1. Selected Findings from a Nationwide Analysis of State Laws Affecting the Use of Immunization Standing Orders* Sara Rosenbaum AcademyHealth ARM June 2, 2007 The full GW CDC standing orders study by Stewart et. al. can be viewed at www.gwhealthpolicy.org

2. Immunization as Medical Practice: the Role of Standing Orders Immunization Practice = the legal practice of medicine: –(1) assess patients and diagnose the need for immunizations, with no contra-indication; –(2) prescribe an immunization; –(3) administer an immunization. Steps (1) and (2) constitute core legal elements associated with the practice of medicine STANDING ORDERS: A formal written protocol authorizing medical care practice by a health professional other than a physician

3. Power Sharing The legal authority to practice medicine under state law can take two forms: 1) Delegation model: allowing a health professional to act under a medical professionals license 2)Independent powers: recognizing the power of a health professional other than a physician to engage in the practice of medicine under certain prescribed conditions.

4. Study Design and Methods Use of legal analysis methods to conduct broad scan of state medical practice law: Professional licensure statutes and regulations applicable to nurses, physician assistants, and pharmacists Opinions issued by state attorney generals and (where applicable and relevant) judicial opinions Legal opinions issued by medical and health professions licensure boards

5. Applied findings to 5 immunization practice settings: Long-term care facilities Acute care hospitals Adult and pediatric private practice in office-based settings Community health settings in in medically underserved and clinician shortage areas Non-health community setting (e.g., grocery store) Study Design and Methods

6. States Authorizing Advanced Practice Nurses to Conduct All 3 Elements of Immunization Practice Under Standing Orders (n=3) WA OR ID MT ND WY SD MN WI MI ILIN OH PA NY ME CA NV UT CO NE KS IA MO KY WV VA NC TX NM AZ OK AR LA TN SC GA FL AL MS NJ RI CT VT MA NH AK HI DE MD DC IL, MD, TN authorize advance practice nurses to conduct all 3 elements of immunization practice

7. States Authorizing Physician Assistants to Conduct All 3 Elements of Immunization Practice Under Standing Orders (n=18) WA OR ID MT ND WY SD MN WI MI ILIN OH PA NY ME CA NV UT CO NE KS IA MO KY WV VA NC TX NM AZ OK AR LA TN SC GA FL AL MS NJ RI CT VT MA NH AK HI DE MD DC Alaska, Arizona, California, Delaware, DC, Louisiana, Maryland, Minnesota, Mississippi, Montana, New Jersey, Ohio, Oklahoma, Tennessee, Texas, Utah, Virginia, Wisconsin authorize physician assistants to conduct all 3 elements of immunization practice under Standing Orders

8. States Authorizing Advanced Practice Nurses or Nurse Practitioners to Conduct All 3 Elements of Immunization Practice Under Their Own Practice License (n=5) WA OR ID MT ND WY SD MN WI MI ILIN OH PA NY ME CA NV UT CO NE KS IA MO KY WV VA NC TX NM AZ OK AR LA TN SC GA FL AL MS NJ RI CT VT MA NH AK HI DE MD DC Source: GWU/SPHHS Review of Standing Orders – February 2007 Delaware, Idaho, Montana, New Hampshire, New York authorize Advanced Practice Nurses or Nurse Practitioners to Conduct All 3 Elements of Immunization Practice Under Their Own Practice Licenses

9. States Authorizing Physician Assistants to Conduct All 3 Elements of Immunization Practice Under Their Own Practice License (n=0) WA OR ID MT ND WY SD MN WI MI ILIN OH PA NY ME CA NV UT CO NE KS IA MO KY WV VA NC TX NM AZ OK AR LA TN SC GA FL AL MS NJ RI CT VT MA NH AK HI DE MD DC Source: GWU/SPHHS Review of Standing Orders – February 2007 No state authorizes physician assistants to conduct all 3 elements of immunization practice under their own practice license

10. How State Laws Address the Site of Immunization Practice 33 states explicitly address the practice sites where non- physician health professionals are permitted to practice Settings include: LTC Facilities Acute Care Hospitals Adult Practice Pediatric Practice Medically Underserved Clinics Public Health Clinics Non-Medical settings Source: GWU/SPHHS Review of Standing Orders – February 2007

11. Explicitly Permissible Immunization Practice Sites: Non-Medical (20 States) WA OR ID MT ND WY SD MN WI MI ILIN OH PA NY ME CA NV UT CO NE KS IA MO KY WV VA TX NM AZ OK AR LA TN SC GA FL AL MS NJ RI CT VT MA NH AK HI DE MD DC Source: GWU/SPHHS Review of Standing Orders – February 2007