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Crossing the Quality Chasm: A New Health System for the 21st Century
incorporate new knowledge and technologies. Regulatory and accreditation requirements can, at times, be at odds with needed innovations (Pew Health Professions Commission, 1993). Statutes and regulations, while not the only factors that influence the practices of nonphysician clinicians, are powerful determinants of their authority and independence (Cooper et al., 1998).
A key regulatory issue that affects the health care workforce and the way it is used is scope-of-practice acts, implemented at the state level. The general public does not have adequate information to judge provider qualifications or competence, so professional licensure laws are enacted to assure the public that practitioners have met the qualifications and minimum competencies required for practice (Pew Health Professions Commission, 1993; Safriet, 1994). Along with licensure, such state laws that define the scope of practice for specific types of caregivers serve as an important component of the overall system of health care quality oversight.
One effect of licensure and scope-of-practice acts is to define how the health care workforce is deployed. In general, medical practice acts are defined broadly so that individual practitioners are licensed for medicine (not a specific specialty), and are thereby permitted to perform all activities that fall within medicine’s broad scope of practice. Although a dermatologist would not likely perform open-heart surgery, doing so is not restricted by licensure. However, patients often seek out information about a physician’s reputation and credentials, and professional societies also monitor the activities of their members. Other health professions have more narrowly defined scopes of practice, having to carve out their responsibilities from the medical practice act in each state (Safriet, 1994).
Although scope-of-practice acts are motivated by the desire to establish minimum standards to ensure the safety of patients, they also have implications for the changes to the health care system recommended in this report. Since, any change can potentially affect scope-of-practice acts, it can be difficult to use alternative approaches to care, such as telemedicine, e-visits, nonphysician providers, and multidisciplinary teams, all of which can help in caring for patients across settings and over time (see Chapter 3).
Current systems of licensure raise both jurisdictional and liability issues for some clinical applications of telemedicine, such as centralized consultation services to support primary care (Institute of Medicine, 1996b) or the provision of online, continuous, 24-hour monitoring and clinical management of patients in intensive care units for hospitals that have no or too few critical care intensivists on staff to provide this coverage (Janofsky, 1999; Rosenfeld et al., 2000). Integrated delivery systems that cross state lines and telemedicine have rendered geographic boundaries obsolete (Finocchio et al., 1998), making it more difficult for those charged by statute to protect the public.
Scope-of-practice acts can include provisions that inhibit the use of nonphysician practitioners, such as advanced practice nurses and physician assistants, for primary care (Pew Health Professions Commission, 1993; Safriet, 1994).