One of the attributes of personal involvement within the public policy (i.e. political) process is a sense at times of being thrust into the Twilight Zone. Vague, nondescript images or themes appear with regularity. And yet, in retrospect, the journey oftentimes seems to have been crystal clear. Undoubtedly this will be the case with Information Technology (IT) and Prescriptive Authority (RxP). The Public Policy Context for IT: At this year’s State of the Union Address, President Bush said:

“Our generation has been blessed by the expansion of opportunity, by advances in medicine, by the security purchased by our parents’ sacrifice. Now, as we see a little gray in the mirror – or a lot of gray – and we watch our children moving into adulthood, we ask the question: What will be the state of their union?... To make our economy stronger and more productive, we must make health care more affordable and give families greater access to good coverage and more control over their health decisions. I ask Congress to move forward on a comprehensive health care agenda with... improved information technology to prevent medical errors and needless costs....”

On other occasions, the President has similarly heralded the potential of technology for the healthcare world. “(T)he health care industry is missing an opportunity, if patients... have to carry files from one specialist to the next. It’s like IT, information technology, hasn’t shown up in health care yet. But it has in one place... and that’s the Veterans Department.... We’re here to talk about how to make sure the Government helps the health care industry become modern in order to enhance the quality of service, in order to reduce the cost of medicine, in order to make sure the patient, the consumer, is the center of the health care decision making process. And we’ve made great progress. There’s a role for the Federal Government.... [to be] helpful in expanding information technology....” At the Cleveland Clinic, the President quoted health care analysts that the efficiencies wrought by electronic medical records could reduce medical costs as much as 20 percent. Electronic records can “help change medicine and save lives.”

President Bush reflected themes from Institute of Medicine (IOM) reports: “The United States spends over 50 percent more per person on health care than many other Western nations. Yet it does not appear that these vast expenditures are buying reliable levels of quality. The care in some places for some conditions is superb, but such is not the case everywhere, for all people, all the time. Health care delivery has been relatively untouched by the revolution in information technology that has been transforming nearly every other aspect of society.... The number of Americans who use the Internet to retrieve health-related information is estimated to be about 70 million [in 2000].... The committee believes information technology must play a central role in the redesign of the health care system if a substantial improvement in quality is to be achieved over the coming decade.... Congress, the executive branch, leaders of health care organizations... should make a renewed national commitment to building an information infrastructure to support health care delivery, consumer health, quality measurement and improvement, public accountability, clinical and health services research, and clinical education....” As APA President Ron Levant has noted, the IOM has concluded that: “The American health care system is confronting a crisis.... The health care delivery system is incapable of meeting the present, let alone the future needs of the American public.”

On June 30th, 2005, the Senate Committee on Commerce, Science, and Transportation, co-chaired by Senators Stevens and Inouye, held a hearing on Health Information Technology (IT). “Health IT, is one of those concepts that seem to have been around for years, yet in actuality, remains in its infancy as it relates to clinical practice. Hearing from consumers, HMOs, insurance companies, and employers, Senators Enzi and Stabenow introduced health IT bills and testified. Two panels of experts followed – the Administration and the private sector.

“There seems to be agreement that electronic health records (EHRs) and the ability to communicate via the electronic arena are needed – both to improve patient safety and to reduce the ever-rising cost of healthcare. Despite our ability to call in an accurate air-strike on Iraqi insurgents by an unmanned aerial vehicle controlled by an operator 6,000 miles away, ‘one third of Americans report having to return for a repeat visit to their health care provider because their clinical information was not available during their first visit,’ stated Dr. Carolyn Clancy, Director for the Agency for Healthcare Research and Quality, HHS. Equally disturbing is a personal experience: a patient committed suicide with the stockpile of antidepressants he accumulated from several different primary care and mental health [professionals], each of whom prescribed care without access to his medical records, and, thus, were not aware of the multiple prescriptions.

“Safety is the driving factor in demanding better health IT for ourselves and our patients. As a nurse, I know firsthand the difficulty of trying to decipher [professionals’] handwriting in medical records. The placement of a mere decimal point can be the difference between a therapeutic dose of medication, and a lethal dose. Dr. David Brailer, National Coordinator for Health Information Technology, HHS, reported that ‘adverse drug events have been reduced by as much as 70 to 80 percent with much of the improvement stemming from the use of health IT.’ Additionally, electronic prescription ordering offers the dual benefit of clarity and of automatic cross-referencing patient drug allergies and deadly drug interactions. Dr. Robert Kolodner, Acting Veterans Health Administration Chief Health Informatics Officer: ‘(T)he most compelling reason to use information technology in health care is that it helps us provide better, safer, more consistent care to all patients.’ Clinical decision support systems are yet another means to facilitate evidence-based practice and contribute to consistent care and patient safety. With these tools, providers spend less time leafing through texts and research articles and can simply employ algorithms on their PDAs to arrive at diagnoses and treatment plans.

“While no one doubts the benefits of improved health IT, there are the critical challenges that must be addressed: interoperability, secure portability, and EHR adoption. Patients must be able to receive the same level of health IT whether in rural, urban, or frontier areas, and interconnectivity must exist across a wide spectrum of providers. Karen Ignagni, President and CEO, America’s Health Insurance Plans, described the concept of the Personal Health Record (PHR), a consumer-driven approach to ensuring patients maintain the core health information necessary for them to receive safe, effective, and efficient care across providers and time.

“EHRs, [professional] order entry, clinical decision support trees, remote patient monitoring, and automated payment programs are but a few of the applications being explored in the health arena. Legislators, federal agencies, and private companies are all committed to developing standards to move health IT to the next level. As health care [professionals], we must be poised and ready to meet the challenges with innovation, creativity, and flexibility.”

The Commonwealth Fund estimates an ideal national health information network would cost $156 billion over five years in capital investment and $48 billion in annual operating costs. [Lt. Col. Vicki Ball is an U.S. Air Force nurse, serving as a Congressional Detailee with Senator Daniel K. Inouye. Views expressed are personal, and do not represent the USAF or DoD.]

The Prescriptive Authority Agenda: During the last legislative session, the Hawaii Psychological Association, in collaboration with the Hawaii Primary Care Association, nearly obtained prescriptive authority (RxP) for their members working within federally qualified community health centers. The resulting legislatively mandated RxP Task Force was a major accomplishment. Jim Quillin, President of the Louisiana Psychological Association shared LPA’s experiences and vision with them:

“Louisiana’s Medical Psychology statute was signed into law on May 6, 2004, and the rules governing this landmark statute were finalized on January 20th of this year clearing the way for the certification of medical psychologists (MPs) under state law. This represented the culmination of a decade of hard work by a small group of extremely dedicated psychologists who believed in themselves and in their ability to effect progressive health care change through the political process. With the unfailing support of the APA Practice Directorate and CAPP, LPA and its sister organization, the Louisiana Academy of Medical Psychologists (LAMP), forged a partnership that brought to fruition, after four legislative sessions, the country’s second statute authorizing psychologists with specialized training the authority to prescribe medications. On February 18th of this year, one of LAMP’s founding members, John Bolter, became the first civilian psychologist in the United States to issue a prescription under state statute.

“We are now embarked upon the implementation of this historical statute. A total of 17 medical psychologists are now authorized to prescribe here in Louisiana, and by Summer’s end, no less than 25 MPs will likely be practicing in Louisiana, and it is my hope that by the end of the year the remainder of those who have completed their training thus far will be doing so as well. A new class of psychologists is underway and being trained, and the next wave of MPs, will follow in due time. I also hope to be able to report to you in the near future another groundbreaking first, the credentialing of an MP to prescribe as part of the medical staff of a hospital. We have also been working with the insurance industry and I believe that I will soon have the pleasure of announcing an important breakthrough in the reimbursement of services provided by MPs, one that may well extend to other states for qualifying psychologists.

“To date, we are successfully feeling our way through the logistics required to fully realize the potential of our law. Louisiana requires a state Controlled and Dangerous Substance Permit before application can be made for a DEA number. This process has gone very smoothly and, with our DEA numbers in hand, we are now authorized to prescribe any drug, Schedule II through V, that has a recognized use (including off-label) in the management of any psychiatric disorder listed under either DSM or ICD. MPs, however, are not permitted to prescribe narcotics, agents which are specifically defined in our law as any ‘...natural or synthetic opiate analgesic used for the treatment of pain.’ We are required to use the abbreviation ‘MP’ following our academic degree (Ph.D. or Psy.D.) on all prescriptions and all medical records we generate, and the Louisiana State Board of Examiners (LSBEP) provides the Louisiana State Pharmacy Board a roster of all MPs in the state. Each of our psychology license numbers have been modified by LSBEP and are now followed by ‘MP’ so that our designation can quickly and easily be determined. The board also requires copies of our state Controlled and Dangerous Substances permits, DEA numbers and Basic Life Support for Health Care Providers certificates.

“To a person, all current MPs have enjoyed excellent relationships with pharmacists, all of whom, across the state, received a memo from the Pharmacy Board earlier this year advising them of MPs as a new class of prescribers in Louisiana. Taking a tip from the Executive Director of that Board, I contacted many of the pharmacies in my area and provided them all the information necessary for them to put me into their systems. Several of them now fax or call my clinic to remind me of expiring prescriptions so that I can discontinue, change or refill as needed. It has also been gratifying to see that non-psychiatric physicians appear to accept and even welcome MPs as partners in the delivery of health care. Whereas organized medicine has been obliged to oppose psychology in this movement, partly in deference to their psychiatric colleagues and partly out of a sense that medicine’s monopoly on health care is waning, rank and file MDs, in my experience, are concerned not with turf issues but rather with providing quality care to their patients. We are not a threat; we are their allies and are being increasingly accepted as such. Patients appear absolutely thrilled with the ability of MPs to prescribe their psychotropic medications. It has freed them of the onerous requirement of seeing two doctors each time a prescription is needed while the close coordination of care between their MP and MD helps ensure optimized outcomes. We have written over 1,000 prescriptions, representing nearly 25,000 treatment days, without incident, for all classes of psychotropic medications.

“As for myself, this implementation period has been interesting. I find that I am conservative in my prescribing habits, adhering to the age old admonition to ‘start low and go slow’ when treating patients psychopharmacologically. My first ‘official’ act as an MP actually was to obtain labs on a new patient I suspected of thyroid disease and refer the patient whose studies were indeed abnormal. Subsequently, I have prescribed for all classes of psychotropic medications across all relevant schedules. All in all, patients have a better than 50-60% chance of leaving my clinic without a prescription so far, as psychotherapeutic/behavioral management was indicated and sufficed. Those for whom medication is necessary report that they find it refreshing that the doctor who prescribes for them also takes the time to listen to them and to approach their care in a more holistic manner.

“As I’ve started prescribing, I’ve found myself pondering afresh the concern of some that we are ‘medicalizing’ psychology. Such concerns, while certainly understandable, appear to be unnecessary. While some of our new professional activities are unmistakably medical in character (i.e., vital signs/review of systems/labs, evaluation of drug-drug and disease-drug interactions, etc.), the ‘medical’ in medical psychology is an adjective that modifies rather than defines who and what we are – psychologists. The opportunity to provide a broader range of therapeutic options certainly has not seemed to diminish my sense of professional identity. Case in point, my oldest daughter, a third year medical student, was able to spend a few days at home. She asked if she could shadow me, with the necessary patient consents, in order to get a better feel for ‘real life’ psychopharmacology. She commented at the end of the day on how numerous patients had pulled her aside and remarked that they hoped that as a future physician she too would take the time to listen to and treat patients like her father. She was clearly impressed and came away with a better recognition of the importance of integrating psychological and medical factors in patient care. It is clearer to me now more than ever that the core of the healing arts, the therapeutic ‘g-factor’ if you would, is still to be found in that somewhat mysterious, elusive bond of the doctor-patient relationship. I don’t find that I am abandoning my psychological roots now that I am actively prescribing and practicing as a medical psychologist. For me, the tide seems like it is running in the other direction – I think I’m discovering them anew. Go figure.”

Aloha

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