Standing Orders Project

INTRODUCTION AND BACKGROUND

The Standing Orders project was developed as a part of our U.S. immunization law studies. The study, entitled The Epidemiology of U.S. Immunization Law: Translating CDC Immunization Guidelines into Practice: State Laws Related to the Use of Standing Orders Covering Immunization Practice, examines the current status of state medical and health professions licensure laws that govern the parameters of medical practice. Non-physician health professionals may be authorized to engage in medical practice either under their own license or through delegated authority from a licensed physician and in a broad range of settings and conditions.

What are Standing Orders?

Standing orders programs are an effective method to increase vaccine delivery and could prove valuable in eliminating disparities in immunization coverage, particularly for the nation's most vulnerable populations. Standing orders are written protocols that describe the circumstances under which an individual other than a physician can engage in the legal practice of medicine. Standing orders describe:

  1. what type of medical practice can be delegated,
  2. what procedures medical personnel must follow,
  3. the patient population that may be served,
  4. the level of physician supervision required, and
  5. the locations where the services may occur.

What are the elements of immunization practice?

Immunization practice can be thought of as a "bundled" set of procedures that together result in the provision of an appropriate immunization to a patient; these procedures consist of:

  1. assessment of a patient's immunization status,
  2. the prescribing of one or more vaccines, and
  3. the administration of one or more vaccines.

METHODS

Researchers identified medical and health professional practice acts and regulations, attorney's general opinions, and professional licensing board decisions from fifty states and the District of Columbia. The data were analyzed to determine:

  1. how the three elements of immunization practice were addressed,
  2. the permissible practice sites, and
  3. the definitions of medical practice.

Categories of health professionals addressed in this report include: registered nurses, all categories of advanced practice nurses, physician assistants and pharmacists.

FINDINGS

The study findings are separated into two categories: 1) permissible action under the professional's own license, and 2) permissible action under delegation.

  • Appendix I presents the definition of medical practice for each jurisdiction.
  • Appendix II [PDF - 121 pages] contains 1) a summary chart explaining how each jurisdiction addresses whether non-physician health professionals are authorized to engage in each of the elements of immunization practice and 2) detailed analysis and statutory language by state. Users may access individual state results by using our flash-based interactive map and clicking on the respective state.
  • Appendix III outlines the settings in which each class of non-physician health professional is permitted to practice.
  • Appendix IV [PDF - 102 pages] illustrates how each jurisdiction manages immunization practice of non-physician health professionals. The summary chart is followed by state-by-state illustrations.
  • Appendix V provides citations for the state authorities referenced in this report.

General Findings

  1. Almost half of the states' laws fail to utilize immunization-specific language when addressing the management of medications among non-physician health professionals.
  2. Nurses, physician assistants, and pharmacists have been granted limited power to conduct immunization practice under their own practice licenses.
  3. There is broad variability in the extent to which states have expressly encouraged immunizations through the use of health professionals working under standing orders.
  4. In order for a single health professional to conduct all three elements of immunization practice, a professional license combined with delegated power may be required.
  5. State laws authorize health professionals to practice in a broad range of settings.

MORE INFORMATION

For more information, please contact Alexandra Stewart, stewarta@gwu.edu or Marisa Cox, mcox@gwu.edu.