ARC 4663C
MEDICINE BOARD[653]
Notice of Intended Action
Proposing rule making related to prescribing psychologists
and providing an opportunity for public comment
The Board of Medicine hereby proposes to amend Chapter 19, “Prescribing Psychologists,” Iowa Administrative Code.
Legal Authority for Rule Making
This rule making is proposed under the authority provided in Iowa Code chapters 17A, 154B and 272C and section 147.76.
State or Federal Law Implemented
This rule making implements, in whole or in part, Iowa Code chapters 17A, 124, 147, 148, 154B and 272C.
Purpose and Summary
This proposed rule making establishes new rules 653—19.10(17A,124,147,148,154B,272C) and 653—19.11(17A,124,147,148,154B,272C), which establish the standards of practice for physicians who supervise a conditional prescribing psychologist and physicians who collaborate with a prescribing psychologist, and new rule 653—19.12(17A,124,147,148,272C), which establishes grounds for discipline.  
Fiscal Impact
This rule making has no fiscal impact to the State of Iowa.
Jobs Impact
After analysis and review of this rule making, no impact on jobs has been found.
Waivers
Any person who believes that the application of the discretionary provisions of this rule making would result in hardship or injustice to that person may petition the Board for a waiver of the discretionary provisions, if any, pursuant to 653—Chapter 3.
Public Comment
Any interested person may submit written or oral comments concerning this proposed rule making. Written or oral comments in response to this rule making must be received by the Board no later than 4:30 p.m. on October 15, 2019. Comments should be directed to:

Kent Nebel
Iowa Board of Medicine
400 S.W. Eighth Street, Suite C
Des Moines, Iowa 50309
Phone: 515.281.7088
Fax: 515.242.5908
Email: kent.nebel@iowa.gov	
Public Hearing
A public hearing at which persons may present their views orally or in writing will be held as follows:

October 15, 2019
9 to 10 a.m.	Board Office, Suite C
400 S.W. Eighth Street
Des Moines, Iowa	
Persons who wish to make oral comments at the public hearing may be asked to state their names for the record and to confine their remarks to the subject of this proposed rule making.
Any persons who intend to attend the public hearing and have special requirements, such as those related to hearing or mobility impairments, should contact the Board and advise of specific needs.
Review by Administrative Rules Review Committee
The Administrative Rules Review Committee, a bipartisan legislative committee which oversees rule making by executive branch agencies, may, on its own motion or on written request by any individual or group, review this rule making at its regular monthly meeting or at a special meeting. The Committee’s meetings are open to the public, and interested persons may be heard as provided in Iowa Code section 17A.8(6).
The following rule-making action is proposed:
	Adopt the following new rules 653—19.10(17A,124,147,148,154B,272C) to 653—19.12(17A,124,147,148,272C):
653—19.10(17A,124,147,148,154B,272C) Standards of practice—supervision of a conditional prescribing psychologist. A supervising physician shall be a person who is licensed to practice medicine and surgery or osteopathic medicine in Iowa who regularly prescribes psychotropic medications for the treatment of mental disorders as part of the physician’s normal course of practice and who supervises a conditional prescribing psychologist. A supervising physician shall be board-certified in family medicine, internal medicine, neurology, pediatrics, or psychiatry. A supervising physician shall fully comply with the following standards of practice.
	19.10(1) Supervision. A supervising physician shall provide appropriate oversight and direction to a conditional prescribing psychologist during the period of supervised practice to achieve patient safety and optimal clinical outcomes. A supervising physician shall ensure that appropriate clinical examinations and necessary testing are performed and that all psychopharmacology services provided are appropriate for the patient’s condition. Supervision may be in person or via electronic communications in accordance with these rules.
	19.10(2) Primary supervising physician. A supervising physician shall determine whether the supervising physician has been designated as a conditional prescribing psychologist’s primary supervising physician and shall fulfill the responsibilities of the primary supervising physician in accordance with these rules. A conditional prescribing psychologist may have more than one supervising physician.
	19.10(3) Maximum number of conditional prescribing psychologists. A supervising physician shall not supervise more than two conditional prescribing psychologists at one time.
	19.10(4) Minimum period of supervision. The primary supervising physician shall ensure that a conditional prescribing psychologist completes a minimum of two years of supervised practice prescribing psychotropic medications to patients with mental disorders in accordance with these rules in order for the conditional prescribing psychologist to be eligible to apply for a prescription certificate.
	19.10(5) Minimum number of patients. The primary supervising physician shall ensure that a conditional prescribing psychologist has seen a minimum of 300 patients who had a diagnosed mental disorder for whom pharmacological intervention was considered as a treatment option, even if a decision was made not to prescribe a psychotropic medication to the patient. The primary supervising physician shall ensure that a conditional prescribing psychologist has treated a minimum of 100 patients with psychotropic medication throughout the supervised practice period.
	19.10(6) Initial assessment. Prior to supervising a conditional prescribing psychologist, each supervising physician shall assess the conditional prescribing psychologist’s relevant education, training, experience, and competence.
	19.10(7) Scope of practice. Each supervising physician shall ensure that all psychopharmacology services provided by a conditional prescribing psychologist are within the competence and scope of practice of the supervising physician and the conditional prescribing psychologist.
	19.10(8) Prescriptive authority. Each supervising physician shall ensure that a conditional prescribing psychologist only prescribes psychotropic medications for the treatment of mental disorders.
	19.10(9) Prescriptions. A supervising physician shall ensure that each prescription issued by a conditional prescribing psychologist identifies the prescriber as a “psychologist certified to prescribe” and includes the Iowa license number of the conditional prescribing psychologist and the name of the supervising physician.
	19.10(10) Active DEA and CSA registration. A supervising physician shall ensure that a conditional prescribing psychologist has an active DEA registration and CSA registration at all times during the period of supervision.
	19.10(11) Patient populations. A supervising physician shall ensure that a conditional prescribing psychologist only provides psychopharmacology services to patient populations within the conditional prescribing psychologist’s education, training, experience, and competence. A supervising physician may establish limitations on the types of populations to whom a conditional prescribing psychologist may provide psychopharmacology services based on the conditional prescribing psychologist’s education, training, experience, and competence.
	19.10(12) Psychotropic medications. A supervising physician shall ensure that a conditional prescribing psychologist only prescribes psychotropic medications that are within the conditional prescribing psychologist’s education, training, experience, and competence. A supervising physician may establish limitations on the types of psychotropic medications that a conditional prescribing psychologist may prescribe based on the conditional prescribing psychologist’s education, training, experience, and competence.
	19.10(13) Specialization. A supervising physician shall ensure that a conditional prescribing psychologist has completed the following training during the supervised practice period to be eligible to prescribe psychotropic medications to the respective population as a prescribing psychologist:
	a. 	Children. To prescribe to patients who are less than 17 years of age, a conditional prescribing psychologist shall complete at least one year of the required two years of supervised practice in either:
	(1)	A pediatric practice,
	(2)	A child and adolescent practice, or
	(3)	A general practice provided the conditional prescribing psychologist treats a minimum of 50 patients who are less than 17 years of age.
	b. 	Elderly patients. To prescribe to patients who are over 65 years of age, a conditional prescribing psychologist shall complete at least one year of the required two years of supervised practice in either:
	(1)	A geriatric practice, or
	(2)	A general practice with patients across the lifespan including patients who are over 65 years of age.
	c. 	Serious medical conditions. To prescribe to patients with serious medical conditions including, but not limited to, heart disease, cancer, stroke, seizures, or comorbid psychological conditions, or patients with developmental disabilities and intellectual disabilities. A supervising physician shall ensure that a conditional prescribing psychologist has completed at least one year prescribing psychotropic medications to patients with serious medical conditions if the conditional prescribing psychologist intends to treat patients with serious medical conditions after the supervised practice period.
	19.10(14) Informed consent. A supervising physician shall ensure that a conditional prescribing psychologist obtains appropriate informed consent before the conditional prescribing psychologist provides psychopharmacology services to a patient.
	19.10(15) Release of information. A supervising physician shall ensure that a conditional prescribing psychologist obtains a release of information authorizing the conditional prescribing psychologist to share information with the supervising physician before the conditional prescribing psychologist provides psychopharmacology services to a patient.
	19.10(16) Primary care physician. A supervising physician shall ensure that each patient has a designated primary care physician before a conditional prescribing psychologist provides psychopharmacology services to a patient. A supervising physician shall ensure that a conditional prescribing psychologist maintains a cooperative relationship with the primary care physician who oversees a patient’s general medical care to ensure that necessary medical examinations are conducted, the psychotropic medication is appropriate for the patient’s medical condition, and significant changes in the patient’s medical or psychological condition are discussed. A supervising physician shall ensure that a conditional prescribing psychologist engages in appropriate consultation with a patient’s designated primary care physician while the conditional prescribing psychologist is providing psychopharmacology services to a patient.
	19.10(17) Chart reviews. A supervising physician shall personally review a representative sample of the conditional prescribing psychologist’s patient charts.
	19.10(18) Performance evaluations. A supervising physician shall regularly evaluate the clinical judgment, skills and performance of a conditional prescribing psychologist to safely provide psychopharmacology services to patients and provide appropriate feedback to the conditional prescribing psychologist.
	19.10(19) Supervision plan. Prior to supervising a conditional prescribing psychologist, a supervising physician shall ensure that a conditional prescribing psychologist has an approved written supervision plan in place. A template may be obtained from the boards of medicine and psychology. The supervision plan shall define the nature and extent of the supervisory relationship and outline specific parameters for review of the supervisory relationship. The supervision plan shall take into account the supervising physician’s and conditional prescribing psychologist’s relevant education, training, experience, and competence and the nature and scope of the psychopharmacology services to be provided. The supervising physician and conditional prescribing psychologist shall each maintain a copy of the supervision plan and provide a copy of the plan to the boards of medicine and psychology upon request. The supervision plan shall include the following:
	a. 	Conditional prescribing psychologist’s information. The name, license number, address, telephone number, and email address of the conditional prescribing psychologist.
	b. 	Supervising physician’s information. The name, license number, DEA registration number, CSA registration number, address, telephone number, email address, and practice locations of the supervising physician.
	c. 	Designation of the primary supervising physician. Designation of the conditional prescribing psychologist’s primary supervising physician.
	d. 	Period of supervision. The beginning date of the supervision plan and estimated date of completion.
	e. 	Locations and settings. A description of the locations and settings where and with whom supervision will occur.
	f. 	Scope of practice. A description of the scope of practice of the supervising physician and the conditional prescribing psychologist.
	g. 	Methods of communication. A description of how the supervising physician and conditional psychologist may communicate for appropriate supervision.
	h. 	Initial assessment. A description of the steps the supervising physician has taken to assess a conditional prescribing psychologist’s relevant education, training, experience, and competence prior to supervising the conditional prescribing psychologist.
	i. 	Limitations on psychotropic medications. A description of any limitations on the types of psychotropic medications the conditional prescribing psychologist may prescribe consistent with the supervising physician’s and prescribing psychologist’s relevant education, training, experience, and competence.
	j. 	Limitations on patient populations. A description of any limitations on the types of populations the conditional prescribing psychologist may treat with psychotropic medications consistent with the supervising physician’s and prescribing psychologist’s relevant education, training, experience, and competence.
	k. 	Expectations and responsibilities. A description of the expectations and responsibilities of the supervisory relationship.
	l. 	Specialization. A description of the specialized training to be completed by the conditional prescribing psychologist in order to provide psychopharmacology services to children (less than 17 years of age), elderly persons (over 65 years of age), or patients with serious medical conditions, including but not limited to heart disease, cancer, stroke, seizures, or comorbid psychological conditions, or patients with developmental disabilities and intellectual disabilities in accordance with subrule 19.3(4).
	m. 	Chart reviews. A description of the steps the supervising physician has taken to personally review a representative sample of the conditional prescribing psychologist’s patient charts.
	n. 	Consultation between the supervising physician and the primary care physician. A requirement that the supervising physician consult with the patient’s primary care physician on a regular basis regarding the patient’s psychotropic treatment plan and any potential complications.
	o. 	Performance evaluations. A description of the steps the supervising physician has taken to regularly evaluate the clinical judgment, skills and performance of a conditional prescribing psychologist to safely provide psychopharmacology services to patients and provide appropriate feedback to the conditional prescribing psychologist.
	p. 	Termination of the supervision plan. A description of how the supervision plan may be terminated and the process for notifying affected patients.
	q. 	Signatures. Signatures of the conditional prescribing psychologist and all supervising physicians.
	r. 	Amendment to the supervision plan. A requirement that a conditional prescribing psychologist shall inform the board of psychology of any amendments to the supervision plan, including the addition of any supervising physicians, within 30 days of the change and that any amendment to a supervisory plan be subject to approval of the board of psychology.
	s. 	Request for extension. If the primary supervising physician determines that a conditional prescribing psychologist is unable to successfully complete the supervised practice prior to the expiration of the conditional prescription certificate, the conditional prescribing psychologist may request an extension of the conditional prescription certificate provided that the conditional prescribing psychologist and the primary supervising physician can demonstrate that the conditional prescribing psychologist is likely to successfully complete the supervised practice within the extended time requested.
	19.10(20) Certification of completion. At the conclusion of the supervised practice period, the primary supervising physician shall certify the following:
	a. 	Supervision. That each supervising physician has provided supervision to the conditional prescribing psychologist in accordance with these rules.
	b. 	Minimum period of supervised practice. That the conditional prescribing psychologist has successfully completed a minimum of two years of supervised practice.
	c. 	Minimum number of patients. That the conditional prescribing psychologist has seen a minimum of 300 patients who had a diagnosed mental disorder with whom pharmacological intervention was considered as a treatment option, even if a decision was made not to prescribe a psychotropic medication to the patient, and that the conditional prescribing psychologist has treated a minimum of 100 patients with psychotropic medication throughout the supervised practice period.
	d. 	Specialization. That a conditional prescribing psychologist who intends to provide psychopharmacology services to children (less than 17 years of age), elderly persons (over 65 years of age), or patients with serious medical conditions, including but not limited to heart disease, cancer, stroke, seizures, or comorbid psychological conditions, or patients with developmental disabilities and intellectual disabilities, has successfully completed a minimum of one year of supervised practice with the respective populations during the supervised practice period.
	e. 	Demonstrated competence. That a conditional prescribing psychologist has successfully completed the supervised practice period and demonstrated competence in psychopharmacology by demonstrating competency in the milestones sufficient to obtain a prescription certificate in accordance with paragraph 19.2(3)“f”.
653—19.11(17A,124,147,148,154B,272C) Standards of practice—collaboration with a prescribing psychologist. A collaborating physician shall be a person who is licensed to practice medicine and surgery or osteopathic medicine in Iowa, who regularly prescribes psychotropic medications for the treatment of mental disorders as part of the physician’s normal course of practice, and who serves as a resource for a prescribing psychologist pursuant to a collaborative practice agreement. A collaborating physician shall be board-certified in family medicine, internal medicine, neurology, pediatrics, or psychiatry. A collaborating physician shall fully comply with the following standards of practice:
	19.11(1) Collaboration. A collaborating physician shall provide appropriate collaboration with a prescribing psychologist to achieve patient safety and optimal clinical outcomes. A collaborating physician shall ensure that appropriate clinical examinations and necessary testing are performed and that all psychopharmacology services provided are appropriate for the patient’s condition. Collaboration may be in person or via electronic communications in accordance with these rules. A prescribing psychologist may have more than one collaborating physician.
	19.11(2) Maximum number of prescribing psychologists. A physician shall not serve as a collaborating physician for more than two prescribing psychologists at one time.
	19.11(3) Initial assessment. Prior to serving as a collaborating physician, a physician shall assess a prescribing psychologist’s relevant education, training, experience, and competence.
	19.11(4) Scope of practice. A collaborating physician shall ensure that all psychopharmacology services provided by a prescribing psychologist are within the competence and scope of practice of the collaborating physician and the prescribing psychologist.
	19.11(5) Prescriptive authority. A collaborating physician shall ensure that a prescribing psychologist only prescribes psychotropic medications for the treatment of mental disorders.
	19.11(6) Delegation. A collaborating physician shall ensure that a prescribing psychologist does not delegate prescriptive authority to any other person.
	19.11(7) Narcotics. A collaborating physician shall ensure that a prescribing psychologist does not prescribe narcotics.
	19.11(8) Active DEA and CSA registration. A collaborating physician shall ensure that a prescribing psychologist has an active DEA registration and CSA registration at all times during the period of collaboration.
	19.11(9) Patient populations. A collaborating physician shall ensure that a prescribing psychologist only provides psychopharmacology services to patient populations within the prescribing psychologist’s education, training, experience, and competence. A collaborating physician may establish limitations on the types of populations to whom a prescribing psychologist may provide psychopharmacology services based on the prescribing psychologist’s education, training, experience, and competence.
	19.11(10) Psychotropic medications. A collaborating physician shall ensure that a prescribing psychologist only prescribes psychotropic medications that are within the prescribing psychologist’s education, training, experience, and competence. A collaborating physician may establish limitations on the types of psychotropic medications that a prescribing psychologist may prescribe based on the prescribing psychologist’s education, training, experience, and competence.
	19.11(11) Specialization. A collaborating physician shall ensure that a prescribing psychologist has completed at least one year of the required two years of supervised practice with the respective population in accordance with subrule 19.3(4) before the prescribing psychologist provides psychopharmacology services to children (less than 17 years of age), elderly persons (over 65 years of age), or patients with serious medical conditions, including but not limited to, heart disease, cancer, stroke, seizures, or comorbid psychological conditions, or patients with developmental disabilities and intellectual disabilities.
	19.11(12) Informed consent. A collaborating physician shall ensure that a prescribing psychologist obtains appropriate informed consent before a prescribing psychologist provides psychopharmacology services to a patient.
	19.11(13) Release of information. A collaborating physician shall ensure that a prescribing psychologist obtains a release of information authorizing the prescribing psychologist to share information with the collaborating physician before the prescribing psychologist provides psychopharmacology services to a patient.
	19.11(14) Primary care physician. A collaborating physician shall ensure that each patient has a designated primary care physician before a prescribing psychologist provides psychopharmacology services to a patient. A collaborating physician shall ensure that a prescribing psychologist maintains a cooperative relationship with the primary care physician who oversees a patient’s general medical care to ensure that necessary medical examinations are conducted, the psychotropic medication is appropriate for the patient’s medical condition, and significant changes in the patient’s medical or psychological condition are discussed. A collaborating physician shall ensure that a prescribing psychologist engages in appropriate consultation with a patient’s designated primary care physician while the prescribing psychologist is providing psychopharmacology services to a patient.
	19.11(15) Chart reviews. A collaborating physician shall personally review a representative sample of the prescribing psychologist’s patient charts.
	19.11(16) Performance evaluations. A collaborating physician shall regularly evaluate the clinical judgment, skills and performance of a prescribing psychologist to safely provide psychopharmacology services to patients and provide appropriate feedback to the prescribing psychologist.
	19.11(17) Collaborative practice agreement. Prior to serving as a collaborating physician for a prescribing psychologist, the collaborating physician shall ensure that the prescribing psychologist has a written collaborative practice agreement in place . A template may be obtained from the boards of medicine and psychology. The collaborative practice agreement shall define the nature and extent of the collaborative relationship and outline specific parameters for review of the collaborative relationship. The collaborative practice agreement shall take into account the collaborating physician’s and prescribing psychologist’s relevant education, training, experience, and competence and the nature and scope of the psychopharmacology services to be provided. The collaborating physician shall review the terms of the collaborative practice agreement with the prescribing psychologist at least once each year. The collaborating physician and prescribing psychologist shall each maintain a copy of the collaborative practice agreement and provide a copy of the agreement to the boards of medicine and psychology upon request. The collaborative practice agreement shall include the following:
	a. 	Prescribing psychologist’s information. The name, license number, DEA registration number, CSA registration number, address, telephone number, email address, and practice locations of the prescribing psychologist.
	b. 	Collaborating physician’s information. The name, license number, DEA registration number, CSA registration number, address, telephone number, email address, and practice locations of the collaborating physician.
	c. 	Period of collaboration. The time period covered by the collaborative practice agreement.
	d. 	Locations and settings. A description of the locations and settings where and with whom collaborative practice will occur.
	e. 	Scope of practice. A description of the scope of practice of the collaborating physician and the prescribing psychologist.
	f. 	Methods of communication. A description of how the collaborating physician and prescribing psychologist may communicate for appropriate collaboration.
	g. 	Initial assessment. A description of the steps the collaborating physician has taken to assess a prescribing psychologist’s relevant education, training, experience, and competence prior to collaborating with a prescribing psychologist.
	h. 	Limitations on psychotropic medications. A description of any limitations on the types of psychotropic medications the prescribing psychologist may prescribe consistent with the collaborating physician’s and prescribing psychologist’s relevant education, training, experience, and competence.
	i. 	Limitations on patient populations. A description of any limitations on the types of populations the prescribing psychologist may treat with psychotropic medications consistent with the collaborating physician’s and prescribing psychologist’s relevant education, training, experience, and competence.
	j. 	Expectations and responsibilities. A description of the expectations and responsibilities of the collaborative relationship.
	k. 	Specialization. A description of the specialized training the prescribing psychologist has completed in order to provide psychopharmacology services to children (less than 17 years of age), elderly persons (over 65 years of age), or patients with serious medical conditions, including but not limited to, heart disease, cancer, stroke, seizures, or comorbid psychological conditions, or patients with developmental disabilities and intellectual disabilities in accordance with subrule 19.3(4).
	l. 	Chart reviews. A description of the steps the collaborating physician has taken to personally review a representative sample of the prescribing psychologist’s patient charts.
	m. 	Consultation between the collaborating physician and the primary care provider. A requirement that the collaborating physician consult with the patient’s primary care physician on a regular basis regarding the patient’s psychotropic treatment plan and any potential complications.
	n. 	Performance evaluations. A description of the steps the collaborating physician has taken to regularly evaluate the clinical judgment, skills and performance of the prescribing psychologist to safely provide psychopharmacology services to patients and provide appropriate feedback to the prescribing psychologist.
	o. 	Termination of the collaborative practice agreement. A provision describing how the collaborative practice agreement may be terminated and the process for notifying affected patients.
	p. 	Signatures. Signatures of the collaborating physician and the prescribing psychologist.
653—19.12(17A,124,147,148,272C) Grounds for discipline. A physician who fails to comply with these rules may be subject to disciplinary action by the board of medicine.