Hawaii-2022-SB2442-Amended

SECTION 1. The legislature finds that Hawaii continues to face a critical physician shortage. According to the 2021 annual report on findings from the Hawaii physician workforce assessment report, Hawaii has an unmet need for seven hundred thirty-two full time physicians across the State, with predictions for increased need each year. Maui county and Hawaii county face the most severe shortages and lack forty per cent of the health care providers they need. Paradoxically, physician assistant practice in Hawaii has grown by thirty-six per cent between 2016-2020. This is most noticeable on the neighbor islands, where physician assistant presence has grown by one hundred five per cent Hawaii county, one hundred fourteen per cent in Kauai county, and thirty-five per cent in Maui county.

The legislature further finds that physician assistants, like advanced practice registered nurses, can help address this need, especially in rural communities where the shortage of health care providers is most acute. Further, physician assistants are one of the three health care professionals (along with physicians and nurse practitioners) authorized by the Affordable Care Act to provide primary care, which remains the area where the statewide shortage of providers is most significant.

The legislature also finds that physician assistants receive rigorous medical training and are skilled health care providers who routinely take medical histories, perform physical examinations, order and interpret laboratory tests, diagnose illnesses, develop and manage treatment plans, prescribe medications, and assist in surgery. Physician assistants work in various clinical settings, locations, and specialties in collaboration with a licensed physician. Studies have shown that when physician assistants practice to the full extent of their abilities and training, hospital readmission rates and lengths of stay decrease and infection rates go down.

Before practicing as a physician assistant, a candidate must graduate from an accredited program and pass a national certification exam to be licensed to practice medicine. Like physicians and advanced practice registered nurses, physician assistants must also complete extensive continuing medical education throughout their careers.

The legislature also finds that streamlining physician assistants' existing requirements relating to supervision by physicians is consistent with physician assistant training and education, and responds to the needs of the collaborating physician, facility, medical specialty, and patient population, thereby increasing the efficiency and delivery of health care, while lessening overall administrative burdens.

The legislature further finds that Act 181, Session Laws of Hawaii 2019, took one step toward modernizing the practice of physician assistants by authorizing the supervision of physician assistants by a physicians' group and authorizing supervising physicians or groups to establish practice-specific requirements for review of medical records of patients seen by physician assistants. This first step successfully decreased the administrative burdens on supervising physicians without compromising patient care.

Accordingly, the purpose of this Act is to continue streamlining the medical records review process for physician assistants as established by Act 181, Session Laws of Hawaii 2019, by including review of controlled substance prescriptions issued by physician assistants.

SECTION 2. Section 453-5.3, Hawaii Revised Statutes, is amended by amending subsection (g) to read as follows:

"(g) For medical records of patients seen by physician assistants:

(1) Each physician assistant and supervising physician, osteopathic physician, or group of physicians shall establish written guidelines for the review of medical records as appropriate to the specific practice. These guidelines shall be kept in the office of the practice setting in which either the physician assistant or supervising physician, osteopathic physician, or group of [[]physicians[]] practices, and shall be made available to the Hawaii medical board and the regulated industries complaints office or its designees;

(2) The supervising physician, osteopathic physician, or group of physicians shall review medical records as required by this subsection; provided that:

(A) When supervising a physician assistant with less than one year of practice experience as a licensed physician assistant, the supervising physician, osteopathic physician, or group of physicians shall:

(i) For the first six months of supervision, review fifty per cent of the medical records within thirty days of the patient visit; [~~and~~]

(ii) For the next six months of supervision, review twenty-five per cent of the medical records within thirty days of the patient visit[.]; and

(iii) For physician assistants that issue controlled substance prescriptions, at least fifty per cent of the records reviewed under subparagraphs (A)(i) or (A)(ii) shall include controlled substance prescriptions. If the number of records with controlled substance prescriptions does not amount to at least fifty per cent of the requirements in subparagraphs (A)(i) or (A)(ii), the supervising physician, osteopathic physician, or group of physicians shall review as many as are available.

The board may, on a case-by-case basis, require physician assistants that begin in a new practice specialty with less than one year of full-time practice experience in the specialty to comply with this subparagraph; and

(B) When supervising a physician assistant with more than one year of practice experience as a licensed physician assistant, the supervising physician, osteopathic physician, or group of physicians shall:

(i) Establish a process for the regular review of a sample of medical records, including a sample of controlled substance records, if applicable, of patients seen by the physician assistant; and

(ii) For at least thirty minutes each month, perform an audit and review of the medical records; and

(3) Notwithstanding paragraph (2), a supervising physician, osteopathic physician, or group of physicians may require additional supervisory requirements at any time for patient safety."

SECTION 3. Section 329-38, Hawaii Revised Statutes, is amended by amending subsection (i) to read as follows:

"(i) Prescriptions for controlled substances shall be issued only as follows:

(1) All prescriptions for controlled substances shall originate from within the State and be dated as of, and signed on, the day when the prescriptions were issued and shall contain:

(A) The first and last name and address of the patient; and

(B) The drug name, strength, dosage form, quantity prescribed, and directions for use. Where a prescription is for gamma hydroxybutyric acid, methadone, or buprenorphine, the practitioner shall record as part of the directions for use, the medical need of the patient for the prescription.

Except for electronic prescriptions, controlled substance prescriptions shall be no larger than eight and one-half inches by eleven inches and no smaller than three inches by four inches. A practitioner may sign a prescription in the same manner as the practitioner would sign a check or legal document (e.g., J.H. Smith or John H. Smith) and shall use both words and figures (e.g., alphabetically and numerically as indications of quantity, such as five (5)), to indicate the amount of controlled substance to be dispensed. Where an electronic prescription is permitted, either words or figures (e.g., alphabetically or numerically as indications of quantity, such as five or 5), to indicate the amount of controlled substance to be dispensed shall be acceptable. Where an oral order or electronic prescription is not permitted, prescriptions shall be written with ink or indelible pencil or typed, shall be manually signed by the practitioner, and shall include the name, address, telephone number, and registration number of the practitioner. The prescriptions may be prepared by a secretary or agent for the signature of the practitioner, but the prescribing practitioner shall be responsible in case the prescription does not conform in all essential respects to this chapter and any rules adopted pursuant to this chapter. In receiving an oral prescription from a practitioner, a pharmacist shall promptly reduce the oral prescription to writing, which shall include the following information: the drug name, strength, dosage form, quantity prescribed in figures only, and directions for use; the date the oral prescription was received; the full name, Drug Enforcement Administration registration number, and oral code number of the practitioner; and the name and address of the person for whom the controlled substance was prescribed or the name of the owner of the animal for which the controlled substance was prescribed.

A corresponding liability shall rest upon a pharmacist who fills a prescription not prepared in the form prescribed by this section. A pharmacist may add a patient's missing address or change a patient's address on all controlled substance prescriptions after verifying the patient's identification and noting the identification number on the back of the prescription document on file. The pharmacist shall not make changes to the patient's name, the controlled substance being prescribed, the quantity of the prescription, the practitioner's Drug Enforcement Administration number, the practitioner's name, the practitioner's electronic signature, or the practitioner's signature;

(2) An intern, resident, or foreign-trained physician, or a physician on the staff of a Department of Veterans Affairs facility or other facility serving veterans, exempted from registration under this chapter, shall include on all prescriptions issued by the physician:

(A) The registration number of the hospital or other institution; and

(B) The special internal code number assigned to the physician by the hospital or other institution in lieu of the registration number of the practitioner required by this section.

The hospital or other institution shall forward a copy of this special internal code number list to the department as often as necessary to update the department with any additions or deletions. Failure to comply with this paragraph shall result in the suspension of that facility's privilege to fill controlled substance prescriptions at pharmacies outside of the hospital or other institution. Each written prescription shall have the name of the physician stamped, typed, or hand-printed on it, as well as the signature of the physician;

(3) An official exempted from registration shall include on all prescriptions issued by the official:

(A) The official's branch of service or agency (e.g., "U.S. Army" or "Public Health Service"); and

(B) The official's service identification number, in lieu of the registration number of the practitioner required by this section. The service identification number for a Public Health Service employee shall be the employee's social security or other government issued identification number.

Each prescription shall have the name of the officer stamped, typed, or handprinted on it, as well as the signature of the officer; and

(4) A physician assistant registered to prescribe controlled substances under the authorization of a supervising physician shall include on all controlled substance prescriptions issued:

(A) The Drug Enforcement Administration registration number of the supervising physician; and

(B) The Drug Enforcement Administration registration number of the physician assistant.

Each written controlled substance prescription issued shall include the printed, stamped, typed, or hand-printed name, address, and phone number of both the supervising physician and physician assistant, and shall be signed by the physician assistant. [The medical record of each written controlled substance prescription issued by a physician assistant shall be reviewed and initialed by the physician assistant's supervising physician within seven working days.]"

SECTION 4. Statutory material to be repealed is bracketed and stricken. New statutory material is underscored.

SECTION 5. This Act shall take effect on July 1, 2022.

THE SENATE	S.B. NO.	2442
THIRTY-FIRST LEGISLATURE, 2022		S.D. 2
STATE OF HAWAII