TWENTY-NINTH LEGISLATURE, 2017
STATE OF HAWAII
A BILL FOR AN ACT
relating to prescriptive authority for certain clinical psychologists.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF HAWAII:
SECTION 1. The legislature finds there is an insufficient number of prescribing mental health care providers available to serve the needs of Hawaii's people. The delivery of quality, comprehensive, accessible, and affordable health care is enhanced by collaborative practice between licensed clinical psychologists and medical doctors. Providing advanced training in psychopharmacology to certain clinical psychologists who wish to become prescribing psychologists will be beneficial to residents of Hawaii who live in rural or medically underserved communities, particularly in locations where mental health professionals with prescriptive authority are in short supply.
The legislature further finds that the mental health needs of the State continue to outweigh present capacity, particularly in remote or rural communities. According to a Report on Findings from the Hawaii Physician Workforce Assessment Project (December 2014), physician shortages, including psychiatry, are highest in Hawaii's rural areas. Across the different counties, the greatest shortage of psychiatrists is found in Maui county, which has a 41.2 per cent shortage, followed by Hawaii county, with a 39.2 per cent shortage, and Kauai county, which has a 29.5 per cent shortage. The report reflects no shortage of psychiatrists in the city and county of Honolulu.
According to the federal Centers for Disease Control and Prevention, suicide is the third leading cause of death for persons between the ages of ten and twenty-four and the tenth leading cause of death in the United States. Suicide was the single leading cause of fatal injuries in Hawaii from 2004 to 2013, with a generally increasing trend in the annual suicide rate among residents. On average, one hundred seventy people die from suicide and eight hundred fifty-two people attempt suicide in Hawaii each year. Studies have shown that many people who commit suicide had received little or no treatment for their mental health problems due to barriers to accessing appropriate and effective care in the community, including lengthy wait times for appointments and a lack of accessible mental health care providers. While causes for suicide are complex, the most commonly reported contributing factors include depression, relationship problems, and serious medical problems. These are conditions that occur frequently but have been found to respond favorably to evidence-based treatments, such as cognitive behavioral therapy and psychotropic medications, when identified and treated early.
A 2015 article in the Honolulu Star-Advertiser reported that fifty-one per cent of all people arrested in 2013 in Honolulu suffered from serious mental illness or severe substance intoxication. This represents an almost two-fold increase in arrests of individuals with psychiatric illness or substance abuse issues in the period following substantial cuts to state-supported mental health services in 2009. A 2014 survey by the Treatment Advocacy Center indicates that there are ten times more people with serious mental illness in jails and prisons than there are in state psychiatric institutions across the country.
The legislature additionally finds that according to the National Alliance on Mental Illness and the federal Substance Abuse and Mental Health Services Administration, approximately thirty-two thousand adults in Hawaii, representing more than three per cent of the population, live with serious mental illness. However, this figure may not completely reflect the scope of need, as it does not include individuals with other clinical diagnoses such as unipolar depression, anxiety disorders, adjustment disorders, substance abuse, or post-traumatic stress disorder.
The legislature also finds that clinical psychologists are licensed health professionals with an average of seven years of post-baccalaureate study and three thousand hours of post-graduate supervised practice in the diagnosis and treatment of mental illness. However, because the current scope of clinical psychologists' practice does not include prescribing medications, these providers' patients must consult with and pay for another provider in order to obtain psychotropic medications when indicated.
The legislature has previously authorized prescription privileges for advanced practice registered nurses, optometrists, dentists, and naturopathic physicians. Licensed clinical psychologists with specialized education and training in preparation for prescriptive practice have been allowed to prescribe psychotropic medications to active duty military personnel and their families in federal facilities and the United States Public Health Service, including the Indian Health Service, for decades. In recent years, Iowa, Illinois, Louisiana, and New Mexico adopted legislation authorizing prescriptive authority for advanced trained psychologists. There are approximately one hundred thirty psychologists with prescriptive authority in Louisiana and New Mexico. Furthermore, there have been no adverse events or complaints brought against any of these prescribing psychologists regarding their practice. In Louisiana and New Mexico, prescribing psychologists have been able to fill positions that were vacant for a number of years and continue to serve predominantly indigent or rural populations.
The legislature further finds that the American Psychological Association has developed a model curriculum for a master's degree in psychopharmacology for the education and training of prescribing psychologists. Independent evaluations of the federal Department of Defense psychopharmacological demonstration project by the United States General Accounting Office, now known as the Government Accountability Office, and the American College of Neuropsychopharmacology, as well as the experiences of Louisiana and New Mexico, have found that appropriately trained prescribing psychologists can prescribe and administer medications safely and effectively.
The purpose of this Act is to authorize the board of psychology to grant prescriptive authority to prescribing psychologists who meet specific education, training, and registration requirements.
SECTION 2. Chapter 465, Hawaii Revised Statutes, is amended by adding a new part to be appropriately designated and to read as follows:
"Part . Prescribing psychologists
§465- Definitions. As used in this part unless the context otherwise requires:
"Advanced practice registered nurse with prescriptive authority" means an advanced practice registered nurse, as defined in section 457-2, with prescriptive authority granted pursuant to section 457-8.6.
"Clinical experience" means a period of supervised clinical training and practice in which clinical diagnoses and interventions, which can be completed and supervised as part of or subsequent to earning a post-doctoral master of science degree in clinical psychopharmacology training, are learned.
"Controlled substance" shall have the same meaning as in section 329-1.
"Forensically encumbered" means a person who has been found to be detained by Hawaii courts for forensic examination, or committed to certain psychiatric facilities under the care and custody of the director of health for appropriate placement by the family courts, district courts, or circuit courts; has been placed on conditional release or released on conditions by a judge in Hawaii courts; or is involved in mental health court of a jail diversion program.
"Narcotic drug" shall have the same meaning as in section 329-1.
"Opiate" shall have the same meaning as in section 329-1.
"Prescribing psychologist" means a clinical psychologist who has undergone specialized training in clinical psychopharmacology, passed a national proficiency examination in psychopharmacology approved by the board, and been granted a prescriptive authority privilege by the board.
"Prescription" means an order for a psychotropic medication or any device or test directly related to the diagnosis and treatment of mental and emotional disorders pursuant to the practice of psychology.
"Prescriptive authority privilege" means the authority granted by the board to prescribe and administer psychotropic medication and other directly related procedures within the scope of practice of psychology in accordance with rules adopted by the board.
"Primary care provider" means a physician or osteopathic physician licensed or exempted from licensure pursuant to section 453-2 or an advanced practice registered nurse with prescriptive authority.
"Psychotropic medication" means only those agents related to the diagnosis and treatment of mental and emotional disorders pursuant to the practice of psychology, except drugs classified into schedule I, II, or III pursuant to chapter 329, opiates, or narcotic drugs; provided that psychotropic medication shall include stimulants for the treatment of attention deficit hyperactivity disorder regardless of the stimulant's schedule classification.
"Serious mental illness" means bipolar I disorder, bipolar II disorder, delusional disorder, major depressive disorder with psychotic features, psychosis secondary to substance use, schizophrenia, schizophreniform disorder, and schizoaffective disorder, as defined by the most current version of the Diagnostic and Statistical Manual of Mental Disorders.
§465- Administration. (a) The board shall prescribe application forms and fees for application for and renewal of prescriptive authority privilege pursuant to this part.
(b) The board shall develop and implement procedures to review the educational and training credentials of a psychologist applying for or renewing prescriptive authority privilege under this part, in accordance with current standards of professional practice.
(c) The board shall determine the exclusionary formulary for prescribing psychologists.
(d) The board shall have all other powers which may be necessary to carry out the purposes of this part.
§465- Prescriptive authority privilege; requirements. Beginning on July 1, 2018, the board shall accept applications for prescriptive authority privilege. Every applicant for prescriptive authority privilege shall submit evidence satisfactory to the board, in a form and manner prescribed by the board, that the applicant meets the following requirements:
(1) The applicant possesses a current license pursuant to section 465-7;
(2) The applicant successfully graduated with a post doctoral master's degree in clinical psychopharmacology from a regionally-accredited institution with a clinical psychopharmacology program designated by the American Psychological Association, or the equivalent of a post doctoral master's degree, as approved by the board; provided that any equivalent shall include: study in a program offering intensive didactic education, including instruction in anatomy and physiology, biochemistry, neuroanatomy, neurophysiology, neurochemistry, physical assessment and laboratory examinations, clinical medicine and pathophysiology, clinical and research pharmacology and psychopharmacology, clinical pharmacotherapeutics, research, and professional, ethical, and legal issues;
(3) The applicant has clinical experience that includes:
(A) A minimum of four hundred hours completed in no less than twelve months and no more than forty-eight months;
(B) Supervision of a minimum of one hundred patients; and
(C) No less than two hours per week of supervision by a licensed physician or osteopathic physician, an advanced practice registered nurse with prescriptive authority, or a prescribing psychologist; and
(4) The applicant has successfully passed the nationally recognized Psychopharmacology Examination for Psychologists developed by the American Psychological Association's Practice Organization's College of Professional Psychology relevant to establish competence across the following content areas: neuroscience, nervous system pathology, physiology and pathophysiology, biopsychosocial and pharmacologic assessment and monitoring, differential diagnosis, pharmacology, clinical psychopharmacology, research, integrating clinical psychopharmacology with the practice of psychology, diversity factors, and professional, legal, ethical, and interprofessional issues; provided that the passing score shall be determined by the American Psychological Association's Practice Organization's College of Professional Psychology.
§465- Prescriptive authority privilege; renewal. (a) The board shall implement a method for the renewal of prescriptive authority privilege in conjunction with the renewal of a license under section 465-11.
(b) To qualify for the renewal of prescriptive authority privilege, a prescribing psychologist shall present evidence satisfactory to the board that the prescribing psychologist has completed at least eighteen hours biennially of acceptable continuing education, as determined by the board, relevant to the pharmacological treatment of mental and emotional disorders; provided that a first-time prescriptive authority privilege holder shall not be subject to the continuing education requirements under this section for the first prescriptive authority privilege renewal.
(c) The continuing education requirement under this section shall be in addition to the continuing education requirement under section 465-11.
(d) The board may conduct random audits of licensees to determine compliance with the continuing education requirement under this section. The board shall provide written notice of an audit to a licensee randomly selected for audit. Within sixty days of notification, the licensee shall provide the board with documentation verifying compliance with the continuing education requirement established by this section.
§465- Prescriptive authority privilege; prescribing practices. (a) It shall be unlawful for any psychologist not granted prescriptive authority privilege under this part to prescribe, offer to prescribe, administer, or use any sign, card, or device to indicate that the psychologist is so authorized.
(b) A valid prescription issued by a prescribing psychologist shall be legibly written and contain, at a minimum, the following:
(1) Date of issuance;
(2) Original signature of the prescribing psychologist;
(3) Prescribing psychologist's name and business address;
(4) Name, strength, quantity, and specific instructions for the psychotropic medication to be dispensed;
(5) Name and address of the person for whom the prescription was written;
(6) Room number and route of administration if the patient is in an institutional facility; and
(7) Number of allowable refills, if applicable.
(c) A prescribing psychologist shall comply with all applicable state and federal laws and rules relating to the prescription and administration of psychotropic medication.
(d) A prescribing psychologist shall:
(1) Prescribe and administer only in consultation and collaboration with a patient's primary care provider; provided that a written collaborative agreement between a patient's primary care provider and a prescribing psychologist shall be established and signed prior to the prescribing psychologist prescribing any psychotropic medication for the patient;
(2) Prescribe and administer only in consultation and collaboration with a patient's primary care provider regarding changes to a medication treatment plan, including dosage adjustments, addition of medications, or discontinuation of medications; provided that for patients who are forensically encumbered or for patients with a diagnosis of serious mental illness:
(A) A prescribing psychologist shall prescribe and administer only in accordance with a treatment protocol agreed to by the prescribing psychologist and the treating department of health psychiatrist, and with notification to all other health care providers treating the patient; and
(B) A prescribing psychologist may enter into a collaborative agreement with the department of health; and
(3) Document the consultation in the patient's medical record.
(e) A prescribing psychologist shall not prescribe or administer for any patient who does not have a primary care provider.
(f) A prescribing psychologist shall not delegate prescriptive authority to any other person.
§465- Prescriptive authority privilege; exclusionary formulary. (a) A prescribing psychologist may only prescribe and administer medications for the treatment of mental health disorders as defined by the most current version of the Diagnostic and Statistical Manual of Mental Disorders.
(b) The exclusionary formulary for prescribing psychologists shall consist of drugs or categories of drugs adopted by the board.
(c) The exclusionary formulary and any revised formularies shall be made available to licensed pharmacies at the request of the pharmacies at no cost.
(d) Under the exclusionary formulary, prescribing psychologists shall not prescribe or administer:
(1) Schedule I controlled substances pursuant to section 329-14;
(2) Schedule II controlled substances pursuant to section 329-16;
(3) Schedule III controlled substances pursuant to section 329-18, including all narcotic drugs and opiates; and
(4) For indications other than those stated in the labeling approved by the federal Food and Drug Administration for patients seventeen years of age or younger;
provided that prescribing psychologists may prescribe and administer stimulants for the treatment of attention deficit hyperactivity disorder, regardless of the stimulant's schedule classification.
§465- Drug Enforcement Administration; registration. (a) Every prescribing psychologist shall comply with all federal and state registration requirements to prescribe and administer psychotropic medication.
(b) Every prescribing psychologist shall file with the board the prescribing psychologist's federal Drug Enforcement Administration registration number. The registration number shall be filed before the prescribing psychologist issues a prescription for a controlled substance.
§465- Violation; penalties. Any person who violates this part shall be guilty of a misdemeanor and, on conviction, fined not more than $1,000 or imprisoned not more than one year, or both. Any person who violates this part may also be subject to disciplinary action by the board."
SECTION 3. Section 329-1, Hawaii Revised Statutes, is amended as follows:
1. By adding two new definitions to be appropriately inserted and to read:
""Psychologist with prescriptive authority privilege" means a clinical psychologist who has undergone specialized training in clinical psychopharmacology, has passed a national proficiency examination in psychopharmacology approved by the board of psychology, and has been granted prescriptive authority privilege to prescribe and administer psychotropic medication by the board of psychology pursuant to part of chapter 465.
"Psychotropic medication" means only those agents related to the diagnosis and treatment of mental and emotional disorders pursuant to the practice of psychology, as defined in section 465-1, except drugs classified into schedule I, II, or III pursuant to this chapter, opiates, or narcotic drugs; provided that psychotropic medication shall include stimulants for the treatment of attention deficit hyperactivity disorder regardless of the stimulant's schedule classification."
2. By amending the definition of "practitioner" to read:
(1) A physician, dentist, veterinarian, scientific investigator, or other person licensed and registered under section 329-32 to distribute, dispense, or conduct research with respect to a controlled substance in the course of professional practice or research in this State;
(2) An advanced practice registered nurse with
prescriptive authority licensed and registered under section 329-32 to
prescribe and administer controlled substances in the course of professional
practice in this State; [
(3) A psychologist with prescriptive authority privilege licensed and registered under section 329-32 to prescribe and administer psychotropic medication in the course of professional practice in this State; and
(3)] (4) A pharmacy, hospital, or other
institution licensed, registered, or otherwise permitted to distribute,
dispense, conduct research with respect to or to administer a controlled
substance in the course of professional practice or research in this State."
SECTION 4. Section 329-38, Hawaii Revised Statutes, is amended by amending subsection (g) to read as follows:
"(g) 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 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.
shall have the name of the officer stamped, typed, or handprinted on it, as
well as the signature of the officer; [
(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.
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[
(5) A psychologist with prescriptive authority privilege registered to prescribe and administer psychotropic medication pursuant to part of chapter 465 in consultation and collaboration with a licensed physician or osteopathic physician or advanced practice registered nurse with prescriptive authority shall include on any psychotropic medication prescription issued in compliance with this chapter:
(A) The Drug Enforcement Administration registration number of the licensed physician or osteopathic physician; and
(B) The name of the patient's primary care provider as follows: each written psychotropic medication prescription issued in compliance with this chapter shall include the printed, stamped, typed, or hand-printed name, address, and phone number of the licensed physician or osteopathic physician or advanced practice registered nurse with prescriptive authority and the psychologist with prescriptive authority privilege, and shall be signed by the psychologist with prescriptive authority privilege."
SECTION 5. Section 329-39, Hawaii Revised Statutes, is amended by amending subsection (b) to read as follows:
"(b) Whenever a pharmacist sells or dispenses any controlled substance on a prescription issued by a physician, dentist, podiatrist, or veterinarian, or any psychotropic medication on a prescription issued in compliance with this chapter by a psychologist with prescriptive authority privilege, the pharmacist shall affix to the bottle or other container in which the drug is sold or dispensed:
(1) The pharmacy's name and business address;
(2) The serial number of the prescription;
(3) The name of the patient or, if the patient is an animal, the name of the owner of the animal and the species of the animal;
(4) The name of the physician, dentist, podiatrist, [
veterinarian, or psychologist with prescriptive authority privilege, by
whom the prescription is written; and
(5) Such directions as may be stated on the prescription."
SECTION 6. Section 346-59.9, Hawaii Revised Statutes, is amended by amending subsection (i) to read as follows:
"(i) All psychotropic medications covered
by this section shall be prescribed by a psychiatrist, a physician, [
an advanced practice registered nurse with prescriptive authority under chapter
457 and duly licensed in the State[ .], or a prescribing psychologist
authorized under part of chapter 465."
SECTION 7. Chapter 465, Hawaii Revised Statutes, is amended by designating sections 465-1 to 465-15, as part I and inserting a title before section 465-1, to read as follows:
"Part I. General Provisions"
SECTION 8. Section 465-3, Hawaii Revised Statutes, is amended by amending subsection (e) to read as follows:
Nothing] Other than as
provided in part , nothing in this chapter shall be
construed as permitting the administration or prescription of drugs, or in any
way engaging in the practice of medicine as defined in the laws of the
SECTION 9. (a) The board of psychology shall submit a report to the legislature, no later than twenty days prior to the convening of the regular session of 2021, on the authorization of prescriptive authority to prescribing psychologists who meet specific education, training, and registration requirements pursuant to this Act.
(b) The board of psychology shall collaborate with the department of health when preparing information in the report regarding the treatment of patients who are forensically encumbered or patients with a diagnosis of serious mental illness pursuant to this Act.
SECTION 10. If any provision of this Act, or the application thereof to any person or circumstance, is held invalid, the invalidity does not affect other provisions or applications of the Act that can be given effect without the invalid provision or application, and to this end the provisions of this Act are severable.
SECTION 11. Statutory material to be repealed is bracketed and stricken. New statutory material is underscored.
SECTION 12. This Act shall take effect on July 1, 2018, and shall be repealed on August 31, 2025; provided that, upon repeal, sections 329-1, 329-38, 329-39, 346-59.9, and 465-3, Hawaii Revised Statutes, shall be reenacted in the form in which they read on the day before the effective date of this Act.
Prescribing Psychologists; Clinical Psychologists; Prescriptive Authority Privilege; Board of Psychology
Authorizes and establishes procedures and criteria for prescriptive authority for clinical psychologists who meet specific education, training, and registration requirements, including requiring prescribing psychologists to adhere to all applicable statutory regulations. Requires the board of psychology to report to the legislature prior to the regular session of 2021. Effective July 1, 2018. Sunsets August 31, 2025.
The summary description of legislation appearing on this page is for informational purposes only and is not legislation or evidence of legislative intent.