A nurse practitioner who reads my blog is concerned about how medication prescriptions are processed at her facility. Refills are sent to the pharmacy via the electronic medical records system, which allows prescriptions to be refilled before she issues her approval. She is concerned about her legal liability.
At the NP's facility, when RNs or certified medical assistants order e-prescriptions, they send it to the patient's healthcare provider for approval or rejection around the same time they send it to the pharmacy. The NP personally wants to accept or reject a refill request prior to the prescription being filled. Moreover, she does not want her name used to refill prescriptions that she has not authorized. She also points out that neither RNs nor CMAs have prescriptive authority in her state. The NP took her concerns to risk management, but they were not addressed, she said. Nor did she initially receive support from her department director. But after her colleagues understood the issue, they supported her request to process all prescriptions refills she orders. The issue here is not with the use of EMRs to refill prescriptions. Rather, the issue is the use of RNs and CMAs -- who have no prescriptive authority in the NP's state -- in processing refills.
It does not matter that the protocol at the facility supports this process, since legally these two groups do not have the authority to be involved in the process.
When any medical facility allows staff members to practice outside their scope of practice, it legally risks its licensure and risks its reimbursement for these medications by health insurance organizations, including Medicare and Medicaid. It also may be violating state and federal laws. Additionally, should a patient injury or death occur because of an RN or CMA accepting or rejecting a medication in error, the facility risks a lawsuit alleging the corporate theory of negligence, among other allegations. The RN and CMA also risk being named in such a suit. These staff members also risk disciplinary action by the state board of nursing and the body who certifies the medical assistant (most often the state board of medical examiners). Professional disciplinary cases are costly, often lengthy and can result in a professional license or certification being suspended or rescinded. But not all states have the policies in regard to CMAs and their lack of authority to participate in medication refills or orders. The American Association of Medical Examiners states CMAs play a vital role in regard to medication orders or refills, with or without an EMR. A CMA is able to accept verbal orders from an "overseeing, delegating or supervising physician" as long as such an order doesn't require the CMA to exercise "independent professional judgment" when carrying out the orders, or to make clinical assessments or evaluations. Likewise, in most states CMAs can communicate, by telephone or electronically, a physician's orders for new prescriptions or refills without professional judgments or comments regarding the prescription before transmission.
However, a prescription transmission cannot occur until the physician has "reviewed, approved and executed the prescription order."
RNs (non-NPs) cannot order medications or refills. Standing orders have been used for years to try and circumvent this prohibition, and they often have been helpful to legal challenges. However, keep in mind that not all states approve standing orders. An RN is allowed to transmit an order by an authorized healthcare provider, but the order must be written (or oral, if allowed by the facility and the state), and the order must be reviewed, approved and signed (or some other form of attestation) before transmitted. Obviously, this brief blog cannot cover all of the issues or concerns about EMRs and the role others outside of the prescribing healthcare provider play in this process. What are your concerns? How have you handled the same or similar practice situation? What legal pitfalls concern you? Share them in the comments section below. Editor's note: Nancy Brent's posts are designed for educational purposes only and are not to be taken as specific legal or other advice. Individuals who need advice on a specific incident or work situation should contact a nurse attorney or attorney in their state. Visit The American Association of Nurse Attorneys website to search its attorney referral database by state.
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