• NPs are prepared at the graduate level and are deemed competent clinicians upon graduation and passage of national certification. There is no evidence to support the need for additional post-licensure supervision of NPs’ practice beyond current educational and certification standards.

• The five-year post-licensure “transition to practice” requirement is the result of political compromise with no evidence to support the regulatory mandate.  This has created variability from state to state, making Virginia an outlier with the most arduous practice environment in the nation for NPs.

• The five-year requirement creates a costly bottleneck to building provider workforce and equitable distribution in primary care delivery for underserved and vulnerable populations. Unduly burdensome regulations on top of this requirement will result in additional bottlenecks compromising access to care.

• Many NPs may have multiple team physicians during the transition period and there needs to be several signature lines for the physician. Each could specify the full time equivant period of supervision if sequential collaborative MDs exist.

• Request that the attestation form be a simple check box of the requirements listed in the statute. For example:

[ ] Patient care team physician has served with the NP pursuant on a practice

agreement

[ ] Patient care team physician routinely practiced with a patient population and

practice area for which the NP is certified and licensed

• Request that office administrators, human resources department, health system administrators, credentialing documents, etc., may be used as other evidence.

• Request that an NP in any state or working for U.S. Armed Forces, U.S. Veterans Administration or the Public Health Service submit evidence that the five-year full-time equivalent collaborative requirements have been met with signature from employer, physician, practice administrator, etc.

(While I am the named commenter, I am submitting this comment on behalf of the University of Virginia Health System.)

The University of Virginia Health System thanks you for the opportunity to comment on the promulgation of regulations to implement HB 793.  The University of Virginia Health System employs and teaches many people who hold divergent opinions concerning the implementation of HB 793.  Taking into account these different perspectives, we have identified the following issues of importance that we ask be considered when developing regulations for HB 793.

Equivalent of at least five years of full-time clinical experience:

• Consider implementing a system for the initial licensing of independent Nurse Practitioners (NPs) that is similar to the ACGME competencies review, including an evaluation of the NP’s skills each year.This will help ensure there is an accounting for all five years of clinical experience, and it will enable timely remediation of any weak areas.It is recognized that this could work for new NPs, but existing NPs with greater than five years’ experience should be allowed to provide other evidence of meeting the five year clinical experience requirement.

• On the other hand, consider whether such a system would create more barriers in the regulations than already exist in the statutory requirements and would thwart the intent of HB 793 to allow NPs to practice to their full scope and to meet the needs of patients.

Routine practice in a practice area included within the category for which the NP was certified and licensed:

• The approved legislation requires five years of collaborative practice in a specific practice area and patient population.Consider clarifying how practice area and patient population will be defined and clarify how a NP could move between populations and practice types, and what additional supervision/documentation would be required. For example, how would an NP transition from outpatient cardiology to inpatient CCU or floorcare? Or from outpatient cardiology to dermatology or vice versa?

• Consider adopting the APRN Consensus Model which is the regulatory model that guides these types of situations. This was developed in 2008 and endorsed by over 40 nursing organizations. This Model and later statements make it clear that an APRN's practice is not setting-specific but population-specific.For example, an Acute Care NP can manage heart failure patients with acute needs in any setting—from ICU to clinic to community.

• It will be important for hiring entities and credentials committees to know the specific patient population and practice area for which the NP qualified for independent practice.To this end, consider making this information readily available to hiring entities and credentials committees.The most straightforward way to accomplish this would be to specify the patient population and practice area on the BOM/BON issued license.As an alternative, the BOM/BON could develop a system to share this information with hiring entities and credentials committees by secure electronic means.

Requirements of an attestation of practice:

• The attestation could be a check-box type document that the collaborating physician could complete and sign.

• Indicate the FTE of the experience (1 FTE for fulltime, 0.8 FTE for 32 hours per week/part time, etc.)

• Consider including on the attestation form check-boxes specific to the patient populations and practice area that the NP has practiced in, and also check-boxes that cover the specific competencies the person has mastered in the practice area.

• Consider whether checking off a long list of NP competencies on the attestation form is too burdensome and creates unnecessary barriers for the NP.

Acceptance of “other evidence” demonstrating that the applicant met the requirements:

• There will be cases where the collaborating physician or physicians who worked with the NP during the required five years are unable or unwilling to sign off on approval of independent practice for that NP.In these cases, the NP may submit other evidence demonstrating that he or she has met the requirements.Consider developing a formal panel and procedures for evaluating such evidence that includes representatives from both the BON and BOM.The procedures should include actively seeking input from the NP’s collaborating physicians during the time period in question.

• Consider taking proactive action to prevent the above situation from occurring by adding a requirement to NP practice agreements requiring annual reviews as part of the five year clinical experience process. The collaborating physician should be required to discuss the review with the NP, and provide a copy. This could help with documentation and remediation issues, and could allow the NP to leave the practice if the collaborating physician failed to complete the review.On the other hand, consider whether such a requirement would set up the NP for failure if the collaborating physician failed to perform the annual evaluations; leaving the practice may not be a solution if the NP cannot locate a new collaborating physician.

Endorsement of experience in other states:

• We suggest that the BON/BOM follow a similar process as is required now for NPs, i.e., the NP provides primary validation from the school where the individual obtained the NP degree, evidence of NP licensure that is in good standing from another state, evidence of professional certification issued by an agency accepted by the BON/BOM, and fingerprinting.

• To meet Virginia’s five year clinical practice requirement, consider requiring the NP to meet the same attestation requirement that in-state applicants must provide, including allowing the out-of-state applicant the same opportunity to provide other evidence, if necessary, to demonstrate meeting the five year clinical practice requirement.

• Consider allowing the out-of-state applicant who has less than five years clinical experience to receive credit for their prior years of experience rather than requiring them to practice a full five years in Virginia before becoming eligible to practice independently.

• Consider the case of a NP that has practiced in a state that has a supervisory NP law rather than a collaborative NP law—how would that impact endorsement?

Fee associated with submission of attestation and issuance of autonomous designation:

• We suggest that the BON/BOM impose a reasonable fee, perhaps similar to the renewal fee and the frequency of renewal fees imposed on physicians by the BOM.

Unprofessional conduct – falsification of attestation:

• We suggest that the BON/BOM apply the same rules that already exist for physicians and nurses concerning unprofessional conduct.

Thank you for your consideration of these issues.

As an advanced practice nurse (APN), I am highly concerned about the message this legislation sends to the public about the legitimacy and competency of all APN roles, not just nurse practitioners (NP). The medical community, with whom I have respectfully worked alongside for forty years, continues to demand all oversight of healthcare delivery. This mindset reflects the ongoing belief of our physician colleagues that medical practice encompasses the whole of healthcare, and pharmacists, physical therapists, dieticians and professional nurses (and other healthcare providers) require direction by physicians in order that patients receive appropriate care. The evidence does not substantiate this.

Healthcare is increasingly complex with no one discipline capable of “knowing” what each discipline has taken years of education and clinical experience to learn and henceforth, apply in the care of patients. There is mounting appreciation that interprofessional teamwork and patient-centered care are the most important components of our future healthcare system particularly for patients with multiple chronic conditions. The current effort to develop regulations needs to be undertaken in the spirit called for by multiple national bodies, i.e. the IOM’s “The Future of Nursing” Report, the Institute of Healthcare Improvement, the Joint Commission and numerous others. Let healthcare professionals provide the care they were educationally prepared to deliver. The time is now for true leadership in the commonwealth of Virginia in guiding the redesign of our healthcare system so patients receive the care they deserve.

I would challenge the Joint Boards to participate in these discussions in a manner that eliminates barriers to all advanced nursing practice, and in this case, permits NPs the autonomy to deliver primary care as they were educationally prepared. NPs, like all APNs, are deemed competent to provide nursing care through educational preparation, national licensing examinations and certifications. I would specifically request that clear lines of accountability be established in these regulations for our physician colleagues. There is significant risk for license censure when APN practice is tied to physician practice. APNs have been wrongly held accountable for unprofessional physician conduct (i.e. dereliction of duty, etc.) while the involved physician(s) were not concomitantly reprimanded by the Board of Medicine. This constitutes regulatory bullying, wherein the professional competence and reputation of APNs is damaged while the physician remains unscathed. Finally, the regulations should distinguish this type of workplace violence so that the instigators and facilitators of regulatory bullying may be held accountable. Let the regulations reflect a just practice environment.

The Medical Society of Virginia (MSV) serves as the voice for more than 30,000 physicians, residents, medical students, physician assistants and physician assistant students, representing all medical specialties in all regions of the Commonwealth. These clinicians deliver health care each day to the millions of residents of the Commonwealth. The MSV appreciates the opportunity to provide comment on House Bill 793. 

House Bill 793 will allow nurse practitioners the ability to transition to practice without maintaining a practice agreement with a patient care team physician.  Our members work with their nurse practitioner colleagues each day and believe they are valuable members of the patient care team. The MSV believes the regulations must ensure all practitioners are prepared to deliver care that meets Virginia’s standard of care requirements. Patients deserve to be assured that every health care provider that practices autonomously has the requisite experience to provide safe and high quality care. With the wide variation in nurse practitioner programs, the regulations must require that a nurse practitioner who seeks to practice autonomously is appropriately prepared and can meet the necessary core competencies. Thus, MSV surveyed physicians and physician assistants across practice settings, practice size, and specialties for feedback.

Physicians and other clinicians provided feedback on the following issues:

• Strongly support matching identical or similar physician specialty to a nurse practitioner specialty;
• Identifying the core competencies, educational requirements, and clinical experience needed for nurse practitioners through the attestation process;
• Statutory requirement on physician relationship for emergencies or referrals; and
• Physician liability for attestation.

Similar specialties and patient care population

First, it is important to note lines 341-344 of the law provide that a nurse practitioner seeking to practice without an agreement must have worked with “a patient care team physician who routinely practiced with a patient population and in a practice area included within the category for which the nurse practitioner was certified and licensed.” The medical community believes it is of the utmost importance that the regulatory standards ensure that the physician-nurse practitioner training must require alignment either between similar patient population and/or the national certification category for each practitioner. The MSV has developed a crosswalk for consideration as a basic framework. For those nurse practitioners without a nationally certified specialty, the Joint Boards must create a strong process to consider their educational and practical experience.

We also have concerns that any one physician will be able to provide the requisite training. In the current process of practice agreements, the nurse practitioner practices in a given clinical location where many resources are available and new situations can be immediately addressed by a practicing physician.

Core Competencies

Physicians are prepared to practice autonomously after four years of medical school, five to seven years of a specialized residency program, and standardized national testing that ensures their ability to safely care for patients. Only after rigorous training, testing, and supervision by expert clinical faculty, are physicians permitted to practice independently. Medical school was revolutionized after the Flexner Report[i] in 1910 which found that medical schools as a for-profit enterprise did not yield positive results. Under this model, physicians’ level of practice was variable at best, and incompetent and harmful at its worst. This is relevant as we consider the impact of various education models on patient care. The medical community is very concerned about achieving and maintaining a sufficient standard for core competencies for all practitioners who practice autonomously.

Understanding these core competencies such as differential diagnosis, clinical pharmacology, identifying and managing multiple co-morbidities and referral protocol are vital in practicing independently. Further suggestions are attached in Appendix A for your consideration. The medical community requests that you develop a robust standard that defines competencies that should be met and are equivalent of at least five years of full-time clinical experience.  It is important that such a knowledge base be determined by the Joint Boards of Medicine and Nursing in order to provide full confidence in public safety.  Annual review of hours and monitoring of a nurse practitioner as they move through the attestation process would ensure that their training has met these high standards.  This knowledge base and a plan for transition to practice should be specified at the onset of the transition to practice period of training.

To ensure the required clinical experience meets the aforementioned standards, a nurse practitioner at the start of the five year period, should submit to the Joint Boards of Nursing and Medicine a plan that outlines how they will meet the education and training requirements as established in the final regulations.

Emergency Referrals and Liability

Under the current system of care, the patient care team physician and nurse practitioner have an established partnership to address complex cases or emergencies. As individual nurse practitioners transition on their own, they will be required to “establish a plan for referral of complex medical cases and emergencies to physicians or other appropriate health care providers.” The MSV strongly supports patients having access to the most appropriate health care provider, especially for complex or emergency issues; there is concern about how this will be accomplished. Physicians are concerned about the management of this relationship. Will they unknowingly be designated as part of a nurse practitioner’s plan? Who would be accountable for the care of the patient?  Do these physicians have to be readily available at all times?  Is the physician able to review the patient panel and records regularly? These questions all lead to concerns of patients’ well-being.

Physicians are also concerned about the potential for liability.  As illustrated in the questions above, what legal responsibility are they incurring as a result of being unofficially associated with a nurse practitioner? Further, there are concerns about their potential liability regarding attestation. The attestation must be carefully constructed so that physicians are attesting only to the completion of the required time while being of the same specialty and/or treating the same population; it is the responsibility of the Joint Boards to ensure competency for nurse practitioners. Currently, Virginia statute provides that a physician is not liable solely for being a patient care team physician; the regulations need to extend this same liability protection to physicians for signing off on attestation.

The Medical Society of Virginia appreciates the opportunity to provide comments on this important issue. Should you have questions or need additional information, please do not hesitate to reach out to Ralston King (rking@msv.org).

Sincerely,

Kurtis S. Elward, M.D., M.P.H., FAAFP

President

Medical Society of Virginia

[i] Cooke, M., Irby, D., Sullivan, W., Ludmerer, K. (2006) American Medical Education 100 Years After the Flexner Report. New England Journal of Medicine, 355:1339-1344. Retrieved from  https://www.nejm.org/doi/full/10.1056/NEJMra055445

Medical Society of Virginia Public Comments

Appendix A – Suggested Core Competencies

These are comments from a wide array of physicians who have worked with nurse practitioners and who wished to convey their experience in what skill set affords the ability to provide appropriate patient care.

• Good fund of knowledge, sufficient clinical experience via residency and fellowships, excellent physical exam skills, pharmacology knowledge, managing patients with co-morbidities.

• Differential diagnosis and to be steeped particularly in Internal Medicine which would be helpful as a basic start in any subspecialty.

• In addition to anatomy, pathology, pharmacology, history/physical examination, differential diagnosis, and management of the complex patient, a clinical experience pathway that provides opportunity to distinguish conditions that may rapidly become critical from those conditions that are unlikely to become critical.

• Core knowledge in specialty, knowledge of pharmacotherapy in said specialty, ability to generate a reasonable differential diagnosis and plan of action, the ability to manage several different issues simultaneously, and the ability to know when to refer and who to refer to.

• Experience with diverse patient populations. Background in internal medicine, so a practitioner can make an adequate evaluation and judgment of a condition of a patient.

• Having a broad scope of medicine to handle pharmacology, differential diagnosis, co-morbidities, and how multiple fields of medicine overlap, proper work up, referrals and what their limits are.

• Ability to take comprehensive history and generate differential diagnosis. Understand medication and medication interactions. Also in children understand weight based dosing. Understand community resources and refer appropriately.

• Differential diagnosis referral protocol medical knowledge, including current evidence based medicine. This also will include managing complex patients and their co-morbidities with multiple medications

• The ability to critically think in the areas of history taking, physical examination, diagnostic study and imaging interpretation, pharmacology, differential dx, and having understanding of the patient population and health system/setting that you work in.

• Diagnostic acumen, clinical exam specialty skills, differential diagnosis, managing medications, interpreting lab and radiographic testing, referral sources.

• Diagnostic capabilities with both visual and pathological correlation, ability to prescribe and manage medications in an aging population, appropriate work up and treatment algorithm for both common and rare dermatological conditions.

• Understanding of normal physiology. Understanding pathophysiology of disease states. An ability to compile a comprehensive differential diagnosis list and narrow down this list in an efficient manner. The ability to balance the care of complex patients with a number of comorbid conditions.

• Competent history taking and physical exam. Differential diagnosis; know when to refer and/or ask for consultation.

• Practice-based Learning and Improvement: Show an ability to investigate and evaluate patient care practices, appraise and assimilate scientific evidence, and improve the practice of medicine.

• Patient Care and Procedural Skills: Provide care that is compassionate, appropriate, and effective treatment for health problems and to promote health.

• Systems-based Practice: Demonstrate awareness of and responsibility to the larger context and systems of health care. Be able to call on system resources to provide optimal care (e.g. coordinating care across sites or serving as the primary case manager when care involves multiple specialties, professions or sites).

• Medical Knowledge: Demonstrate knowledge about established and evolving biomedical, clinical, and cognate sciences and their application in patient care.

• Interpersonal and Communication Skills: Demonstrate skills that result in effective information exchange and teaming with patients, their families and professional associates (e.g. fostering a therapeutic relationship that is ethically sound, uses effective listening skills with non-verbal and verbal communication; working as both a team member and at times as a leader). Professionalism: Demonstrate a commitment to carrying out professional responsibilities, adherence to ethical principles and sensitivity to diverse patient populations.

• To be able to practice independently, one must be able to recognize both uncommon as well as common presentations of illness and disease. Must be aware of latest recommendations. Must be able to recognize when course of illness or treatment is not as expected and have knowledgeable base to intervene appropriately

• Pharmacology, differential diagnosis, diagnostic ordering, referral protocol, dual diagnosis co-management

• Emergency management. Safety/adverse effects management, risk assessment (in our field suicide, violence, relapse, etc. prognosis/outcome and disability assessment and opinion, referral for hospice palliative care (example, terminal dementia patients), assessment of testing needs - in our field for EEG, MRI, Psychometry, etc.

• Specialty specific exam, differential diagnosis, proper imaging and lab orders, prescription management, influence of co-morbidities on active problems, proper follow-up.

• Understanding normal physiology and pathophysiology. Being able to create a broad differential diagnosis. Understanding pharmacology and which medications to prescribe. Also to know which medications to prescribe when patients have various organ failures.

• Differential diagnosis Evaluation and management of disease processes. Ability to discuss goals of care with patients and families Ability to know when one does not know - know when to ask for help (appropriate consultation).

• Differential diagnosis, surgical skills, managing immunosuppressive medications and immunosuppressive patients.

• Differential diagnosis, multiple procedures such as intubation, lumbar punctures, central lines, thoracostomy, cricothyroidoyomy, ultrasound, control of nosebleeds, etc., pharmacology, triaging, handling multiple complex patients simultaneously, knowing when to admit vs outpatient treatment, know when need emergent referral vs urgent or outpatient referral.

• Solid knowledge of medication interactions, side effects, pharmacokinetics. Ability to think outside of the box. Experience with disease process. Differential diagnosis and appropriate workup.

• Pharmacology, differential diagnosis, experience with rotations in various core fields (pulmonary, GI, cardiac, endocrine, rheum, ID etc.). In hospital experience is also a necessary requirement.

• Understanding the interplay between disease states and the various treatment options available.
• The ability to take a thorough history with the answers leading to more in depth questions, do a complete physical, and be able to assimilate the information into a diagnosis or differential. Then the ability to do a cost effective workup to confirm or narrow down the diagnosis.

• Ability to develop a robust differential diagnosis, recognizing when patients have problems/require treatment outside one's skill set, ability to critically evaluate evolving medical science and safely incorporate relevant portions into practice, managing patients with comorbidities, mastery of standards of care, stability within a single lane of practice.

• Ability to develop a robust Differential diagnosis, recognizing when patients have problems/require treatment outside one's skill set, ability to critically evaluate evolving medical science and safely incorporate relevant portions into practice, managing patients with comorbidities, mastery of standards of care, stability within a single lane of practice, perspective supervision on testing, such as stress testing.

• Risk stratification, EKG interpretation, recognizes tissue quality that is not normal. Assemble differential diagnoses. Develop treatment; plan to work through the differential. Utilize technology to manage the process of treating patients.

• Working knowledge of medication efficacy, adverse effects, and therapeutic range. Adequate differential diagnosis, for each problem. Knowledge of illnesses with significant co-morbidities.

• History taking, physical examination, differential diagnosis, appropriate ordering of diagnostic tests, pharmacology, and referral protocol.

• Profound knowledge of medication side effects and potential unknown interactions, based on pharmacodynamics of the medication. Ability to formulate a differential diagnosis in a non-linear fashion.

• Prioritizing care for sicker patients as well as the most life threatening aspects of each patient’s condition and taking ownership of the care without unnecessary referrals to multiple other specialists when cases get more challenging Ability to formulate/initiate treatment plans for all the patients who are normally covered within a particular specialty, not only the top 10 diagnosis.

• Full education with complete anatomy and physiology course work, full complement of clinical pharmacology course work, full understanding and competence of managing patients with multiple co-morbidities, evidence of health outcomes that are within the national averages and not below, an established referring access to specialties, backup for caseloads that require additional clinical expertise.

• Understanding of physiology, Understanding of organ systems, tools needed for efficient evaluation of problems. 1. Obtaining a focused, thorough history 2. Understanding of risk factors for various comorbidities 3. Physical exam appropriate for complaint- with the knowledge of what is normal and what you are looking for in each step 4. Understand the underlying pathophysiology of disease so as to link various history and physical exam findings 5. Thorough knowledge of evidence based medicine 6. Ability to develop a reasonable differential diagnosis with the reasoning for and against each differential 7. Understand the risks and benefits of serious work ups, with the knowledge of how to respond to abnormal results of said workups 8. Understand the various treatment modalities, with their risks and benefits. Knowledge of disease, differential diagnosis, treatment options / algorithms, potential side effects, associations with internal disease, diagnostic testing, procedures (biopsies, injections, excisions), managing complex patients, drug interactions.

• Able to take a full history and do a thorough PE including a rectal, filament testing for diabetics, neurologic testing. Fully evaluate lab, x-ray, pathology and the tests. Read EKGs formulate disease hypotheses; know when to follow and when to refer. Discuss diseases with patients and family. Follow-up and be available.

• Understanding of pharmacology, drug interactions, physiology of body systems and pharmacodynamics. 2. Understanding of basic disease processes, complications, prevention and treatment. 3. Recognition of emergency scenarios and ability to manage emergency scenarios to basic lifesaving techniques and triage. 4. Adequacy to ensure follow up of abnormalities and test data etc. 5.Understanding of aseptic technique, sterilization, and disease control, both for procedures and for communicable diseases. 6. Ability to properly hand off and refer problems out of knowledge base or scope of ability, e.g. no dumping or putting referral into patients responsibility when it should be the practitioner's responsibility.

• Understanding of pathophysiology, pharmacology, indications for surgical referrals as well as managing psychiatric and developmental comorbidities Interpretation of medical imaging and neurophysiology results, referral pattern and facilitation of consultations.

• Strong knowledge base, ability to recognize limitations, extensive knowledge of pharmacology, ability to refer to MD quickly, managing multiple health problems with the understanding of why we do things - for ex, not just giving diuretic for swollen legs but recognizing that this maneuver might be life threatening if heart failure symptoms are due to pericardial effusion.

• Differential diagnosis Management of chronic conditions Understanding of management of complications of pregnancy/postpartum care Understanding of when to refer/transfer care

• Pharmacology Procedural skills (IUDs, biopsies, etc.). Adherence to current best clinical practice guidelines.

• A working knowledge of a broad range of medical conditions and interactions as well as the ability to recognize situations or conditions that may be rare, but if unrecognized or not addressed, can lead to significant morbidity or mortality. The ability to formulate a differential diagnosis that is appropriately focused (so as not to promote a shotgun approach to the workup) while recognizing the existence of less likely but critically important conditions/situations. The ability to demonstrate a clear understanding of the limitations of one's training and the need to refer patients to specially trained providers when it is in the patient's best interest WITHOUT needing to rely solely on specialists for conditions typically treated by others within one's field. An appropriate respect for training differences amongst different provider types and the ability to acknowledge that "we don't know what we don't know" and to discuss cases with other providers when patients are atypical or have atypical responses to treatment.

• Knowledge in basic science, pathology, physiology. The training and experience to apply this knowledge to create a differential diagnosis. Appropriate diagnostic testing. Formulating a treatment plan. Ability to carry out the treatment plan. Ability to recognize when a treatment plan is not working. Knowledge of ones limitations.

• Comprehensive background in pathology, physiology, anatomy, pharmacology, co-morbidity disease/injury management, radiology, wound management, methodical diagnostic protocol.

• Exposure to mental health issues, demonstrated communication skills are also important pharmacology, differential diagnosis, knowing when to refer, managing co-morbidities, recognizing and managing common mental health co-morbidities, vaccination schedules/side effects/counseling, developmental assessment and recognition/management of abnormalities; recognizing and addressing social determinants of health; effective care coordination skills; effective community interactions (schools, CSBs, etc.), ability to manage and support those with disabilities (including knowledge of waivers, disability benefits, etc.).

• Adequate clinical patient contact hours under the supervision of an experienced provider, demonstrated knowledge in pharmacology and pharmokenetics, documented core knowledge in illness and disease mechanisms coupled with treatment modalities of the same, established resources for consultation and collaboration with adequate peers for management of difficult/refractory patients.

• Physiology, pharmacology, physical diagnosis, referral protocol, pathology, hematology, laboratory science, management of chronic illness.

• The ability to do a proper examination, understand what testing to order (and not order), and interpretation of results. They will also need to be familiar with the wide range of disease processes and how that's relevant to each other. They will also need to be familiar with various therapeutic options as well as contraindications. They should also need to have a process to keep up to date with changing technology, information, guidelines, etc.

• Core competencies include pathophysiology, anatomy and physiology, pharmacology, the ability to have a wide differential diagnosis but know which are the most critical and relevant tests to order to determine etiology. It is vitally important for clinicians to know what they do not know and when to ask for help through consultation or referral. Knowledge of systems based practice and the barriers to care for different patient populations are also important. Autonomous practice should be limited to those who are able to shoulder the associated liability and consequences.

• Knowledge of oncology drugs and comprehensive treatment of cancer. Hematology knowledge. Pain management. End of life issues.

• Accurate history taking, physical exam, creation and refinement of differential diagnosis, pharmacology, lifesaving procedures, routine procedures, appropriate consultation, admission criteria recognition, discharge and follow up plan creation, EMTALA procedure, documentation, medicolegal concerns.

• Pharmacology, correct visual diagnosis of cancer and concerning lesions (often incredibly subtle), differential diagnosis, referral protocol, appropriate procedural technique AND appropriate decision making for performance of procedures such as biopsies and cryosurgery.

• Pharmacology principles such as pharmacokinetics and pharmacodynamics. Rapid evaluation of critically ill patients and initiation of therapy with continuous reassessment Management of multiple co-mire diseases in the acute setting pharmacology, knowledge of emergent vs. non-emergent complaints, differential diagnosis, managing complex patients, knowledge of vaccinations.

• Critical thinking skills and medical synthesis skills Strong foundation in basic and clinical sciences in order to generate a broad differential diagnosis. Clinical pharmacology skills. Ability to manage patients with multiple co-morbidities. Understanding of the interdependency of the health care system and navigating the complexities. Laboratory ordering and interpretation. Clinical pharmacology and medication prescribing.

On behalf of the Virginia Academy of Family Physicians (“VAFP”), we are writing to provide comment as the Joint Boards of Medicine and Nursing consider regulations to carry out House Bill 793.  The VAFP represents nearly 3,000 family physicians and family medicine residents across Virginia.

In commenting regarding the topics specifically under consideration at the Joint Boards upcoming meeting, VAFP respectfully requests that you consider the following:

Equivalent of at least five years of full-time clinical experience
• VAFP’s position is that the quality of the five year’s of full-time clinical experience is equally important to the quantity of the experience.  After medical school, physicians achieve post-graduate, formal, structured training in medical residency programs.  Some physicians go on to complete additional formal, structured training in fellowship programs.  The Joint Boards regulations in this area should seek to ensure the quality of the nurse practitioner’s five years of full-time clinical experience mirrors the quality of a medical residency program as closely as possible.

Routine practice in a practice area included within the category for which the NP was certified and licensed
• VAFP’s position is that it is fundamentally important for there to be alignment between the attesting physician’s board certification and the category for which the NP was certified and licensed.  For instance, a Board certified family physician should attest to a family practice nurse practitioner’s qualifications for independent practice.  It would be inappropriate for a family physician to attest to a nurse practitioner practicing in an acute care setting, such as cardiology.  Likewise, it would be inappropriate for a cardiologist to attest to a nurse practitioner practicing in a family practice setting.  Additionally, “routine,” as set forth in line 342 of House Bill 793,  should be defined to ensure that the physician and the nurse practitioner have robust overlap in their physical presence during their interactions with their common patient population in order to promote the collaboration and training necessary to empower the nurse practitioner to practice independently.

Requirements of an attestation of practice
• VAFP’s position is that the physician attestation should include, in addition to the stated requirements of Lines 339 – 345 of House Bill 793, significant detail regarding the patient population served by the attesting physician and the nurse practitioner, a description of the amount and nature of collaboration between the physician and the nurse practitioner while serving the common patient population, and any recommendations by the attesting physician for  limitations on the nurse practitioner’s independent practice.

Fee associated with submission of attestation and issuance of autonomous designation
• VAFP has no position on the appropriate fee associated with an attestation and application for independent practice.

Acceptance of “other evidence” demonstrating that the applicant met the requirements
• VAFP’s position is that the Board should maintain a very conservative standard for other evidence, in lieu of a physician attestation, satisfactory to justify independent practice.  Absence of a physician attestation may be indicative that the non-attesting physician has reservations regarding the nurse practitioner’s readiness for independent practice. VAFP strongly recommends that the Joint Boards require that a statement be sought from a non-attesting physician so that the Joint Boards may fully evaluate the circumstances of the nurse practitioner’s application for independent practice. 

Endorsement of experience in other states
• VAFP’s position is that the standard for endorsement in other states should mirror the standards for the composition of the five years of full-time clinical experience established for Virginia-based nurse practitioners. The attestation should require a similar accounting of both these clinical hours and their composition.
 

Unprofessional conduct – falsification of attestation
• VAFP’s position is that falsification of an attestation constitutes unprofessional conduct and should subject the offending nurse practitioner to disciplinary action by the Joint Boards.

The VAFP appreciates the opportunity to provide input into the Joint Board’s regulatory development process.  Thank you for your efforts to ensure that the regulatory framework established to implement House Bill 793 best protects the health and safety of all Virginians. 

Respectfully,

Rupen Amin, M.D.        Jesus Lizarzaburu, M.D.
President, VAFP           Legislative Chair, VAFP