270. Non-Physician Providers
270.992 CMS and Specialty Society Principles Regarding APN Scope of Practice
Physician-Led Health Care Teams
- Health care that is effective, efficient, and safe results from the work of patient-centered provider teams – networks of individual providers acting in well-integrated and well-defined relationships. This has always been so for in-patient hospital care, and is increasingly a hallmark of high-quality health care in every medical setting.
- Provider teams may work in a number of forms, varying with the needs of the patient, the environment in which the care is being provided, and the skills and training of the members of the team. In all cases each provider’s work is integrated with the work of others for the betterment of the patient.
- All effective health care teams respect the specialized skills and knowledge of each participating member; and each member contributes in a defined and coordinated way to achieving optimal care and optimal patient outcomes.
- The duties, responsibilities, supervisory relationships and boundaries for each member of the team should be explicitly delineated by protocols, medical staff rules, or other similar means.
- Leadership and overall responsibility for patient care are essential requirements for all effective, efficient and safe medical care. While every provider working in a team contributes a specialized capability, leadership is necessary to integrate the whole to maximize the health benefits to the patient. By the greater depth, length and breadth of their medical education, training, and experience physicians are in most circumstances uniquely qualified for this role.
Scope of Practice
- The optimal degree of interaction among the members of a team is environment-dependent. It may vary with the setting, the facility, and the area of health care. An Advanced Practice Nurse, for example, may have less direct physician contact or supervision in a rural clinic than in a major-city hospital, yet for the same reason require more readily available access to physician expertise. The central criterion is that which provides the best quality and safest care.
- In no circumstance may Advanced Practice Nurses or other health care professionals practice beyond their license, education, training and experience.
- Facilities such as hospitals, group practices, out-patient clinics, ACOs and other integrated-care arrangements must establish guidelines or protocols describing the scope of practice for Advanced Practice Nurses and other health care professionals. Such guidelines must be established with participation from physicians having experience and skill in the type of health care being provided. In hospitals the protocols and guidelines should have approval of the medical staff and governing board of the facility.
- Where facilities establish the scope of practice with guidelines or protocols, the facility must be accountable for the effects of their application.
- The practice of Nurse Anesthetists is subject to all of the preceding principles, and to additional considerations reflecting the nature of anesthesiology and its diverse applications.
- A nurse anesthetist must be supervised either by an anesthesiologist or by the operating physician for the procedure. If not in continuous physical presence, the supervising physician must be immediately available to attend to the patient when needed.
- In settings without anesthesiologists the supervising physician may be the operating surgeon, obstetrician, or other physician performing the procedure if the facility’s medical staff and governing board determine that the supervising physician has the necessary skill and training to provide such supervision.
- If in any case the supervising physician or the nurse anesthetist determines that there is not the necessary expertise within the team to perform a procedure safely, that procedure should not be performed.
(BOD-1, AM 2012; Reaffirmed, BOD-1, AM 2014)
270.993 Scope of Practice
(BOD-1, AM 2009; Sunset, BOD-1, AM 2014)
The Colorado Medical Society opposes the licensing of naturopaths and supports enforcing the Medical Practice Act, which prohibits the unlicensed practice of medicine and the use of the term physician by any person other than an MD or DO.
(RES-4, AM 2005; Reaffirmed, BOD-1, AM 2014)
270.995 Physical Examinations
(RES-14, AM 2003; Sunset, BOD-1, AM 2014)
270.996 Opposition to Psychologists Prescribing Medication
The Colorado Medical Society opposes prescriptive authority for psychologists.
(Late RES-29, AM 2002; Reaffirmed, BOD-1, AM 2014)
270.997 Non-Physician Providers
The Colorado Medical Society (CMS) defines non-physician providers (NPPs) as physician assistants (PAs) and advanced practice nurses (APNs). The CMS defines APNs as professional nurses with additional education and clinical experience beyond traditional nursing education. APNs include clinical nurse specialists, certified registered nurse anesthetists, certified nurse midwives, and nurse practitioners.
The CMS encourages the profession of medicine to study the roles, education, scope of practice, potential for autonomy and accountability, and quality issues regarding NPPs to create a basis for informed recommendations and ongoing dialogue with public policy makers and other health professionals.
Role: The CMS supports incentives to facilitate the education and practice of NPPs that focus on the need for (medical) primary care skills.
Education: The CMS supports minimum education requirements and minimum clinical experience requirements for all NPPs. The CMS supports the requirement for a master’s level of education in order to be eligible for the title of APN. The CMS supports the definition of APN in Colorado statute to assure title protection and appropriate educational preparation. In addition to specific education requirements the CMS supports a clinical experience criterion, such as a formal internship. The CMS believes that the PA programs, which include minimum education requirements, clinical experience and certification, provide an excellent model for NPP licensure. The CMS recommends that physicians have input into the education and clinical requirements of NPPs in Colorado, specifically with regard to that content which is in the domain of medicine.
Scope of Practice: The CMS supports the development and implementation of uniform regulations for both APNs and PAs. Any functions that are traditional to the practice of medicine must be accompanied by specific education, certification, clinical experience, and require physician review and approval.
- Independent Medical Functions: The CMS believes that independent medical functions should be limited to those practitioners who are licensed to practice medicine as defined in the Medical Practice Act. NPPs do not have the minimum education, clinical experience and certification tests required by the Medical Practice Act.
- Collaborative Practice: The CMS supports the concept of collaborative practice between physicians and NPPs. Collaborative practice includes those medical functions that relate to self-limited and stable chronic conditions, as well as preventive services, provided by an NPP, which do not require the physical presence of the participating physician. The CMS supports mechanisms to facilitate collaborative practice plans.
- NPP Practice with Delegated Medical Functions: The CMS recognizes that currently NPPs perform delegated medical functions under existing statutes. The CMS recommends no modifications of this practice with the following exceptions:
- On-site physician supervision shall not be limited to a specific number of NPPs, provided the physician supervisor can document adequate supervision.
- Specific protocols are not required with on-site supervision.
- Physician sign off on charts is required weekly.
Representation of NPPs in the CMS: The CMS supports dialogue between organized medicine and NPPs in order to promote the role of NPPs as members of the health care team.
Additional Information: Collaborative Practice Plan Guidelines
(RES-44, AM 1994; Reaffirmed, BOD-1, AM 2014)
270.998 Collaboration Among Physicians, Physician Assistants, Nurses and Pharmacists
The Colorado Medical Society supports the collaboration of advanced practice nurses, clinical pharmacists, physician assistants and physicians which would define and clarify educational standards and expand the role of this team especially in medically underserved areas and populations.
(RES-54, AM 1993; Reaffirmed, BOD-1, AM 2014)
270.999 Regulation of Allied Health Professionals
The Colorado Medical Society supports the following position on regulation of allied health professionals:
- Regulation should be imposed upon a profession for the primary purpose of protecting the public. Secondarily, regulation should be imposed to protect the allied health professional practice in a safe manner.
- If regulation is needed, the form of regulation should be that which is the minimum necessary to protect the public and ensure that the allied health professional can practice in a safe manner.
- All regulation of allied health professionals must be subject to periodic review by the legislature to insure its continuing necessity and appropriateness. This ensures that the regulations are current and most effective in protecting the public.
- Definitions: Certification (also called Title Protection): granted to an individual who has met certain prerequisite qualifications. Includes the right to use the “title” of the profession or occupation or to assume of use the term “certified” in conjunction with the title. Licensure: a process by which a statutory regulatory entity grants to an individual who has met certain prerequisite qualifications, the right to perform prescribed professional and occupational tasks and to use the title of the profession or occupation. Registration: a process which requires that, prior to rendering services, all practitioners formally notify a regulatory entity of their intent to engage in the profession or occupation.
(RES-21, IM 1990; Revised, BOD-1, AM 2014)