SECTION 1. The legislature finds there are an insufficient number of prescribing mental health care providers available to serve the needs of Hawaii's people. The delivery of quality, comprehensive, accessible, and affordable health care is enhanced by collaborative practice between licensed clinical psychologists and medical doctors. Providing advanced training in psychopharmacology to certain psychologists who wish to become medical psychologists would be beneficial to residents of Hawaii, particularly those who live in rural or medically underserved communities where mental health professionals with prescriptive authority are in short supply.

The legislature further finds that the mental health needs of the State continue to outweigh present capacity. According to the federal Centers for Disease Control and Prevention, suicide is the third leading cause of death for youth between the ages of ten and twenty-four and the tenth leading cause of death in the United States. Suicide was the single leading cause of fatal injuries in Hawaii from 2004 to 2013, with a generally increasing trend in the annual suicide rate among residents. On average, one hundred seventy people die from suicide and eight hundred fifty two people attempt suicide in Hawaii each year. Studies have shown that people who commit suicide receive little or no treatment for their mental health problems due to pervasive stigma against mental illness that prevents many from seeking help and barriers to accessing appropriate and effective care in the community. While causes for suicide are complex, the most commonly reported reasons include depression, relationship problems, and serious medical problems, which are conditions with significantly high rates of occurrence within the general population.

Information from the Honolulu police department revealed that in 2006, 1,435 people were involuntarily taken to emergency rooms for psychiatric evaluation and treatment. During the first four months of 2007, the Honolulu police department responded to four hundred four calls to assist in psychological crises that required emergency attention. Based on a review of the records, approximately fifty-four per cent of these calls resulted from inadequate medication management. Although mental health needs in the State continue to grow, in recent years, the adult mental health division has had to limit eligibility criteria by diagnosis as well as direct services, including case management and crisis management, due to economic shortfalls.

The legislature additionally finds that research indicates that there is an insufficient amount of prescribing mental health care providers available to serve the needs of the people in Hawaii. According to the National Alliance on Mental Illness, approximately thirty-two thousand adults in Hawaii live with serious mental illness and approximately twelve thousand children in the State live with serious mental health conditions. However, only forty-five per cent of adults in Hawaii who live with serious mental illnesses received services from Hawaii's public mental health system. According to the federal Substance Abuse and Mental Health Services Administration, adults diagnosed with serious mental illness represent more than three per cent of the total State population, although this figure does not include individuals with other clinical diagnoses such as unipolar depression, anxiety disorders, adjustment disorders, substance abuse, or post-traumatic stress disorder.

The legislature also finds that clinical psychologists, also known as medical psychologists, are licensed health professionals with an average of seven years of post-baccalaureate study and three thousand hours of post-graduate supervised practice in the diagnosis and treatment of mental illness. Because the current scope of clinical psychologists' practice does not include prescribing medications, patients must consult with and pay for another provider to obtain psychotropic medications when indicated.

The legislature has previously authorized prescription privileges to advanced practice registered nurses, optometrists, dentists, podiatrists, osteopaths, and naturopathic physicians. Licensed clinical psychologists with specialized education and training in preparation for prescriptive practice have been allowed to prescribe psychotropic medications to active duty military personnel and their families in federal facilities and the Indian Health Service for decades. In recent years, Louisiana and New Mexico adopted legislation authorizing prescriptive authority for medical psychologists. In 2014, Illinois became the third state authorizing medical psychologists to prescribe. In the ten years since the Louisiana law was enacted, there have been no complaints against medical psychologists regarding prescribing. In Louisiana and New Mexico, medical psychologists are able to fill positions that were vacant for a number of years and continue to serve predominately indigent or rural populations.

The legislature further finds that the American Psychological Association has developed a model curriculum for a master's degree in psychopharmacology for the education and training of prescribing medical psychologists. Independent evaluations of the federal Department of Defense psychopharmacological demonstration project by the United States General Accounting Office, now known as the Government Accountability Office, and the American College of Neuropsychopharmacology, as well as the experiences of New Mexico and Louisiana, have found that appropriately trained medical psychologists can prescribe medications safely and effectively. A master of science in clinical psychopharmacology is currently offered at the University of Hawaii at Hilo college of pharmacy.

The purpose of this Act is to authorize the board of psychology to issue certificates of prescriptive authority to medical psychologists who meet certain education, training, and registration requirements.

SECTION 2. Chapter 465, Hawaii Revised Statutes, is amended by adding a new part to be appropriately designated and to read as follows:

"Part . Medical psychologists

§465- Definitions. As used in this part unless the context otherwise requires:

"Board" means the board of psychology established under section 465-4.

"Certificate of prescriptive authority" means a certificate issued by the board that grants a medical psychologist the authority to prescribe and distribute, without charge, drugs and other directly related procedures within the scope of the practice of psychology in accordance with rules adopted by the board.

"Drug" shall have the same meaning as in section 461-1; provided that the term "drug" shall include controlled substances except narcotics; provided further that the term "drug" shall be limited to only those agents related to the diagnosis and treatment of mental and emotional disorders pursuant to the practice of psychology, as that term is defined in section 465-1. Nothing in this chapter shall be construed to permit a medical psychologist to administer or prescribe a narcotic.

"Medical psychologist" means a psychologist who has undergone specialized training in clinical psychopharmacology, passed a national proficiency examination in psychopharmacology approved by the board, and holds a current certificate of prescriptive authority issued by the board.

"Narcotics" means natural and synthetic opioid analgesics and their derivatives used to relieve pain.

"Prescription" means an order for a drug or any device or test directly related to the drug or the decision to order or continue or discontinue the order of the drug.

§465- Administration. (a) The board shall prescribe an application form for examination, certification, and certification renewal pursuant to this part.

(b) The board shall develop and implement procedures to review the educational and training credentials of a psychologist applying for a certificate of prescriptive authority and for renewal of a certificate of prescriptive authority under this part, in accordance with current standards of professional practice.

(c) The board shall issue or renew a certificate of prescriptive authority to any qualified medical psychologist who is not in violation of this part.

(d) The board shall establish the grounds for denial, suspension, or revocation of a certificate of prescriptive authority for any medical psychologist found guilty of violating this part.

(e) The board shall issue an identification number to be placed on a certificate of prescriptive authority issued pursuant to this part.

(f) The board shall maintain a current roster of every medical psychologist certified to prescribe under this part, including each medical psychologist's name, last known address, identification number issued by the board, and federal Drug Enforcement Administration registration number.

(g) The board shall have all other powers which may be necessary to carry out the purposes of this part.

§465- Certificate of prescriptive authority; requirements. (a) Every applicant for a certificate of prescriptive authority shall submit evidence satisfactory to the board, in a form and manner prescribed by the board, that the applicant meets the following requirements:

(1) The applicant possesses a current license at the doctoral level to provide health care services as a psychologist in the State;

(2) Prior to submitting an application, the applicant successfully completed minimum educational and training requirements either during the doctoral program required for licensure under this part or in an accredited undergraduate or master level program that consists of the following:

(A) Specific minimum undergraduate biomedical prerequisite coursework, including medical terminology (class or proficiency), chemistry or biochemistry with lab (two semesters), human physiology (one semester), human anatomy (one semester), anatomy and physiology, microbiology with lab (one semester), and general biology for science majors or cell and molecular biology (one semester);

(3) The applicant successfully graduated with a post doctoral master's degree in clinical psychopharmacology from a regionally-accredited institution or equivalent to a post doctoral master's degree, as approved by the board, including:

(A) Study in a program offering intensive didactic education, and including the following core areas of instruction: basic life sciences, neurosciences, clinical and research pharmacology and psychopharmacology, clinical medicine and pathophysiology, physical assessment and laboratory examinations, clinical pharmacotherapeutics, research, professional, ethical, and legal issues. The didactic portion of the education shall consist of a minimum of sixty credit hours; and

(B) Clinical experience that includes a supervised experiential training practicum, of at least fourteen months and thirty-six credit hours, where the applicant was actively involved in consultation with psychiatrists or physicians regarding the prescribing of psychotropic medications, and which consists of a research project, direct face-to-face supervision, and a clinical rotation phase where students complete rotations in emergency medicine, family medicine, geriatrics, internal medicine, obstetrics and gynecology, pediatrics, psychiatrics, surgery, and one elective of the student's choice; program approval standards addressing faculty qualifications, regular competency evaluation and length of clinical rotations, and instructional settings, including hospitals, hospital outpatient clinics, community mental health clinics, and correctional facilities, in accordance with those of the Accreditation Review Commission on Education for the Physician Assistant; and

(4) The applicant has successfully completed the nationally recognized Psychopharmacology Exam for Psychologists developed by the American Psychological Association's Practice Organization's College of Professional Psychology relevant to establish competence across the following content areas: neuroscience, nervous system pathology, physiology and pathophysiology, biopsychosocial and pharmacologic assessment and monitoring, differential diagnosis, clinical psychopharmacology, research, and integrating clinical psychopharmacology with the practice of psychology and professional, legal, ethical, and interprofessional issues.

(b) The board shall issue a certificate of prescriptive authority to any applicant who has met all of the requirements of subsection (a).

§465- Certificate of prescriptive authority: renewal. (a) The board shall implement a method of renewal of a certificate of prescriptive authority in conjunction with the renewal of a medical psychologist's license to practice psychology required under section 465-11.

(b) To qualify for renewal of a certificate of prescriptive authority, a medical psychologist shall present evidence satisfactory to the board that the medical psychologist has completed at least twenty hours annually of acceptable continuing education, as determined by the board, relevant to the pharmacological treatment of mental and emotional disorders.

(c) The continuing education requirement under this section shall be in addition to the continuing education requirement under section 465-11.

§465- Certificate of prescriptive authority; prescribing practices. (a) No medical psychologist shall issue a prescription unless the medical psychologist holds a valid certificate of prescriptive authority.

(b) A prescription issued by a medical psychologist shall:

(1) Comply with applicable state and federal laws;

(2) Clearly identify the issuing psychologist as a medical psychologist certified to prescribe; and

(3) Include the medical psychologist's identification number.

(c) A medical psychologist holding a valid certificate of prescriptive authority shall consult and collaborate with the patient's physician of record to ensure that the medical psychologist:

(1) Prescribes only in consultation and collaboration with a patient's physician of record and with the concurrence of that physician; and

(2) Consults with the patient's physician of record, obtains concurrence upon initiating, and reconsults prior to making changes to a medication treatment plan, including dosage adjustments or adding or discontinuing a medication; provided that the medical psychologist and the physician shall document the consultation in the patient's medical record.

(d) A medical psychologist shall not prescribe for any patient who does not have a primary or attending physician.

(e) A medical psychologist shall not delegate prescriptive authority to any other person.

§465- Drug Enforcement Administration; registration. (a) A medical psychologist authorized under this part shall obtain a Drug Enforcement Administration registration number.

(b) A medical psychologist shall file with the board the individual's federal Drug Enforcement Administration registration number. The registration number shall be filed before the medical psychologist issues a prescription for a controlled substance.

§465- Coordination; board of pharmacy. (a) The board shall provide to the board of pharmacy an annual list of medical psychologists holding valid certificates of prescriptive authority. The list shall contain the name and identification number of each medical psychologist and the effective date of prescriptive authority.

(b) The board shall promptly provide the board of pharmacy with the names of any medical psychologists who are added or deleted from the list.

(c) The board shall notify the board of pharmacy in a timely manner of the revocation, suspension, or reinstatement of any certificate of prescriptive authority.

§465- Violation; penalties. Any person who violates this part shall be guilty of a misdemeanor and, on conviction, fined not more than $500 or imprisoned not more than six months, or both."

SECTION 3. Chapter 465, Hawaii Revised Statutes, is amended by designating sections 465-1 to 465-15, as part I and inserting a title before section 465-1, to read as follows:

"Part I. General Provisions"

SECTION 4. Section 465-3, Hawaii Revised Statutes, is amended to read as follows:

"§465-3 Exemptions. (a) This chapter shall not apply to:

(1) Any person teaching, lecturing, consulting, or engaging in research in psychology insofar as the activities are performed as part of or are dependent upon employment in a college or university; provided that the person shall not engage in the practice of psychology outside the responsibilities of the person's employment;

(2) Any person who performs any, or any combination of the professional services defined as the practice of psychology under the direction of a licensed psychologist in accordance with rules adopted by the board; provided that the person may use the term "psychological assistant", but shall not identify the person's self as a psychologist or imply that the person is licensed to practice psychology;

(3) Any person employed by a local, state, or federal government agency in a school psychologist or psychological examiner position, or a position that does not involve diagnostic or treatment services, but only at those times when that person is carrying out the functions of such government employment;

(4) Any person who is a student of psychology, a psychological intern, or a resident in psychology preparing for the profession of psychology under supervision in a training institution or facility and who is designated by a title as "psychology trainee", "psychology student", "psychology intern", or "psychology resident", that indicates the person's training status; provided that the person shall not identify the person's self as a psychologist or imply that the person is licensed to practice psychology;

(5) Any person who is a member of another profession licensed under the laws of this jurisdiction to render or advertise services, including psychotherapy, within the scope of practice as defined in the statutes or rules regulating the person's professional practice; provided that, notwithstanding section 465-1, the person does not represent the person's self to be a psychologist or does not represent that the person is licensed to practice psychology;

(6) Any person who is a member of a mental health profession not requiring licensure; provided that the person functions only within the person's professional capacities; and provided further that the person does not represent the person to be a psychologist, or the person's services as psychological;

(7) Any person who is a duly recognized member of the clergy; provided that the person functions only within the person's capacities as a member of the clergy; and provided further that the person does not represent the person to be a psychologist, or the person's services as psychological; or

(8) Any psychologist employed by the United States Department of Defense, while engaged in the discharge of the psychologist's official duty and providing direct telehealth support or services, as defined in section 431:10A-116.3, to neighbor island beneficiaries within a Hawaii National Guard armory on the island of Kauai, Hawaii, Molokai, or Maui; provided that the psychologist employed by the United States Department of Defense is credentialed by Tripler Army Medical Center.

(b) Nothing in this chapter shall in any way restrict any person from carrying on any of the psychological activities as defined in section 465-1; provided that such person does not offer psychological services as defined in this chapter except as such activities are incidental to the person's lawful occupational purpose.

(c) A person may use the title of industrial/organizational psychologist, provided that the person registers with the board, and:

(1) Is professionally competent in the practice of industrial/organizational psychology; [~~and~~]

(2) Holds a doctoral degree from an accredited institution of higher education with training and education in industrial/organizational psychology, satisfactory to the board; and

(3) Provides psychological service or consultation to organizations [~~which~~] that does not involve the delivery or supervision of direct psychological services to individuals or groups of individuals, without regard to the source or extent of payment for services rendered.

(d) Nothing in this chapter shall prevent the provision of expert testimony by a psychologist who is otherwise exempted by this chapter.

[~~(e) Nothing in this chapter shall be construed as permitting the administration or prescription of drugs, or in any way engaging in the practice of medicine as defined in the laws of the State.~~]"

SECTION 5. Statutory material to be repealed is bracketed and stricken. New statutory material is underscored.

SECTION 6. This Act shall take effect on July 1, 2050.

HOUSE OF REPRESENTATIVES	H.B. NO.	1072
TWENTY-EIGHTH LEGISLATURE, 2015		H.D. 1
STATE OF HAWAII