Physician Voices for Patient Safety
On this page:
About the bill
Impact on patients in DC
Impact of physicians in DC
What can you do?
Resources
About the bill
In November 2023, DC Health introduced B25-545, the Health Occupations
Revisions General Amendment Act of 2023. This bill was a comprehensive
rewrite of the law overseeing medical licensing and regulation in
Washington, DC. Unfortunately, the bill as written overhauled
scope of practice, place allied health professionals in oversight
positions of medical licensing, and remove the physician from the center
of the care team. After much work and a number of legislative wins, the bill passed the Council on May 7.
MSDC has long advocated that a physician is the most qualified professional at the head of a care team. Physicians have the most health education and pre-practice experience of any health professional, and thus must be involved in all but the most mundane health care decisions. Allied health professionals are a valuable part of the care team, but their medical education and experience limits their role.
The Medical Society of the District of Columbia (MSDC) is the leading voice for physicians in Washington, DC, committed to uniting physicians to advocate for physician-led health care in Washington, DC that protects patients from harm and increases access to quality care. MSDC is leading a coalition of Washington, DC specialty medical societies to advocate against the Health Occupations Revisions General Amendment Act of 2023.
Impact on DC medicine
Below is a breakdown of some of the major changes the bill contains; click on the title to expand how the bill would change that item.
Currently the Board of Medicine is composed of 10 physicians and 4 members of the public. The bill as amended would reduce the number of physicians to 9 and adds 2 physician assistants but keep
the four members of the public health.
The concern: The bill would codify that APRNs could independently diagnose, prescribe, and administer medicine.
The details: See the analysis from G2L Law Firm on the APRN provisions | See our one-pager on this issue that you can share with colleagues and the Council
The solutions: Independent Advanced Certified Nurse Practitioners should have a defined scope of practice limited to the following functions:
- Practice only in the field of certification;
- Comprehensive physical assessment of patients;
- Certify to the clerk of the court that an adult has given birth;
- Certify to the Transportation authority that an individual has special needs for certain health reasons;
- Complete date of birth and medical information on a birth certificate;
- Complete a death certificate if medical examiner does not take charge and deceased was under the care of the PN;
- Establish medical diagnosis of common short-term and chronic stable health problems;
- File a replacement death certificate;
- Issue a “do not resuscitate order” in medical emergencies;
- Order, perform, and interpret laboratory and diagnostic tests;Prescribe drugs and devices under DC controlled substance Schedules II-V with a valid DEA license, and medical marijuana under DC laws;
- Provide emergency care within the scope of their skills;
- Refer patients to appropriate licensed physicians or other health care providers;
- Certify to utility company that a client has a serious illness or the need for life-support equipment;
- Witness an advanced directive;
- Sign off on home health/care orders.
The concern: As seen below, additional allied health professions are permitted to apply anesthesia. Most concerning is the scope expansion that could permit nurse anesthetists to practice without physician collaboration.
The details: See our one-pager on this issue that you can share with colleagues and the Council
The solution: This bill asks to repeal Section 603 of DC official code ₰3-1206.03, and this action will allow nurse anesthetists to administer anesthesia without an anesthesiologist or other physician's direct collaboration. Language seeking repeal of Section 603 of DC official code ₰3-1206.03 should not be included.
This bill adds Sec. 605a, which contains language that a CRNA may plan and deliver anesthesia, pain management, and related care to patients or clients of all health complexities across the lifespan. Language adding Sec. 605a should be removed from this bill.
The expands audiologists' scope to include "cerumen management" and "interoperative neurophysiologic monitoring" and permits audiologists to screen for cognitive, depression and vision.
The bill completely rewrites the definition of the practice of "chiropractic". Chiropractors could:
- Diagnose and treat biomechanical or physiological conditions that compromise neural integrity or organ system function
- Refer patients for further medical treatment or diagnostic testing
The details: See our one-pager on this issue that you can share with colleagues and the Council
The bill would expand pharmacists' scope to include:
- Ordering labs
- Scheduling and monitoring drug therapy
- Ordering, interpreting, and performing more tests
The details: See our one-pager on this issue that you can share with colleagues and the Council
The bill would permit physical therapists to independently evaluate and treat disability, injury, or disease. PTs may also order imaging as part of their treatment plan.
The concern: The bill expands podiatrists scope of practice to allow:
- apply anesthesia as part of treatment; and
- administer vaccines and injections.
The details: See our one-pager on this issue that you can share with colleagues and the Council
Throughout the bill, restrictions on nursing scope of practice are removed or loosened throughout. Specific language outlining what and how nurses can practice is removed and replaced with more vague language giving the Mayor (read DC Health)
the ability to dictate scope. This applies to many different nursing types, like APRNs and NPs.
Articles on scope of practice
What DC Physicians Need to Know About Cures Act Info Blocking Rules
At its April 19 meeting, the MSDC Board held a lengthy discussion about the CURES Act's "info blocking" requirements that are coming online soon. The Board wants all DC physicians to be aware of the requirements, what is and is not included, and how to speak out if you are concerned about the new regulations.
Below is a Q&A drawn heavily from the great work done by the American Medical Association. You can see their in-depth guidance here and here.
Where is this requirement coming from?
Congress passed and President Obama signed into law the 21st Century Cures Act in 2016. The bill's aim is to increase interoperability between EHRs and improve access by patients to their medical records. In March 2019, the Office of the National Coordinator for Health Information Technology (ONC) issued a proposed rule that was finalized May 2020. The rule established the requirements on "information blocking".
What is information blocking?
Information or "info blocking" is the inability of an interested party to access a medical record. This includes a physician trying to access a patient record from another EHR or provider, or a patient trying to download their medical record or provide it to a new physician. The Cures Act rule further defines it as a business, technical, or organization practice that discourages or prevents access to electronic health information (EHI) when the actor preventing access knows or should know they should not interfere with access.
How does the rule define EHI?
The rules defines EHI as electronic protected health information in a designated record set (defined by HIPAA) regardless of whether the records are used or maintained by the "covered entity". This means your medical, billing, and other patient records are now available to patient access once they are signed by the physician.
Under the new rules, what are common ways I may be info blocking my patients?
The rules are broad and situationally based, although generally speaking an act or omission to interfere with EHI access may be considered info blocking. Some examples, per the AMA, include:
- Requiring a patient's written consent before sharing EHI
- Disabling a feature that allows sharing of EHI to other users
- Delaying sharing information in a requested format even if the EHR has the ability to do so
It is important to know that no harm needs to be done to be considered info blocking; the intent to restrict access is sufficient.
What are the exceptions to the info sharing rules?
The legislation and rule defined two categories of exceptions: not fulfilling requests to access, exchange, or use EHI; and procedures for fulfilling requests to access, exchange, or use EHI. To qualify for an exception, the action or policy must (1) be reasonable and necessary; (2) address significant risk; AND (3) be subject to strict conditions. The exceptions are below:
- Preventing harm exception - information is withheld to prevent physical harm
- Privacy exception - information is withheld under state and federal privacy laws
- Security exception - access to information is restricted due to uniform security processes targeting a specific security concern
- Infeasibility exception - it is not physically possible for a provider to give the information in the way requested.
- Health IT performance exception - information is not provided because routine maintenance of systems are being conducted
- Content and manner exception - info blocking is not applicable if the provider meets the content request and manner condition of the request. This exception lasts for 24 months after May 1, 2020.
- Fee exception - a practice may charge a reasonable fee for accommodating the EHI request
- Licensing exception - this exception applies to building interoperability elements into an EHI request.
What can I do if I have concerns or stories about these requirements?
You can contact Robert Hay at MSDC or Ela Cameron at the American Medical Association.
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