Nuts & olts : S 337 eremy Adler, PA-C reg Mennie, PA-C ob Miller, PA S 337 OALS Increase flexibility and improve utilization of PAs in California s Workforce Recognize that PA and physicians are both PROFESSIONALs and should be empowered to determine how to best work together to provide high quality care Ease administrative burdens and eliminate cosignatures consistent with AAPA model practice act Shift to the focus to the quality outcome and welfare of patients treated by PA/physician team, rather than focus on the relationship between the PA and physician Ensure medical decisions dominate patient care, rather than administrative. Rescheduling of HCP to CII demanded substantial new administrative burden S 337 : From Egg to Chicken Introduced by Senator Fran Pavley2/23/15 Amended in Senate 4/13/15 Senate usiness & Professions Committee 4/20/15 Senate Appropriations Committee 5/12/16 Senate Floor Vote 5/26/15 Amended in Assembly 6/16/15 Assembly usiness & Professions Committee 6/23/16 Assembly Appropriations Committee 7/8/15 Assembly Floor Vote Consent 7/16/15 Senate Concurrence Ordered back to Assembly for Amendments 7/16/15 Amended in Assembly 9/1/15 Assembly Floor Vote 9/3/15 Enrolled and sent to overnor 9/8/15 Approved by overnor and Chaptered 10/6/15 (PA DAY!) CAPA members letters and SP letters of support Meetings with Senators and Assembly members. Sacramento Lobby Day Not to forget stakeholder meetings, calls, discussion with PA oard, Medical oard of California, California Medical Association, California Academy of Family Physicians, Osteopathic Physicians and Surgeons of California, California Pharmacists Association and others
HCP Rescheduled from III to II Effective 10/6/14 Concerns of Opposition California Pharmacist Association The DEA is attempting to curb overprescribing of HCPs (Hydrocodone Combination Products to reduce abuse and ensure more judicious use of these drugs. This bill would counter the efforts of the DEA by reducing supervision of PAs relative to their prescribing of HCPs and all other Schedule II drugs. Medical oard of California [the MC] recognizes that the intent of this bill is to provide flexibility and allow for a more team-based approach in PA supervision, which the [MC] believes is a laudable goal. The recent amendments addressed concerns raised by the [MC]. However, the [MC] still has concerns related to the reduced physician review of Schedule II drug orders from 100 percent to 20 percent, as this is a significant reduction of supervising physician review for types of opioid medications that are prevalent for abuse. PA oard Concerns of Opposition
A rowing Problem with EHR How to Comply? CCR, 1399.546. Reporting of PA Supervision. Each time a physician assistant provides care for a patient and enters his or her name, signature, initials, or computer code on a patient s record, chart or written order, the physician assistant shall also enter the name of his or her supervising physician who is responsible for the patient. When a physician assistant transmits an oral order, he or she shall also state the name of the supervising physician responsible for the patient. S 337 Added to &P Code 3502. (a) The medical record, for each episode of care for a patient, shall identify the physician and surgeon who is responsible for the supervision of the physician assistant. Compliance Made Possible For 1399.546 3502. (f) Compliance by a physician assistant and supervising physician and surgeon with this section shall be deemed compliance with Section 1399.546 of Title 16 of the California Code of Regulations.
SA-CME Question #1 When functioning under protocols, the mechanism of supervision documentation for PA/SP teams must be identified in the Delegation of Services Agreement. TRUE FALSE Physician Required to Countersign Documents and MRs 1399.540 (b) A delegation of services agreement shall be signed and dated by the physician assistant and each supervising physician. 3502. (c)(1)(d)protocols shall be signed and dated by the supervising physician and surgeon and the physician assistant. 3502 Countersign MRs reviewed by SP. ointly sign documentation of Med. Record Review Meetings 3502.1 (e) MRs for Schedule II orders. Minimum 20% IFPA has passed the Controlled Substance Education Course SA-CME Question #1 - ANSWER When functioning under protocols, the mechanism of supervision documentation for PA/SP teams must be identified in the Delegation of Services Agreement. TRUE FALSE There is NO PROVISION that requires the mechanism of documenting supervision be included in the DSA
SA-CME Question #2 A PA must hold a certificate of completion of a Controlled Substance Education Course in order to obtain a DEA Registration to prescribe controlled substances. TRUE FALSE SA-CME Question #2 - ANSWER A PA must hold a certificate of completion of a Controlled Substance Education Course in order to obtain a DEA Registration to prescribe controlled substances. TRUE FALSE DEA Registration is required to prescribe a controlled substance, but DEA DOES NOT require completion of course SA-CME Question #3 When a PA prescribes a schedule II controlled substance, the medical records must always be cosigned by a SP. TRUE FALSE
SA-CME Question #4 A PA must take a Controlled Substance Education Course to prescribe controlled substances in California. TRUE FALSE Countersignatures for Schedule II (If No Controlled Substance Course) 3502.1 (c)(2)a physician assistant may notadminister, provide, or issue a drug order to a patient for Schedule II through Schedule V controlled substances without advance approvalby a supervising physician and surgeon for that particular patient AND 3502.1 (e)(1) The medical record of anypatient cared for by a physician assistant for whom the physician assistant s Schedule II drug order has been issued or carried out shall be reviewed, countersigned, and dated by a supervising physician and surgeon within seven days. If The PA Has Passed The Controlled Substance Education Course: 3502.1 (c)(2) advanced approval unless the physician assistant has completed an education course AND 3502.1 (e)(2) the supervising physician and surgeon shall review, countersign, and date, within seven days, a sample consisting of the medical records of at least 20 percent of the patients cared for by the physician assistant for whom the physician assistant s Schedule II drug order has been issued or carried out. AND 3502.1 (e)(2) Physician assistants who have a certificate of completion of the course shall be deemed to have met the education course Requirement.
SA-CME Question #5 If a PA has taken the Controlled Substance Education Course prior to the implementation of S 337, they will need to retake the course to be able to have the cosignaturesdecreased for medical records when schedule II medication is prescribed. TRUE FALSE SA-CME Question #4 - ANSWER A PA must take a Controlled Substance Education Course to prescribe controlled substances in California. TRUE FALSE PAs are not required to take course, but must obtain advanced approval and have 100% of schedule II controlled substance medical records cosigned within 7 days SA-CME Question #5 - ANSWER If a PA has taken the Controlled Substance Education Course prior to the implementation of S 337, they will need to retake the course to be able to have the cosignaturesdecreased for medical records when schedule II medication is prescribed. TRUE FALSE Physician assistants who have a certificate of completion of the course shall be deemed to have met the education course Requirement
SA-CME Question #6 To enjoy the expanded scope of practice from the Controlled Substance Education Course, it must be taken at a frequency of: a. Every 2 years b. Every 6 years c. Only once, it doesn t need to be retaken d. Every 10 years SA-CME Question #6 - ANSWER To enjoy the expanded scope of practice from the Controlled Substance Education Course, it must be taken at a frequency of: a. Every 2 years b. Every 6 years c. Only once, it doesn t need to be retaken d. Every 10 years SA-CME Question #7 A PA has completed a Controlled Substance Education Course and prescribes 20 patients schedule II medications over the month. What minimum percent of the medical records that month require cosignaturesby the SP? (Note, if a cosignatureis required, it must be dated within 7 days of treatment by the PA) a. 100% -all 20 medical records b. 5% -1 medical records c. 20% - 4 medical records d. None 0%
SA-CME Question #7 - ANSWER A PA has completed a Controlled Substance Education Course and prescribes 20 patients schedule II medications over the month. What minimum percent of the medical records that month require cosignaturesby the SP? (Note, if a cosignatureis required, it must be dated within 7 days of treatment by the PA) a. 100% -all 20 medical records b. 5% -1 medical records c. 20% - 4 medical records d. None 0% SA-CME Question #8 Upon completion of the Controlled Substance Education Course, all of the following are true when a PA is functioning with protocols EXCEPT: a. A controlled substance may be prescribed without the prior approval of a SP b. A SP must cosign a minimum of 20% of the medical records when schedule II medications are prescribed c. When prescribing a controlled substance, a PA is no longer subject to reasonable quantitative limitations consistent with the customary medical practice of the SP d. A PA holding a successful completion certificate of the Controlled Substance Education Course, do not need to retake the course to enjoy the benefits implemented in S337 SA-CME Question #8 - ANSWER Upon completion of the Controlled Substance Education Course, all of the following are true when a PA is functioning with protocols EXCEPT: a. A controlled substance may be prescribed without the prior approval of a SP b. A SP must cosign a minimum of 20% of the medical records when schedule II medications are prescribed c. When prescribing a controlled substance, a PA is no longer subject to reasonable quantitative limitations consistent with the customary medical practice of the SP d. A PA holding a successful completion certificate of the Controlled Substance Education Course, do not need to retake the course to enjoy the benefits implemented in S337 PAs still are subject to reasonable quantitative limitations for controlled substance prescribing
S 337 Added Options For Documentation 3502. (c)(2)(a) The supervising physician and surgeon shall use one or more of the following mechanisms to ensure adequate supervision of the physician assistant functioning under the protocols: S 337 PA Practice Act 3502. (2)(A) (i), (ii), (iii) Option (i) Existing Since 2008 3502. (c)(2)(a)(i) The supervising physician and surgeon shall review, countersign, and date a sample consisting of, at a minimum, 5 percent of the medical records of patients treated by the physician assistant functioning under the protocols within 30 days of the date of treatment by the physician assistant.
An Example Year 5% Cosign 5% F 5% M 5% A 5% M 5% 5% 5% A 5% S 5% O 5% N 5% D 5% No Schedule II Controlled Substances Prescribed
SA-CME Question #9 What percent of medical records must be COSINEDwithin 30 days of treatment by the PA if schedule II medications are not prescribed and the PA has chosen medical records review meetings while functioning under protocols? a. 0% b. 5% c. 20% d. 100% SA- CME Question #10 All of the following are true regarding Medical Records Review Meetings EXCEPT: a. The total number of records reviewed must at minimum include 10 per month for 10 months of the year. b. Medical Records Review Meetings must occur in person. c. The PA and SP shall both jointly sign documentation to memorialize that the meeting(s) occurred, but do not require details of the content of the meeting(s). d. It is acceptable for a Medical Records Review Meeting to have occurred when casually walking down a hospital corridor and the documentation for that meeting need not be in the patient s medical record. What s New Medical Records Review Meeting 3501. (a)(12) Medical records review meeting means a meeting between the supervising physician and surgeon and the physician assistant during which medical records are reviewed to ensure adequate supervision of the physician assistant functioning under protocols. Medical records review meetings may occur in person or by electronic communication.
Option (ii) is NEW Medical Records Review Meeting Do 10/10 PA Practice Act 3502. (c)(2)(a) (ii), The supervising physician and surgeon and physician assistant shall conduct a medical records review meeting at least once a month during at least 10 monthsof the year. During any month in which a medical records review meeting occurs, the supervising physician and surgeon and physician assistant shall review an aggregate of at least 10 medical records of patients treated bythephysician assistant functioning under protocols. Documentation of medical records reviewed during the month shall be jointly signed and dated by the supervising physician and surgeon and thephysician assistant. SA-CME Question #9 - ANSWER What percent of medical records must be COSINEDwithin 30 days of treatment by the PA if schedule II medications are not prescribed and the PA has chosen medical records review meetings while functioning under protocols? a. 0% b. 5% c. 20% d. 100% Medical Records Review Meeting documentation requirements DO NOT include medical record cosignatures. The Universe s 10% Law The10% Rulemeans that when energy is passed in an ecosystem from one trophic level to the next, only ten percent of the energy will be passed on.
S 337 (ii) 10/10 rule Less Time Less Energy igger return If you choose to CHOICE Minimum 10 Charts/month 10 months out of the year Minimum 100 charts Reviewing Skyping and Talking Sitting and Talking Walking and Talking Calling and Talking Let s do Lunch Document the meeting 10/10 SA-CME Question #10 -ANSWER All of the following are true regarding Medical Records Review Meetings EXCEPT: a. The total number of records reviewed must at minimum include 10 per month for 10 months of the year. b. Medical Records Review Meetings must occur in person. c. The PA and SP shall both jointly sign documentation to memorialize that the meeting(s) occurred, but do not require details of the content of the meeting(s). d. It is acceptable for a Medical Records Review Meeting to have occurred when casually walking down a hospital corridor and the documentation for that meeting need not be in the patient s medical record. Meetings may occur in person or by electronic communication
MATH 76 = Average number of patients seen per week for PA s. 44 = Average number of weeks worked per year. =5% minimum number of charts needing signature. 167 charts 2014 Statistical Profile of Certified Physician Assistants. NCCPA. NOT a SA-CME Question Which is Less? a. 167 b. 100
One EXAMPLE of documentation sheet Option (iii) is NEW Combination PA Practice Act 3502. (c)(2)(a) (iii), 3502. (c)(2)(a)(iii) The supervising physician and surgeon shall review a sample of at least 10 medical records per month, at least 10 monthsduring the year, using a combination of the countersignature mechanismdescribed in clause (i) and the medical records review meeting mechanism described in clause (ii) During each month for which a sample is reviewed, at least one of the medical records in the sample shall be reviewed using the mechanism described in clause (i) and at least one of the medical records in the sample shall be reviewed using the mechanism described in clause (ii). WHAT#&@?!
Wait a second. This is EASIER! SA-CME Question #11 A PA/SP team chose to document with all available mechanisms, including cosignatures, medical record review meetings and the combination mechanism of both. If 500 patients were seen by the PA over the month, and no schedule II medications were prescribed, all of the following are compliant with documentation EXCEPT: a. 5% cosignature of the medical records which is 25 cosignatures b. 10 medical records reviewed through medical record review meetings c. 1 medical record reviewed through a medical record review meeting and 9 medical records cosigned d. This month, NO medical records were reviewed through cosignaturesor medical records review meetings because the requirements were met using the mechanisms in answers and/or C above for 10 months during the year, and this is an off month. e. All of the above are TRUE S 337 Added Options For Documentation 3502. (c)(2)(a) The supervising physician and surgeon shall use one or more of the following mechanisms to ensure adequate supervision of the physician assistant functioning under the protocols:
An Example Year MRM (10) F MRM (10) M MRM (10) A signed (5) + MRM (5) M signed (1) + MRM (9) MRM (10) None A MRM (10) S signed (4)+ MRM (6) O signed 5% N None D MRM (10) MRM= Medical Record Review meeting (ii) Signed= Supervising Physician countersign (i) SA-CME Question #11 - ANSWER A PA/SP team chose to document with all available mechanisms, including cosignatures, medical record review meetings and the combination mechanism of both. If 500 patients were seen by the PA over the month, and no schedule II medications were prescribed, all of the following are compliant with documentation EXCEPT: a. 5% cosignature of the medical records which is 25 cosignatures b. 10 medical records reviewed through medical record review meetings c. 1 medical record reviewed through a medical record review meeting and 9 medical records cosigned d. This month, NO medical records were reviewed through cosignaturesor medical records review meetings because the requirements were met using the mechanisms in answers and/or C above for 10 months during the year, and this is an off month. e. All of the above are TRUE S 337 Highlights Putting it Together Each and every time entering SP is now once per episode of care Certificate of Completion from CSEC enables cosignature reduction from 100% down to 20% on schedule II controlled substance medical records New mechanisms to document supervision through Medical Records Review Meetings and combination options reater flexibility in options empowers PA/SP teams QUESTIONS?