Washington Legislature Concerned About Chiropractic Scope Expansion

In December 2013 the Chiropractic Board in Washington state was denied in their attempt to expand the scope of practice. In a Sunrise Review the Department of Health stated:

"Although chiropractic training includes basic understanding of body and organ systems, including the cardiovascular system, the department is unable to find that it prepares chiropractors to potentially be the sole evaluator of all or most medical conditions. Examining a patient to evaluate his or her overall health should be done by a primary care provider who can use their broad spectrum of training, clinical residency, and experience to conduct the evaluations, and whose daily practice includes functions of primary care."

Apparently paying no mind to the opinion of the Department of Health, the Washington Chiropractic Board then attempted to include the performance of EKG's in the scope through an interpretative statement instead of the rulemaking process according to minutes from meetings of the Washington State Chiropractic Quality Assurance Commission on February 13 and 28, 2014.

According to the documents in 2011, the National Board of Chiropractic Examiners conducted a scope-of-practice survey of the states and then in September 2013, an inquiry was received from an out-of-state chiropractor insisting EKGG/ECGs were on the approved list before and wondered why it was removed.

In October 2013, the Instrumentation Procedures/Standard of Care Committee of the Chiropractic Commission reviewed and discussed EKG/ECGs and RCW 18.25.005 and considered the use of EKG/ECG for differential diagnosis determining that EKG/ECG met the requirements of WAC 246-808-505 and that it falls under the scope-of-practice. Committee members reported to the full commission and recommended that it be added to the approved List. On December 12, 2013, the commission reviewed the committee’s recommendations and discussed RCW 18.25.005 and chiropractors use of EKG/ECGs for differential diagnosis and voted 12 in favor, and one member opposed, to add EKG/ECG to the approved list. One member was absent for the vote.

According to the minutes the rationale included:

• EKG/ECG devices can be used as part of a chiropractic differential diagnosis to serve the public by providing greater access to health care. For example, the chiropractor may practice in a rural area where they are the closest access point to healthcare.
• A chiropractor is required to perform a physical examination on every patient. If the chiropractor finds a concern or condition that falls outside of the chiropractic scope-of-practice, the patient can be referred to another healthcare provider.
• University of Western States and Life West Chiropractic Colleges were contacted. They verified that the EKG/ECG fundamentals are taught in the chiropractic colleges and competency is obtained in the construct of providing a differential diagnosis.
• The National Board of Chiropractic Examiners (NBCE) also verified that EKG/ECG fundamentals are covered in their exam.

Then in January 2014, during a legislative hearing in the House Health and Wellness Committee for HB 2338, the Chiropractic Commission’s approval of EKG/ECGs was noted. Then in February 2014, the commission received a letter from a current commission member addressing his concerns with having EKG/ECGs on the approved List.

According to the minutes, the commission maintains it followed the protocol outlined in WAC 246-808-505 when they reviewed and added EKG/ECG to the approved List at the December 12, 2013 meeting. The Commission asserts it was not added as an expansion to the scope-of-practice.

The commission revisited the issue of including EKG/ECGs on the List and a motion was made to vote and remove EKG/ECG from the List until a better review process is created. However, after further discussion ensued, the motion was amended to not remove EKG/ECG from the List but to keep it on the List and add qualifying language to the approved Diagnostic Equipment and Analytic Techniques section, to read:

Diagnostic Equipment & Analytic Techniques: The Commission does not endorse any specific company or product. Below is a list of categories of “diagnostic equipment utilized for differential diagnosis and appropriate referral for non-neuromusculoskeletal conditions. Following each title are examples of equipment:”

The commission voted 12 in favor, and one abstained, to approve the new description of the “Diagnostic Equipment and Analytic Techniques List” and to send this to the committee for a thorough review and documentation.

Commission Changes Mind Again

Then just 15 days after they voted to keep EKG's within the scope, the Washington State Chiropractic Quality Assurance Commission held a special meeting on February 28, 2014.

According to the minutes, during that meeting Commission members reviewed recent legislative activity regarding chiropractors using EKGs. They also revisited the issue of including EKG on the List, as follows:

• Lori Grassi, Executive Director with the Washington State Chiropractic Association was notified that the legislature has concerns with chiropractors not being trained to perform an EKG. They are concerned that the commission is trying to expand the scope of practice without going through the proper avenue.
• During the HB2338 House Committee on Healthcare and Wellness (committee) hearing, the commission, Board of Physical Therapy, and the Board of Naturopathy were mentioned. The perception of the legislature, and some members of the public, is that these boards and the commission are trying to expand their scope of practices through Interpretive Statements and other policies instead of through the rulemaking process.
• The committee is not happy that the commission didn’t remove EKG/ECG from the list during the February 13, 2014 meeting.

According to the minutes, Commission members are interested in an avenue to communicate with the legislature to answer any questions and concerns they may have. They also felt it would be a good opportunity to educate them on the chiropractic core curriculum and what they are trained to do. They reiterated that EKGs are covered as part of the chiropractic college education and that the National Board has questions on it pertaining to EKGs.

Ms. Grassi also mentioned that the WSCA board is doing a site visit of the University of Western States and is going to see if there are legislative representatives that are interested in going.

Then in a complete reversal of their previous vote the Commission members voted eleven in favor to remove EKG from the List. Three commission members were absent for the vote.

Washington has officially joined a number of other states incuding Colorado, Arizona, New Mexico, New York, Texas and Georgia to name a few, that are seeking to expand their scopes of practice to include drugs, primary care and diagnostic procedures historically within the province of allopathic medicine. These efforts are being backed by major state, national and international chiropractic associations and chiropractic colleges such as those within the Chiropractic Summit and includes even those that were once considered conservative strongholds within the profession.

Interested chiropractors are encouraged to stop supporting those groups and organizations that support such expansion and to watch the activities of their state boards very closely.

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