Medical Assistant Update: Training and Scope of Practice

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A medical assistant (MA) is an unlicensed individual who performs basic administrative, clerical or technical support services on behalf of a licensed practitioner. Many MAs are certified by an educational institution or their employer as being competent to perform specified tasks. Although the specific scope of practice for medical assistants varies from state to state, unlicensed personnel generally may not diagnose, treat, prescribe for, operate upon, or perform any invasive procedure upon patients. Physicians should be aware of their responsibility to ensure that MAs working under their direction are adequately trained and supervised.

General Recommendations:

  • Ensure your MAs’ level of competency; consider hiring MAs certified by formal training institutions and/or certified by agencies such as the American Association of Medical Assistants (AAMA) www.aama-ntl.org or the Multiskilled Medical Certification Institute (MMCI) www.mmciinc.com.
  • Develop a written office policy that specifies the duties an MA can and cannot perform in your practice.
  • Do not delegate services to your MA that you yourself are not well versed in, such as aesthetic treatments.
  • Do not ask MAs to perform tasks or duties that require independent medical judgment.
  • For information on MAs performing cosmetic procedures, please see Issue #4 of The Exchange.

State-Specific Information:

Alaska

Physicians are responsible for direct supervision of MAs when delegating routine duties. Unlicensed assistive personnel are prohibited from providing services that are considered the practice of medicine, such as:

  • Patient assessment or evaluation of care
  • Health counseling
  • IV therapy
  • Procedural sedation
  • Home dialysis therapy
  • Oral tracheal suction
  • Medication management
  • Chemical peels
  • Liposuction
  • Autotransplantation
  • Administration of Botox or dermal fillers, or the use of certain lasers.

For more information on lasers and dermatologic procedures, see Alaska State Medical Board guidelines: https://www.commerce.alaska.gov/web/cbpl/ProfessionalLicensing/StateMedicalBoard/BoardGuidelinesPolicies.aspx

Alaska law specifically provides that advanced nurse practitioners can delegate injections of certain drugs to certified medical assistants under certain circumstances (see https://www.commerce.alaska.gov/web/Portals/5/pub/NUR_delegation_regs.pdf).

Currently, the Alaska State Medical Board lists injections as one of several services which physicians are not authorized to delegate to medical assistants. See http://www.aama-ntl.org/docs/default-source/legal/ak-bomed-guide-delegation.pdf?sfvrsn=4.

In response to lobbying by community physicians and the Alaska State Medical Association (ASMA), in approximately June 2018 Alaska’s legislature passed HB 108. The bill revises Alaska Statute to include the following:

Sec. 08.64.106. Delegation of routine medical duties. The board shall adopt regulations authorizing a physician, podiatrist, osteopath, or physician assistant licensed under this chapter to delegate routine medical duties to an agent of the physician, podiatrist, osteopath, or physician assistant. The regulations must (1) require that an agent who is not licensed under this chapter may perform duties delegated under this section only if the agent meets applicable standards established by the board; (2) require that a physician, podiatrist, osteopath, or physician assistant may not delegate duties related to pain management and opioid use and addiction; and (3) define the phrase “routine medical duties.”

To date, the Board has not defined “routine medical duties.”

The section of HB 108 (codified as AS Sec. 08.64.108) designed to empower the Board to define required MA training, education and qualifications for certification did not pass.

California

Compared with most other states, California has more detailed regulations pertaining to what MAs can and cannot do. Specific training requirements, levels of supervision and scope of practice guidance can be found on the Medical Board of California website:

One of the most common areas our PSRM specialists see regarding MAs operating outside of their scope of practice pertains to how prescriptions are handled. California physicians should be aware that Medical Assistants can call in a prescription refill if specifically directed, so long as it is a routine refill that is exact and has no changes. An MA may not call in a new prescription, even according to a written protocol, or a refill with changes. Another issue is patients mistaking an MA for a nurse or other licensed individual. MAs must disclose their “practitioner’s license status” (Medical Assistant or Certified Medical Assistant) on a name tag with letters of at least 18-point type while working.

Hawaii

Hawaii presently has no certification requirements, minimal education requirements, and no governing body for medical assistants. There is no Hawaii case law or administrative ruling that defines the scope of practice of a medical assistant or the potential parameters of liability for the conduct of an MA. In the absence of specific guidance from these quarters, MIEC has asked defense counsel to provide guidance. It should be noted that there is a difference between what could be argued is technically permitted and what is the recommended course of action from a risk management perspective.

According to counsel, the Hawai’i statute that requires licensure for physician assistants (licensed individuals) recognizes that an unlicensed individual appropriately trained and supervised by a physician may perform limited tasks. The key words in the statute are “trained,” “limited,” and “direction.”

Training– Training should be specific to the tasks the MA will be undertaking and should by documented, either by the physician employer or through formal education and certification. The University of Hawai’i community college system provides instruction in both clinical and administrative medical assistance with students attaining either a Certificate of Achievement or Associate of Science degree.

Limited– In the absence of specific guidance under Hawai’i law we can look to other states for guidance. Those states that define medical assistance scope of practice typically allow undertaking of simple diagnostics such as taking and recording vital signs and administering medications, including sample injections. Refilling medications by standing order is appropriate; changing medications without direct consultation with a licensed professional would not be nor would independently prescribing medications. Invasive procedures such as starting IV’s and catheter insertions, diagnosis and interpretation of test results, and telephone triage are not typically considered within the MA’s scope of practice.

Direction– The word “direction” suggests that the MA’s duties must be undertaken with some degree of supervision by a licensed professional. In the absence of any specific guidance from Hawaii law on the extent of that supervision, the statute pertaining to the supervision required of a physician is somewhat analogous. Hawaii requires that the conduct of a physician assistant be directed and supervised by a physician at all times. The physical presence of the supervising physician is not necessarily required unless the circumstances require such physical presence. A related issue is whether the supervision of the MA can be delegated to a PA or nurse practitioner. Again, the Hawaii regulatory framework does not offer guidance on this issue. However, a reasonable conclusion is that a licensed provider such as a PA, RN or NP could supervise and train an MA. Additionally, support for RN supervision of MAs can be found in the administrative rules governing the practice of nursing where it is stated that “unlicensed assistive personnel” can be used to provide tasks of nursing care under the specific delegation and supervision of a registered nurse (not an LVN).

Common sense should be followed; if there is any doubt that a particular clinical task is outside the training and/or abilities of the MA, that task should not be undertaken by the MA. Physicians who are unsure about the appropriateness of a particular task should consult with MIEC. Although Medical Assistants are an indispensable part of the health care team, jurors will not look kindly on a physician who uses MAs to perform tasks that would be more appropriate to a licensed individual. They often interpret this as the physician prioritizing a less costly employee over the safety of the patient.

For guidance on MAs performing cosmetic/aesthetic services in Hawaii, please see the information on page nineteen in the July, 2013 edition of The Exchange

Idaho

There are no regulations specifically governing the scope of practice of MAs in Idaho. As unlicensed individuals who are not permitted to practice medicine, MAs are authorized to “administer a remedy, diagnostic procedure or advice” only as specifically directed by a physician. The Idaho Board of Medicine report, “The Appropriate Role of Unlicensed Medical Personnel,” (Winter 2012/2013) stated that unlicensed personnel are not permitted to exercise independent judgment, provide assessments, interpretations or diagnoses, or perform invasive procedures. The IBOM report further recommends that physicians:

  • Ensure appropriate supervision by being on-site or immediately available to respond promptly to any questions or problems that arise
  • Have regularly scheduled conferences between physicians and medical personnel
  • Have written protocols outlining basic principles of planned procedures and treatments
  • Orders are to be authenticated by the author of the order
  • Clearly identify by title when performing delegated service duties (e.g., name tags with the designation of MA)

Idaho’s Controlled Substances Act allows delegation to unlicensed personnel so long as the substance is administered “in [the physician’s or practitioner’s] presence.” The Board of Medicine has said that this could be interpreted to mean in the same office (as opposed to in the same room), but no case law exists to date to clarify the definition.

With respect to obtaining informed consent, Idaho Code requires that the person at whose direction the care is rendered be the person to obtain informed consent. An MA can perform the administrative task of documenting that consent was obtained.

We thank John Tiemessen of Clapp, Peterson, Tiemessen, Thorsness & Johnson, LLC, and Thomas Cook of Lyons, Brandt, Cook & Hiramatsu for their assistance in preparing this information for Alaska and Hawaii, respectively. Information for the Idaho section was excerpted from the IMA-sponsored webinar, “Liability for the Acts of Others,” presented by Kim C. Stanger of Holland & Hart LLP, September 2017.