History of Prescribing Authority


Summary from December 1999

Legislative History of Plenary Prescriptive Authority for New Hampshire Advanced Registered Nurse Practitioners

1975: The New Hampshire Nurse Practice Act (RSA 326-B) was amended to recognize the status of the Advanced Registered Nurse Practitioner ("ARNP").

Currently in this State, the term "ARNP" encompasses all advanced practice nurses who are credentialed by the New Hampshire Board of Nursing ("BON"), including:

Certified nurse-midwives (CNM);Pediatric nurse practitioners;Family nurse practitioners;Women's health nurse practitioners;Adult nurse practitioners;Geriatric nurse practitioners;School nurse practitioners;Psychiatric/mental health nurse practitioners;Emergency/trauma nurse practitioners;Neo-natal nurse practitioners;Certified registered nurse anesthetists (CRNA);Acute care nurse practitioners;Community health nurse practitioners;Reproductive health nurse practitioners; and,Oncology nurse practitioners.

Every nurse practitioner practices in one or more of the defined areas listed above. Practice in each area requires specialty training and examination. To practice within an area is to act within one's "scope of practice." To act outside one's scope of practice is not permitted and any such act may be subject to disciplinary proceedings by the BON.

1983: HB 425 was passed, which further amended RSA 326-B, granting ARNPs the authority to prescribe medication, based on protocols that were established jointly with a collaborative physician – the collaborative physician was only necessary if the ARNP wished to prescribe. Apart from their prescriptive practice, ARNPs could practice independently in New Hampshire. The medications that could be prescribed were from a formulary, developed by the New Hampshire Board of Nursing, and subject to approval by the New Hampshire Board of Medicine. HB 425 also required ARNPs to obtain a Drug Enforcement Administration (DEA) number to prescribe both uncontrolled and controlled substances.

1991: SB 158 came in response to a proposed federal rule change that attempted to define an ARNP as an "affiliated practitioner" whose prescriptive authority was dependent upon collaboration with a medical doctor ("MD"), to the extent that an affiliated practitioner would have to: 1) relinquish his or her DEA number; and, 2) suffix onto the DEA number of the collaborating MD. New Hampshire ARNPs had prescribed under their own DEA numbers since 1983, based on protocols with a collaborating MD – not suffixed to an MD DEA number. State law provided for more independent practice than the federal proposal, allowing greater access and improved health care for patients – particularly those in underserved and rural areas in New Hampshire. Possible ramifications of the federal proposal would have caused a step backward in health care in the State, and because ARNPs had demonstrated responsible and safe prescribing practices for almost ten years in New Hampshire, NPs decided to set about changing the state law to assure that ARNPs would be able to maintain their own DEA numbers.

SB 158 called for plenary (independent) prescriptive authority and continuation of a formulary. Secure in the knowledge that every ARNP is accountable to the BON and limited to actions within his or her respective "scope of practice," coupled with the impeccable record held by the BON for its diligence in the regulation of practice, the ARNPs recommended that the BON, in conjunction with an Advisory Council to be established, provide oversight of the formulary and ARNP prescriptive practice.

The Advisory Council would consist of eight members:

One member of the Board of Nursing;Two ARNPs;Two MDs;One pharmacist; and,One member of the general public.

Following lengthy discussions and a meeting hosted by the New Hampshire Nurses' Association, SB158 passed the Senate in March 1991, with amendment. Participants in the debate included the New Hampshire Nurses' Association, the New Hampshire Nurse Practitioner Association, the New Hampshire Board of Nursing, the New Hampshire Medical Society, the New Hampshire Board of Medicine and the Vermont/New Hampshire Anesthesiology Association. The bill, as amended, had the support of ARNPs, individual MDs, pharmacists and consumer advocates.

Despite the amended language, however, the American Anesthesiology Society, the American Medical Association, the New Hampshire Medical Society and the Vermont/New Hampshire Anesthesiology Association opposed the legislation. When SB 158 crossed over to the House, members of these opposing organizations argued that the bill would give ARNPs "a license to practice medicine and prescribe everything in the drug book." ARNPs, consumer advocates, and agencies that use ARNP services, such as the New Hampshire Home Care Association, testified in support. Once again, there were a number of supportive statements from physician and pharmacy colleagues, despite organized medicine's continued staunch opposition.

Following the Committee hearing, a subcommittee was created. Finally, a compromise was reached whereby:

Plenary (independent) prescriptive authority for uncontrolled and controlled substances was granted, pursuant to a formulary, within an ARNP's scope of his or her designated specialty area (scope of practice) based on protocol* guidelines.A designated slot on the Board of Nursing for an ARNP was created.The Joint Health Council ("JHC") was established to create and administer the formulary that would govern the prescriptive practice of ARNPs.

The composition of the JHC was altered to the following:

Chair of the BON, or BON-member designee;One ARNP, current BON-member, currently licensed, appointed by the BON Chair;Chair of the Board of Medicine ("BOM"), or BOM-member designee;Two physicians, one of whom must be current BOM-member, currently licensed, appointed by the BOM Chair, with experience working collaboratively with ARNPs;Chair of the Board of Pharmacy ("BOP"), or BOP-member designee; and,One BOP member, appointed by the BOP Chair, currently licensed as clinical pharmacist.

(*Protocols are defined in the rules and regulations of the New Hampshire Nurse Practice Act (NUR 101.44) as, "agreements established by the involved individuals that address specific function parameters."

1993: HB 593 enabled ARNPs to dispense that which they could prescribe. This bill was working its way thorough the legislative process at the same time the JHC was deliberating on the possibility of creating an exclusionary formulary.

An exclusionary formulary lists only those drugs that may not be prescribed, and was viewed by the Joint Health Council as a possible solution to keeping the ARNP formulary a manageable instrument. The New Hampshire Medical Society became involved at this point and, over strenuous objection by ARNPs and health care advocates, pushed through an amendment to HB 593, requiring all new FDA-approved drugs manufactured after September 1994 to be reviewed by the JHC before they may be prescribed by ARNPs.

The amended law created tremendous confusion in the formulary (for example: looking at the formulary for a post-1994 drug, it is impossible to determine if the drug does not appear on the list because it has been reviewed and was approved, or because it has not yet been subject to the review), and caused serious delays in the process of approving new drugs for their available use by ARNPs for their patients.

1998: HB 1421 attempted to deal with the explosion of new drugs coming to market, requiring the JHC to review only new, FDA-approved drugs that have been requested for use by New Hampshire ARNPs. Pursuant to this amendment, new routes of administration (i.e., oral, injection, IV) for previously approved substances need not be requested. Prior to this, all FDA-approved drugs were being reviewed, which only added to the confusion as different companies would have approval for the same drug under a different name, and previously approved drugs were being denied or restricted under a different name.

1999: Laboring under an antiquated formulary that has not been updated since 1997, ARNPs requested the introduction of HB 530, which established a legislative study committee to review the policies and procedures of the JHC. Recognizing the need for improved access to newly available prescription medications, the demonstrated safe prescriptive practices of New Hampshire ARNPs, and the history of strong oversight by the Board of Nursing, the study committee voted 5-0 to recommend the following amendments to current law:

Repeal RSA 326-B:10-a.Delete all references to the Joint Health Council and formulary from RSA 326-B:10.