Cathy Jordan

by Cathy Jordan

rimary care - with its focus on preventive medicine and early disease detection - is a key component in reforming the nation's overburdened health care system. But in Georgia, there are still many costly and unnecessary roadblocks to efficient health care:

A senior citizen, living on a fixed income, has a host of illnesses that require medical attention from several different health care providers. After being evaluated by a geriatric nurse practitioner at one clinic, he has to wait for a doctor he has never seen to sign his prescription.

An inner-city preschool child has an earache, but nobody in her family can get off work to take her to a doctor. Through a Head Start program, she is examined by a pediatric nurse practitioner, who diagnoses the child with an ear infection and strep throat. Before she can get a prescription, though, she still has to see a doctor. Someone must take time off from work and take her by bus to the nearest clinic.

A busy executive is suffering from abdominal pain. He reschedules his meetings and heads across town to see his family nurse practitioner. After a comprehensive physical exam, the nurse practitioner offers to call a medication order into the pharmacy. Not having his HMO information with him, though, the businessman asks to take the written prescription with him so he can have it filled later. But the nurse practitioner cannot legally write the prescription.

For the past five legislative sessions, a hotly debated issue has been whether advanced practice registered nurses (APRNs) in Georgia should be allowed to write a prescription for a medication or medical device as part of patients' overall treatment plan. Georgia is now the only state that doesn't allow APRNs to write prescriptions!

This year, the proposed bill, HB 784, passed the House but stalled in the Senate. It would have allowed APRNs - nurse midwives, nurse anesthetists, psychiatric/mental health clinical nurse specialists, and nurse practitioners (pediatric, adult, and family) - to prescribe medications within their specialty area or scope of practice at the time of service.

Current law allows these professionals to "administer, order, or dispense drugs" under delegated medical authority as authorized by protocol. But ordering is not construed as prescribing or issuing a written prescription.

The most recent proposal called for establishing collaborative practice agreements that set terms and conditions for the exercise of prescriptive authority by the APRN within a particular practice setting and with a particular physician or set of physicians. Under terms of HB 784, physicians and APRNs would have had to mutually agree on this written plan, and physicians would have had to sign off on the prescription within 10 working days. No more than two APRNs would have prescriptive authority per physician practice, and APRNs could not write prescriptions for Class 2 narcotics such as morphine and Ritalin.

ARPNs routinely conduct physical exams, take medical histories, diagnose and treat common acute minor illnesses and injuries, manage chronic illnesses, order and interpret lab tests and x-rays, and counsel and educate patients. They order drugs, treatments, and diagnostic studies by protocol.

Protocol implies that the authority to perform these medical acts derives from physician delegation. In actuality, physicians see very few of the patients that APRNs care for and then only when the APRN requests special consultation for advanced medical needs.

Most patients with routine problems such as sore throats, ear infections, or coughing are examined and treated by an APRN. The physician usually only signs the prescription -- without seeing or discussing the patient's case. However, the act of leaving the patient's room and walking down the hall to get a prescription signed, multiplied by each patient seen, expends a great deal of clinical time toward prescription signing and away from patient care. An APRN might spend as much as an hour a day just getting physician signatures for prescriptions. This is not trivial, in light of the time constraints put on health care providers by managed care.

Presently APRNs can call a prescription into a pharmacy under the name of a collaborating physician but can't write that prescription. Written prescriptions ensure a safer form of documentation to the patient and reduce the risk of error since one drug may be mistaken for another on a phone call. Also, freeing the physician from signing each prescription for the APRN promises to use physician services more appropriately and cost-effectively since their time with patients will be less interrupted and fragmented.

Without prescriptive authority, APRNs are limited to seeing patients near or in a physician practice. Prescriptive authority would allow APRNs to broaden their practice to more medically underserved areas of our state and increase access to care. In addition, prescriptive authority would decrease the cost of health care in Georgia as APRNs can provide prescriptions to those in need in a timely and convenient manner.

Still, some physicians question whether APRNs possess the knowledge base to write prescriptions.

All APRNs in Georgia must meet rigorous education, certification, and continuing education requirements. Skills needed for advanced practice (such as proficiency in pathophysiology, pharmaceuticals, and patient assessment and management) are built on knowledge learned in college nursing programs and integrated into the APRN's course work. A master's degree or higher in nursing within the respective specialty and national certification is required for all APRNs. Nurses who meet these requirements specialize in caring for specific populations, including families, the elderly, and those with psychiatric problems.

Twenty-five years of studies comparing physicians and APRNs reveal equivalent quality of care in those specific areas commonly shared by the two professions. A recent study reported in JAMA followed 1,316 adults who were randomly assigned to the ambulatory care of either nurse practitioners or physicians. Nurse practitioners had the same authority, responsibilities, productivity and administrative requirements, and patient population as primary care physicians. No statistically significant difference in patient outcomes was found.

Additionally, researchers have determined that APRNs have better patient outcomes in illnesses where communication with patients is integral to recovery and wellness. APRNs do the bulk of patient education, listening to patients, and counseling them on how to take their medications and get follow-up care.

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Nurse practitioners historically have been the significant and sometimes only health care providers to the state's chronically underserved -- the elderly, the poor, and people in rural areas. Now APRNs are emerging as competent, efficient health care providers for patients who can afford to go to a private practice. Passage of HB 784 would have helped all Georgians by allowing APRNs to better manage minor and chronic illnesses.

For more information on HB 784, see www.state.ga.US/services/leg.

Pediatric APRN Cathy Jordan is an assistant clinical professor in the Nell Hodgson Woodruff School of Nursing at Emory. She has spent more than a decade advocating for prescriptive authority for advance practice nurses in Georgia.

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