Labs Stop VA from Allowing APRNs to Perform Lab Tests

The laboratory sector has successfully fought a Department of Veterans Affairs (VA) rule that would have allowed advanced practice registered nurses (APRNs) to “perform and supervise” lab testing. Numerous organizations, including the American Society for Clinical Laboratory Service (ASCLS), American Association for Clinical Chemistry (AACC) and American Society for Clinical Pathology (ASCP) raised concerns about the rule’s provision on lab testing, noting that the Clinical Laboratory Improvement Amendments (CLIA) regulations address titles and qualifications regarding who can perform lab tests and what tests they can perform.

A May 2016 proposed rule would have granted APRNs’ full practice authority in four roles while serving as employees in the VA health system, which provides medical and hospital services to veterans. That would mean the APRNs could practice “to the full extent of their education, training and certification, without the clinical supervision or mandatory collaboration of physicians.” Ultimately, the VA granted full practice authority in three roles: Certified Nurse Practitioner, Certified Nurse Specialist, and Certified Nurse Midwife. APRNs were not granted full practice authority in the role of Certified Registered Nurse Anesthetists at this time.

The language raising the laboratory sector’s ire stated that a Certified Nurse Practitioner “may order, perform, or supervise laboratory studies.” The VA acknowledged in the Dec. 14, 2016 final rule that commenters objected that such language fails to “‘adequately appreciate the levels of complexity involved in laboratory testing,’ and that there are rigid standards for laboratory tests that require rigorous academic and practical training, which are not part of the training for APRNs.” Other comments suggested the rule needed to more carefully distinguish the duties of an APRN and a laboratory specialist.

The VA agreed, responding in the final rule—which was effective Jan. 13, 2017—”We agree with the commenter in that the proposed language might be construed as allowing CNPs the ability to perform laboratory studies. It is not VA’s intent to have APRNs take over the role of laboratory specialists. These specialists perform a crucial role at VA medical facilities and are skillfully trained in performing the various testing techniques that allow health care professionals to properly treat a veteran’s medical conditions.” So the VA changed the proposed language to instead clarify that a CNP could order lab testing (or imaging) and “integrate the results into clinical decision making.”

“We have successfully convinced the VA to adjust the language to better protect patients while expanding access to care for our nation’s veterans,” the ASCLS said in a statement. The ASCP similarly praised the change in the language and took the opportunity to highlight a similar issue relating to the Centers for Medicare and Medicaid Services’ April internal memo that allowed those with a bachelor’s degree in nursing to perform high complexity testing and those with associate degree to perform moderate complexity testing. The ASCP had earlier objected to that memo arguing it “significantly lowers the qualifications necessary to perform high and moderate complexity testing and could have significant repercussions for test quality and patient safety.” In praising the changes in the VA final rule, ASCP noted “Given the VA’s position on laboratory testing by APRNs, ASCP plans to discuss with the Centers for Medicare & Medicaid [Services] its interpretation that a bachelor’s degree in nursing is equivalent to a degree in biology.”