practice of non-physician clinicians such as advanced

practice registered nurses. The AMA recognizes the value of APRNs

within the healthcare delivery system but expresses concern that the

nurse practitioner does not have an adequate clinical foundation for

independent practice. The AMA opposes the enactment of legislation

to authorize the independent practice of medicine by any individual who

has not completed the state’s requirements for licensure to engage in the

practice of medicine and surgery. The AOA acknowledges the role of

non-physician clinicians in the healthcare delivery system but advocates

for direct physician supervision, as does the AMA. Additionally,

while considering national studies of non-physician medical providers,

the Physicians Foundation, a non-profit organization that represents

the interests of physicians, notes that there is a lack of evidence that

physicians provide higher quality care than non-physician providers.

In December 2012 the National Governors Association (NGA)

issued a white paper that reviewed the research on the performance

of nurse practitioners (the largest of the four types of APRNs). This

review also evaluated the state rules governing nurse practitioner scope

of practice. The NGA undertook the review because of the perceived

need for states to increase the number of primary healthcare providers.

The NGA findings substantiate the IOM report in that there is variation

between states’ regulations with 16 states and the District of Columbia

allowing for nurse practitioners to practice completely independently of

a physician, and to the full extent of their training. Another eight states

(including West Virginia) allow nurse practitioners to diagnose, treat and

refer patients independently but not to prescribe independently. States

tend to place most of their restrictions on the nurse practitioner’s ability

to prescribe.

In the white paper, the NGA noted that “Some observers believe

that physician groups … have financial concerns about broadening state

scope of practice rules for nurses but it is important to note that a recent

analysis shows no variation in physician earnings between states that have

expanded APRN scope of practice laws and states that have not.” The

NGA concluded that based on the review on health services research, nurse

practitioners are well qualified to deliver certain elements of primary care.

The Federal Trade Commission has also weighed into the public

policy debate in West Virginia. In a September 2012 statement issued

to the West Virginia Legislature’s Joint Committee on Health, the FTC

concludes:

Isaacs, S., Jellinek, P. Accept No Substitute: A Report on Scope of Practice. November

2012.

Performance Evaluation & Research Division | pg. 11

Janaury 2014

In 1992, the West Virginia Legislature

created the requirement for a collab-

orative agreement between a nurse

practitioner (now known as an APRN)

and a physician prior to being granted

the authority by the Nursing Board to

prescribe certain medications.

Removing the requirement that APRNs who

want to prescribe medications have a collaborative

agreement with a physician has the potential

to benefit consumers by expanding choices for

patients, containing costs and improving access.

We encourage the West Virginia legislature to

carefully review the safety record of APRNs in

West Virginia and to consider whether the current

requirement is necessary to assure patient safety

in light of the almost twenty years of prescribing

experience of West Virginia APRNs, as well as

the findings of the Institute of Medicine. Absent

countervailing safety concerns regarding APRN

prescribing practices, removing the collaborative

agreement for prescriptive authority appears to be

a procompetitive improvement in the law that would

benefit West Virginia health consumers.

States have found that the public policy decisions about changes

in scope of practice for APRNs are not easy, and can take time for the

assessment of all of the issues involved. In Colorado, the process of

expanding the scope of APRN practice began in 1994, but was not fully

implemented for autonomous practice until 2008. The state of Nevada

revised its law in 2013 to allow independent prescriptive authority,

following six years of legislative debate. Nevada’s legislative scope

of practice has been expanded in order to compensate for the lack of

physicians in the state and to offer primary care services to patients in

remote areas. Nevada’s law goes into effect in 2014.

Collaborative Agreements Are Required by WV Code and

Defined by Rule

The first change in APRN scope of practice proposed by the

Applicant is to eliminate the written collaborative agreement requirement

as a prerequisite to the APRN obtaining limited prescriptive authority.

In 1992, the West Virginia Legislature created the requirement for a

collaborative agreement between a nurse practitioner (now known as

an APRN) and a physician prior to being granted the authority by the

Nursing Board to prescribe certain medications. This requirement is for

the establishment of a collaborative agreement between an APRN and an

osteopathic or allopathic physician. It is not described as a supervisory

agreement in Code. The current requirement in West Virginia Code

§30-7-15a follows:

pg. 12 | West Virginia Legislative Auditor

Advanced Practice Registered Nurses

The Nursing Board is required to

forward verification of all advanced

practice nurses with collaborative

agreements to the Board of Medi-

cine, the Board of Osteopathic Medi-

cine, and the Board of Pharmacy.

(a) The board may, in its discretion, authorize an advanced

practice registered nurse to prescribe prescription drugs

in a collaborative relationship with a physician licensed

to practice in West Virginia … . An authorized advanced

practice registered nurse may write or sign prescriptions

or transmit prescriptions verbally or by other means of

communication.

(b) … an agreement to a collaborative relationship

for prescriptive practice between a physician and an

advanced practice registered nurse shall be set forth in

writing. Verification of the agreement shall be filed with

the board by the advanced practice registered nurse.

… Collaborative agreements shall include, but are not

limited to, the following:

(1) Mutually agreed upon written guidelines or protocols

for prescriptive authority as it applies to the advanced

practice registered nurse’s clinical practice;

(2) Statements describing the individual and shared

responsibilities of the advanced practice registered nurse

and the physician pursuant to the collaborative agreement

between them;

(3) Periodic and joint evaluation of prescriptive practice;

and

(4) Periodic and joint review and updating of the written

guidelines or protocols.

Certified nurse-midwives are required in §30-15-7a to have

a written collaborative agreement. The Nursing Board is required to

forward verification of all advanced practice nurses with collaborative

agreements to the Board of Medicine, the Board of Osteopathic Medicine,

and the Board of Pharmacy and provides a master list of APRNs and

collaborating physicians to these boards with updates on a monthly

basis.

The Legislative Auditor determined that the Nursing Board

regularly provides this information to the respective medical boards.

However, this information is not used by the medical boards to audit the

performance of physicians according to the terms of the collaborative

agreements. The Board of Medicine noted that it does not have legislative

authority to audit the agreements. However, the Board of Medicine issued

collaborative agreement guidelines for physicians in 2012 recommending

limits on the number of collaborative agreements per MD. The limits

Performance Evaluation & Research Division | pg. 13

Janaury 2014

APRNs in West Virginia are allowed

to diagnose, treat and refer without

a physician’s written collaborative

agreement.

are 3 collaborative agreements per MD, unless the practice setting is a

hospital, indigent clinic or federally qualified health care center when the

limit is 4 agreements per MD.

The Osteopathic Board stated that it has not issued any guidelines

for DOs. The Osteopathic Board recently reviewed some written

collaborative agreements, and stated

Upon review of the recently submitted Collaborative

Agreements … there is no standardization of the

agreements at all. They range from a one page

document to 10-12 pages. One collaborative agreement

did not even list what the Nurse Practitioner could do,

it simply listed 17 different protocols from published

articles written by different clinical specialists. Only

the articles were cited, the protocols themselves were

not.

The Board of Pharmacy noted that it uses the Nursing Board

information on prescriptive authority and APRNs whose authority has

been terminated to remove those APRNs from access to the Controlled

Substance Automated Prescription Program database to prevent

unauthorized use. It does not use the Nursing Board information in any

other way.

From A Cost-Benefit Perspective, the Cost of the Written

Collaborative Agreement As It Currently Exists May

Exceed the Benefit

The Legislative Auditor considered whether there is a public

benefit from the written collaborative agreement remaining in place.

APRNs in West Virginia are allowed to diagnose, treat and refer without a

physician’s written collaborative agreement. A collaborative agreement is

only required for APRNs who wish to prescribe medications.

Therefore,

independent self-employed practitioners must find and pay a physician

to enter into a written collaborative agreement. This can present the

following problems for an independent APRN practitioner in many areas

of the state.

The limited drug formulary includes controlled substances, and medications for chron-

ic conditions such as diabetes.

pg. 14 | West Virginia Legislative Auditor

Advanced Practice Registered Nurses

Almost one-third (30.1 percent) of all

of West Virginia’s active physicians

(primary care and other specializa-

tions) are age 60 or older according

to the AAMC, ranking the state 6th

in the nation for an aging physician

population.

Problems With Obtaining Written Collaborative Agreements

• Difficulty finding a physician collaborator: Anecdotal

evidence from self-employed APRNs indicates that physicians are

reluctant to enter into collaborative agreements due to increased

liability concerns. APRNS may invite numerous physicians to

collaborate before finding a physician willing to enter into a

formal collaboration. One APRN notes that she pays for additional

medical malpractice insurance for her collaborating physician. In

rural areas it is difficult to locate a physician willing to enter into

a collaborative agreement.

• Cost: APRNs in a practice do not pay physicians for a written

collaborative agreement. However, APRNs that are self-

employed usually pay the physician an hourly rate. The APRN

has no control over how long the physician will take to review

charts, and how many hours will be billed. The rate paid by one

self-employed Morgantown APRN is $250/hour.

• Revocation of agreement by physician or APRN: The physician

can revoke the agreement at any time and for any reason. The

APRN may be forced to terminate the agreement with the

physician if there is an issue with the physician’s license, or other

practices. Under either circumstance, the self-employed APRN

can remain in practice but is not able to prescribe medication

for current patients until a new physician is located and a new

collaborative agreement is in place.

Few West Virginians currently receive health care services from

APRNs in independent practices. The Legislative Auditor considered

the cost of the written collaborative agreement requirement as it restricts

APRNs from developing independent practices, and consequently

restricts public access to primary healthcare. Increasing access to

primary healthcare is a key focus of healthcare reform. According

to the Association of American Medical Colleges (AAMC) the state

has 1,372 MDs and 375 DOs who are active primary care physicians.

Almost one-third (30.1 percent) of all of West Virginia’s active physicians

(primary care and other specializations) are age 60 or older according to

the AAMC, ranking the state 6th in the nation for an aging physician

population. In addition, West Virginia ranks in the bottom five states for

the health of its population according to the 2013 edition of America’s

Health Rankings. The West Virginia Rural Health Association concludes

that the state faces an increased demand for primary healthcare services

Performance Evaluation & Research Division | pg. 15

Janaury 2014

There is wide variation in the details

of current collaborative agreements.

and a new wave of shortages of providers at the same time as an expansion

in the numbers of newly insured and Medicaid-eligible West Virginians

under the Affordable Care Act.

Variations Among Written Collaborative Agreements

The Legislative Auditor also considered whether the written

collaborative agreement is currently achieving an evaluation of the

APRN’s prescriptive practice, and whether the written collaborative

agreement is providing a layer of protection to the public. The Legislative

Auditor found the following:

• The majority of written collaborative agreements take place

in work settings such as practices, clinics and hospitals. In

these close working environments, physicians already have

knowledge of the APRN’s prescriptive and clinical practice. In

these settings, many of the written collaborative agreements spell

out employer-employee duties, and responsibilities. Practice

standards already exist. The collaborative agreement becomes

an added document to be maintained by the medical director, or

administrator. Some administrators and collaborating physicians

in these settings indicate that the agreements are time-consuming

and can be duplicative of effort.

• The written collaborative agreements are not required to

conform to practice evaluation standards. No standards exist

in Code or rule addressing on-site or remote supervision, the

number, percentage, or frequency of chart reviews, or limiting

either the numbers of APRNs with whom a physician may have

an agreement, or the number of physicians with whom an APRN

may have agreements. In addition, there is no provision for the

variation of experience levels of APRNs, so that an APRN with

17 years of prescribing authority has the same requirement for a

written collaborative agreement as a newly graduated APRN who

has just received prescribing authority from the Nursing Board.

Consequently there is wide variation in the details of current

collaborative agreements. This variation may reflect not only

the lack of required standards but also that there are variations

in the APRNs’ collaborations with physicians, and that in long-

term collaborations the physician is confident in the APRNs’

experience and prescribing practices.

• Physicians and APRNs have multiple collaborative agreements.

In a review of a list of all 956 current collaborative agreements

provided by the Nursing Board, about 55 physicians (both MDs

pg. 16 | West Virginia Legislative Auditor

Advanced Practice Registered Nurses

APRNs maintain multiple agreements

so that if a physician discontinues an

agreement, the APRN will still retain

limited prescriptive authority.

and DOs) are listed as having 5 or more agreements with separate

APRNs despite Board of Medicine guidelines. The West Virginia

Board of Osteopathic Medicine does not have policy or guidelines

for written collaborative agreements. A review of the APRN master

list issued by the Nursing Board found APRNs with agreements

with as many as 21 separate physicians. Some APRNs have

multiple collaborative agreements because they are working in

group practices. Other APRNs maintain multiple agreements so

that if a physician discontinues an agreement, the APRN will still

retain limited prescriptive authority. Table 1 shows the number

and type of physicians with written collaborative agreements.

The yellow row in Table 1 highlights the beginning point where

physicians exceed the number of collaborative agreements

recommended by the Board of Medicine guidelines.

Table 1

Numbers of Separate APRN Collaborative Agreements Held by Physicians*

Number of Separate APRN

Agreements per Physician

Number of MDs Number of DOs

13 4 0

9 3 0

8 1 1

7 6 6

6 7 1

5 23 3

4 29 4

3 48 18

2 150 30

1 418 104

PERD analysis based on information received from the West Virginia Board of Examiners of Registered

Nurses.

*Physicians include Osteopathic Doctors (DOs) and Allopathic Doctors (MDs).

It is questionable whether one physician provides a substantive

review of prescriptive and clinical practice when engaged in collaborative

agreements with 13 different APRNS. The Legislative Auditor found

one practice where all physicians on staff have written collaborative

agreements with all of the APRNs because of the practice rotation

requirements.

It is questionable whether one physi-

cian provides a substantive review

of prescriptive and clinical practice

when engaged in collaborative agree-

ments with 13 different APRNS.

Performance Evaluation & Research Division | pg. 17

Janaury 2014

It is clear that while APRNs can pro-

vide primary healthcare, and assist in

meeting the future demand, to date

few APRNs have established indepen-

dent practices.

It is equally questionable whether an APRN with 21 different

physician agreements can meet varied requirements in the collaborative

agreements. Attending physicians in graduate medical education programs

in West Virginia are limited to 4 first year residents per 1 physician,

although this limitation is to allow for supervision and teaching of the

new residents.

Aside from the Nursing Board’s documentation of their existence,

and date, written collaborative agreements are not monitored or audited

to determine if the physicians and APRNs perform according to the

agreement requirements. Given the variation in practice settings, lack

of evaluative standards, multiplicity and general variability, the current

written collaborative agreements do not appear to be achieving a consistent

benefit of protection to the public.

The Legislative Auditor concludes that there may be some protection

for the public from the written collaborative agreement requirement as it

applies to APRNs who are inexperienced in prescribing, although as the

written collaborative agreement is currently structured, the protections

are inconsistent. There also appears to be a financial cost associated with

the development of independent APRN practices, particularly in rural

areas. It is clear that while APRNs can provide primary healthcare, and

assist in meeting the future demand, to date few APRNs have established

independent practices. Given the lack of standardization within the written

collaborative agreements, and the difficulty experienced by independent

APRNs in rural areas in finding a collaborating physician, the cost of the

written agreement appears to exceed the benefits to the public once an

APRN has prescribing experience.

Some States Allow APRNs to Prescribe Medications

Independently

Sixteen states and the District of Columbia currently allow

APRNs to practice and prescribe medications independently.

Appendix

A contains a map showing these states. The state of Nevada will allow

APRN independent prescriptive authority starting in 2014. The Legislative

Auditor contacted the nursing boards in all 16 states to determine if

there are any outstanding issues when APRNs practice and prescribe

independently. Information and specific disciplinary issues regarding

APRNs was requested. The following 10 replies were received.

According to the American Association of Nurse Practitioners, these states are: Alas-

ka, Arizona, Colorado, Hawaii, Idaho, Iowa, Maine, Montana, New Hampshire, New

Mexico, North Dakota, Oregon, Rhode Island, Vermont, Washington, and Wyoming.

pg. 18 | West Virginia Legislative Auditor

Advanced Practice Registered Nurses

Alaska does not maintain information

on rural practice, or self-employed

practitioners.

1. Alaska: The advanced practice nurses (ANPs) in Alaska have

had autonomous practice since 1984 and controlled substance

prescriptive authority since about 1988. Disciplinary issues

have been no different from other nurses. ANPs can prescribe

controlled substances which seldom presents a problem. The

rate of drug problems requiring discipline is no different than

the rate of the general population of nurses. Alaska does

not maintain information on rural practice, or self-employed

practitioners. Some advanced practice nurses practice

hundreds or even thousands of miles from hospitals, and use

telemedicine, telephone consultation and Medevac services.

Alaska has a system of consultation and referral where APNs

must describe for the nursing board how they would consult

if necessary and identify to whom they would refer patients.

2. Colorado: Colorado noted that it has moved toward autonomy

for APRNs since 1994. Full autonomy was reached in 2008.

Colorado currently has 4,816 active licensed APRNs. It does

not capture data on independent or solo practice. The nursing

board notes that there are no identifiable disciplinary issues

related specifically to APRNs, and there are no identifiable

medical malpractice issues that have arisen or appear related

to APRN autonomous practice. In addition, there is no pattern

of patient safety concerns that appears related to autonomous

practice of APRNs.

3. Hawaii: Hawaii amended its law in 2010 to allow APRNs

with prescriptive authority to practice without a collegial

working relationship with a licensed physician. Hawaii has

not noted any increase in the number of disciplinary actions

against APRNs. However, other state laws were not amended

and this has created some barriers for APRNs practicing to

their full scope.

4. Iowa: According to the nursing board, Iowa’s rules for

the advanced registered nurse practitioners (ARNP) were

established in 1983 to allow ARNP practice. Iowa’s rules do

not require supervision of ARNPs. Iowa does not keep data

on independent practitioners. Iowa’s nursing board notes

that there has been an increase in discipline concerning the

prescribing of pain medications for pain management.

5. Maine: Maine allowed NP autonomous practice starting in

1996. Maine’s nursing board does not track data on nurse

practitioners (NPs) that are self-employed but notes that most

Colorado currently has 4,816 active

licensed APRNs. It does not capture

data on independent or solo practice.

Performance Evaluation & Research Division | pg. 19

Janaury 2014

Maine’s nursing board states that it

recently compared prescribing prac-

tice of Maine NPs to physicians and

found no difference.

are not self-employed. There are 1,230 licensed NPs. Maine’s

nursing board states that it recently compared prescribing

practice of Maine NPs to physicians and found no difference.

6. New Hampshire: Approximately two-thirds of the APRNs

are in an independent practice however it is not known what

percentage work in rural areas. A small percentage of APRNs

have been adjudicated for drug diversion. The executive

director estimated there had been 5-10 cases of APRN

discipline in the past 5 years, and about half of these cases are

related to drug diversion.

7. New Mexico: New Mexico has had independent practice and

prescriptive authority for advanced practice registered nurses

for more than 20 years, however certified nurse midwives

are regulated by the New Mexico Board of Health. APRNs

are not over represented in the complaints received by the

Board. Issues related to improper prescribing practices are

not common. New rules for management of chronic pain

with controlled substances require those APRNs with Drug

Enforcement Administration (DEA) registration and the

ability to prescribe opiates to increase scrutiny of patients in a

variety of ways.

8. Vermont:Vermont first allowed APRNs to practice

autonomously in 2011. Vermont stated that the nursing

board knows of no disciplinary issues that relate specifically

to APRNs, and knows of no medical malpractice issues.

Vermont does not track information on APRNs that are self-

employed.

9. Washington: Based on information provided from this board,

a little over half of advanced registered nurse practitioners

(ARNP) practice in rural counties. In terms of disciplinary

issues, the advanced practice advisor noted that there had only

been 2 or 3 cases of overprescribing controlled substances that

required disciplinary action. Other prescribing issues have

been dealt with by education and limitations on prescriptive

authority. Washington stated that no medical malpractice

issues have arisen as a result of legislation granting ARNPs

autonomy in scope of practice and prescriptive authority for

legend medications and controlled substances.

Legend medications are state regulated drugs that are not scheduled as controlled

substances.

Vermont stated that the nursing board

knows of no disciplinary issues that re-

late specifically to APRNs, and knows

of no medical malpractice issues.

pg. 20 | West Virginia Legislative Auditor

Advanced Practice Registered Nurses

New Mexico Board of Medicine:...”

Bottom line, Advanced Nurse Practi-

tioners are well respected by most phy-

sicians and are hailed by patients.”

10. Wyoming: The nursing board noted that autonomous practice

began in 2005. The state does not collect information on self-

employment or independent practice. Disciplinary issues

specific to APRNs relate to pain management prescription

practices. There are not any medical malpractice issues

specific to APRNs. Certified registered nurse anesthetists

(CRNAs) were unsuccessful in their attempt this year to

eliminate collaborative practice.

In addition to the boards of nursing, the Legislative Auditor

contacted boards of medicine in the six states that are considered to have

some of the nation’s most expansive nurse practitioner scopes of practice.

The boards of medicine were asked if there are issues, or concerns that

physicians express or experience in regard to advanced practice registered

nurses who practice and prescribe independently. Two boards of medicine

replied.

1. Arizona Board of Medicine: This board stated “We do not have

any direct knowledge about concerns regarding Autonomous

Nurse Practitioner (s)” and referred us to the nursing board for

complaint information.

2. New Mexico Board of Medicine: The executive director of this

board replied “Once in a while we hear some grumbling about

nurse independent practice, but overall NM has only benefited from

Advanced Practice Nurses. As far as we know, very few Nurse

Practitioners (as we call them here) are practicing independently.

They are part of a team of practitioners including MDs, DOs, &

PAs. NM, like most states, needs more primary care practitioners

like Nurse Practitioners and Physician Assistants. … Bottom

line, Advanced Nurse Practitioners are well respected by most

physicians and are hailed by patients.”

Additional Requirements for WV APRN Limited

Prescriptive Authority

The written collaborative agreement with a physician is only one

requirement that the APRN in West Virginia must meet before receiving

limited prescriptive authority. The APRN must complete additional

requirements specific to pharmacology training and federal requirements,

which include:

These states are Alaska, Arizona, New Hampshire, New Mexico, Oregon and Wash-

ington.

Performance Evaluation & Research Division | pg. 21

Janaury 2014

Drugs in Schedule II are considered

to be more dangerous than those in

Schedule V. In West Virginia, APRNs

are not permitted to prescribe Sched-

ule II drugs.

• state licensure (in good standing) as an advanced practice

registered nurse having met national certification;

• completion of undergraduate instruction in pharmacology, and an

advanced pharmacology graduate course with 45 pharmacology

contact hours;

• completion of 15 advanced pharmacology contact hours within

2 years prior to the initial application for limited prescriptive

authority; and

• compliance with federal Drug Enforcement Administration

(DEA) requirements in order to prescribe Schedules III through

V drugs.

West Virginia regulates all medications that are not available

over the counter. Both the state and the federal government regulate

controlled substances. There are five categories of controlled substances,

or “schedules,” which are grouped according to whether they have an

accepted medical use in the United States, their potential for abuse and

the likelihood of dependence when abused. Schedule I drugs have no

medical use and are illegal. Drugs in Schedules II through V have medical

value for use as prescription medications. However, drugs in Schedule II

are considered to be more dangerous than those in Schedule V. In West

Virginia, APRNs are not permitted to prescribe Schedule II drugs.

The DEA serves as the primary federal agency responsible for

enforcement of the federal Controlled Substances Act (CSA), ensuring that

all controlled substance transactions take place within a “closed system”

of distribution. All legitimate handlers of controlled substances, including

APRNs, register with the DEA and receive a DEA registration number.

They must maintain strict accounting for all distributions of controlled

substances, or risk suspension or revocation of their registration.

Training Requirements Vary Among Medical Practitioners

The Legislative Auditor reviewed the variation in state education

requirements between allopathic (MD) and osteopathic (DO) physicians,

dentists, physician assistants and advanced practice registered nurses,

all of whom can prescribe controlled substances and other medications.

Both PAs and APRNs are considered mid-level medical practitioners

but they are trained to assume different roles. PAs function under the

close supervision of a physician, while APRNs are trained to function as

independent practitioners, with a broader scope of practice depending on

specialized training. Educational requirements for professional licensure

vary, in addition to the length of educational degree programs and the

specific education requirements in state code for pharmacology training.

All legitimate handlers of controlled

substances, including APRNs, regis-

ter with the DEA and receive a DEA

registration number.

pg. 22 | West Virginia Legislative Auditor

Advanced Practice Registered Nurses

Of the two non-physician practitioners shown in Table 2, the PA

not only works in a physician-supervised setting but also must have two

years of patient care experience before applying for prescriptive authority.

The APRN is not required to be supervised in order to practice, and is

not required to demonstrate two years of patient care experience before

obtaining prescriptive authority. The single standard in the licensure

requirement for all five medical practitioner categories is the successful

completion of a national certification examination in their respective

fields.

Table 2

West Virginia Healthcare Practitioner Requirements for

Education, License, and Scope of Prescriptive Authority

Practitioner

Type

Practitioner

Title

semester

hours

college

BS/

Master Doctorate

4 yrs

1 yr*

Residency

National

Certification

Exam

Prescriptive

Authority

Physician

Practitioner

Allopathic

Physician

(MD)

• • • •

Limitations

Osteopathic

Physician

(DO)

• • • •

Limitations

Dentist (DDS)

• • •

Limitations

(w/n scope of

practice)

Non-

Physician

Practitioner

Advanced

Practice

Registered

Nurse (APRN)

•

months

2+yrs)

•

Limitations ^

(w/n scope of

practice)

Physician

Assistant (PA)

•

(24-28

months)

•

Limitations+

Source: Legislative Auditor review of educational requirements from all state colleges and universities offering training for the

five categories of prescribing practitioner.

*Advanced Training following graduation from medical school.

° Standard 4-yr BS/BA or Master in Physician Assistant Studies

^ APRN limitations: DEA controlled substance Schedules III to V; other limitations on non-controlled substance prescription

drugs.

+PA limitations: 72 hr supply from DEA Schedule III and smaller of 90 dosage units or 30 day supply from Schedule IV and V;

after 2 yrs patient care experience

In Table 2, the admission and graduation requirements of the

state institutions offering physician training, dentist training, physician

Performance Evaluation & Research Division | pg. 23

Janaury 2014

assistant training and advanced practice registered nurse training were

reviewed. The educational programs are offered by West Virginia

University, Marshall University, the WV School of Osteopathic Medicine,

West Liberty University, Alderson-Broaddus College, the University of

Charleston and Wheeling Jesuit University.

In order to analyze one aspect of public protection, the Legislative

Auditor reviewed current disciplinary information against the two

main types of mid-level medical practitioners, physician assistants and

advanced practice registered nurses from the National Practitioner Data

Bank.

Table 3 shows this information.

Table 3

Adverse Actions* Against Mid-Level Medical Practitioners in

Independent Practice States Compared to West Virginia

State

Advanced Practice

Registered Nurses

Adverse

Actions in

CY2012

Physician

Assistants

Adverse Actions

in CY2012

Alaska

780 2 506 0

Arizona

5,495 2 2,248 15

Colorado

3,184

0 2,289 12

Hawaii

912

1 329 0

Idaho

658

1 662 1

Iowa

1,329

1 1,123 3

Maine

1,088

2 737 4

Montana

553

0 504 1

New Hampshire

1,675 1 556 1

New Mexico

1,969 0 714 4

North Dakota

475

1 289 0

Oregon

2,283 9 1,224 5

Rhode Island

690

4 399 2

Vermont

500

1 379 3

Washington

5,458 4 2,611 10

Wyoming

423

0 247 1

Total Adverse Actions

29 62

West Virginia

2,149 0 713 8

Sources: The National Practitioner Data Bank. APRN census from Nursing Board websites and the Henry J.

Kaiser Family Foundation. PA census for 2013 from the American Academy of Physician Assistants.

*The Data Bank defines adverse action as (1) an action taken against a practitioner’s clinical privileges or

medical staff membership in a health care facility, or (2) a licensure disciplinary action.

The National Practitioner Data Bank is an information clearing house created by Con-

gress and housed in the U.S. Department of Health and Human Services, Health Re-

sources and Services Administration. Information is compiled from a variety of state

and federal sources.

pg. 24 | West Virginia Legislative Auditor

Advanced Practice Registered Nurses

Studies that were reviewed of patient

care concluded that nurse practitio-

ners are capable of successfully man-

aging chronic conditions in patients

suffering from hypertension, diabetes,

and obesity as evidenced.

Physician assistants, directly supervised by physicians and

generally fewer in number in each state than APRNs, have been in

involved in more adverse actions, either being disciplined by their

respective regulatory board, or having practice privileges or medical

staff membership removed in the past year. APRNs show far fewer

adverse actions. Colorado, Montana, New Mexico and Wyoming show

no actions against APRNs in CY 2012. The experience of these 16 states

does not show an increase in the risk of harm to the public from APRN

autonomous practice.

Nationally APRNs Provide Safe Treatment

The Legislative Auditor reviewed national information relating

to the four categories of APRNs and concludes that APRNs provide safe

and effective treatment within their scope of practice.

1. Certified Nurse Practitioners (CNP)

Certified nurse practitioners comprise the largest segment of

APRNs nationally and in West Virginia. The CNP provides a wide range

of preventive and acute health care services, ranging from taking health

histories and providing physical examinations, diagnosing and treating,

interpreting laboratory results, prescribing and managing medications and

providing health teaching and counseling to prevent illness and maintain

health.

The research review by the NGA, conducted specifically on

research relating to nurse practitioners, suggests they can perform many

primary care services as well as physicians, and that there is equal or higher

patient satisfaction. The areas in which nurse practitioners provided at

least equal quality of care to physicians were in patient satisfaction, time

spent with patients, prescribing accuracy, and the provision of preventive

education. Studies that were reviewed of patient care concluded that nurse

practitioners are capable of successfully managing chronic conditions in

patients suffering from hypertension, diabetes, and obesity as evidenced

by physiological measures of patient outcomes such as decreased

cholesterol, blood pressure and weight.

None of the studies in the NGA’s research literature review

raise concerns about the quality of care offered, and most studies

showed that nurse practitioners provided care that is comparable to

physicians on several process and outcome measures. The studies also

suggest that nurse practitioners may provide increased access to care.

Performance Evaluation & Research Division | pg. 25

Janaury 2014

2. Certified Nurse Midwives (CNM)

Certified nurse midwives are educated in nursing and midwifery.

They provide primary healthcare to women of child-bearing age, including

prenatal care, labor and delivery care, care after birth, gynecological

exams, newborn care, family planning, menopausal management, and

counseling in health maintenance. CNMs attend more than 7 percent of

all births in the United States; over 95 percent of these are in hospitals.

Various research studies conclude that CNMs provide a safe and

viable alternative to maternity care in the United States, particularly for

low-to-moderate-risk women. Low-risk patients in Washington State

were found to have received fewer obstetrical interventions than similar

patients cared for by family physicians and obstetricians, especially lower

cesarean rates and resource use. In a different study, nurse midwives had

statistically significant fewer infant abrasions, perineal lacerations, and

complications; higher patient satisfaction with care; and lower hospital

and professional fee charges. Finally, high-risk women in an inner-city

hospital were compared with all U. S. deliveries for a one year period

and CNMs were found to be able to provide safe care to these high-risk

patients.

3. Certified Registered Nurse Anesthetist (CRNA)

A CRNA is a registered nurse who is educated to engage in

nurse anesthesia. CRNAs administer more than 34 million anesthetics

in the United States each year. CRNAs practice in every setting where

anesthesia is available and are the primary providers of anesthesia care

in rural America. They administer every type of anesthetic, and provide

care for every type of surgery or procedure, from open heart to cataract

to pain management. CRNAs provide anesthesia in collaboration with

surgeons, anesthesiologists, dentists, podiatrists, and other qualified

healthcare professionals. CRNAs practice in every setting in which

anesthesia is delivered: traditional hospital surgical suites and obstetrical

delivery rooms; critical access hospitals; ambulatory surgical centers; the

offices of dentists, podiatrists, ophthalmologists, plastic surgeons, and

pain management specialists.

Few studies have been conducted on anesthesia outcomes perhaps

due to a 1988 study by the Centers for Disease Control and Prevention

that concluded that anesthesia-caused mortality and severe morbidity

were too low to warrant a broader study. In general, anesthesia related

accidents are infrequent due to improvements and technological and safety

measures developed over the past 40 years. However, in recent years

a 2003 study assessed surgical patients’ safety with regard to CRNAs

pg. 26 | West Virginia Legislative Auditor

Advanced Practice Registered Nurses

Numerous studies show that clinical

nurse specialists have had good re-

sults in reducing employer health care

costs, reducing the costs of chronic

condition care, preventing hospital

acquired conditions, reducing the

lengths of stay in acute and commu-

nity based settings, improving mental

health management, and preventing

hospital readmissions.

versus anesthesiologists.

The study reviewed 404,194 anesthesia cases

across 22 states, finding no statistically significant difference in the

mortality rate for CRNAs and anesthesiologists working together versus

working individually. The researchers concluded that inpatient surgical

mortality is not affected by whether the anesthesia provider is a CRNA

or an anesthesiologist.

4. Clinical Nurse Specialists (CNS)

The CNS is a clinician in a specialized area of nursing practice by

population (pediatrics), setting (critical care), disease (cardiovascular), or

type of problem (wound or pain). The CNS provides both health promotion

and maintenance through assessment, diagnosis, and management of

acute and chronic patient problems that includes both pharmacologic and

non-pharmacologic interventions. The CNS also provides prenatal care,

preventive and wellness care, behavioral health care and care for chronic

conditions. Numerous studies show that clinical nurse specialists have had

good results in reducing employer health care costs, reducing the costs of

chronic condition care, preventing hospital acquired conditions, reducing

the lengths of stay in acute and community based settings, improving

mental health management, and preventing hospital readmissions.

There are 2,149 advanced practice registered nurses in West

Virginia as of November 2013. Table 4 shows the number of licensees

by category listed in the most recent Nursing Board Annual Report.

Table 4

West Virginia Advanced Practice Registered Nurses

Category Licenses

Certified Nurse Practitioners (CNP)

1,156

Certified Nurse Midwives (CNM)

Certified Registered Nurse Anesthetists (CRNA)

753

Clinical Nurse Specialists (CNS)

Source: The West Virginia Board of Examiners for Registered Professional Nurses

Adverse Actions against West Virginia APRNs Reviewed

Since the first request by the Applicant is to remove the written

collaborative agreement between the APRN and a physician, the Legislative

Auditor analyzed the safety of APRN practice in West Virginia by

Pine, M, Holt, KD, Lou, YB. Surgical mortality and type of anesthesia provider. AANA

J. 2003 April: 71, 109-16.

Performance Evaluation & Research Division | pg. 27

Janaury 2014

While national research indicates that

APRNs provide safe treatment and

prescribing accuracy, decisions to

make changes to state code should be

informed by examination of the prac-

tice of state APRNs.

reviewing prescribing complaints against APRNs and medical malpractice

court cases. While national research indicates that APRNs provide safe

treatment and prescribing accuracy, decisions to make changes to state

code should be informed by examination of the practice of state APRNs.

Prescribing Complaints

The Legislative Auditor requested information from the Nursing

Board on prescribing complaints against advanced practice registered

nurses for the time period from CY 1990 through CY 2013. The

Nursing Board stated that 30 complaints had been filed between 1992

and 2013. Over this time period, 13 complaints have been dismissed.

Of the remaining prescribing complaints, five complaints relate to an

APRN prescribing medications that should not have been prescribed, or

prescribing without a DEA number. In addition, 7 prescribing complaints

resulted from an APRN prescribing either after failing to renew an existing

collaborative agreement, or prescribing after a collaborative agreement

had terminated. Four of these 7 APRNs were assessed a non-disciplinary

fine and administrative costs, and three APRNs signed agreements

placing their RN license on probation. Of the remaining complaints one

was denied initial prescriptive authority related to legal probation and

five are still pending.

Medical Malpractice

The Legislative Auditor requested a legal search for medical

malpractice cases against advanced practice nurses in all roles from 1993

through July 2013. The legal staff in Legislative Services found four

cases from publicly available records. Legal staff explained that these are

appellate cases, and that a review of any other cases, such as those cases

only going to circuit court, and not being appealed, is not practical.

Two cases, in 2003 and 2005 involved two different nurse

anesthetists or CRNAs. In the 2003 case, the nurse anesthetist settled

with the patient prior to a trial. The 2005 case was dismissed, and later on

appeal remanded for further proceedings. There was no further information

available on the case. Certified nurse midwives were involved in the other

two cases. In a 2001 case, a CNM, county health department, hospital

and physician were alleged to have failed to diagnose and treat a breast

cancer. A trial found for the patient in this case. A 2013 case that went to

trial alleged the use of a prescription oral contraception contributed to the

death of a patient. However, a jury found in favor of the CNM and the

physician. There were no cases found that involved either clinical nurse

specialists or nurse practitioners.

pg. 28 | West Virginia Legislative Auditor

Advanced Practice Registered Nurses

The Legislative Auditor was not able

to find any reports that tracked medi-

cal malpractice claims to autonomous

practice by APRNs.

In 21 years, the safety record that can be documented shows that

APRNs have been involved in four medical malpractice appellate court

cases and received 30 complaints related to prescribing practices. Of the

court cases, only one was specifically related to a prescription medication.

In that case a jury found in favor of the CNM and the physician. Of the

complaints, the majority related to administrative failures by the licensee.

From the information provided, it was not possible to determine if any

complaints related to actual errors in prescribing.

APRN Medical Malpractice Analysis Report, Rates and

Paid Claims

Medical malpractice paid claims, analyses by insurers and rate

trends also provide some information on the safety of APRN practice. The

Legislative Auditor was not able to find any reports that tracked medical

malpractice claims to autonomous practice by APRNs. However, the

Legislative Auditor contacted the senior vice president for the healthcare

division of AON Affinity, one of the nation’s largest insurers of nurse

practitioners. AON provides nurse practitioner liability insurance through

a CNA partnership with the Nurse Service Organization (NSO) which

writes about 19 percent of the liability coverage for nurse practitioners

in the United States. The senior vice president notes that NSO works

to keep a national pricing structure due to the small population of NPs

in some states. He stated that rates have doubled over the past 10 years

from an average rate of $500 to $600 per year to an average of $1,400+

per year. He explained this by stating:

“…technically, it’s because we are seeing increasing

severity of indemnity payments as well as the increasing

frequency of claims therefore demanding rate increases.

However, what we at NSO feel has been driving this

includes: the physician shortage, less MDs moving into

family practice, thus helping to fuel the demand/growth of

NPs as a profession, which has then allowed NPs to act

as a primary care provider. This greater exposure has led,

as well as the greater number of NPs to increased claims

and thus rates. However, by comparison, NPs rates are

far less than a family practice MDs rates.”

CNA/NSO also analyzes its paid malpractice claims to provide

information and risk control recommendations to nurse practitioners.

The 2012 analysis provides information for paid claims from CY 2007

Performance Evaluation & Research Division | pg. 29

Janaury 2014

The most common prescribing errors

were analyzed in the CNA/NSO re-

port. The highest percentage of the

most common errors (4.5 percent) was

in a failure to recognize contraindica-

tion and/or know the adverse interac-

tion among ordered medications.

through December 31, 2011. The total amount in paid claims by CNA/

NSO for its covered nurse practitioners in all states during this period was

$44,370,490. The average paid indemnity claim increased from $186,282

to $221,852 during this time period. The most frequent allegations against

nurse practitioners involved:

• failure to diagnose, and delay in making the correct diagnosis (43

percent),

• failure to provide the proper treatment and care (29.5 percent),

and

• errors in medication prescribing (16.5 percent).

The most common prescribing errors were analyzed in the CNA/

NSO report. The highest percentage of the most common errors (4.5

percent) was in a failure to recognize contraindication and/or know

the adverse interaction among ordered medications. The improper

prescribing and/or management of anticoagulants followed at 3 percent

of claims. Prescribing the wrong medication, prescribing the wrong dose

and the improper prescribing and management of controlled drugs each

constituted 2.5 percent of the closed claims of prescribing errors. The

remaining 1.5 percent of prescribing errors was not analyzed.

Review of APRN malpractice insurance rates

The Legislative Auditor requested information on medical

malpractice rates for APRNs from West Virginia and the 16 states where

APRNs have autonomous practice. This request was made in order to

determine whether there had been a change in rates between CY 2003

and 2013 that might reflect increasing medical malpractice claims. Eight

states responded, but only three responses contained historical data to

show rate changes. They were West Virginia, Alaska and Oregon. The

states included rate information for all carriers of this type of insurance.

The following information was gained.

• Alaska. Alaska provided 10-year historical rate information from

four insurers: American Casualty, Continental Casualty, Medical

Insurance Exchange of California (MEIC) and Norcal Mutual. The

rate information showed rate increases and rate decreases, so that no

trend could be established for Alaska.

• Oregon. Oregon’s historical rate information was variable among 10

insurers, and the longest span of time was 6 years with Continental

Casualty. This insurer showed a rate increase of 5 percent over 6

years. The rate information for the other companies showed rate

increases and rate decreases so that no trend could be established for

Oregon.

pg. 30 | West Virginia Legislative Auditor

Advanced Practice Registered Nurses

The Legislative Auditor concluded

that due to the lack of response by the

16 states, trend information for insur-

ance rates was not able to be estab-

lished.

• West Virginia. West Virginia provided rates for 7 insurers but

historical data for only one insurer, American Casualty. The historical

data covered 11 years, and showed rates at $761 in 2002 increasing to

$1,784 in 2013, for an NP in employed in family practice. For a self-

employed NP in family practice the rate was $761 in 2002 increasing

to $2,540 in 2013. These were much higher increases than those seen

in Alaska and Oregon.

The Legislative Auditor concluded that due to the lack of response

by the 16 states, trend information for insurance rates was not able to be

established.

Comparison of West Virginia paid medical malpractice claims

The Legislative Auditor reviewed the safety of the practice

of West Virginia APRNs by reviewing annual data of the number and

the respective aggregate dollar amounts of paid medical malpractice

practice claims by all insurers for four types of medical practitioners.

These comparisons are seen in Tables 5 and 6. Both paid claims tables

reflect small numbers and amounts of medical malpractice claims paid

for West Virginia APRNs and PAs. APRNs, PAs, MDs and DOs medical

malpractice paid claims were compared for the time period from CY 2002

through 2012 in Table 5.

Table 5

West Virginia Medical Malpractice Claims Paid CY 2002–2012

Medical Practitioners Number of Paid Claims

Amount of Paid Claims in Millions

APRNs 16 $8.63

PAs 9 $3.43

DOs 109 $32.15

MDs 1,095 $227.34

Source: National Practitioner Data Bank Medical Malpractice Payment Reports

Table 5 extends over a 10 year period, aggregating the amounts

of paid claims. The year that a claim is paid does not reflect the year

that the claim was filed, and claims are generally filed at some time prior

to payment. The Legislative Auditor also reviewed the paid medical

malpractice claims data for CY 2012. This information is shown in Table

Performance Evaluation & Research Division | pg. 31

Janaury 2014

In West Virginia, APRNs show no

medical malpractice paid claims for

any type of practice problem in CY

2012; over the past 10 year period,

there have been 16 medical malprac-

tice paid claims totaling $8.63 mil-

lion.

Table 6

West Virginia Medical Malpractice Claims Paid in CY 2012

Medical Practitioners Number of Paid Claims

Amount of Paid Claims in Millions

APRNs 0 0

PAs 0 0

DOs 11 $2.78

MDs 61 $12.41

Source: National Practitioner Data Bank Medical Malpractice Payment Reports

The review of the medical malpractice paid claims report for

CNA/NSO shows that prescribing error comprises 16.5 percent of all

paid claims nationally for this major insurer of nurse practitioners. In

West Virginia, APRNs show no medical malpractice paid claims for any

type of practice problem in CY 2012; over the past 10 year period, there

have been 16 medical malpractice paid claims totaling $8.63 million. The

Legislative Auditor acknowledges that the comparison between rates for

mid-level practitioners and physicians reflects the differing liabilities

between the practice of primary care and of specialties, including

obstetrics and surgery.

Conclusion

The Legislative Auditor’s review does not find any apparent public

safety issues with the prescribing and clinical practice of experienced

APRNs. However, there are oversight issues with the written collaborative

agreement that need to be addressed legislatively. The Legislative Auditor

concludes the present requirement in state code for written collaborative

agreements does not provide for standardization in terms of physician

review and evaluation of prescribing practice, or in terms of the number

of agreements that either a physician or an APRN shall enter into. Once

collaborative agreements are established, there is no audit of the written

collaborative agreements to determine if physicians are conducting the

review of prescribing and clinical performance according to the terms

of the written agreement. Further, written collaborative agreements do

not take into account the clinical or prescribing experience of advanced

practice registered nurses. Finally, the written collaborative agreement is

difficult to obtain for APRNs who are self-employed, especially in rural

areas of the state.

The Legislative Auditor is concerned about the impact of the

collaborative agreement requirement on access to crucial primary and

preventive health care for rural West Virginians. While the lack of

standardization and absence of any official review process reinforces the

Applicant’s argument that the collaborative agreement is unnecessary,

pg. 32 | West Virginia Legislative Auditor

Advanced Practice Registered Nurses

the Legislative Auditor finds that some degree of clinical supervision

and collaboration is appropriate for inexperienced APRNs. In addressing

the Applicant’s request to eliminate the written collaborative agreement

requirement as a prerequisite to the APRN obtaining limited prescriptive

authority, the Legislative Auditor finds that the written collaborative

agreement requirement for advanced practice registered nurses should be

revised in code and rule, and may be removed when certain conditions

are met.

Recommendations

1. The Legislature should revise the statute to allow Advanced Practice

Registered Nurses in U.S. Department of Health and Human

Services, Health Resources and Services Administration (HRSA),

designated Health Professional Shortage Areas (HPSA), with five

years of clinical prescribing experience, a recommendation from his

or her collaborative physician and no actions against their licenses

to prescribe and practice independently, without a collaborative

agreement. The Legislature, as a part of such a statutory change,

should authorize the Board of Medicine to license those Advanced

Practice Registered Nurses who want prescriptive authority to

practice independently without a collaborative agreement.

2. The Legislature should revise the statute to move responsibility

for prescriptive authority licensure of independently practicing

Advanced Practice Registered Nurses from the West Virginia

Board of Examiners for Registered Professional Nurses to the

West Virginia Board of Medicine.

3. The Legislature should amend the statute to direct the West Virginia

Board of Medicine to promulgate Legislative Rules developing a

standardized written collaborative agreement as well as a review

process for those written collaborative agreements. The statute

should allow for agreements to be entered into by both allopathic

(MD) and osteopathic (DO) physicians.

4. The Legislature should direct the Board of Medicine to promulgate

Legislative Rules creating an application process and criteria for

prescriptive authority licensure of Advanced Practice Registered

Nurses with five or more years of clinical experience.

5. If implemented, the Legislature should consider reviewing the

impacts of these actions upon the public health and safety in five

years.

Performance Evaluation & Research Division | pg. 33

Janaury 2014

The opinion of legal staff of Legisla-

tive Services is that this is a distinct

section of state code and should not

be construed to be the same as the re-

quirement for a written collaborative

agreement for prescriptive authority

for CNMs.

The Requirement for a Collaborative Relationship Between

Certified Nurse Midwives and Physicians Should Remain.

Summary

In Finding 2, the Legislative Auditor considered the Applicant’s

request to remove the requirement in state code for a collaborative

relationship between a certified nurse midwife and a physician. This

requirement should remain in Code as it is a reasonable expectation for

the protection of the public.

Collaborative Relationship of a Nurse Midwife to a

Physician

The Applicant, in addition to requesting the removal of the written

collaborative agreement for prescribing authority, presented proposed

legislation that removes §30-15-7 from Code. West Virginia Code §30-

15-7 requires the APRN who is a certified nurse midwife to practice in a

collaborative relationship with physicians trained and practicing in fields

that directly relate to obstetrical and gynecological care. WVC §30-15-7

states:

The license to practice nurse-midwifery shall entitle

the holder to practice such profession according to the

statement of standards of the American college of nurse-

midwives, and such holder shall be required to practice

in a collaborative relationship with a licensed physician

engaged in family practice or the specialized field of

gynecology or obstetrics, or as a member of the staff of any

maternity, newborn or family planning service approved

by the West Virginia department of health and human

resources, who, as such, shall practice nurse-midwifery

in a collaborative relationship with a board-certified or

board-eligible obstetrician, gynecologist or the primary-

care physician normally directly responsible for obstetrical

and gynecological care in said area of practice.

The Legislative Auditor requested a legal opinion regarding this

section of code, and whether it establishes a requirement for general

midwife practice that is separate from the requirement for a written

collaborative agreement for prescriptive authority for certified nurse

midwives in §30-15-7a. The opinion of legal staff of Legislative Services

is that this is a distinct section of state code and should not be construed

to be the same as the requirement for a written collaborative agreement

for prescriptive authority for CNMs.

FINDING 2

pg. 34 | West Virginia Legislative Auditor

Advanced Practice Registered Nurses

Conclusion

The Applicant argues that all APRNs are trained to practice

autonomously and that requirements for collaboration are not necessary as

all four roles of APRNs are trained to identify situations where collaboration

is necessary. However, while §30-15-7 does not require that a written

agreement or any other proof of the collaborative relationship between

the CNM and a physician be demonstrated, it states a clear expectation

of the CNM. This is an expectation that is prudent, and reasonable for

the protection of the public. Therefore, the Legislative Auditor finds that

the requirement for certified nurse midwives to establish a relationship to

collaborate with physicians trained and practicing in fields that directly

relate to obstetrical and gynecological care should remain in Code.

Recommendation

6. The Legislature should continue WVC §30-15-7 requiring the

establishment of a collaborative relationship between a certified

nurse midwife and a physician practicing in fields that directly

relate to obstetrical and gynecological care.

Performance Evaluation & Research Division | pg. 35

Janaury 2014

The restrictions to the drug formulary

were revised in rule as recently as

June 12, 2013.

The Legislative Auditor Recommends Retaining Limitations

on Advanced Practice Registered Nurse Prescriptive

Authority by Retaining the Current Restricted Drug

Formulary.

Summary

In Finding 3, the Legislative Auditor considered the request to

remove all restrictions to prescribing medications. This would involve

removing drug formulary limitations imposed on the prescriptive

authority of advanced practice registered nurses. The Legislative Auditor

considered whether the public benefits or is harmed by the drug formulary

restrictions remaining in place. The restrictions to the drug formulary

were revised in rule as recently as June 12, 2013. The Legislative Auditor

concludes that the limitations on prescriptive authority imposed by the

restricted drug formulary provide an important layer of public protection

and should be maintained.

Request to Expand Medication Prescribing

In the application the Applicant requests an expansion of medication

prescribing to allow APRNs to prescribe and monitor medications based

on best practice evidence. The Applicant argues that the current law

is convoluted and cumbersome and does not allow for appropriate and

timely prescribing of medication for primary care patients. The Applicant

notes that the current law restricts the kind and amount of medications

that the APRN may prescribe. The Applicant gives examples of current

rheumatoid arthritis therapies, pain medications and certain endocrine

treatments that are common primary care prescriptive interventions.

The Legislative Auditor evaluated this request to determine whether the

public benefits from the current restrictions in the drug.

Exclusionary APRN Prescription Formulary Detailed in

WV Code and Rule

WVC §30-7-15a (c) lays out restrictions to APRN prescribing

authority. APRNs are not allowed to prescribe from Schedules I and

II of the Controlled Substances Act (which include opiates and other

pain medications) and are limited to a 72 hour supply (no refills) from

Schedule III. APRNs are not allowed to prescribe antineoplastics,

radiopharmaceuticals, general anesthetics, and MAO inhibitors.

MAO

inhibitors are used in the treatment of depression and neurological

disorders such as Parkinson’s disease.

Except when in a collaborative agreement with a psychiatrist.

FINDING 3

pg. 36 | West Virginia Legislative Auditor

Advanced Practice Registered Nurses

The rule revision received input from

the West Virginia Medical Associa-

tion, the West Virginia Board of Medi-

cine and the West Virginia Board of

Pharmacy.

APRNs can prescribe an annual supply of any medication (with

the exception of controlled substances) prescribed for the treatment of

a chronic condition, other than chronic pain management. A chronic

condition is defined as a condition which lasts three months, generally

cannot be prevented by vaccines, can be controlled but not cured by

medication and does not generally disappear. These conditions, with

the exception of chronic pain, include but are not limited to arthritis,

asthma, cardiovascular disease, cancer, diabetes, epilepsy and seizures,

and obesity.

WVC §30-7-15a (c) requires the Nursing Board to promulgate

legislative rules governing the eligibility and extent to which an APRN

may prescribe drugs. “Such rules shall provide… a state formulary

classifying those categories of drugs which shall not be prescribed by

advanced practice registered nurse(s) ….” Over the years, the restrictions

in the drug formulary for APRNs have been revised. The most current

revision was in 2013. This revision followed public meetings held by the

Nursing Board. The rule revision received input from the West Virginia

Medical Association, the West Virginia Board of Medicine and the West

Virginia Board of Pharmacy. APRNs are currently required to have a

written collaborative agreement with a physician in order to prescribe.

Drugs excluded from APRN prescriptive authority are listed in legislative

rule §19-8-5 which can be seen in Appendix B.

Concerns Related to Expanding the Formulary

The Legislative Auditor solicited comments from professional

groups and organizations that could be considered stakeholders in the

impact of the APRN application to expand the scope of practice. The

following entities were contacted: the West Virginia Board of Medicine,

the West Virginia Board of Osteopathic Medicine, the West Virginia Board

of Pharmacy, the West Virginia Board of Dentistry, the West Virginia

Board of Optometry, the West Virginia State Medical Association, the

West Virginia Academy of Family Physicians, and the Department of

Health and Human Resources Bureau for Public Health. Comments

are contained in Appendix C. Physicians and dentists raised differing

concerns related to expanding the drug formulary. Summaries of both

groups’ concerns follow.

• Prescription medication concerns: Many physicians’ groups

questioned the training and education of APRNs to prescribe

controlled substances. Most noted that the removal of limitations

on Schedule II and III controlled substances could exacerbate

the drug diversion problem in West Virginia. The state currently

holds the distinction of having the most drug overdose deaths, the

Performance Evaluation & Research Division | pg. 37

Janaury 2014

The Dental Board noted that expan-

sion of prescriptive authority for

CRNAs may have unintended conse-

quences.

majority of which are from prescription drugs, of any state in the

nation.

• Dental Practice Act concerns: The West Virginia Board of

Dentistry noted that the Dental Practice Act was revised in the

2013 legislative session, and significant modifications were made

to the section covering the administration of anesthesia in dental

settings. The APRN designation of certified registered nurse

anesthetist (CRNA) is impacted in that many dentists employ

CRNAs to administer anesthesia in their offices. The Dental Board

noted that expansion of prescriptive authority for CRNAs may

have unintended consequences. If CRNAs are given an expanded

scope to prescribe anesthesia, this could afford an opportunity for

dentists to avoid the requirements of the new legislation. The

Dental Board suggested that it would be prudent to wait at least

a year to evaluate the effects of the modifications to the Dental

Practice Act before expanding the prescribing scope of APRNs.

In response to the pharmacology education concerns raised

by physician stakeholders, the Legislative Auditor examined the

pharmacology coursework requirements and continuing education

requirements in state code for practitioner licensure, and prescriptive

authority and renewals. They are found in Table 7.

pg. 38 | West Virginia Legislative Auditor

Advanced Practice Registered Nurses

Table 7

West Virginia Healthcare Practitioners

Pharmacology Specific Education Requirements

Practitioner Type Practitioner Title

Pharmacology Coursework

in completing degree(s)

Continuing Education

Physician

Practitioners

Allopathic Physician (MD)

Doctoral: (WVU) 7 semester

hours (Marshall) 12 semester

hours

• Drug Diversion Therapy: 3 hours

in previous two year period

Osteopathic Physician

(DO)

Doctoral: (SOM) 9 semester

hours

• Drug Diversion Therapy: 3 hours

in previous two year period

Dentist (DDS) Doctoral: 5 semester hours

• Drug Diversion Therapy: 3 hours

in previous two year period

Non-Physician

Practitioners

Advanced Practice

Registered Nurse (APRN)

Undergraduate: 1 course

Graduate: 3 semester hours*

• Initial License: Advanced

Pharmacology: 1 semester hour

in previous two year period

• Renewal License: Pharmacology

Minimum 8 contact hours (about

half of a semester hour)

• Drug Diversion Therapy: 3 hours

in previous two year period

Physician Assistant (PA) 4 semester hours

• Rational Drug Therapy:10 clock

hours in previous two year

period

• Drug Diversion Therapy: 3 hours

in previous two year period









West Virginia laws and rules governing the practice of physicians

and dentists are non-specific as to the number of pharmacology-specific

educational hours to be completed as part of their degree work.

However,

the laws and rules governing the practice of APRNs and PAs stipulate

the number of pharmacology-specific educational hours these mid-level,

non-physician practitioners must complete as part of their degree work.

The varying number of pharmacology semester hours offered in different state medi-

cal programs do not reflect additional pharmacology information integrated into the

physician’s clinical training.

Performance Evaluation & Research Division | pg. 39

Janaury 2014

For all other prescribing, such as the

annual supply of any drug prescribed

for a chronic condition that is not

pain management, the limited drug

formulary provides a layer of public

protection in that it is specific and

detailed in regard to medications that

are either limited, or not allowed to be

prescribed by APRNs.

In response to the drug diversion concerns raised, the Legislative

Auditor reviewed actions taken by the DEA against West Virginia DEA

registration numbers from medical practitioners between CY 2002 and

CY 2012. In this period, DEA took actions to suspend or revoke the

registration numbers of 10 MDs, and 4 DOs, but no DEA actions were

taken against West Virginia APRN or PA registrations. The 16 autonomous

practice states report that while there are few complaints against APRNs,

they do experience some problems related to pain medication prescribing

(involving controlled substances). A total 13 DEA actions have been

taken against APRN registration numbers in these states over a 10 year

period.

Restrictions in the APRN Drug Formulary Provide

Protection for the Public

Additionally, there is an MAO-specific provision in legislative

rule for the restricted drug formulary. The requirement is for a

collaborative agreement with a psychiatrist in order to prescribe MAO

inhibitors. The Legislative Auditor concludes that the requirement of a

collaborative agreement with a psychiatrist should remain, despite the

recommendation in Finding 1 to relax the collaboration requirement

when certain conditions are met. For all other prescribing, such as the

annual supply of any drug prescribed for a chronic condition that is not

pain management, the limited drug formulary provides a layer of public

protection in that it is specific and detailed in regard to medications that

are either limited, or not allowed to be prescribed by APRNs. While

APRN prescribing practice in West Virginia appears to be safe, given

that the state is currently struggling with the multiple problems of drug

abuse and prescription drug overdose deaths, this does not appear to be an

appropriate time to relax the restrictions of the current drug formulary.

Conclusion

The restricted prescriptive formulary for APRNs provides a

layer of protection to the public if the written collaborative agreement

is removed. APRNs are trained to recognize and to treat common health

problems, monitor specific chronic conditions, provide preventive care

and educate patients. Self-employed APRNs are able to function with the

current prescriptive restrictions. When a condition requires medications

beyond the APRN’s prescriptive authority, the APRN can refer patients to

a physician. It is the opinion of the Legislative Auditor that the human

and economic costs of prescription drug abuse and addiction in West

Virginia are too high. Expanding the number of practitioners able to

prescribe Schedule II narcotics is adverse to the public health and interest.

pg. 40 | West Virginia Legislative Auditor

Advanced Practice Registered Nurses

Therefore, the Legislative Auditor concludes that limitations through a

restricted drug formulary should remain.

Recommendations

7. The Legislature should not expand the limited prescriptive

authority for Advanced Practice Registered Nurses by removing

restrictions in the APRN drug formulary at the present time.

8. The Legislature should continue to require collaborative

relationships between a psychiatrist and an APRN for the

prescription of MAO inhibitors.

Performance Evaluation & Research Division | pg. 41

Janaury 2014

The Applicant makes the request

that whenever any law or regulation

requires a signature, certification,

stamp, verification, affidavit or en-

dorsement by a physician, it is impor-

tant that it also be deemed to include

a signature, certification, stamp veri-

fication, affidavit or endorsement by a

nurse practitioner.

The Request for the Addition of the Same Signatory

Authority as Physicians on All Health Care Documents

Is Too Broad and Non-Specific to Be Evaluated by the

Legislative Auditor.

Summary

The Legislative Auditor was not able to provide an evaluation on

the Applicant’s request to provide Advanced Practice Registered Nurses

with global signature authority. The proposed legislation would allow

APRNs the same signature authority as physicians wherever physicians

are required to sign documents. The Applicant did not provide a list of

the signature authority documents that APRNs want to be able to sign.

Therefore, the Legislative Auditor was not able to provide an analysis

of whether to grant global signature authority to Advanced Practice

Registered Nurses.

Request for Global Signature Authority

In the application, the Applicant requests an expansion of practice

to include the ability to sign documents related to patient care. The

Applicant notes that West Virginia law does not consistently support the

APRNs ability to sign health related documents, such as death certificates,

Do Not Resuscitate Orders, or certain Handicap Supportive Services. The

Applicant makes the request that whenever any law or regulation requires

a signature, certification, stamp, verification, affidavit or endorsement by

a physician, it is important that it also be deemed to include a signature,

certification, stamp verification, affidavit or endorsement by a nurse

practitioner. The Applicant does not provide a specific list of documents

for the analysis.

Proposed Change to Existing West Virginia Code

The Applicant proposes the following language be inserted in a

new section, §30-7-15d, of state Code.

Allowance of APRNs for global signatures on patient care

documentations. (a) Whenever any law or regulation

requires a signature, certification, stamp, verification,

affidavit or endorsement by a physician, it shall be

deemed equal to include a signature, certification, stamp,

verification, affidavit or endorsement by an advanced

practice registered nurse.

FINDING 4

pg. 42 | West Virginia Legislative Auditor

Advanced Practice Registered Nurses

Lacking a detailed list of the specific

documents, it is not possible to provide

an analysis.

Specific Information Not Provided

The Legislative Auditor was asked to provide an analysis

of whether the APRNs should be granted global signatory

authority for healthcare documents. The Applicant lists three

examples, death certificates, Do Not Resuscitate orders and

various handicapped accessible documentations. Some states

allow APRNs to sign death certificates. In West Virginia, the

Office of Vital Statistics in the Bureau for Public Health notes

that it would not oppose a change allowing APRNs to have the

ability to sign death certificates.

Aside from the three examples given, there was no list

attached to the application. Based on the scope of practice

authorities for APRNs listed by Barton Associates

, which shows

that West Virginia APRNs can sign some handicapped documents,

this request is not only non-specific but also confusing. The

Legislative Auditor does not know whether there are three

documents, or a much larger number of documents that would be

affected by global signatory authority. Lacking a detailed list of

the specific documents, it is not possible to provide an analysis.

It may be that this request has merit, but the information provided

was too limited.

Barton Associates, an agency supplying temporary physicians, CRNAs and CNPs

created an interactive graphic based on The Pearson Report 2012, (an annual report

on state laws) to provide information on the varied authorities under different states’

APRN scope of practice laws.

Performance Evaluation & Research Division | pg. 43

Janaury 2014

Appendix A

States That Allow APRNs to Practice and Prescribe Independently

pg. 44 | West Virginia Legislative Auditor

Advanced Practice Registered Nurses

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Appendix B

Legislative Rule 19CSR8 - Limited Prescriptive Authority for

Nurses in Advanced Practice

pg. 46 | West Virginia Legislative Auditor

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pg. 48 | West Virginia Legislative Auditor

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Appendix C

West Virginia Stakeholder Comments

pg. 54 | West Virginia Legislative Auditor

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WEST VIRGINIA LEGISLATIVE AUDITOR

PERFORMANCE EVALUATION & RESEARCH DIVISION

Building 1, Room W-314, State Capitol Complex, Charleston, West Virginia 25305

telephone: 1-304-347-4890 | www.legis.state.wv.us /Joint/PERD/perd.cfm | fax: 1- 304-347-4939