[Federal Register Volume 88, Number 49 (Tuesday, March 14, 2023)]
[Notices]
[Pages 15858-15860]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2023-05142]


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DEPARTMENT OF VETERANS AFFAIRS


Notice of Request for Information on the Department of Veterans 
Affairs Orthotist, Prosthetist, and Prosthetist-Orthotist Standard of 
Practice

AGENCY: Department of Veterans Affairs.

ACTION: Request for information.

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SUMMARY: The Department of Veterans Affairs (VA) is requesting 
information to assist in developing a national standard of practice for 
VA Orthotists, Prosthetists, and Prosthetist-Orthotists. VA seeks 
comments on various topics to help inform VA's development of this 
national standard of practice.

DATES: Comments must be received on or before May 15, 2023.

ADDRESSES: Comments must be submitted through www.regulations.gov. 
Except as provided below, comments received before the close of the 
comment period will be available at www.regulations.gov for public 
viewing, inspection, or copying, including any personally identifiable 
or confidential business information that is included in a comment. We 
post the comments received before the close of the comment period on 
the following website as soon as possible after they have been 
received: https://www.regulations.gov. VA will not post on 
Regulations.gov public comments that make threats to individuals or 
institutions or suggest that the commenter will take actions to harm 
the individual. VA encourages individuals not to submit duplicative 
comments. We will post acceptable comments from multiple unique 
commenters even if the content is identical or nearly identical to 
other comments. Any public comment received after the comment period's 
closing date is considered late and will not be considered in a 
potential rulemaking.

FOR FURTHER INFORMATION CONTACT: Ethan Kalett, Office of Regulations, 
Appeals and Policy (10BRAP), Veterans Health Administration, Department 
of Veterans Affairs, 810 Vermont Avenue NW, Washington, DC 20420, 202-
461-0500. This is not a toll-free number.

SUPPLEMENTARY INFORMATION: 

Authority

    Chapters 73 and 74 of 38 U.S.C. and 38 U.S.C. 303 authorize the 
Secretary to regulate the professional activities of VA health care 
professions to make certain that VA's health care system provides safe 
and effective health care by qualified health care professionals to 
ensure the well-being of those Veterans who have borne the battle.
    On November 12, 2020, VA published an interim final rule confirming 
that VA health care professionals may practice their health care 
profession consistent with the scope and requirements of their VA 
employment, notwithstanding any State license, registration, 
certification, or other requirements that unduly interfere with their 
practice. 38 CFR 17.419; 85 FR 71838. Specifically, this rulemaking 
confirmed VA's current practice of allowing VA health care 
professionals to deliver health care services in a State other than the 
health care professional's State of licensure, registration, 
certification, or other State requirement, thereby enhancing 
beneficiaries' access to critical VA health care services. The 
rulemaking also confirmed VA's authority to establish national 
standards of practice for its health care professionals which would 
standardize a health care professional's practice in all VA medical 
facilities.
    The rulemaking explained that a national standard of practice 
describes the tasks and duties that a VA health care professional 
practicing in the health care profession may perform and may be 
permitted to undertake. Having a national standard of practice means 
that individuals from the same VA health care profession may provide 
the same type of tasks and duties regardless of the VA medical facility 
where they are located or the State license, registration, 
certification, or other State requirement they hold. We emphasized in 
the rulemaking and reiterate here that VA will determine, on an 
individual basis, that a health care professional has the necessary 
education, training and skills to perform the tasks and duties detailed 
in the national standard of practice and will only be able to perform 
such tasks and duties after they have been incorporated into the 
individual's privileges, scope of practice, or functional statement. 
The rulemaking explicitly did not create any such national standards 
and directed that all national standards of practice would be 
subsequently created via policy.

Need for National Standards of Practice

    As the Nation's largest integrated health care system, it is 
critical that VA develops national standards of practice to ensure 
beneficiaries receive the same high-quality care regardless of where 
they enter the system and to ensure that VA health care professionals 
can efficiently meet the needs of beneficiaries when practicing within 
the scope of their VA employment. National standards are designed to 
increase beneficiaries' access to safe and effective health care, 
thereby improving health outcomes. The importance of this initiative 
has been underscored by the COVID-19 pandemic. With an increased need 
for mobility in our workforce, including through VA's Disaster 
Emergency Medical Personnel System, creating a uniform standard of 
practice better supports VA health care professionals who already 
frequently practice across State lines. In addition, the development of 
national standards of practice aligns with VA's long-term

[[Page 15859]]

deployment of a new electronic health record (EHR). National standards 
of practice are critical for optimal EHR implementation to enable the 
specific roles for each health care profession in EHR to be consistent 
across the Veterans Health Administration (VHA) and to support 
increased interoperability between VA and the Department of Defense 
(DoD). DoD has historically standardized practice for certain health 
care professionals, and VHA closely partnered with DoD to learn from 
their experience.

Process To Develop National Standards of Practice

    Consistent with 38 CFR 17.419, VA is developing national standards 
of practice via policy. There will be one overarching national standard 
of practice directive that will generally describe VHA's policy and 
have each individual national standard of practice as an appendix to 
the directive. The directive and all appendices will be accessible on 
VHA Publications website at: https://vaww.va.gov/vhapublications/ 
(internal) and https://www.va.gov/vhapublications/ (external) once 
published.
    To develop these national standards, VA is using a robust, 
interactive process that is consistent with the guidance outlined in 
Executive Order (E.O.) 13132 to preempt State law. The process includes 
consultation with internal and external stakeholders, including State 
licensing boards, VA employees, professional associations, Veterans 
Service Organizations, labor partners, and others. For each identified 
VA occupation, a workgroup comprised of health care professionals 
conducts State variance research to identify internal best practices 
that may not be authorized under every State license, certification, or 
registration, but would enhance the practice and efficiency of the 
profession throughout the agency. The workgroup is comprised of VA 
employees who are health care professionals in the identified 
occupation; they may consult with internal stakeholders at any point 
throughout the process. If a best practice is identified that is not 
currently authorized by every State, the workgroup determines what 
education, training, and skills are required to perform such task or 
duty. The workgroup then drafts a proposed VA national standard of 
practice using the data gathered during the State variance research and 
incorporates internal stakeholder feedback to date.
    The proposed national standard of practice is internally reviewed, 
to include by an interdisciplinary workgroup consisting of 
representatives from Quality Management; Field Chief of Staff; Academic 
Affiliates; Field Chief Nursing Officer; Ethics; Workforce Management 
and Consulting; Surgery; Credentialing and Privileging; Field Chief 
Medical Officer; and EHR Modernization.
    Externally, the proposed national standard of practice is provided 
to our partners in DoD. In addition, VA labor partners are engaged 
informally as part of a pre-decisional collaboration. Consistent with 
E.O. 13132, a letter is sent to each State board and certifying 
organization that includes the proposed national standard and an 
opportunity to further discuss the national standard with VA. After the 
States and certifying organizations have received notification, the 
proposed national standard of practice is published to the Federal 
Register for 60 days to obtain feedback from the public, including 
professional associations and unions. At the same time, the proposed 
national standard is published on an internal VA site to obtain 
feedback from VA employees. Feedback from State boards, professional 
associations, unions, VA employees, and any other person or 
organization who informally provides comments via the Federal Register 
will be reviewed. VA will make appropriate revisions in light of the 
comments, including those that present evidence-based practice and 
alternatives that help VA meet our mission and goals, and that are 
better for Veterans or VA health care professionals. We will publish a 
collective response to all comments at https://www.va.gov/standardsofpractice.
    After the national standard of practice is finalized, approved and 
published in VHA policy, VA will implement the tasks and duties 
authorized by that national standard of practice. Any tasks or duties 
included in the national standard will be incorporated into an 
individual health care professional's privileges, scope of practice, or 
functional statement following any training and education necessary for 
the health care professional to perform those functions. Implementation 
of the national standard of practice may be phased in across all 
medical facilities, with limited exemptions for health care 
professionals as needed.

National Standard for Orthotist, Prosthetist, and Prosthetist-Orthotist

    The proposed format for national standards of practice when there 
are State licenses and a national certifying organization is as 
follows. The first paragraph provides general information about the 
profession and what the health care professionals can do. The second 
paragraph references the education and certification needed to practice 
this profession at VA. The third paragraph confirms that this 
profession follows the standard of practice set by the national 
certifying body. A final statement explains that while VA only requires 
a national certification, some States also require licensure for this 
profession. The standard includes information on which States offer an 
exemption for Federal employees and where VA will preempt State laws, 
if applicable.
    We note that the proposed standards of practice do not contain an 
exhaustive list of every task and duty that each VA health care 
professional can perform. Rather, it is designed to highlight whether 
there are any areas of variance in how this profession can practice 
across States and how this profession will be able to practice within 
VA notwithstanding their State license, certification, registration, 
and other requirements.
    VA Orthotists, Prosthetists, and Prosthetist-Orthotists are health 
care professionals who are specifically educated and trained to manage 
comprehensive orthotic and/or prosthetic patient care. VA qualification 
standards require Orthotists, Prosthetists, and Prosthetist-Orthotists 
to have an active, current, full, and unrestricted certification from 
either the American Board of Certification (ABC) in Orthotics, 
Prosthetics & Pedorthics or from the Board of Certification (BOC). VA 
reviewed whether there are any alternative certifications or State 
requirements that could be required for Orthotists, Prosthetists, and 
Prosthetist-Orthotists and found that 15 States require a license to 
practice as an Orthotist, Prosthetist, and Prosthetist-Orthotist. Of 
those, VA found that all 15 States exempt Federal employees from their 
State license requirements.
    While VA qualification standards for Orthotists, Prosthetists, and 
Prosthetist-Orthotists require one certification from either ABC or 
BOC, VA proposes to adopt a standard of practice consistent with the 
ABC certification. There is no variance between these two national 
certifications; however, ABC standards set more specific expectations 
for education, training, and practice areas. Therefore, VA Orthotists, 
Prosthetists, and Prosthetist-Orthotists will follow the standard as 
set by this national certification. The standard for the ABC 
certification can be found here: https://www.abcop.org/publication/scope-of-practice.

[[Page 15860]]

Proposed National Standard of Practice for Orthotist, Prosthetist and 
Prosthetist-Orthotist

    Orthotists, Prosthetists and Prosthetist-Orthotists are health care 
professionals who are specifically educated and trained to manage 
comprehensive orthotic and/or prosthetic patient care. This includes 
patient assessment, formulation of a treatment plan, implementation of 
the treatment plan, follow-up, and practice management. Documentation 
by the Orthotists, Prosthetists and Prosthetist-Orthotists is part of 
the patient's medical record and assists with establishing medical 
necessity for orthotic and/or prosthetic care.
    Orthotists, Prosthetists and Prosthetist-Orthotists in the 
Department of Veterans Affairs (VA) possess the education and 
certification from either the American Board of Certification (ABC) or 
Board of Certification (BOC) required by VA qualification standards, as 
more specifically described in VA Handbook 5005, Staffing, Part II, 
Appendix G32.
    This national standard of practice confirms that Orthotists, 
Prosthetists and Prosthetist-Orthotists practice according to the 
Orthotist and Prosthetist standards from the American Board of 
Certification, available at: https://www.abcop.org. As of March 2022, 
all Orthotists, Prosthetists and Prosthetist-Orthotists in VA follow 
the standards associated with this national certification.
    Although VA only requires a certification, 15 States require a 
State license in order to practice as an Orthotist, Prosthetist and 
Prosthetist-Orthotist in that State: Alabama, Arkansas, Florida, 
Georgia, Illinois, Iowa, Kentucky, Minnesota, New Jersey, Ohio, 
Oklahoma, Pennsylvania, Tennessee, Texas, and Washington. However, all 
15 States exempt Federal employees from their State license 
requirements.
    As of March 2022, there is no variance in how VA Orthotists, 
Prosthetists and Prosthetist-Orthotists practice in any State.

Request for Information

    1. Are there any required trainings for the aforementioned 
practices that we should consider?
    2. Are there any factors that would inhibit or delay the 
implementation of the aforementioned practices for VA health care 
professionals in any States?
    3. Is there any variance in practice that we have not listed?
    4. What should we consider when preempting conflicting State laws, 
regulations, or requirements regarding supervision of individuals 
working toward obtaining their license or unlicensed personnel?
    5. Is there anything else you would like to share with us about 
this national standard of practice?

Signing Authority

    Denis McDonough, Secretary of Veterans Affairs, approved this 
document on February 21, 2023, and authorized the undersigned to sign 
and submit the document to the Office of the Federal Register for 
publication electronically as an official document of the Department of 
Veterans Affairs.

Luvenia Potts,
Regulation Development Coordinator, Office of Regulation Policy & 
Management, Office of General Counsel, Department of Veterans Affairs.
[FR Doc. 2023-05142 Filed 3-13-23; 8:45 am]
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