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| Montana Administrative Register Notice 24-156-77 | No. 2 01/31/2013 | |
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BEFORE THE BOARD OF MEDICAL EXAMINERS DEPARTMENT OF LABOR AND INDUSTRY STATE OF MONTANA
TO: All Concerned Persons 1. On September 20, 2012, the Board of Medical Examiners (board) published MAR notice no. 24-156-77 regarding the public hearing on the proposed amendment and adoption of the above-stated rules, at page 1809 of the 2012 Montana Administrative Register, issue no. 18. 2. On October 19, 2012, a public hearing was held on the proposed amendment and adoption of the above-stated rules in Helena. Several comments were received by the October 29, 2012, deadline. 3. The board has thoroughly considered the comments received. A summary of the comments received and the board's responses are as follows: COMMENT 1: Twenty-eight commenters supported the amendments as proposed. Generally, the commenters thanked the board for making the changes in the best interest of Montana, and discussed the difficulty of finding and keeping trained Emergency Medical Technicians (EMTs) in rural Montana, the high cost of attending training, and the hardships involved in serving as a volunteer EMT, many using personal experiences to illustrate their points. One commenter noted that the option of National Registry of Emergency Medical Technicians (NREMTs) registration is a good one for Montana EMTs who do not plan to move to another state, since Montana is capable of producing a test of the same quality as the NREMT test. RESPONSE 1: The board appreciates all comments made during rulemaking. COMMENT 2: Thirteen commenters supported the board as the governing body for Emergency Care Providers (ECPs), the option of requiring either NREMT registration or local accreditation, and board-approved ECP courses of instruction at the local level or with an organization offering an accredited curriculum. The commenters asked the board to extend the time period for completion of transition courses to one year. RESPONSE 2: The board carefully considered the suggestion to grant a one-year transition period for ECPs taking transition courses, and agrees the timeframe is too short. The board is therefore amending ARM 24.156. 2701, 24.156.2731, 24.156.2751, 24.156.2754, and 24.156.2757 to provide a longer transition period. COMMENT 3: Nine commenters supported the amendments and particularly the elimination of NREMT registration as a requirement for EMTs. The commenters related difficulty in traveling to test centers, the associated expenses of testing at a national level, and personal experiences of rural living and traveling to test. RESPONSE 3: The board appreciates all comments made during rulemaking. COMMENT 4: One commenter supported the amendments, but wanted the 30-day requirement for medical directors in ARM 24.156.2732(1) to become 90 days. RESPONSE 4: The board has carefully considered this recommendation to extend the 30-day requirement to notify the board of providing medical direction to 90 days. The board agrees that 30 days may not be enough time for a physician to be compliant with this notice requirement. However, since any noncompliance with board rules is a possible ground for disciplinary action, the board is amending ARM 24.156.2732 to extend the timeframe to 60 days and facilitate maximum compliance. COMMENT 5: One commenter supported the cleanup and minor changes in the amendments, but stated that the accreditation program was "intuitively" the trend in the industry, although requiring the accredited program to be a two-year associate degree would be a hardship for rural services. The commenter appeared to oppose allowing an option to NREMT registration. RESPONSE 5: The board carefully considered the suggested changes. The board is not requiring a two-year associate degree of an accredited program in order for an individual to meet licensing requirements. COMMENT 6: One commenter supported replacing the use of "prehospital" to "out of hospital" in the rules, stating it more accurately reflects the work of EMTs, and supported alignment with National Registry. The commenter asked if endorsements could be included in the EMT full course and appeared to oppose Montana having an option to NREMT registration. RESPONSE 6: The board notes that endorsements are numerous and above-and-beyond the basic training required at the national level. Endorsements allow individuals to pursue more advanced skills as they deem necessary or desirable for their communities. COMMENT 7: Three commenters opposed the amendments in their entirety, asking the board to change all of what was proposed to avoid crippling Montana's EMS programs and to not diminish the high quality training requirements of EMS providers. RESPONSE 7: The board appreciates all comments made during rulemaking. COMMENT 8: Two commenters opposed the move away from NREMT registration as a requirement for licensure, noting that 42 states require NREMT. RESPONSE 8: The board appreciates all comments made during rulemaking. COMMENT 9: Three commenters opposed the amendments and particularly paramedic training and the NREMT as the standard recognized by the Department of Transportation (DOT) and across the country. One commenter was concerned that the amendment to ARM 24.156.2751, regarding endorsements, would allow the medical director to sign off on competency of EMT-B, AEMTs, and paramedics without a minimum testing standard, leading to inconsistencies in training, skills, ability, and knowledge; ultimately creating inconsistencies in patient care. The commenters suggested that Montana would make it easier to become a paramedic and noted that 44 states require accreditation for paramedic level training, asserting that Montana is bucking a national trend. RESPONSE 9: The board notes that the NREMT is a private company registration. The standards used by the NREMT and the board are federal DOT standards that are not part of, nor promulgated by, the NREMT. The minimum standards adopted by the board in rule and used by medical directors are the federal DOT standards. COMMENT 10: Four commenters opposed the amendments moving away from national registration and cited the threat that local training poses to portability of licensure. Two suggested there would be future problems in standards, professional opportunity, and patient care, and recommended that the board not amend the rules as written. Commenters urged the board to continue supporting NREMT registration, and offered the history of the EMS Workforce Agenda for the Future, noting that 46 states rely on the NREMT.
RESPONSE 10: The board understands the concerns about portability, but notes that every state that uses the NREMT registration utilizes it differently. It is no longer the sole method for EMT licensure and portability is determined on a state-by-state basis. Montana does not set the standards of other state's reciprocity or portability requirements. An individual seeking to be trained in Montana who has concerns about portability can still opt for NREMT registration if that individual feels that the registration is necessary for his or her career. COMMENT 11: One commenter asked the board to adopt the EMS Educational Agenda for the Future as set forth by the DOT's National Highway Traffic Safety Administration Standards (NHTSA) and to continue to utilize the NREMT certification process. The commenter also requested that the current EMT-B skills endorsement system be maintained, and opined that creating a separate EMS training and certification system just for Montana would be costly and cumbersome. RESPONSE 11: The board has embraced the DOT's NHTSA and is retaining the current EMT-B skills endorsement system, with the exception of endotracheal intubation. The board is removing this endorsement because of national poor patient outcomes and a lack of data to support its efficacy. COMMENT 12: One commenter supported the amendments except the change to ARM 24.156.2717(4) which requires AEMTs to identify the medical director for relicensure like a paramedic. The commenter also suggested that ARM 24.156.2732(7)(a) should allow family nurse practitioners to give online medical control, even if requiring MD/DO oversight. Additionally, the commenter suggested the board amend New Rule II to require EMTs attain 24 hours of continuing education credit for renewal. RESPONSE 12: The board believes that medical practitioners providing medical oversight to all levels of EMTs must be identified to ensure patient safety. The board has no jurisdiction over nurses and cannot authorize nurse practitioners to give online medical control. Additionally, continuing education is competency-based using national standards and the board sets required CE hours to ensure the competency is met. COMMENT 13: One commenter asked how to locate the skill verification form for moving from EMT-FR, with endorsements, to the new EMT. Another asked if the board had developed and approved the I99 to paramedic bridge program, when it will be available, and what forms will be needed. RESPONSE 13: The board appreciates the commenters' questions and notes that the information is available on the board's web site. COMMENT 14: One commenter asked if EMT first responders with no endorsement and without doing the skill verification, would then not qualify for a license? The commenter questioned if an EMT-B with fewer than four endorsements, but no skills verification, would become an EMT with or without endorsements? Lastly, the commenter asked if an EMT basic with four endorsements has to do the skills verification to remain an EMT with endorsements, or whether the EMT would revert to an EMT with no endorsements? The commenter also questioned why the board failed to include a provision to grandfather volunteer responders. RESPONSE 14: The board has carefully considered these questions. With the exception of first responders, the board does not mandate advancement to any other level of EMTs/ECPs. However, first responders without additional skills verification cannot meet the DOT EMR standards and cannot be licensed at the EMR level. COMMENT 15: One commenter supported the amendments to allow EMS services to continue to design their courses to meet the needs of the community and volunteer agencies, and supported the option of registry or nonregistry pathways. RESPONSE 15: The board appreciates all comments made during rulemaking. COMMENT 16: One commenter opposed the proposed rules in their current form and requested the board reject them. The commenter made an equal protection argument stating that offering options to NREMT registry was discrimination. The commenter stated that the NREMT test is not going away and noted that the board has five additional years to write better rules. RESPONSE 16: The board believes that an equal protection argument is misplaced, since the proposed rules provide more options to individuals seeking to become EMTs. COMMENT 17: One commenter disagreed with the proposed rule changes stating such changes will establish a separate, unequal, and nonaccredited licensing system. The commenter asserted that doctors, physician assistants, and respiratory therapists are tested and accredited on a national level. RESPONSE 17: The board notes that it relies on a national curriculum to maintain consistency of standards. 4. The board has amended ARM 24.156.2705, 24.156.2711, 24.156.2713, 24.156.2715, 24.156.2717, 24.156.2719, 24.156.2741, 24.156.2745, 24.156.2761, 24.156.2771, and 24.156.2775 exactly as proposed. 5. The board has adopted NEW RULES I (24.156.2752), II (24.156.2718), III (24.156.2755), IV (24.156.2707), and V (24.156.2708) exactly as proposed. 6. The board has amended ARM 24.156.2701, 24.156.2731, 24.156.2732, 24.156.2751, 24.156.2754, and 24.156.2757 with the following changes, stricken matter interlined, new matter underlined: 24.156.2701 DEFINITIONS (1) through (1)(f) remain as proposed. (g) "Clinical preceptor" means an individual trained to a level greater than the student, who is responsible for supervising and teaching the student in a clinical setting in an approved course or program, under the supervision of the medical director or lead instructor in the case of an EMT-basic course or EMT course after December 31, (h) through (j) remain as proposed. (k) "Emergency medical technician - basic" or "EMT-B" means an individual licensed by the board as an EMT-B or, after January 1, (l) "Emergency medical technician - first responder" or "EMT-F" means an individual licensed by the board as an EMT-F or, after January 1, (m) "Emergency medical technician - intermediate" or "EMT-I" means an individual licensed by the board as an EMT-I or, after January 1, (n) "Emergency medical technician - paramedic" or "EMT-P" means an individual licensed by the board as an EMT-P or, after January 1, (o) through (v) remain as proposed. 24.156.2731 FEES (1) remains as proposed. (a) EMT-F, or after December 31, (b) EMT-B, or after December 31, (c) EMT-I, or after December 31, (d) EMT-P, or after December 31, application fee 60 (e) remains as proposed. (f) EMT-F, or after December 31, renewal fee 20 (g) EMT-B, or after December 31, renewal fee 30 (h) EMT-I, or after December 31, renewal fee 40 (i) EMT-P, or after December 31, biennial renewal fee 60 (j) through (3) remain as proposed. 24.156.2732 MEDICAL DIRECTION (1) Within (a) through (9) remain as proposed. 24.156.2751 LEVELS OF ECP LICENSURE INCLUDING ENDORSEMENTS (1) remains as proposed. (2) On January 1, (a) and (b) remain as proposed. (c) EMT-FRs with an ambulance endorsement and a skill verification form prescribed by the board and on file with the board before December 31, (d) EMT-Bs who have completed a skill verification form prescribed by the board and on file with the board before December 31, (e) EMT-Bs who have the airway endorsement and completed a skill verification form prescribed by the board and on file with the board before December 31, (f) EMT-Bs who have the medication endorsement and have completed a skill verification form prescribed by the board and on file with the board before December 31, (g) EMT-Bs who have the IV and IO (intravenous infusion and intraosseous infusion) initiation endorsement and have completed a skill verification form prescribed by the board and on file with the board before December 31, (h) EMT-Bs who have the IV and IO maintenance endorsement and have completed a skill verification form prescribed by the board and on file with the board before December 31, (i) EMT-Bs with an airway, IV/IO (initiation and maintenance), monitoring, medication endorsement, and a skill verification form prescribed by the board and on file with the board before December 31, (j) EMT-Intermediate 99s who have completed a skill verification form prescribed by the board and on file with the board before December 31, (k) EMT-Intermediate 99s who have completed the paramedic bridge program as developed by the board and on file with the board before December 31, (l) EMT-Paramedics who have completed a transition program developed by the board and on file with the board before December 31, (m) EMT-Paramedics who have a critical care endorsement prescribed by the board and on file with the board before December 31, (3) Following January 1, (a) through (d) remain as proposed. 24.156.2754 INITIAL ECP COURSE REQUIREMENTS (1) remains as proposed. (2) EMT-F or, after December 31, (a) conduct the EMT-F or, after December 31, (b) through (d) remain as proposed. (3) EMT-B or, after December 31, (a) conduct the EMT-B or, after December 31, (b) through (4) remain as proposed. 24.156.2757 ECP CLINICAL REQUIREMENTS (1) remains as proposed. (2) EMT-B or, after December 31, (a) through (3) remain as proposed. BOARD OF MEDICAL EXAMINERS ANNA EARL, MD, PRESIDENT /s/ DARCEE L. MOE /s/ PAM BUCY Darcee L. Moe Pam Bucy, Commissioner Alternate Rule Reviewer DEPARTMENT OF LABOR AND INDUSTRY Certified to the Secretary of State January 22, 2013
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