SB2672 SD1.DOC

SECTION 1. The legislature finds that advanced practice registered nurses provide a wide variety of health care services to people in Hawaii. The legislature further finds that section 323-3, Hawaii Revised Statutes, requires each hospital within the State to allow advanced practice registered nurses to practice within the full scope of their practice, including as primary care providers. Advanced practice registered nurses are also recognized as participating primary health care providers for insurance purposes under the State's insurance code.

The legislature also finds that certain sections within the Hawaii Revised Statutes omit advanced practice registered nurses from the definitions or designations of health care entities who may provide health care, prescribe drugs, or sign forms. The outdated statutes must be amended to authorize increased participation by advanced practice registered nurses and recognize appropriately trained advanced practice registered nurses as primary care providers. Authorizing increased participation by advanced practice registered nurses in certain circumstances, especially with regard to global signature authority, will enable improved access to health care services, expedite the process of processing paperwork, and provide optimal care at the initial point of access for Hawaii patients, especially in rural and underserved areas.

The purpose of this Act is to improve patient access to medical care by clarifying the circumstances under which advanced practice registered nurses may practice to the fullest extent of their training and education.

SECTION 2. Section 328-1, Hawaii Revised Statutes, is amended by amending the definition of "out-of-state practitioner" to read as follows:

""Out-of-state practitioner" means a physician, surgeon, osteopathic physician and surgeon, advanced practice registered nurse, dentist, podiatrist, or veterinarian authorized to prescribe drugs to patients under the applicable laws of any state of the United States except the State of Hawaii, or a physician, surgeon, osteopathic physician and surgeon, advanced practice registered nurse, dentist, podiatrist, or veterinarian authorized to prescribe drugs under the applicable laws of Hawaii, but practicing in a state other than Hawaii."

SECTION 3. Section 334-59, Hawaii Revised Statutes, is amended by amending subsection (b) to read as follows:

"(b) Emergency examination. A patient who is delivered for emergency examination and treatment to a facility designated by the director shall be examined by a licensed physician or advanced practice registered nurse without unnecessary delay, and may be given such treatment as is indicated by good medical practice. A psychiatrist, advanced practice registered nurse, or psychologist may further examine the patient to diagnose the presence or absence of a mental disorder, assess the risk that the patient may be dangerous to self or others, and assess whether or not the patient needs to be hospitalized."

SECTION 4. Section 338-9, Hawaii Revised Statutes, is amended by amending subsection (b) to read as follows:

"(b) In preparing a certificate of death or fetal death the person in charge of the disposition of the body shall:

(1) Obtain and enter on the certificate the personal data and other information pertaining to the deceased person required by the department from the person best qualified to supply them;

(2) Present the certificate of death to the physician or advanced practice registered nurse last in attendance upon the deceased, or to the coroner's physician, who shall thereupon certify the cause of death to the physician's or advanced practice registered nurse's best knowledge and belief, or present the certificate of fetal death to the physician, advanced practice registered nurse, midwife, or other person in attendance at the fetal death, who shall certify the fetal death and such medical data pertaining thereto as can be furnished; provided that fetal deaths of less than twenty-four weeks or intentional terminations of pregnancy performed in accordance with section 453-16 may be certified by a nurse or other employee based upon the physician's records; and

(3) Notify immediately the appropriate local agent, if the death occurred without medical attendance, or if the physician or advanced practice registered nurse last in attendance fails to sign the death certificate. In such event the local agent shall inform the local health officer, and refer the case to the local health officer for immediate investigation and certification of the cause of death prior to issuing a permit for burial, or other disposition of the body. When the local health officer is not a physician or when there is no such officer, the local agent may complete the certificate on the basis of information received from relatives of the deceased or others having knowledge of the facts.

If the circumstances of the case suggest that the death or fetal death was caused by other than natural causes, the local agent shall refer the case to the coroner for investigation and certification."

SECTION 5. Section 338-10, Hawaii Revised Statutes, is amended to read as follows:

"§338-10 Late determination of the cause of death. If the cause of death cannot be determined within three days, the certification of its cause may be filed after the prescribed period, but the attending physician, advanced practice registered nurse, or coroner's physician shall notify in writing the local agent of the department of health of the district in which the death occurred of the reason for late filing, in order that a permit for the disposition of the body may be issued.

As used in this section, "late" means more than three days after the date of death."

SECTION 6. Section 386-1, Hawaii Revised Statutes, is amended by amending the definition of "health care provider" to read as follows:

""Health care provider" means a person qualified by the director to render health care and service and who has a license for the practice of:

(1) Medicine or osteopathy under chapter 453;

(2) Dentistry under chapter 448;

(3) Chiropractic under chapter 442;

(4) Naturopathic medicine under chapter 455;

(5) Optometry under chapter 459;

(6) Podiatry under chapter 463E; [~~and~~]

(7) Psychology under chapter 465[.]; and

(8) Advanced practice registered nurse under chapter 457."

SECTION 7. Section 386-27, Hawaii Revised Statutes, is amended by amending subsection (a) to read as follows:

"(a) All health care providers rendering health care and services under this chapter shall be qualified by the director and shall remain qualified by satisfying the requirements established in this section. The director shall qualify any person initially who has a license for the practice of:

(1) Medicine or osteopathy under chapter 453;

(2) Dentistry under chapter 448;

(3) Chiropractic under chapter 442;

(4) Naturopathic medicine under chapter 455;

(5) Optometry under chapter 459;

(6) Podiatry under chapter 463E; [~~and~~]

(7) Psychology under chapter 465[.]; and

(8) Advanced practice registered nurses under chapter 457."

SECTION 8. Section 457-8.6, Hawaii Revised Statutes, is amended by amending subsection (d) to read as follows:

"(d) Advanced practice registered nurses shall be considered qualified if they have met the requirements of section 457-8.5(a), and have met the advanced pharmacology requirements for initial prescriptive authority pursuant to rules adopted by the board. Only qualified advanced practice registered nurses authorized to diagnose, prescribe, and institute therapy or referrals of patients to health care agencies, health care providers, and community resources and, only as appropriate to the practice specialty in which the advanced practice [[]registered[]] nurse is qualified, may:

(1) Prescribe and administer over the counter drugs, legend drugs, and controlled substances pursuant to this chapter and to chapter 329 and request, receive, and dispense manufacturers' prepackaged samples of over the counter drugs, and non-controlled legend drugs to patients under their care; provided that an advanced practice registered nurse shall not request, receive, or sign for professional controlled substance samples;

(2) Prescribe, order, and dispense medical devices and equipment; and

(3) Plan and initiate a therapeutic regimen that includes nutritional, diagnostic, and supportive services including home health care, hospice, and physical and occupational therapy."

SECTION 9. Section 461-1, Hawaii Revised Statutes, is amended by amending the definition of "practice of pharmacy" to read as follows:

""Practice of pharmacy" means:

(1) The interpretation and evaluation of prescription orders; the compounding, dispensing, and labeling of drugs and devices (except labeling by a manufacturer, packer, or distributor of nonprescription drugs and commercially legend drugs and devices); the participation in drug selection and drug utilization reviews; the proper and safe storage of drugs and devices and the maintenance of proper records therefor; the responsibility for advising when necessary or where regulated, of therapeutic values, content, hazards, and use of drugs and devices;

(2) Performing the following procedures or functions as part of the care provided by and in concurrence with a "health care facility" and "health care service" as defined in section 323D-2, or a "pharmacy" or a licensed physician[,] or a licensed advanced practice registered nurse with prescriptive authority, or a "managed care plan" as defined in section 432E-1, in accordance with policies, procedures, or protocols developed collaboratively by health professionals, including physicians and surgeons, pharmacists, and registered nurses, and for which a pharmacist has received appropriate training required by these policies, procedures, or protocols:

(A) Ordering or performing routine drug therapy related patient assessment procedures;

(B) Ordering drug therapy related laboratory tests;

(C) Initiating emergency contraception oral drug therapy in accordance with a written collaborative agreement approved by the board, between a licensed physician or advanced practice registered nurse with prescriptive authority and a pharmacist who has received appropriate training that includes programs approved by the American Council of Pharmaceutical Education (ACPE), curriculum-based programs from an ACPE-accredited college of pharmacy, state or local health department programs, or programs recognized by the board of pharmacy;

(D) Administering drugs orally, topically, by intranasal delivery, or by injection, pursuant to the order of the patient's licensed [~~physician's order,~~] physician or advanced practice registered nurse with prescriptive authority, by a pharmacist having appropriate training that includes programs approved by the ACPE, curriculum-based programs from an ACPE-accredited college of pharmacy, state or local health department programs, or programs recognized by the board of pharmacy;

(E) Administering:

(i) Immunizations orally, by injection, or by intranasal delivery, to persons eighteen years of age or older by a pharmacist having appropriate training that includes programs approved by the ACPE, curriculum-based programs from an ACPE-accredited college of pharmacy, state or local health department programs, or programs recognized by the board of pharmacy; and

(ii) Vaccines to persons between fourteen and seventeen years of age pursuant to section 461-11.4;

(F) As authorized by the written instructions of a licensed [~~physician's written instructions,~~] physician or advanced practice registered nurse with prescriptive authority, initiating or adjusting the drug regimen of a patient pursuant to an order or authorization made by the patient's licensed physician or advanced practice registered nurse with prescriptive authority and related to the condition for which the patient has been seen by the licensed physician[;] or advanced practice registered nurse with prescriptive authority; provided that the pharmacist shall issue written notification to the patient's licensed physician or advanced practice registered nurse with prescriptive authority or enter the appropriate information in an electronic patient record system shared by the licensed physician[,] or advanced practice registered nurse with prescriptive authority, within twenty-four hours;

(G) Transmitting a valid prescription to another pharmacist for the purpose of filling or dispensing; or

(H) Providing consultation, information, or education to patients and health care professionals based on the pharmacist's training and for which no other licensure is required; and

(3) The offering or performing of those acts, services, operations, or transactions necessary in the conduct, operation, management, and control of pharmacy."

SECTION 10. Statutory material to be repealed is bracketed and stricken. New statutory material is underscored.

SECTION 11. This Act shall take effect upon its approval; provided that the amendments made to section 334-59(b), Hawaii Revised Statutes, by section 3 of this Act shall not be repealed when that section is reenacted on July 1, 2020, pursuant to section 24 of Act 221, Session Laws of Hawaii 2013.

THE SENATE	S.B. NO.	2672
TWENTY-EIGHTH LEGISLATURE, 2016		S.D. 1
STATE OF HAWAII