Understanding Nurse Protocol Agreements in Georgia: A Complete Overview
What Exactly is a Nurse Protocol Agreement
Georgia law regulating nurse protocol agreements is codified in O.C.G.A. § 43-26-2(e)(5). Georgia law permits physicians to delegate medical tasks to nurses, physician assistants and nurse practitioners if these individuals are working under a written "nurse protocol agreement." The nurse protocol agreement must be entered into by a physician and a nurse with a Georgia issued advanced or general nursing license who has met specific educational and training requirements set out in the statute. (O.C.G.A. § 43-26-2(e)(1)). Such a nurse must also have a current certification by a national certifying organization approved by the Georgia Board of Nursing as having been trained in the area of practice proposed in the nurse protocol agreement . (O.C.G.A. § 43-26-2(e)(1)). The statute requires that nurse protocol agreements between physicians and nurses be limited in each instance to the evaluation and treatment of stable and chronic conditions. (O.C.G.A. § 43-6-2(e)(2)(2)). Nurse protocol agreements cannot be used to delegate "specific medical tasks to a layperson, or to delegate any medical task that requires technical skills as determined by the Board [of Nursing]." (O.C.G.A. § 43-26-2(e)(3)). However, there are a number of special circumstances in which a nurse protocol agreement can be used to delegate medical tasks to a layperson. (O.C.G.A. § 43-26-2(e)(3)).
Legal Aspects in Georgia
Georgia, like many states, has a legal framework governing nurse protocol agreements (NPAs). Enacted in 1993, Georgia Code Section 43-26-3 provides licensure requirements for nurses that enter into Nurse Protocol Agreements, for the purpose of carrying out medical acts, orders or prescriptions of a supervising and collaborating physician. Further, there is a Georgia Board of Nursing Rule that governs such Nurse Protocol Agreements.
In order to enact an NPA in Georgia, the physician must possess an unrestricted Georgia medical license, and be board certified in the area of medical specialization that the protocol covers. Further, the physician must practice medicine in the state of Georgia at least 20 hours per week. The physician will need to maintain an approved plan of prescriptive authority through the Georgia Drugs and Therapeutics Committee, through the applicable Georgia Composite Medical Board Rules. The physician must have authorized at least 2 Nurse Practitioners to dispense prepackaged drugs when working under a Georgia NPA.
The Nurse Practitioner that works under a Georgia NPA must have a current and unrestricted license to practice nursing, and a Georgia APRN license to prescribe drugs. The nurse practitioner must practice full-time in Georgia. Further, they must be a graduate of an accredited and nationally accredited Nurse Practitioner program. The Nurse Practitioner will need to be board certified in the area of medical specialization that the protocol covers. If prescribing drugs, they will need to have a collaborative drug agreement with the physician.
What Roles and Responsibilities does it Entail
Because physician oversight is inherent in the patient care process, physician and nurse collaboration is a key element to the nurse protocol. All protocols specify the detailed relationship between the nurse and the collaborating physician that are authorized under Georgia law. The nurse protocol requires a clear delineation of the scope of practice authority for the nurse in a manner that is consistent with the nurse’s education, training, and experience. Thus, the ability to utilize advanced nursing knowledge, judgement, skills, and interventions to identify and respond to health care needs of patients in specific practice arenas is limited to those nurses whose education and training corresponds to the achievement of those competencies. Nurse protocol agreements may not include the use of specific prescriptive authority unless the nurse holds an APRN license with prescriptive authority.
The effective use of the nurse protocol is based upon the quality of the protocol agreement. By nature, the establishment of the collaborative relationship between the advanced practice nurse and the physician is not standard for all. A nurse protocol surety bond allows physicians the ability to distinguish their practices, and thereby lay the foundation for creating a particular and unique nurse collaborative agreement. Specifically defining the distinct scope of practice relationship establishes the parameters of the medical/nurse protocol agreement and allows the physician to clearly stipulate the areas of practice exclusion. This allocation of responsibility and liability helps physicians who use the nurse protocol achieve a more meaningful collaborative relationship with APRNs, and standardize care in their medical practices.
Benefits and Downsides
Benefits and challenges are associated with the use of Nurse Protocol Agreements. Generally, nurse protocol agreements are considered beneficial by nurse practitioners because they allow nurse practitioners to engage in collaborative practice without the direct supervision of a physician. Nurse practitioners can be reimbursed by third party payers for services rendered under protocols, including protocols that authorize nurse practitioners to dispense medications. Physicians may derive some benefit from nurse protocol agreements because physicians are not required to be on the premises at the time a nurse practitioner is rendering care to a patient; however, as nurse protocol agreements are a catalyst for contracting for nursing care, most physicians expect some compensation or management consideration from the nurse practitioners with whom they partner. As we have mentioned, collaborative practice arrangements including NPAs also have the potential to present unique challenges for the NP in Georgia. Where a NPA fails to meet the requirements of the Nurse Practice Act or is poorly drafted, unintended violations of the law can result; this was obvious in the Doe v. Botluck case. Additionally, where a NPA is not supported by sound policies and procedures, appropriate training, or sufficient oversight, the failure of a physician to provide supervision of the NPA can create liability exposure for both parties. Further, the success of a nurse protocol agreement in achieving the intended purpose of improving professional practice, enhancing the quality of patient care, and increasing access to healthcare is dependent on whether the physician, nurse practitioner, or clinic can adequately oversee practice of the nurse practitioners with whom they partner. Also, due to the increasing attention and scrutiny by state healthcare regulators, particularly from the physician assistant side, the longevity of nurse protocol agreements remains questionable in the current health care environment.
How To Set Up a Protocol Agreement
In order to establish a nurse protocol agreement, both the physician and the nurse practitioner must have an active Georgia license. The nurse practitioner must also hold specialty certification in the area for which the physician wishes to delegate to the nurse practitioner. The nurse practitioner must provide proof of liability insurance to the physicians medical malpractice insurer.
In Georgia, nurse protocol agreements are only able to be approved by the Georgia Composite Board of Nursing or the medical corporation and its medical staff that employs the nurse practitioner. In order to obtain approval, the nurse practitioner must file a request to be granted the authority to practice in accordance with the nurse protocol agreement. The request must include the nurse protocol agreement itself, copies of current certification or eligibility for certification as an APRN, documentation of completion of pharmacology coursework, a copy of liability insurance, copies of all current state certifications or licenses, a current resume or CV, and other information requested by the supervising physician. The supervising physician, as well as a physician member of the medical staff must approve the request .
If the nurse protocol agreement seeks to delegate authority to prescribe drugs or devices, the medical corporation and its medical staff must also complete the applicable prescriptive authority forms. The prescriptive authority request must be accompanied by a processing fee.
Once the approval request is properly filed, the request is forwarded to the Board. A Board designee will review the request and conduct a peer review, if necessary. The nurse practitioner is forwarded a copy of the approval request to review and submit comments.
Based on the review and any comments, the responsible licensing agency ultimately determines whether or not to approve the nurse protocol agreement. If approved, the nurse practitioner will be placed on either a provisional or full approval status. Provisional status only approves the nurse practitioner for a period not to exceed 1 year from the date of approval. Conditional full approval will also be granted for a period not to exceed 1 year, not to begin earlier than the end of a provisionally approved employment status and only with payment of an additional processing fee.
Mistakes and How To Avoid Them
Common mistakes with nurse protocol agreements are often preventable if the parties understand and respect the role of each practitioner in the practice arrangement. Issues most often arise when one party tries to exert control over the other. Unfortunately, these conflicts are the root cause of numerous Medicaid and Medicare fraud and abuse disputes, and neuralgia is a common defense (after someone has already been caught) rather than a proactive approach.
One example of a common mistake is the "Formulary." The NP’s ability to prescribe medications in Georgia is limited by the "Formulary," i.e. he or she can only prescribe what is on the nurse protocol Formulary. During our expert witness investigations, we see formulary issues over and over again. A great example is the primary care market in which agents for pharmaceutical companies have "dropped off" sample bags (with free samples) for a number of years. The inside note indicates that if the physician would like more samples, he or she can contact the agent. The agent then comes back with a supply of free samples. At the same time, the NP is also allowed to prescribe drugs from the Formulary, and in these cases, far too often, the NP is not actually following the protocols as specified in the protocol nurse practitioner agreement (rules). Because the medical staff member that visits the NP’s office never sees a protocol nurse, the nurse is often unaware of the error. And it is just that, an error, not fraud, because no money is passing through this arrangement. There is no payment for that drug being issued, but it is a violation of the Georgia law governing protocol nurse practitioners.
Another common mistake is simply for failure to get another health care professionals to review the treatment before the NP prescribes. In fact, there are Georgia laws that require additional professionals to be part of the nurse protocol process. If the NP prescribes something outside of his or her area of expertise, and the physician in fact has made arrangements for another niche specialist in the case to be reviewed by the other physician, those protocols should specify that the other physician must approve that type of treatment prior to the NP issuing the prescription.
These types of errors can lead to serious investigations by the state medical board, and any attempt to claim that the NP really didn’t know there was a conflict is unlikely to be successful. The sober truth is that the NP should have know that NP’s are only allowed to follow their own protocol nurse practitioner agreement and proceed on the basis of that – not someone else’s protocols.
Another common issue seen by investigators is the nurses mentoring the other nurses. This is a very, very bad mistake that does not mean that the services are not payable, and they are routinely paid under Georgia Medicaid. But it is manufactured care, and frankly, I don’t think that those claims are going to survive much longer as the programs shift to data analytics. It is only a matter of time until the Office of Inspector General basically says, "we are going to cut ALL managed care payments because they cannot show that there is any objective reason to pay for the managed care treatment. Not to mention that the operation of nurses teaching other nurses is not allowed under the Medicare / Medicaid statutes.
Future Trends and Research
As the healthcare landscape in Georgia continues to evolve, the future of nurse protocol agreements (NPAs) is likely to be shaped by a combination of technological advancements and a greater emphasis on healthcare access. With the rise of telehealth and mobile health technologies, nurse practitioners (NPs) may have more freedom to operate outside of the constraints of traditional NPAs, as they can remotely monitor patients and provide real-time care without being physically present. However, changes in technology may also lead to an increased demand for more robust NPAs, particularly in rural areas where NPs may be the primary healthcare providers.
The push for universal healthcare coverage and reduced healthcare costs, combined with a shortage of primary care providers, may also drive the expansion of NPAs beyond what is currently permitted in Georgia. As healthcare systems and stakeholders grapple with the challenges of providing affordable and accessible care , they may look to NPs as a solution, which would necessitate an expansion of the scope of NPAs.
Furthermore, as more states adopt NPAs and expand their use, Georgia may see pressure to modernize its NPAs in order to keep pace with other states. The proliferation of NPAs in other states could lead to a standardized approach, as the advantages of NPAs become more widely known and shared. In addition, patient advocacy and public policy efforts may add momentum to NPs’ calls for greater independence, potentially resulting in legislative changes.
In Georgia, NPs will likely continue to push for NPAs that allow them to practice more autonomously. They may also seek to establish NPAs that take advantage of new technologies, such as artificial intelligence and advanced data analytics, which could empower them to make more informed decisions about patient care. In any case, the future of NPAs in Georgia is likely to be influenced by these and other developments in the healthcare arena.