YEAR-END REPORT - 2019 Published 23-Dec-2019 HPTS Issue Brief 12-23-19.8 Health Policy Tracking Service - Issue Briefs Healthcare Providers & Facilities Healthcare Information Technology Authored by Julie A. Fleming, a compliance attorney on the Publisher's Staff and a member of the Minnesota bar, and Sydney Brude, a compliance attorney at the Publisher's Staff and a member of the Minnesota bar. 12/23/2019 I. Introduction Health information technology, or health IT, has become a critically important tool in facilitating the exchange of patient healthcare information between different providers and between those providers and their patients. Health IT has the potential to improve the efficiency and effectiveness of the U.S. healthcare system by reducing medical errors and redundancies in the delivery of healthcare services as well as providing patients with healthcare information. Efforts to establish nationwide health IT began with a 2006 executive [FN1] order issued by President Obama's predecessor George W. Bush that called for development of a national health information network by 2014. However, the cost burden and concerns about protecting the private medical information of individuals have posed significant challenges to widespread adoption of health IT. Recognizing these challenges as well as the benefits of health IT, President Barack Obama signed into law the American Recovery and Reinvestment Act (ARRA) of 2009, an economic recovery measure to preserve and create jobs and invest in the nation's infrastructure, including the healthcare system. The act included $19 billion in funding for health IT, which will help achieve the nationwide objective to expand the ability to share crucial medical information electronically. Passage of the ARRA sustains the momentum toward a nationwide health information network and is indicative of the need and desire for innovation in reforming the U.S. healthcare system. Previously, the National Conference of State Legislatures (NCSL) listed Health Information Exchanges (HIEs) as one of the top [FN2] legislative issues for 2012. According to the NCSL, a major focus will be how to get health care providers, especially those participating in the Medicaid program, to adopt certified electronic health records (EHRs). In addition, states are responsible for building and implementing health information exchanges where health care providers can access EHRs. By mid-year 2012, every state should have Medicaid EHR Incentive programs in place and will be working toward building an HIE by late 2014 or early 2015 as required by deadlines attached to federal cooperative agreements. This issue brief highlights federal and state legislative and programmatic activity affecting medical information and efforts to store and exchange such information electronically. Topics covered include privacy issues affecting medical records and prescription information, electronic health records (EHRs), health information exchanges (HIEs), telehealth/telemedicine, and electronic prescribing (e-prescribing). Reports of studies that could influence future policy, activities of major players in the private sector and state and federal initiatives are also highlighted in this issue brief. II. Privacy and Security of Personal Medical Information With efforts underway to digitize paper medical records, the security of confidential medical information is under full scrutiny as reports of medical identity theft are on the rise. Since August 2009 when the Breach Notification Rule requiring that HIPAA-covered entities to report any breach involving the personal health information of more than 500 individuals to the Office for Civil Rights there have [FN3] [FN4] over 65,000 breaches and over 32 million people have had protected health information compromised. In May 2014, a class action lawsuit was filed in federal court against both the University of Pittsburgh Medical Center (UPMC) and Ultimate Software Group, a payroll software company UPMC uses, seeking damages and protection for employees affected by a recent breach of confidential [FN5] data. The lawsuit alleged negligence on behalf of the defendants that resulted in the compromise of Social Security numbers and other information for 27,000 employees. In April UPMC Vice President of Privacy and Information Security John Houston told reporters © 2020 Thomson Reuters. No claim to original U.S. Government Works. -1- that UPMC was providing its employees the opportunity to sign up for a credit monitoring service and that UPMC would underwrite the cost of the service for one year. The lawsuit also sought a court injunction forcing 25 years' worth of identity theft insurance, credit restoration services, and credit and bank monitoring services. In July 2015 UPMC announced a breach that comprised personal [FN6] information of 722 clients. This breach occurred on June 4 when an email containing the information was accidently sent to an unauthorized person. The email contained names, member identification numbers, birth dates and phone numbers but it did not contain medical records, Social Security numbers or any financial information. UPMC reported the incident to federal authorities on July 2 after UPMC had investigated the breach. UPMC is in the process of notifying the affected persons. This is the third breach of customer and patient data that UPMC has experienced since early 2014. In recent years several breaches of protected health information have been reported. Recently Anthem, one of the nation's largest [FN7] health insurers announced that it learned on January 29, 2015 that it had been the victim of an external cyberattack. It is believed that possibly as many as 80 million records of past and current customers, as well as Anthem employees, were breached. While Anthem has said that medical information was not compromised, the hackers were able to access names, birthdays, social security numbers and income data. In response to the attack Anthem has hired a cybersecurity firm to identify any vulnerabilities in its computer system. In addition, it is offering free identity repair services and credit monitoring. On the same day that Anthem learned about its cyberattack, Washington's Premera Blue Cross (“Premera”) also learned it had been [FN8] the target of a cyberattack. Premera has sent notice of the attack to approximately 11 million affected individuals and is providing two years of free credit monitoring and identity theft protection services to those individuals. In addition, Premera is coordinating with the FBI's investigation into this attack and is working closely with Mandiant, one of the world's leading cybersecurity firms, to conduct a comprehensive investigation of the incident and to remove the infection created by the attack. Premera's investigation found that the attackers may have gained unauthorized access to members' information, which could include members' name, date of birth, Social Security number, mailing address, email address, telephone number, member identification number, bank account information, and claims information, including clinical information. Individuals who do business with Premera and provided the company with their email address, personal bank account number, or Social Security number are also affected. However, to date Premera has not determined that any such data was removed from Premera's systems and has no evidence that such data has been used inappropriately. Washington's Premera Blue Cross last March disclosed a cyberattack with a potential 11 million victims included 6 million current and [FN9] former customers in Washington. The breach, which was initially discovered in January, took place eight months earlier, on May 5, 2014. Since the announcement approximately 830,000 of the 11 million customers have registered for credit monitoring and identity-theft protection after their personal and medical information may have been compromised. Premera has stated that to date there is no evidence of any criminal activity on any customer's account because of the cyberattack. However, Premera currently faces 38 class- action lawsuits containing reports that may argue otherwise. The lawsuits include reports of such incidents as false tax returns and packages received that were never ordered. The lawsuits have been consolidated and transferred to U.S. District Judge Michael Simon. Lead counsel Kim Stephens from Tousley Brain Stephens said the multidistrict litigation panel that determines if multiple cases can be consolidated was initially worried that most of the federal judges in the state are covered by Premera. The trial is set to start in February 2018 but there is always the possibility that it could be settled early. The attack is still under investigation by the FBI, which is working with the company to determine the scope of the incident. In addition, Premera is working to work with Mandiant, a security firm, to investigate the breach and help repair Premera systems. According to Redspin, Inc., a healthcare IT security assessment service, in its “2014 Breach Report: Protected Health Information [FN10] (PHI).” over 40 million Americans suffered a breach of their personal health information from 2009 through the end of 2014. This number, however, does not include the records breach at Anthem or Premera. In 2014 there were 164 incidents of breaches of personal healthcare information were reported to the HHS Office of Civil Rights, impacting nearly 9 million patient records. This was a 25% increase over 2013. More than 50% of the 2014 breaches were caused by hacking attacks. One of the major breaches in 2014 happened at the Michigan Department of Community Health. The Department notified 2,595 [FN11] individuals and the Department of Health and Human Services regarding the situation. The breach occurred when a laptop and a flash drive were stolen on either the evening of January 30 or early in the morning of January 31, 2014 from an employee of the State Long Term Care Ombudsman's Office. While the information contained on the laptop was encrypted, the information on the flash drive was not. That information contained personal information on about 2,595 living and deceased individuals, including their names and address. In addition, 1,539 records contained either a Social Security numbers or Medicaid identification number. The Department of Community Health offered credit monitoring services at no cost to people whose Social Security number or Medicaid number were compromised. Also, a credit file death suppression service was offered to the families of deceased individuals to assist them in securing their deceased loved one's credit file. After discovering the breach, the Ombudsman Office began a review of its data security processes to prevent any future data breaches, and the Department of Community Health began conducting additional training on data security, in particular portable electronic devices, for the Ombudsman's and the Department's employees. © 2020 Thomson Reuters. No claim to original U.S. Government Works. -2- In December 2014 the Anchorage Community Mental Health Services (ACMHS) agreed to pay $150,000 in a settlement involving [FN12] HIPAA violations due to unpatched and unsupported software. HHS's Department of Civil Rights (OCR) began their investigation after ACMHS notified them of a breach affecting 2,743 persons due to malware that compromised the security of ACMHS's IT sources. The OCR found the breach was directly related to the failure to identify and address certain basic risks such as not regularly updating IT software and running outdated, unsupported software. The settlement agreement includes a corrective action plan and requires ACMHS to report its compliance for a two-year period. The OCR along with the Office of the National Coordinator of Health Information Technology offer a Security Rule Risk Assessment Tool for help organizations to conduct regular of the safeguard they have in place. In the fall of 2014 California Consumer Watchdog, a consumer advocacy group, began urging customers to opt out of a new database of patient records called the California Integrated Data Exchange (or Cal Index) that is backed by Blue Shield of California and Anthem [FN13] Inc. because of potential data breaches. In November 2014 the insurers sent notices to almost half of their 9 million California customers informing them that their medical records would be part of the database unless they specifically dropped out. Consumer Watchdog, which supports the use of electronic health records and the sharing of patient data, believes that the customers are unable to make informed decisions about Cal Index when it has not posted its full security and privacy policy. In December 2014 a spokesperson for the Department of Veterans Affairs announced that the VA had notified 7,054 veterans that a possible flaw in one of its patient databases, which is managed by a vendor providing home telehealth services, may have [FN14] exposed their personal information. The spokesperson said, “An investigation was immediately initiated, and security scans were conducted by VA, which confirmed the concern,” the spokesman said. “The contracted vendor has assured VA that only vendor staff and VA staff had accessed this information. The security flaw in the vendor database was immediately corrected and VA continues to closely monitor the application.” The VA's policy requires notification of a breach to veterans within 60 days, however the Department averages 28 days. The VA plans to spend $60 million on cyber security efforts in fiscal 2015. In February 2014, Texas' St. Joseph Health System reported that it had experienced a three-day long data security attack in December 2013, when hackers gained unauthorized access to a server containing patient and employee Social Security numbers, dates of birth, [FN15] addresses and medical information for some 405,000 individuals. Officials from the health system said that the hackers operated from IP addresses in China and several other locations. According to Department of Health and Human Services this was one of the largest hacking incidents reported in the United States. Unfortunately, the breach at St. Joseph Health System was only one of several major data breaches in 2013. A study by Trustwave Holdings Inc. found that found that data breaches increased by 54% in 2013 with weak passwords accounting contributing to 31% [FN16] of the breaches. The survey also looked at data breaches by industry and found that in 2013 only two percent of the data breaches in the U.S. were in the health care field. In addition, the survey found that 71% of all breach victims did not detect the breach themselves. Some of the major health data breaches in 2013 occurred at Advocate Medical Group (4,029,530 persons affected), AHMC Healthcare (729,000 persons affected), Texas Health Harris Methodist Hospital Fort Worth (277,014 persons affected), and [FN17] Indiana Family & Social Services Administration (187,533 persons affected). According to Becker's Hospital Review in 2013 the top five causes of healthcare information data breaches were: stolen laptops, information that was inappropriately accessed by [FN18] employees, unsecured transmissions or employee errors, misplaced files or electronic storage, and scams or online hacking. These alarming findings indicate a critical need to assess and improve measures to protect medical information. The Healthcare Information and Management Systems Society (HIMSS) announced in February 2014 the results of its sixth annual Security Survey. [FN19] In creating the survey, HIMSS surveyed 283 information technology and security professionals employed by hospitals and physician practices. The results of the survey show that 92% of all respondents reported that their organizations perform a risk assessment to evaluate the risks to patient data. The number of physician practices doing so increased from 65% in 2012 to 78% in 2013. Over half of the respondents said their organization has tested their data breach response plan. Of those respondents two-thirds said their plan was tested annually. More than 50% reported their IT budget had increased over the previous years. The survey also found the physician practices tend to spend more on security than hospitals. An October 2012 report by Verizon examining cyber-attacks found that hackers either guessing or using caused 72% of the attacks on health care organizations in 2011 and 2012 automated systems to guess the passwords that allowed them access to computer [FN20] systems. The report found smaller organizations represented the majority of data breach victims and that of all the breaches studied for the report 7% of them involved healthcare providers. That number was up from 1% in 2011. The authors of the report believe that healthcare providers are attacked not because they of the fact that are in the health industry but because they are vulnerable and have financial and personal information that can be used to create fraudulent accounts. Under HIPAA and CMS's meaningful use rules healthcare providers are required to make security assessments that can create a baseline and show areas, such as password protection, which need improvement. The Verizon report also found that point-of-sales systems, such as a machine connected to a credit card skimmer, are the most targeted systems. The report recommends that smaller businesses, such has health care providers, should: (a) implement a firewall or Access Control List on remote access services; (b) change the default credentials of point-of-sales systems and other internet-facing devices; and (c) if a third-party has been hired to handle IT security, make sure that [FN21] they have actually done the first two items. © 2020 Thomson Reuters. No claim to original U.S. Government Works. -3- Another report also raises questions about security. CORL Technologies, a provider of Vendor Security Risk Management solutions, [FN22] recently announced the results of its first Vendor Intelligence Report. The report, which analyzed the practices of 150 vendors from June 2013 to June 2014, found that most of healthcare vendors lack minimum security. Under the report, 58% of vendors scored in “D” grade range for their culture of security and 8% scored in the “F” range. These poor grades reflect a lack of confidence based on demonstrated weaknesses with their culture of security. The report found that only 4% of vendors scored in the “A” high confidence grade range, 16% scored in the “B” moderate confidence grade range and 14% scored in the “C” indeterminate confidence grade range. The report also found that healthcare organizations are failing to hold vendors accountable for meeting minimum acceptable standards or otherwise mitigate vendor-related security weaknesses. The report found that only 32% of vendors have security certifications. Such certifications include FedRAMP, HITRUST, ISO 27001, SSAE-16, SOC 2 and SOC 3. In light of the growing concerns about protecting the privacy of personal information, it will be imperative that the development of a nationwide health IT system incorporates rigorous measures to protect confidential medical data. Lawmakers and government agencies are pressing forward with measures to secure the privacy of personal medical information. In addition, in an effort to increase patient confidence in electronic health records, an HHS advisory panel recommended in October 2010 that healthcare providers should provide patients with layered and easy to understand notices of how health information exchanges will use and protect their medical [FN23] information. The panel suggested that a summary notice be included the required HIPAA privacy practices summary. They recommended that the summary notice be written so that 90 percent of patients can understand it. In addition, the panel recommended that physicians have face-to-face discussions with their patients about information exchange practices, especially when a third party handles the transport of personal data and could trigger the need for consent. The underlying principle of the recommendations is that a patient should not be surprised by what happens to his or her information. The Office of the National Coordinator of Health IT announced in September 2011 the development of a Personal Health Records [FN24] (PHR) Model Privacy Notice. The Notice is designed to be a standardized template that a web-based PHR company can use to inform consumers about its privacy and security policies. The Notice is intended to be like other consumer-oriented labels that have been developed for other industries, such as the nutrition facts label for food and the Model Privacy Notice developed for the financial services industry for compliance with the Gramm-Leach Bliley Act. It was created to focus only on some important information and is not intended to substitute for more comprehensive privacy policies. In December 2012, HHS launched a new education initiative and set of online tools provide health care providers and organizations practical tips on ways to protect their patients' protected health information when using mobile devices such as laptops, tablets, and [FN25] smartphones. The initiative is called Mobile Devices: Know the RISKS. Take the STEPS. PROTECT and SECURE Health Information and is available at www.HealthIT.gov/mobiledevices. It offers educational resources such as videos, easy-to-download fact sheets, and posters to promote best ways to safeguard patient health information. “The use of mobile health technology holds great promise in improving health and health care, but the loss of health information can have a devastating impact on the trust that patients have in their providers. It's important that these tools are used correctly,” said Joy Pritts, HHS' Office of the National Coordinator for Health Information Technology (ONC) chief privacy officer. “Health care providers, administrators and their staffs must create a culture of privacy and security across their organizations to ensure the privacy and security of their patients' protected health information.” In March 2014 HHS announced the release of a new security risk assessment tool to help health care providers in small to medium [FN26] sized offices to conduct risk assessments of their organizations. The tool is the result of a collaborative effort by the HHS Office of the National Coordinator for Health Information Technology and Office for Civil Rights. It is designed to help practices conduct and document a risk assessment in a thorough, organized fashion at their own pace by allowing them to assess the information security risks. A security risk assessment is a key requirement of the HIPAA Security Rule and a core requirement for providers seeking payment through the Medicare and Medicaid EHR Incentive Program, commonly known as the Meaningful Use Program. These risk assessments, can uncover potential weaknesses in a health care provider's security policies, processes and systems. The tool can be downloaded from the HealthIT.gov website which also has a User Guide and Tutorial video to help providers begin using the tool. Videos on risk analysis and contingency planning are available at the website to provide further context. The tool is available for both Windows operating systems and iOS iPads. In addition to increasing the security of data, more and more physicians are also purchasing data breach insurance. A new study from Experian and the Ponemon Institute found that 32% of healthcare provider organization have already purchased data breach insurance [FN27] to mitigate the financial risks of a breach and that 41% of such organizations are considering such insurance. The study also found that 77% of healthcare organizations believe that cyber risk insurance was important. Such insurance would enable a provider to cover the high costs of a data breach. Chris Apgar, CEO of Apgar & Associates, a privacy and security-consulting firm, conducted a risk analysis for a nine-doctor physician practice and found that the cost of notification alone in the event of a breach would be more than $100,000. The Government Accounting Office recommended in September 2013 that the Centers for Medicare and Medicaid Services (CMS) take [FN28] steps to implement a technical solution for removing Social Security numbers (SSN) from Medicare cards. Currently the health insurance claims number on Medicare beneficiaries' cards includes as one component the beneficiary's (or other eligible person's, such as a spouse's) SSN. GAO believes this raises the risk that the number could be obtained, and identity theft could be committed. CMS © 2020 Thomson Reuters. No claim to original U.S. Government Works. -4- has already collected information and data as part of its most recent study of SSN removal that could contribute to the identification and development of an information technology solution. GAO studied CMS's efforts related to the removal of SSNs from Medicare cards. GAO's objectives in studying CMS's efforts related to the removal of SSNs from Medicare card were to (1) assess actions CMS has taken to identify and implement IT solutions for removing SSNs from Medicare cards and (2) determine whether CMS's ongoing IT modernization initiatives could facilitate SSN removal efforts. To do this, GAO reviewed agency documentation and interviewed officials. GAO believes that some of the efforts CMS has underway to modernize its IT systems could be leveraged to facilitate the removal of SSNs from Medicare cards. The Department of Health and Human Services agreed with GAO's recommendations, provided that certain constraints were addressed. However, GAO maintains that its recommendations are warranted as originally stated. In December 2013 the Department of Health and Human Services' Office of the Inspector General (OIG) released a report showing [FN29] that hospitals were not fully implementing all the recommended fraud safeguards in their EHR technology. They study was designed to determined how hospitals that received EHR Medicare incentive payments, administered by CMS, had implemented recommended fraud safeguards for EHR technology. The OIG conducted an online questionnaire to all the 864 hospitals that had received Medicare incentive payments as of March 2012. The questionnaire focused on the presence of features and capabilities in Certified EHR Technology based on the RTI International (a company that the ONC contracted to develop recommendations to enhance data protection) recommended safeguards regarding audit functions, EHR user authorization and access, and EHR data transfer. In addition, the OIG conducted structured onsite interviews at eight of the hospitals. The study found that while almost all the hospitals with EHR technology had RTI-recommended audit functions in place, most of the hospitals were not be using them to their full extent. The OIG did find that nearly all the hospitals were using RTI-recommended data transfer safeguards and that just less than 50% of the hospitals had begun implementing RTI-recommended tools to include patient involvement in anti-fraud efforts. In addition, only approximately 25% of the hospitals had policies regarding the use of the copy-paste feature in EHR technology, which, if used improperly, could pose a fraud vulnerability. In conclusion, the OIG recommended that: (i) audit logs be operational whenever EHR technology is available for updates or viewing; (ii) ONC and CMS strengthen their collaborative efforts to develop a comprehensive plan to address fraud vulnerabilities in EHRs; and (iii) CMS develop guidance on the use of the copy-paste feature in EHR technology. CMS and ONC concurred with all those recommendations. Then in January 2014 the OIG published its second report concerning the lapses in the oversight of government programs concerning [FN30] Electronic Health Records (EHRs). The previous report concerned hospitals not adopting fraud safeguards when implementing [FN31] their EHR technology. The January report examines what the Centers for Medicare & Medicaid Services (CMS) and its contractors have done to address vulnerabilities in EHRs. According to Danielle Fletcher, a program analyst for the Office of Evaluation [FN32] and Inspections, while EHRs can improve care and lower costs, some experts believe they may make it easier to commit fraud. In preparing the report the OIG reviewed policies and guidance documents concerning EHRs and fraud vulnerabilities that CMS and its contractors have released for healthcare providers as well as documents on EHRs and Medicare claims that CMS gave to its contractors. In addition, the OIG sent an online questionnaire to CMS administrative and program integrity contractors. The OIG found that CMS had provided little guidance to its contractors regarding fraud vulnerabilities in EHRs. In addition, it found that CMS and its contractors have adopted few program integrity practices for EHRs. For example, the OIG found that few contractors were reviewing EHRs differently from paper medical records. This is a problem because EHR technology can be used to both mask the authorship of the medical record and to distort information to inflate health care claims. The OIG also found that some of the contractors could not tell whether some providers had used the “copy-paste” function to bulk up EHRs to fraudulently bill for services that were not provided. In addition, the OIG found that few hospitals permitted patients to review their EHRs, which enables patients to discover errors and fraudulent activity. The OIG report contains two specific recommendations: (i) that CMS provide guidance on detecting fraud in EHRs to its contractors and (ii) that CMS should direct its contractors to use providers' audit logs because audit log data distinguishes paper medical records from EHRs. CMS agreed with the first recommendation and agreed in part with the second recommendation. In 2012 LogRhythm and FairWarning, Inc. announced a partnership to provide comprehensive privacy auditing and monitoring [FN33] capabilities to detect and defend against unlawful access to EHRs. This effort will ensure compliance with regulatory mandates such as Health Insurance Portability and Accountability Act of 1996 (HIPAA) and ensure network security. The partnership will enable common customers in the healthcare industry to monitor and secure the entire range of systems and applications across their organizations, and to perform comprehensive forensic investigations of suspected breaches. In addition to data breaches, natural disasters also can affect data security. In order to sure their residents' health information is available after a hurricane or other wide-spread disasters, four Gulf states have partnered with six states in the East and Midwest to [FN34] help patients and providers access critical health information when they are unable to visit their regular doctors or hospitals. Working with the Office of the National Coordinator for Health IT (ONC), health information exchange (HIE) programs in Alabama, Georgia, Louisiana, Florida, South Carolina, North Carolina, Virginia, Michigan, Wisconsin, and West Virginia announced their partnership to allow for the exchange of health information among providers caring for patients who are displaced from their homes. All the state HIE programs participating in the initiative currently have established at least one operational interstate connection and are working with other states including Arkansas and Mississippi. This initiative is being made possible through information technology © 2020 Thomson Reuters. No claim to original U.S. Government Works. -5- infrastructure provided through “Direct,” a tool developed by an ONC-led collaboration with broad health IT industry participation that allows for the secure exchange of health information over the Internet. A guidebook, published by the Agency for Healthcare Research and Quality, can also help primary care clinicians connect their patients' electronic health records to a local HIE hub and regional health information organizations. A 2013 study in the British Medical Journal found that a small percentage of physicians were committing possible patient privacy [FN35] violations on Twitter. The study was designed to investigate potential violations of patient confidentiality or other breaches of medical ethics committed by physicians and medical students using the social networking site Twitter. The researchers looked at 237 accounts of physicians and medical students active on Twitter between July 2007 and March 2012. A total of 13,780 tweets were examined. Slightly more than 90% of physicians and medical students stated their full name and many used a self-identifying image on their Twitter accounts even though Twitter demands no personal information from its users. The researchers determined that 276 [FN36] (1.9%) tweets were as “unprofessional.” These findings correlate with a 2011 Research Letter published in JAMA. These tweets were more common among users writing under a pseudonym and among medical students. For the most part the “unprofessional tweets” discussed typically included severe profanity, sexual content, or references to heavy drinking. The researchers found that 26 (0.2%) tweets written by 15 (6.3%) physicians and medical students included information that could violate patient privacy. Such information did not include personal identification numbers or patients' names, however parts of the patient documentation or otherwise specific indicatory information on patients were found. The researchers concluded that their findings emphasize the importance of every physician and medical student considering his or her presence on social networking sites. As of now it is too early to determine if the introduction of social networking site guidelines for medical professionals will improve awareness. Emphasizing the importance of physicians maintaining the privacy and confidentiality, a position paper by the American College of Physicians and the Federation of State Medical Boards and published in Annals of Internal in April 2013 examines the influence of social media on the patient–physician relationship and provides recommendations for physician communication that preserves [FN37] confidentiality while best using these technologies. The position papers also stresses the importance for physicians of demonstrating respect for patients, ensuring trust in physicians, and establishing appropriate boundaries. While the position papers do not discuss either telehealth or electronic health records, it does offer guidance for practitioners and medical students on such topics as the use of social networking, blogging, cell phone photography, electronic searching, online forums, texting, and e-mailing. For example, the position paper recommends that physicians do not interact with patients on such social networking sites as Facebook. The position papers also stress the physicians' responsibility to ensure to the best of their ability that their professional networks are secure and that only verified and registered users have access to shared information. It stresses that physicians must follow appropriate security protocols for storage and transfer of patient information and that they must follow all applicable state and federal legal requirements, including the HIPAA's privacy rule. Among the recommendations included are: • physicians should keep their professional and social spheres separate and comport themselves professionally in both; • e-mail should only be used by physicians in an established patient–physician relationship after receiving patient consent and where the patient understands the possible risk of privacy; • physicians should include documentation about patient care communications in the patient's medical record; • physicians, trainees, and medical students should be aware that online postings might have future implications for their professional lives; and • physicians should periodically “self-audit” to assess the accuracy of information available about them on physician-ranking Web sites and other online sources. In September 2013, the Rhode Island Board of Medical Licensure adopted guidelines for the appropriate use of social media and social [FN38] networking in medical practice. The guidelines were developed in order to help those physicians who use social media and social networking to maintain public trust and to protect themselves from any unintended consequences of such behavior. Physicians are required to: • protect the privacy and confidentiality of patients; • act in a professional manner; • avoid any requests for online medical advice; • be aware that any information posted online may be available to anyone and can be misconstrued; and • be forthcoming about credentials and conflicts of interest. To aid physicians in understanding the importance of such guidelines several narratives are included that demonstrate where unintended consequences of the use of social media and social networking can undermine a physician-patients relationship. In 2014 a new twist developed regarding the data security practices of HIPAA-covered entities. In January the Federal Trade [FN39] Commission (FTC) ruled that it has authority over HIPAA-covered entities regarding data security issues. LabMD, a laboratory Services Company in the greater Atlanta area, had moved to dismiss a complaint arguing that the FTC had no authority to address © 2020 Thomson Reuters. No claim to original U.S. Government Works. -6- private companies' data security practices as “unfair ... acts or practices” under of the Federal Trade Commission Act. LabMD had also argued that by enacting HIPAA, Congress had implicitly stripped the FTC of any authority to enforce the FTC Act in the field of data security. In dismissing the complaint, the FTC rejected all LabMD's arguments. The FTC stated that accepting LabMD's arguments “would greatly restrict the Commission's ability to protect consumers from unwanted privacy intrusions, fraudulent misuse of their personal information, or even identity theft that may result from businesses' failure to establish and maintain reasonable and appropriate data security measures.” The FTC also stated in its ruling that there is nothing in HIPAA to indicate that Congress intended to restrict the FTC's authority over data security practices. As of now it is too earlier to determine this decision will affect private companies. In September 2014, the Government Accountability Office (GAO) issued a study on the security and privacy of the Healthcare.gov [FN40] website. Several federal agencies, including the Department of Defense, Department of Homeland Security, Internal Revenue Service, Office of Personnel Management, Peace Corps, Social Security Administration, and the Department of Veterans Affairs play key roles in maintaining systems that connect with CMS systems to perform eligibility-checking functions. In addition, several commercial entities, including CMS contractors, participating issuers of qualified health plans, agents, and others also connect to the network of systems that support enrollment in Healthcare.gov. The GAO found that weaknesses remain both in the processes used for managing information security and privacy as well as the technical implementation of IT security controls of the website. GAO noted that CMS has taken many steps to protect security and privacy, such as developing required security program policies and procedures, establishing interconnection security agreements with its federal and commercial partners, and instituting required privacy protections. However, GAO identified weaknesses in the technical controls protecting the confidentiality, integrity, and availability of the Federally Facilitated Marketplace. For example, GAO found that CMS had not always required or enforced strong password controls, adequately restricted access to the Internet, consistently implemented software patches, and properly configured an administrative network. GAO concluded that until such weaknesses are fully addressed, increased and unnecessary risks remain of unauthorized access, disclosure, or modification of the information collected and maintained by Healthcare.gov and the related systems. GAO made six recommendations to implement security and privacy management controls to help ensure that the systems and information related to Healthcare.gov are protected. HHS concurred but disagreed in part with GAO's assessment of the facts for three recommendations. However, GAO believes its recommendations are valid, as discussed in the report. On March 16, 2016, the Department of Health and Human Services Office for Civil Rights (OCR) announced that it has imposed a $1.55 million fine on North Memorial Health Care of Minnesota. In July 2011, an unencrypted laptop was stolen from a business associate employee's vehicle. This resulted in putting 9,497 individuals protected health information at risk. OCCR found that North Memorial failed to comply with HIPAA by failing to have business associate agreements in place and failing to complete a risk analysis [FN41] addressing all potential risks and vulnerabilities to electronic protected health information. In January 2016, Centene Corp, the insurer for Georgia's Medicaid population, announced that it misplaced “6 hard drives that contain [FN42] sensitive personal information for $950,000 people.” The hard drives contain the information for people who received lab services during 2009-2015. The information contains names, address, dates of birth, Social Security numbers, member ID numbers, and health information. However, no financial or payment information is included. The Government Accountability Office (GAO) released a report of cybersecurity and threats to electronic protected health information [FN43] (ePHI) on September 26. The report was critical of the Department of Health and Human Services (HHS). The use of electronic information has allowed provides to more effectively share information and treat their patients. As a result, the information sharing and storing by electronic means is subject to cyber-based threats. The number of reported hackings affecting health care records of 500 or [FN44] more individuals has increased from 0 in 2009 to 56 in 2015. More than 113 million records were breached in 2015 alone. HHS has provided guidance to covered entities on maintaining the privacy and security of protected information. The GAO report found [FN45] that this guidance does not go far enough under other federal cybersecurity guidance. According to the report, the guidance that HHS provides to healthcare providers does not adequately address all relevant privacy and security concerns. The GAO report also found that there are no benchmarks to assess the effectiveness of the HHS's Office for Civil Rights' (OCR) audits and follow-up to ensure implementation of corrective action. The GAO report concluded with a list of five recommendations to improve the security of ePHI. First, “[HHS] should update security guidance for covered entities and business associates to ensure that the guidance addresses implementation of controls described in the National Institute of Standards and Technology Cybersecurity Framework.” Second, “[HHS] should update technical assistance … to address technical security concerns.” Third, “[HHS] should revise the current enforcement program to include following up on the implementation of corrective actions.” Fourth, “[HHS] should establish performance measures for the Office of Civil Rights (OCR) audit program.” Finally, “[HHS] should establish and implement policies and procedures for sharing the results of investigations and audits between OCR and Centers for Medicare & Medicaid Services to help ensure … compliance with the Health Insurance Portability and [FN46] Accountability Act of 1996 and the Health Information Technology for Economic and Clinical Health Act.” RECENT STATE LEGISLATIVE ACTIVITY Arizona © 2020 Thomson Reuters. No claim to original U.S. Government Works. -7- • 2019 AZ S.B. 1297 (NS), adopted May 22, 2019, amends AZ ST § 12-2802 (Confidentiality of genetic testing results; disclosure) adding a statewide health information exchange to the list of individuals and entities to whom genetic testing and information derived from genetic testing may be released to. The amendment is effective August 27, 2019. • 2019 AZ S.B. 1321 (NS), adopted June 7, 2019, amends AZ ST § 36-3805 (Disclosure of individually identifiable health information) clarifying that a health information organization may not transfer individually identifiable health information or deidentified de-identified health information that is accessible through the health information exchange to any person or entity for the purpose of research or using the information as part of a set of data for an application for grant or other research funding, unless the health care provider obtains consent from the individual for the transfer. The amendment is effective August 27, 2019. California • 2019 CA A.B. 288 (NS), amended/substituted March 19, 2019, would adopt CA CIVIL § 1798.90.7 to define “personally identifiable information” and “social networking service.” • 2019 CA S.B. 398 (NS), adopted October 7, 2019, amends CA WEL & INST § 4903 (Access to information and records; confidentiality of records of agency) to provide that the sharing of health information and records with a protection and advocacy agency is permitted to the extent that the sharing is required by law and complies with the requirements of that law. The bill also provides that the Legislature finds and declares that the federal Health Insurance Portability and Accountability Act of 1996 privacy rule permits the disclosure of protected health information to a protection and advocacy agency, without the authorization of the individual who is the subject of the protected health information, to the extent that the disclosure is required by law and the disclosure complies with the requirements of that law. The amendment is effective January 1, 2020. Colorado 2019 CO S.B. 4 (NS), adopted May 17, 2019, amends CO ST § 10-16-1003 (Privacy of health information) to clarify that individually identifiable health information collected for or by a cooperative is subject to HIPAA. The amendment is effective August 2, 2019. Hawaii 2019 HI S.B. 1486 (NS), adopted July 2, 2019, amends HI ST § 329-104 (Confidentiality of information; disclosure of information) allowing the DPS Narcotics Enforcement Division Administrator to disclose confidential information from the Electronic Prescription Accountability System to the U.S. Department of Defense health agency prescription monitoring program and authorized employees of the State DOH Alcohol and Drug Abuse Division and the Emergency Medical Services and Injury Prevention Systems Branch. The amendment is effective July 1, 2019. Illinois 2019 IL H.B. 2189 (NS), adopted July 26, 2019, amends IL ST CH 410 § 513/20 (Use of genetic testing information for insurance purposes) prohibiting a company providing direct-to-consumer commercial genetic testing is prohibited from sharing any genetic test information or other personally identifiable information about a consumer with any health or life insurance company without written consent from the consumer. Maine • 2019 ME S.P. 46 (NS), introduced January 19, 2019, would amend ME ST T. 32 § 86 (Ambulance services and nontransporting medical services) would require that whenever an ambulance transports a patient from the scene of an emergency or from a hospital or other health care facility to another place, the ambulance must be equipped with video recording equipment that is in operation for the duration of the transport and that is producing a clear video record of the care provided to the patient. In accordance with applicable federal and state law, the video records are to be maintained as confidential by the ambulance service operator and, if applicable, by the Emergency Medical Services' Board and the Department of Public Safety. • 2019 ME S.P. 218 (NS), adopted June 13, 2019, amends ME ST T. 24-A § 4304 (Utilization review) requiring, beginning January 1, 2020, that if a health plan provides coverage for prescription drugs, the carrier must accept and respond to prior authorization requests in accordance with subsection 2 through a secure electronic transmission using standards adopted by a national council for prescription drug programs for electronic prescribing transactions. The amendment is effective September 17, 2019. Minnesota • 2019 MN H.F. 167 (NS), engrossed March 15, 2019, would adopt MN ST § 116.0735 (Supplemental Environmental Projects) to prohibit a regulated facility from releasing or disclosing health information except as specified in a written informed consent form signed and dated by the individual subject of the health information or that person's legally authorized representative, to the commissioner or the commissioner of health or pursuant to a specific authorization in law. The bill would also require a regulated facility to establish appropriate security safeguards for protecting the privacy of health information, including procedures for ensuring that © 2020 Thomson Reuters. No claim to original U.S. Government Works. -8- health information is only accessible to persons whose work assignment reasonably requires access to the information and is only being accessed by those persons for purposes described in the procedure. • 2019 MN H.F. 400 (NS), adopted May 22, 2019, would adopt MN ST § 144.348 (Voluntary Nonopiod Directive) to require the Commissioner to adopt rules establishing requirements related to the use of voluntary nonopioid health care directives. The procedures must include the directive in the individual's medical record or interoperable electronic health record. • 2019 MN H.F. 710 (NS), engrossed March 14, 2019, and 2019 MN H.F. 287 (NS), introduced January 22, 2019, would adopt MN ST § 62J.4983 (Direct Secure Messaging) to require each health care provider to have a direct secure messaging address provided by a health information service provider to securely exchange protected health information via the Internet. • 2019 MN S.F. 2452 (NS), engrossed April 29, 2019, would amend MN ST § 256B.0757 (Coordinated care through a health home) to require a behavioral health home services provider to utilize an electronic health record. Nebraska 2019 NE L.B. 556 (NS), adopted May 1, 2019, amends NE ST § 71-2454 (Prescription drug monitoring; system established; provisions included; not public records) to allow an entity to release prescription drug information and other data collected to electronic health record systems or pharmacy-dispensing software systems for integrating prescription drug information into a patient's medical record. The amendment is effective May 1, 2019. New Hampshire 2019 NH S.B. 194 (NS), adopted August 2, 2019, adopts NH ST § 420-P:10 (Safe Harbor for HIPAA Compliance) would provide that a licensee that is in possession of protected health information subject to the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and that has established and maintains programs and procedures regarding information privacy, security, and breach notification that are prescribed by HIPAA and by Parts 160 and 164 of Title 45 of the Code of Federal Regulations established pursuant to HIPAA, shall be considered to meet the requirements of this chapter with respect to such protected health information, provided that the licensee is compliant with the HIPAA privacy, security, and breach notification requirements and submits a written statement certifying such compliance. Furthermore, to the extent a licensee maintains other nonpublic information concerning a consumer in the same manner as protected health information, it shall be considered to meet the requirements of this chapter with respect to such nonpublic information, provided the licensee submits a written statement that it does maintain and protect other nonpublic information as it does protect health information. However, any licensee subject to this HIPAA safe harbor shall continue to be subject to, and shall comply with, the commissioner notification requirements of RSA 420-P:6, I and II. For purposes of this section, the definition of “protected health information” shall be as set forth in HIPAA and the regulations promulgated thereunder and shall be a subset of nonpublic information, as defined in NH ST § 420-P:3(XI). The new section is effective January 1, 2020. New Jersey • 2018 NJ S.B. 2929 (NS), amended/substituted September 12, 2019, would require confidential reporting of drug overdose deaths to the Department of Health. The bill would provide that names and individual identification data collected must not be disclosed by the Department. Requiring the consent of the next of kin or authoritative representative of the individual who is the subject of the information or record in order to disclose confidential or personal identifying information related to the drug overdose death. • 2018 NJ S.B. 2929 (NS), amended/substituted September 12, 2019, would require confidential reporting of drug overdose deaths to the Department of Health. The bill would provide that names and individual identification data collected must not be disclosed by the Department. Requiring the consent of the next of kin or authoritative representative of the individual who is the subject of the information or record in order to disclose confidential or personal identifying information related to the drug overdose death. North Carolina 2019 NC H.B. 883 (NS), introduced April 22, 2019, would require prepaid dental plans and Medicaid and NC Health Choice providers shall be required to submit data through the Health Information Exchange Network in order to ensure effective systems and connectivity to support clinical coordination of care, the exchange of information, and the availability of data to DHHS to manage the Medicaid and NC Health Choice programs for the State. Ohio 2019 OH H.B. 166 (NS), adopted July 18, 2019, amends OH ST § 3798.01 (Definitions) removing the definition for “approved health information exchange” and “office of health transformation.” The bill also amends OH ST § 3798.07 (Disclosure of protected health information to health information exchange without authorization; additional conditions) to clarify the conditions a covered entity is subject to when it discloses protected health information to a health information exchange. The bill is effective July 18, 2019. Rhode Island © 2020 Thomson Reuters. No claim to original U.S. Government Works. -9- 2019 RI H.B. 6026 (NS), introduced April 25, 2019, would amend the Rhode Island Health Information Exchange Act of 2008 to require patient health care providers that participate in the HIE to provider their patients with information that the patient may elect to opt out of disclosure of information from the HIE in accordance with regulations established by the Department of Health. Utah • 2019 UT H.B. 77 (NS), adopted March 22, 2019, amends UT ST § 26-1-37 (Duty to establish standards for the electronic exchange of clinical health information) providing that Department, a local health department, a health care provider, a third party payer, or a qualified network that accesses or reviews clinical health information from or through the electronic exchange is not subject to civil liability for the access or review. The amendment is effective May 14, 2019. • 2019 UT S.B. 38 (NS), adopted March 27, 2019, amends UT ST § 58-60-110 (Unprofessional conduct) adding failure to offer a patient the opportunity to waive the patient's privacy rights under the Standards for Privacy of Individually Identifiable Health Information to the list of conduct that is unprofessional. The amendment is effective May 14, 2019. RECENT STATE REGULATORY ACTIVITY Ohio 2019 OH REG TEXT 524410 (NS), filed July 31, 2019, amends OH ADC 4753-9-01 (“Code of Ethics”) requiring licensee performing research to protect the participants' right to privacy, including but not limited to personal health information. The amendment is effective August 12, 2019. Oklahoma 2019 OK REG TEXT 514835 (NS), adopted May 28, 2019, amends OK ADC 340:2-8-4 (Client rights to access personal health information (PHI)) updating the client's rights to access personal health information. The amendment is effective September 16, 2019. Rhode Island 2019 REG TEXT 510989 (NS), filed January 1, 2019, adopts 180 RI ADC 10-00-3.12 (Medical) providing that the HIPAA Privacy Rule (the Rule) enhances the privacy protections afforded to individual consumers at all levels of health care treatment, payment, and healthcare operations. The Rule requires health care providers, health plans, and health care clearinghouses to carefully monitor the use and disclosure of an individual's protected health information (PHI). The Rule requires the RIVH to provide patients with a notice of the patient's privacy rights and the privacy practices of the RIVH called a Notice of Privacy Practices (Notice). All necessary forms and notices shall be provided upon admission. The rule is effective January 20, 2019. Louisiana 2019 LA REG TEXT 512529 (NS), filed April 20, 2019, adopts 50 LA ADC Pt XV, § 9525 (Reimbursement Methodology) and 50 LA ADC Pt XV, § 9535 (Reimbursement Methodology) requiring the direct cost related to the electronic health record must be added to the compensation costs to arrive at the total direct costs for therapy services. The new rules are effective April 20, 2019. III. Healthcare IT Systems and Electronic Health Records Despite an initial slow pace of adoption of health IT there are encouraging signs of that it is becoming more widely used. At the end [FN47] of 2014, five years since the passage of the HITECH Act, $25.4 billion had been spent on incentive payments to more than [FN48] 410,000 health care providers. Also at the end of 2014, 80% of eligible professionals and 98% of eligible hospitals had qualified for payments by adopting electronic health records. This is an improvement from May of 2013 when the Department of Health and Human Services announced that more than half of all doctors and other eligible providers have received Medicare or Medicaid incentive [FN49] payments for adopting or meaningfully using electronic health records (EHRs). According to a 2012 survey by the Centers for Disease Control and Prevention, only 17% of physicians and only 9% of hospitals were using EHRs in 2008. Several surveys have shown that patients are willing to use information technology to communicate with their providers. In 2011, a Health Care Check-Up Survey by Intuit Health, a developer of patient portal and communication technology, found that Americans [FN50] expect their physicians to be easily accessible online. According to the results, 81% of those surveyed would schedule their own appointment by means of a secure web service and fill out medical/registration forms online prior to their appointment and 78% would use a secure online method to access their medical histories and share information with their doctor. The study also found that fifty-nine percent of Generation Y respondents said they would switch doctors for one with better online access as opposed to only twenty-nine percent of Baby Boomer respondents. A 2015 study published in the Journal of General Internal Medicine examined patients' interest in using the Internet to communicate [FN51] with physicians. The researchers looked at a sample of 4,510 CVS customers with at least one chronic condition in their © 2020 Thomson Reuters. No claim to original U.S. Government Works. -10- household. These subjects were selected from over 100,000 retail pharmacy customers. Of the 4,510 customers contacted, 2,252 (or 50%) responded. The researchers used a survey that included demographic and health information, the use of email or Facebook to communicate with physicians, and the patients' interest in using electronic communication tools to do so. In the prior six months, 37% of the respondent reported contacting their physicians via email. For the same time period 18% had used Facebook. While older age was negatively associated with not using such tools, caregiver status was positively associated with using the tools. While few patients (4% to 8%) were currently using Web-based tools to track their health, fill prescriptions and find health information, 37% to 57% were interested in doing so. The researchers believe that improving the adoption of secure Web messaging systems is a possible solution for addressing both institutional concerns and patient demand. A 2014 study found that 82% of Americans 18 to 34 years of age who have a doctor say that consultations over a mobile device is [FN52] their preferred way to have a consultation. The survey also found that 67% of all Americans who have a doctor said that there are benefits that would make consulting their doctor over a mobile device the best option for them. Among such benefits are if such a consultation lowered the cost of the consultation (36%) or if there were no waiting rooms or cancelled appointments (36%). Shorter consultation times (34%), the doctor having access to full medical histories (32%), doctors available 24 hours a day (29%) were also suggested benefits. In addition, 35% of Americans would like to have the option of a consultation with a doctor via a mobile device while on vacation. The survey was conducted online from March 6 to March 10, 2014 within the United States by Harris Poll on behalf of MDLIVE, a provider of telehealth services and software, among 2,061 adults ages 18 and over. Similar results were found in a 2012 brief by the Optum Institute shows that patients are far ahead of their health care providers in [FN53] seeking online access to health information. The issue brief analyzes the results of a May/June 2012 national survey that the Optum Institute and Harris Interactive did of 1,000 physicians, 400 hospital executives and 2,870 adult consumers about Health IT. The study shows that three out of four patients are willing to go online to view their medical records. In addition, 65% of patients want to be able to communicate with their physicians by e-mail and many others want to communicate via text. These consumers are not only the young. More than half of all seniors want to communicate online with their physicians. The issue brief also shows that almost 70% of patients would like to receive appointment reminders by e-mail and 40% would like to receive text reminders. According to authors of the issue brief providers are in danger of being unable to manage care across a wide range of patient needs. [FN54] Physicians Practice, a leading practice management journal, has released its “2015 Tech Survey” which was sponsored by Kareo. The survey had 1,181 respondents with 61.5% of them being physicians and the remainder other medical professionals. When asked what their most pressing IT problem was, four of the top responses concerned EHRs. A total of 15.5% said EHR's caused a drop in productivity, 14.2% said it was the lack of interoperability, 13.8% said it was the adoption and implementation of EHRs and 13.3% said it was meeting “meaningful use” requirements. However, 62.8% said they have successfully attested to Stage 1 meaningful use rules and have either received their stimulus money or have been notified that they will receive it shortly. In addition, 34.6% have already attested to the Stage 2 rules and 40% are in the process of preparing to do so. Only 19.6% of the respondents said that they do not have EHRs with 30.9% of those respondents saying they do not believe it would improve patient care and 28.4% saying EHRs were too expensive. A small number (10.3%) of those without EHRs said that they plan to purchase an EHR system in the next 12 months. Of those that use EHRs, 66.5% said that EHRs have improved patient documentation. However only 32.3% said that the EHRs have not yet produced a return on investment. A slight majority (51.4%) said that EHRs have not affected the number of patients they see, while 36.9% said they now see fewer patients and 11.7% said they seem more. The vast majority of the respondents (64.6%) said that they do not use social media to communicate about their practice with the community, while 30% said they had a Facebook page, 11.1% use LinkedIn and 9.8% use Twitter. A slight majority (51.2%) said they use smartphones in the performance of their job and 36.2% said they use an iPad or another tablet. The main use given for such devices was to look up drug information (29.7%), followed by recordkeeping/gaining access to patient records (18.9%) and researching information on treatment for specific conditions (9.9%). Only 11.9% of the respondents said they conduct e-visits. Realizing that many patients are eager to take care of new technology, Healthgrades, an online resource for information on physicians and hospitals, has announced that it is partnering with athenahealth to enable almost one million persons a day to look for a physician [FN55] and book an appointment online with athenahealth's network of more than 55,000 health care providers. This partnership is expected to help front offices save time and improve accuracy. The offering is fully automated and permits patients to view appointment availability and to book appointments from Healthgrades. The information is then added to the physicians' schedules on athenahealth's network. This new partnership will enable hospitals use both athenahealth and Healthgrade's Patient Direct Connect solution to further their physician alignment strategies and make it easier to book appointments at no additional cost. In addition to Healthgrades, many hospitals and physicians are using online services, such as InQuicker and ZocDoc, which allow [FN56] patients to make such appointments. Most of the online services let the patient enter a zip code and describe the care they need so find the care they need. In addition, one a patient books an appointment for ER care and the ER becomes backed up, the service will text the patient with a new appointment at a later time. While such services are usually free for patients, the healthcare provider may be charged between $200 and $300 a month for using them. ZocDoc currently has over 6,000,000 patients a month making appointments using their service. © 2020 Thomson Reuters. No claim to original U.S. Government Works. -11- Online health communities can be very effective in providing patient-centered care to persons suffering from chronic conditions. [FN57] Online health communities are Internet-based platforms that bring together a group of patients, a group of professionals, or a mixture of both. Such communities may be either open or closed based on the accessibility of the community content. Members of the community interact using modern communication technologies such as blogs, chats, and forums. The study found that such communities could be used to share experiences, exchange knowledge, and increase disease-specific expertise. The researchers also found that such communities can bridge geographical distances and enable interdisciplinary collaboration across institutions. In addition, the researchers found that such communities can be used to actively engage and empower patients in their health care process and to tailor care to their individual needs. The benefit of texting patients was shown in study published in November 2013 in the Annals of Emergency Medicine, looks at whether low-cost, unidirectional text messages to low-income inner-city patients with diabetes could improve clinical outcome, increase health [FN58] behavior, and decrease use of emergency rooms for acute and chronic care. The researchers conducted a randomized controlled trial of 128 patients with poorly controlled diabetes. One group received two text messages, in either English or Spanish, a day for six months. While the results did not show a statistically significant improvement HbA level, a trend toward improvement was observed. In addition, the results showed increased medication adherence, increased quality of life, and decreased emergency room use. These results were more increased in the Spanish-speaking subgroup. The researchers concluded that text messaging represents a low-cost, highly scalable and assessable solution for reaching individuals who use emergency rooms as their safety net for acute and chronic care. Also, according to a 2014 study, teens with chronic diseases who could text their physicians were better able to manage their own [FN59] health care than teens who could not text their doctors. In addition, these teens were more likely to request help at the first sign of problems. The teens in the study used a new tool called MD2Me to help them transition from pediatric care into adult health care. The researchers looked at 81 young people between the ages of 12 and 20 years old with diabetes, cystic fibrosis or inflammatory bowel disease. Fifty percent of those participating used MD2Me. The remainder received health-management materials by mail and served as a control group. The intervention included two months of intensive Web-based and text-delivered education on general disease management, including tutorials on how to refill prescriptions, how to monitor symptoms and how to talk to physicians and friends about health care issues. The researchers found that the group using MD2Me were significantly more capable of managing their disease. In addition, those teens said that they felt more confident in their ability to advocate for themselves after using MD2Me. They were also more likely to request medical help than the group that received information by mail. In good news for patients, according to Manhattan Research's recently released report entitled “Taking the Pulse® U.S. 2012,” the [FN60] adoption by physicians of both devices and digital media is evolving much faster than previously anticipated. Manhattan Research surveyed 3,015 U.S. practicing physicians online in the first quarter of 2012 across more than 25 specialties. According to the results physician tablet adoption for professional purposes almost doubled since 2011, reaching 62% in 2012. Among tablets, the iPad was the dominant platform. In addition, one-half of tablet-owning physicians said that they have used their device at the point-of-care. The survey also showed that physicians with three screens (tablets, smartphones, and desktops/laptops) spend more time online on each device and go online more often during the workday than physicians with one or two screens. Monique Levy, Vice President of Research at Manhattan Research, said, “The skyrocketing adoption rates of tablets alone, especially iPads, means healthcare stakeholders should revisit many of their assumptions about reaching and engaging with this audience.” On April 14th HIMSS released its 2015 HIMSS Mobile Technology Survey, which covered of more than 200 healthcare provider [FN61] employees. The survey found that almost 90 percent of respondents are utilizing mobile devices within their organizations to engage patients in their healthcare. The report also showed that respondents believe that mobile health technologies are lowering costs and improving the quality of care delivered. Of the respondents, 73 percent use app-enabled patient portals, 62 percent use telehealth services, and 57 percent communicate with patients via text communications. One reason for the adoption of tablets is new applications being offered for health care providers. Allscripts has released Allscripts Wand™, an iPad application that extends the most commonly used functions of Allscripts Professional™ and Enterprise™ solutions. [FN62] Allscripts believes the application has great potential as a recent study in Archives of Internal Medicine found that iPad use in hospitals could reduce delays and improve continuity of patient care. In addition, a poll of more than 5,000 physicians conducted by the Physicians Consulting Network revealed that 27% of primary care and specialty physicians own an iPad or similar device, a rate that is five times higher than the general population. The new WAND application will enable healthcare providers to: • review appointment lists and current patient status; • retrieve patient data quickly, with drill-down access to details; • input real-time information like vitals and medications from the examination room • access EHR information anytime of the day; • view a timeline of key patient information such as lab results, medications, vital signs, and more; and © 2020 Thomson Reuters. No claim to original U.S. Government Works. -12- • e-prescribe with electronic transmission to pharmacies. A study by the Health Research and Educational Trust on the attitudes of Americans concerning health information technology showed [FN63] that almost 80% of the American public favor the use of EHRs and believe EHRs could improve care. Almost 60% of those surveyed believe EHRs will reduce costs. In addition, 64% feel that the benefits EHRs provide outweigh the privacy risks. Those respondents with higher incomes and greater familiarity in using electronic technologies had the most positive views towards EHRs. Of the respondents, 64% had heard of e-prescribing and 44% were aware of their physician using such technology. Accenture, a global management consulting, technology services and outsourcing company, found that 41% of U.S. consumers would [FN64] switch physicians in order to gain online access to the EHRs. Their survey, which included more than 9,000 people in nine countries, showed that only 36% of U.S. consumers currently have full access to their EHRs, but more than 57% have taken ownership of their records by self-tracking their personal health information, including their health history (37%), physical activity (34%), and health indicators such as blood pressure and weight (33%). More than 80% of the consumers believed they should have full access to the EHRs while 65% of U.S. physicians believe patients should only have limited access. Currently, according to the survey, 63% of U.S. patients have limited access to their EHRs. In May 2015, IBM Watson Health announced that it is collaborating with Epic and Mayo Clinic to advance patient health by applying [FN65] the cognitive computing capabilities of Watson to Electronic Health Records. Once Watson's capabilities are applied to EHRs, patients and providers should benefit from more rapid and thorough analysis of the medical factors that could impact an individual's health and wellness. Epic currently has more than 350 customers, including some of the largest and most-recognized healthcare systems in the world. In the past 12 months Epic's customers have exchanged more than 80 million medical records. Interoperability with Watson will enable these institutions to apply the cognitive capabilities of Watson to these records through secure, cloud-based Watson services, providing greater clinical insight to help personalize healthcare. The combination of Watson and Epic software could be used to develop patient treatment protocols, personalize patient management for chronic conditions, and intelligently assist doctors and nurses by providing relevant evidence from the worldwide body of medical knowledge, putting new insight into the hands of clinical staff. Providers will be able to share patient-specific data with Watson in real time, within workflows, allowing Watson to bring forth critical evidence from medical literature and case studies that are most relevant to the patient's care. Epic plans to embed Watson's cognitive computing capabilities into its advanced decision support offerings using open standards, including Health Level -7 (HL7) Fast Healthcare Interoperability Resources (FHIR) Application Programming Interfaces (APIs). Central Massachusetts' largest health network, UMass Memorial Health Care, announced in July 2015 that it will spend $700 million [FN66] over the next ten years to upgrade its patient records and information technology systems. The health network will purchase clinical and billing software programs from Epic Systems Corp. of Verona, Wis., the country's biggest vendor of electronic health record systems. It is estimated that at a minimum 1,100 physicians will use the new systems at their practices. Previously, Massachusetts' Partners HealthCare announced that it is spending $1.2 billion to implement Epic's software. Partners' network includes Brigham and Women's Hospital and Massachusetts General Hospital. IBM and Mayo Clinic are currently working together on cognitive computing in clinical trials matching for cancer patients. Watson enables physicians to enroll patients more quickly in the clinical trials that best meet individual patient needs. Over one million patients are seen at Mayo Clinic each year and more than 1,000 clinical trials are available to match patients to at any given time. According to a report published in the Journal of the American Medical Association, health care providers in New York City and New [FN67] Orleans are using EHRs to increase the number of routine HIV screenings. The CDC recommends routine HIV screening all patients between 13 and 64 years of age unless the prevalence of undiagnosed HIV infection among their patients is documented to be less than 0.1%. In New York, a federally qualified health center offered HIV tests to patients that had not been tested the previous year. The offers and any tests agreed to were documented in the patients' EHRs. After starting the program, HIV testing rates increased from 8% to 56%. In New Orleans, a hospital added alerts in EHRs to remind clinicians to offer HIV testing to urgent care and emergency room patients that had not been tested in the previous year. Testing rates for urgent care increased from 3% to 17% and from 17% to 26% in the emergency rooms. Another study recently published in the Journal of Hospital Medicine looked at the impact of EHR implementation on the patient [FN68] experience in hospitals. The researchers used both the Ronald Reagan UCLA Medical Center and the UCLA Medical Center, Santa Monica. The study is based on 3,417 surveys, consisting of 16 questions, completed during the period December 1, 2012 to May 30, 2013. The study included patient representation from 9 departments within UCLA Health. All 16 questions assessing physician- patient communication received better responses in the three months after EHR implementation, compared to the 3 months prior to implementation. Nine questions illustrated statistically significant improvement, however the improvement in the remaining seven questions was not statistically significant. The researchers concluded that the results suggest that EHRs may improve physician-patient communication. A survey published in the June 2013 issue of Annals of Internal Medicine evaluated physicians' reports of electronic health records [FN69] adoption and the ease of use and their ability to use EHRs for patient panel management. The researchers surveyed 1,820 primary care physicians across the country from late 2011 through early 2012. The researchers found that a less than half of the © 2020 Thomson Reuters. No claim to original U.S. Government Works. -13- physicians reported having a basic EHR system and only 9.8% met meaningful use criteria. Also, less than one half of respondents reported the presence of computerized systems for any of the patient population management tasks included in the survey. Physicians with such functionalities reported that these systems varied in ease of use. The researchers did find that those physicians with an EHR that met meaningful use criteria were significantly more likely than those not meeting the standard to rate panel management tasks as easy. The researchers concluded that few physicians could meet meaningful use criteria in early 2012 and using computerized systems for the panel management tasks was difficult. In addition, their results supported evidence that using the basic data input capabilities of an EHR does not translate into the greater opportunity that these technologies promise. The researchers found the most common uses of EHRs were: (1) viewing laboratory results of drugs (80%); (2) use of electronic prescriptions (74%); (3) recording clinical notes (67%); generating lists of patients by demographic criteria (34%); (5) generating quality metrics (31%); and (6) providing patients with [FN70] electronic copies of their health information (14%). A 2014 survey shows that physicians are split as to EHRs. Medscape's 2014 report on Electronic Health Records shows that physicians [FN71] are divided about what they like and dislike about EHRs. The survey found that while 63% of the respondents believe EHRs improve documentation, 27% said they worsened documentation. Also, 39% of the respondents said EHRs improve collections, but 9% said EHRs worsen collections. While 32% of the respondents believed that EHRs improve patient service, 38% disagreed. A total of 34% said that EHRs improve clinical operations, while 35% disagreed. One of the biggest complaints about EHRs was that they decrease face-to-face time with patients (70%). Also, 57% of the respondents said that EHRs keep them from seeing more patients. In addition, 53% said that EHRs did not allow them to manage their staff more effectively. In previous surveys many physicians were dissatisfied with their EHR vendor, but this year 42% said they were either very or somewhat satisfied, 17% of the respondents were neutral and 84% said they would keep their current EHR system. As to privacy concerns, 48% were concerned about the loss of information through a technological malfunction, 47% were concerned about controlling the access to patient information, 39% were concerned about HIPAA compliance and 38% were concerned about possible hacking. Despite the concerns that many of the physicians had, 81% of the respondents said they had become more comfortable using EHRs over time. Similarly, a survey done by NPR in November 2014 of 400 internists found that despite the promise of EHRs freeing up some of the [FN72] physician's time, they often do not. Only 15% of the respondents said they have either much more or somewhat more free time. On the other hand, 59% of the respondents said that using EHRs resulted in either somewhat less or much less free time. A total of 26% said that EHRs had no effect on their free time. In addition, 60% of the internists said that writing up a patient's visit on a computer took more than that the note writing used before EHRs. However, Dr. Leora Horwitz, an internist and the director of the Center for Healthcare Innovation and Delivery Science at NYU Langone Medical Center said that while she generally loses an hour a day by using EHRs, that their benefits outweigh the amount of time they take and that she would not want to return to old way of record keeping. One concern some have about electronic health records is their security. A 2013 study published in the American Journal of Managed Care looks at physician capability to electronically exchange laboratory, pharmacy, and clinical information at a national and state [FN73] level. The researchers used the 2011 National Ambulatory Medical Care Survey Electronic Medical Records Supplement as their data source. That survey covered 4,326 nonfederal office-based physicians who provide direct patient care. The survey asked the physicians about their ability to exchange such information as pharmacy data, laboratory data, and patient clinical summaries. To assess the ability of the physicians to exchange patient clinical summaries, the researchers looked at the percentage of respondents who indicated that they “exchange patient clinical summaries electronically with any other providers.” The researchers found that the ability to exchange clinical information varied widely from state to state. They believe that a state's investment in Health IT and its statutes and regulation regarding Health IT, as well as the presence of regional Health IT organizations in the state may account for this variation. The researchers also found that the fact that not all electronic health records systems offer the same exchange capabilities is a major challenge facing the exchange of clinical information. The study concluded that most physicians currently have the capability of electronically exchanging laboratory and pharmacy information and that one-third can exchange clinical summaries with patients or other providers. Another 2013 study published in JAMA Internal Medicine examined patients' perceptions about sharing their personal health data for purposes other than their own healthcare to establish and evaluate ethical and regulatory structures to oversee the use of such [FN74] data. The researchers examined the views of 3,336 adults (568 Hispanic, 500 non-Hispanic African American, and 2,268 non- Hispanic white). The participants were randomly presented with 6 of 18 possible scenarios concerning secondary use. These scenarios varied according to the purpose of the use (quality improvement, research, or marketing), the sensitivity of the data (whether it included genetic information about their own cancer risk), and the possible users (commercial enterprises, university hospitals, or public health departments). Such scenarios were developed to enable the participants to indicate their preferences for secondary uses. The researchers found that the participants were concerned most about the specific purpose for using their health information, however such differences were smaller among racial and ethnic minorities. The user of the information was of secondary importance, and the sensitivity was not a significant factor in the participants' decisions. The researchers recommend that such preferences be considered in policies governing secondary uses of health information. In addition, a 2014 study published in the Journal of the American Medical Informatics Association, found that concerns about privacy and security may keep patients from being completely honest when they see physicians entering information on electronic health [FN75] records. While 83% of the respondents said they expect hospitals to use EHRs, only 53% said they trust the security of EHRs. © 2020 Thomson Reuters. No claim to original U.S. Government Works. -14- The study used the 2012 Health Information National Trends Survey. In that survey 13% of the respondents said they had withheld information out of concerns the information would not be kept secure or secret. The report's researchers found a positive correlation between patients' willfully withholding information and providers' use of EHRs. The researchers concluded however that the advantages of EHRs outweigh the possibility of patients' withholding information. The researchers recommend that providers discuss EHR privacy and security with their patients. In May 2013 the Office of the National Coordinator for Health Information Technology (ONC) released “Governance Framework for [FN76] Trusted Electronic Health Information Exchange.” This document is intended to serve as the ONC's guiding principles on Health Information Exchange (HIE) governance and to provide a common conceptual foundation applicable to all types of governance models. The document does not prescribe specific solutions. It does, however, describe milestones and outcomes that ONC expects of and from HIE governance entities as they enable electronic HIE. The intended audience for this framework includes state governments, public-private partnerships, and HIE organizations. In addition, ONC believes third party assessors, such as those organizations dealing with certification and accreditation, will find the framework useful as they develop ways to assess the competency, credibility, and trustworthiness of HIE governance entities. The framework includes four categories of principles: • Organization Principles: Five principles intended to instill confidence among governed organizations, their users, and other exchange partners regarding the way in which the electronic exchange is conducted; • Trust Principles: Six principles to ensure patients have trust in the electronic HIE; • Business Principles: Four principles regarding responsible financial and operational HIE policy that is necessary to improve care coordination, improve the efficiency of health care delivery, and mitigate behaviors that could result in proprietary networks and resistance to exchanging information; and • Technical Principles: Six principles concerning the expectations of technical conformance and the use of standards an entity that sets HIE policy should promote. In May 2014, the ONC approved the American National Standards Institute for a second three-year term as the ONC-Approved [FN77] Accreditor (ONC-AA) for the ONC Health Information Technology Certification Program. The ONC certifies electronic health record technology products to ensure they meet the standards to improve health care quality, safety, and efficiency through the promotion of health information technology and electronic health information exchange. The ONC-AA accredits the certification bodies that seek to serve as ONC-Authorized Certification Bodies under this program and to ensure that they continue to meet requirements necessary to maintain accreditation. The American National Standards Institute was approved as the ONC-AA after a competitive process that included an evaluation against a specific set of requirements, including conformance to ISO/IEC 17011, and experience evaluating conformance of certification bodies to ISO Guide 65. Predictably, another cited obstacle, for both physicians and hospitals, to adopting electronic systems is the cost involved. Potential costs to implementing health IT systems ranged from about $20 million for small hospitals to $200 million for major research institutions. [FN78] Among hospitals with no EHR systems in place, nearly three-quarters cited inadequate capital as a barrier, while 44 percent cited maintenance costs, 36 percent cited physician resistance and 32 percent felt the return on investment was unclear. The authors of the hospital study concluded that the survey results “suggest that policymakers face substantial obstacles to the achievement of healthcare [FN79] performance goals that depend on health information technology.” Dr. David Blumenthal, the current National Coordinator for Health Information Technology was one of the authors of the study. To address the issue of the cost of adopting EHR systems, the federal government in 2011 began disbursing incentive payments to [FN80] hospitals and physicians. Then in 2012 HHS Secretary, Kathleen Sebelius announced the next steps for health care providers [FN81] who are using electronic health record (EHR) technology and receiving incentive payments from Medicare and Medicaid. Secretary Sebelius stated, “We have seen great success and momentum as we've taken the first steps toward adoption of this critical technology. As we move into the next stage, we are encouraging even more providers to participate and support more coordinated, patient-centered care.” These proposed rules, from the Centers for Medicaid & Medicaid Services (CMS) and the Office of the National Coordinator for Health Information Technology (ONC), will govern stage 2 of the Medicare and Medicaid Electronic Health Record Incentive Programs. What is considered “meaningful use” is evolving in three stages. Under Stage 1, which began in 2011 and remains the starting point for all providers, the term “meaningful use” consists of transferring data to EHRs and being able to share information, including electronic copies and visit summaries for patients. Under Stage 2, to be implemented in 2014 under the proposed rule, ”meaningful use” includes new standards such as online access for patients to their health information, and electronic health information exchange between providers. Under Stage 3, scheduled to be implemented in 2016, “meaningful use” will include demonstrating that the quality of health care has been improved. CMS' proposed rule specified the Stage 2 criteria that eligible providers must meet to qualify for Medicare and/or Medicaid EHR [FN82] incentive payments. The proposed rule also specified the Medicare payment adjustments that, beginning in 2015, providers will face if they fail to demonstrate meaningful use of certified EHR technology and fail to meet other program participation requirements. Under the proposed rule, Stage 1 was extended an additional year, allowing providers to attest to Stage 2 in 2014. The proposed rule also identified standards and criteria for the certification of EHR technology, so eligible professionals and hospitals can be sure that the © 2020 Thomson Reuters. No claim to original U.S. Government Works. -15- systems they adopt can perform the required functions to demonstrate either stage of meaningful use that would be in effect starting in 2014. In May 2015, the American Hospital Association (AHA) has urged CMS to focus on developing the mature standards and infrastructure needed for efficient and effective health information exchange, and to refrain from finalizing Stage 3 EHR requirements for meaningful [FN83] use until CMS has more experience with Stage 2. AHA's Executive Vice President Rick Pollack in an open letter to CMS stated that while the current Stage 3 proposals offer promising ideas that could further health information exchange and support greater patient engagement, the transition to new technology that supports Stage 2 EHR requirements has been very challenging for providers due to the lack of “vendor readiness, mandates to use untested standards, insufficient infrastructure to meet requirements to share information and compressed timelines.” In addition, Pollack emphasized the Stage 2 EHR requirements have been very expensive. AHA estimates that between 2010 and 2013 $47 billion was spent annually by hospitals on information technology. On Oct. 6, CMS and Office of the National Coordinator for Health Information Technology (ONC) released final rules that simplify [FN84] requirements and add new flexibilities for providers to make electronic health information more readily available. The final rule for 2015 Edition Health IT Certification Criteria (2015 Edition) and final rule with comment period for the Medicare and Medicaid Electronic Health Records (EHRs) Incentive Programs are intended to continue to move the health care industry away from a paper-based system, where a doctor's handwriting needed to be interpreted and patient files could be misplaced. As part of the regulations, CMS announced a 60-day public comment period to gather additional feedback about the EHR Incentive Programs going forward, with the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), which established the Merit- based Incentive Payment System and consolidates certain aspects of several quality measurement and federal incentive programs into one more efficient framework. CMS will use this feedback to inform future policy developments for the EHR Incentive Programs, as well as consider it during rulemaking to implement MACRA, which we expect to release in the spring of 2016. The EHR Incentive Programs [FN85] in 2015 through 2017, major provisions include: • 10 objectives for eligible professionals including one public health reporting objective, down from 18 total objectives in prior stages; • 9 objectives for eligible hospitals and critical access hospitals (CAHs) including one public health reporting objective, down from 20 total objectives in prior stages; and • Clinical Quality Measures (CQM) reporting for both eligible professionals (EPs) and eligible hospitals/CAHs remains as previously finalized. For Stage 3 of the EHR Incentive Programs in 2017 and subsequent years, major provisions include: • 8 objectives for eligible professionals, eligible hospitals, and CAHs: In Stage 3, more than 60 percent of the proposed measures require interoperability, up from 33 percent in Stage 2; • public health reporting with flexible options for measure selection; • CQM reporting aligned with the CMS quality reporting programs; and • finalize the use of application program interfaces (APIs) that enable the development of new functionalities to build bridges across systems and provide increased data access. This will help patients have unprecedented access to their own health records, empowering individuals to make key health decisions. The Stage 3 requirements are optional in 2017. In addition to the final rule for the EHR Incentive Programs, ONC also announced the final rule for the 2015 Edition Health IT Certification Criteria. This rule focuses on increasing interoperability – a secure but seamless flow of electronic health information – and improving transparency and competition in the health IT marketplace. CMS's incentive program is showing definite signs of success. By the end of May 2012 more than 100,000 health care providers were using electronic health records that meet federal standards and had benefitted from the Medicare and Medicaid EHR Incentive [FN86] Programs. Three months earlier, CMS Acting Administrator Marilyn Tavenner and National Coordinator for Health Information Technology Farzad Mostashari, M.D., Sc.M., declared an ambitious goal of getting 100,000 health care providers to adopt or meaningfully use EHRs by the end of 2012, “Meeting this goal so early in the year is a testament to the commitment of everyone who has worked hard to meet the challenges of integrating EHRs and health information technology into clinical practice,” said Acting Administrator Tavenner. In December 2014, the ONC announced that over 400,000 eligible hospitals and professionals participate in [FN87] the Medicare and Medicaid Electronic Health Record Incentive Programs. However, small hospitals are still facing economic challenges in adapting to EHRs. Starting October 2014, hospitals that do not meet [FN88] Medicare's EHR standards will begin to see financial penalties. Many of the country's 2,000 rural and small-town hospitals expressed concerned that they would not be able meet that deadline. Among the financial challenges facing such hospitals is that the average rural hospital is running an annual financial loss of 8%. Also, it is difficult for hospitals to find people with information technology skills outside of large, urban areas. As a result, some small hospitals are turning to bigger hospitals for help. For example, a rural hospital in Red Lodge, Montana decided to become part of the larger Billings Clinic health care system, in part to get IT help. © 2020 Thomson Reuters. No claim to original U.S. Government Works. -16- While aligning with a larger system means giving up some if not all control of a hospital's operations, affiliating with a big network often has benefits and can improve the care in small towns. One of the advantages the doctors at the Red Lodge hospital have found is that now they can share patient records instantly and securely with the large hospital in Billings and get expert advice on an almost daily basis. The Office of Inspector General has found that the Oklahoma Health Care Authority did not always pay Medicaid electronic health [FN89] record incentive payments to professionals in accordance with Federal and State requirements. The State agency incorrectly paid $888,000 to 47 hospital-based professionals and claimed $127,000 more than it paid on its CMS-64 reports. Additionally, the National Level Repository data did not include a $21,000 incentive payment. To aid hospitals in the adoption of EHRs CMS issued a memorandum to State Survey Agency Directors concerning Electronic Health [FN90] Record Navigators. In the memorandum CMS advised hospitals and Critical Access Hospitals (CAHs) that State Survey Agency surveyors may be requesting that experienced hospital/CAH electronic health record users with appropriate system permissions be assigned as “navigators” to assist the surveyors with medical record information retrieval for survey tasks requiring detailed medical record review. CMS believes that providing such assistance is analogous to the traditional expectation for paper-based records that such providers retrieve closed paper medical records requested by surveyors. CMS started that hospitals/CAHs are expected to provide the necessary assistance to enable surveyors to review EHRs. The navigator would pull up records, or appropriate portions of the records, when requested to do so by the surveyor for the surveyor to review via the computer. It is neither expected nor advisable to ask that all requested records be printed out for the survey or to review. Surveyors are expected to request printouts or screen shots selectively, based on their preliminary survey findings. [FN91] Another obstacle to the adoption of electronic systems is the workforce shortage of qualified trained individuals. To address this shortage the HITECH Act authorized the creation of a program to assist in the establishment and/or expansion of programs to train a skilled workforce to facilitate the adoption of EHRs. The Community College Consortia to Educate Health Information Professionals is designed to train individuals to meet the needs of physicians and hospitals. The goal of the Consortia, which consists of over 70- [FN92] member community colleges, is to train 10,500 individuals a year. Several studies have shown that the use of IT technology has definite advantages. A 2013 study published in JAMA shows that e-visits [FN93] for urinary tract infections (UTIs) and sinus infections may be less expensive and just as effective as in-person office visits. An e-visit generally requires the patient to complete an online form after which a doctor or a nurse contacts the patient within a matter of hours with advice concerning treatment. Dr. James Rohrer of the Mayo Clinic said that e-visits are happening across the country and that many insurance companies believe they will cut costs. The study compared all e-visits and office visits for sinus infections and UTIs over a 17-month period at four primary care practices in Pittsburgh, Pennsylvania. The e-visits and the office visits both resulted with seven percent or less of the patients having a follow-up visit for the same conditions. The researchers estimated the average cost for UTIs were $93 for an office visit as opposed to $74 for an e-visit. According to the study the main difference between e-visits and traditional office visits is that e-visit patients tended to be prescribed more antibiotics. The researchers stated that while this may be of concern it was difficult to interpret this fact on its own. Another survey by Premier, Inc. and eHealth Initiative found that the lack of interoperable technology is hurting Accountable Care [FN94] Organizations (ACOs) to improve care. Of the 62 ACOs surveyed, all said that accessing data from external organizations is challenging. In addition, 88% said that integrating data from different sources poses “significant obstacles.” However, the respondents did say that core Health IT components such as EHRs, disease registry, data warehousing and clinical support systems are in place. [FN95] They also responded that using such components has helped improve clinical quality and health outcomes. However, the respondents reported that more advanced capabilities such as those that would support patient engagement, access to care are only in the beginning stages. Cost was given as the chief obstacle to additional Health IT investments by almost 90% of the respondents. In the wake of complaints about interoperability one company, Wisconsin based Epic Systems, the largest seller of electronic health [FN96] records which is expected to generate $1.5 billion in 2014, is beginning to fight back It has come under criticism that it fails to easily share patient records. In a hearing of the House Energy and Commerce Committee, Rep. Phil Gingrey (R-Ga.) spoke of Epic Systems and warned that it was possible that fraud was being committed against the American people. In addition, the FTD has announced that it will monitor the EHR vendors to spot any that impede progress toward “interoperability” and the RAND Corp. has issued a report referring to Epic Systems as a “closed system.” Epic' System's CEO, Judy Faulkner, is now speaking out to defend the company. At the same time the company has hired a Washington, D.C. based lobbyist to meet with various members of congress to clear up what it believes are misperceptions. According to the company, over 680,000 items of patient information were exchanged between Epic and non-Epic customers in September of this year, which was up from 313,000 in June. In addition, the company says that it was the first company to successfully exchange patient information between hospitals with different EHRs. The company also receives approximately 300 requests each month from third parties to integrate Epic Systems with their systems. [FN97] To address interoperability concerns, in early 2015 HHS released a draft of a shared nationwide interoperability roadmap. The roadmap is a proposal to deliver better care and result in healthier people through the safe and secure exchange and use of electronic health information. The roadmap is built on a vision papers that HHS released in June 2014. HHS focused on three key areas in the © 2020 Thomson Reuters. No claim to original U.S. Government Works. -17- roadmap: (i) improving the way providers are paid, (ii) improving and innovating in care delivery, and (ii) sharing information more broadly to providers, consumers, and others to support better decisions while maintaining privacy. The draft Roadmap identifies critical actions to achieve success in sharing information and interoperability and outlines a timeframe for implementation. Along with the announcement, the National Coordinator for Health Information Technology released its Draft 2015 Interoperability Advisory, which sets forth the best available standards and implementation specifications for interoperability of clinical health information. The roadmap is based on a core set of building blocks that HHS believes is necessary to achieve interoperability: • core technical standards and functions; • certification to support adoption and optimization of health IT products and services; • privacy and security protections for health information; • a supportive business, clinical, and regulatory environment; and • rules of engagement and governance. HHS and the Office of the National Coordinator for Health Information Technology (ONC) announced the release of the Final Federal [FN98] Health IT Strategic Plan 2015-2020. While the aim of the Plan is to improve interoperability and the infrastructure of health IT, the goal is to enhance health and wellness. This Final Plan follows a prior Plan released in 2011. In a letter accompanying the Final Plan, the National Coordinator notes: Implementation of the prior Plan created a strong foundation for achieving this Plan's goals and objectives. Over 450,000 eligible professionals and 4,800 eligible hospitals received an incentive payment for participation in the Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs. This incredible achievement was not easy. Hospitals and health care providers have invested capital, time, and hard work to convert their patient medical records from paper systems to EHRs, and to adapt workflow and culture to deliver care in this electronic environment. This has created a strong demand for the seamless sharing of information across [FN99] technology systems, information platforms, location, provider, or other boundaries. The Plan identifies the following federal health IT principles: • focus on value; • be person-centered; • respect individual preferences; • build a culture of electronic health information access and use; • create an environment of continuous learning and improvement; • encourage innovation and competition; and • be a responsible steward of the country's money and trust. From these principles, four goals emerge: • advance person-centered and self-managed health; • transform health care delivery and community health; • foster research, scientific knowledge, and innovation; and [FN100] • enhance nation's health IT infrastructure. The push to adopt EHRs has been driven by the belief that they offer definite benefits to both providers and patients. A 2011 study reported in the Journal of American Medicine, which was done by researchers at the Department of Veterans Affairs, found that the [FN101] use of computers to scan doctors' notes could reduce dangerous complications following surgery. The study employed “natural language processing” to detect clues for possible post-surgery complications. By looking at the records of approximately 3,000 VA patients between the years of 1999 and 2006, the technology dramatically increased the detection of such complications as acute renal failure, deep vein thrombosis, and pneumonia. A study presented in October 2013 in Seattle at the annual meeting of the American College of Emergency Physicians showed that having access to data from a health information exchange improved the quality of emergency care and saved more than $1 million [FN102] in patient charges, or nearly $2,000 per patient. The study looked at a 12-month period, starting February 2012, and included 325,740 patient encounters and 7,525 log-ons to the HIE by 231 eligible clinicians at 11 emergency departments in South Carolina. The study's research team based its conclusions on a sample of 532 patients from this population who had information available in the HIE and for whom the clinicians caring for the patients completed a survey. The total of savings for patients in the sample was $1,035,654, based on Medicare-allowable charges, or $1,947 per patient. The researchers found having access to an HIE for emergency patients resulted in savings by allowing them to avoid the following types of services: Hospital Admissions (56 patients for a total of $551,282), Radiology (298 patients for a total of $476,840), Consultations (61 patients for a total of $6,461), and Laboratory/Microbiology (187 © 2020 Thomson Reuters. No claim to original U.S. Government Works. -18- patients for a total of $2,073). The study also showed 90 percent of participating clinicians reported that their quality of patient care [FN103] improved, and that they were able to save an average of 105 minutes per patient. Another study, this one published in the fall of 2014, looked at whether electronic health records (EHRs) actually improve patient safety. [FN104] While EHRs have been expected to do so, previously the evidence of EHRs' impact on patient safety was inconclusive due to a lack of reliable and comprehensive data. For this study, researchers created a panel of Pennsylvania hospitals during the period 2005 to 2012 using data from a variety of sources. They sourced confidential patient safety data from the Pennsylvania Patient Safety Authority. The researchers used a differences-in-differences identification strategy and found that EHRs lead to a 27% drop in patient safety events. This overall decline was driven by declines in several important subcategories. The found a 30% decline in events due to medication errors and a 25% decline in events due to complications. Another example of the benefits of EHRs was demonstrated in a recent Kaiser Permanente study, published in Medicine & Science in Sports & Exercise, found that an initiative to systematically integrate a patient's physical activity data into the patient's electronic health [FN105] record (EHR) demonstrated a way to improve patient treatment and care quality. According to the study Kaiser Permanente's “Exercise Vital Sign” initiative compiles accurate and valuable information that can help clinicians better treat and counsel patients about their lifestyles. The researchers looked at the EHRs of approximately 1.8 million Kaiser Permanente Southern California patients and found that 86 percent of all eligible patients had an exercise vital sign in their record. Of those patients who had an exercise record incorporated in their EHRs, one-third were meeting national guidelines for physical activity while two-thirds were not. Of those not meeting guidelines, one-third was not doing any exercise. “Embedding questions about physical activity in the electronic health record provides an opportunity to counsel millions of patients during routine medical care regarding the importance of physical activity for health,” said study lead author Karen J. Coleman of the Kaiser Permanente Southern California Department of Research & Evaluation. “In addition, the Exercise Vital Sign has the potential to provide information about the relationship between exercise and health care utilization, cost and chronic disease that has not been previously available.” As part of the initiative, patients are asked about their exercise habits during routine outpatient visits and their responses are included in their EHR, along with other traditional vital signs such as blood pressure, pulse, and temperature. Robert E. Sallis, MD, co-author and chairman of the Exercise is Medicine advisory board. “When incorporated in a healthcare setting, the exercise vital sign can be an important tool for prevention and management of disease.” In October 2014, the Robert Wood Johnson Foundation announced a new initiative “Data For Health” that will seek to explore how [FN106] information and data on health can be harnessed to help people lead healthier lives. In recent years the country has seen a large investment in health information technology resulting in rapid implementation of electronic health records. At the same time there are [FN107] approximately 40,000 health apps and wearable devices that track such things as fitness, mood and sleep. The initiative will assess how health care providers can use such information to make faster decisions that improve the health of the public and promote healthy lifestyles. Key issues the Initiative will focus on are: • how are communities currently using data to improve health; • what are their hopes, aspirations, and concerns about various forms of health information; • what additional data do they want to access; • what is the best way to collaborate in improving health by sharing data among different sectors; and • how to best secure the data? The initiative's advisory committee is hosting a series of “Learning What Works” events in Philadelphia, Pennsylvania; Phoenix, Arizona; Des Moines, Iowa; San Francisco; and Charleston, South Carolina to hear from local leaders, residents, and professionals from a wide range of sectors on what information is important to them and how they might use it to help people lead healthier lives and improve health in their communities. The Office of the National Coordinator for Health Information Technology (ONC) within the U.S. Department of Health and Human Services (HHS) will participate in each of the listening sessions. The advisory committee intends to issue a report and recommendations in early 2015 There is some evidence, however, that suggests that EHRs do little to help patients outside of hospitals. Researchers from Stanford University who analyzed federal data on more than 255,000 patients, about a third of whom had electronic health records (EHRs), released in study in January 2011 which found that often there is no benefit to have an EHR. Using 20 different measures of quality, [FN108] the researchers compared the care of those patients to the care of patients without EHRs. Such measures included whether smokers were counseled on ways to quit and whether proper medication was prescribed for patients with simple infections. On 19 of the 20 measures, they found no benefit from having an EHR. The one exception was dietary advice. The researchers found that patients at high-risk for illness were slightly more likely to receive counseling on a proper diet. Dr. Randall Stafford, a professor at the Stanford Prevention Research Center and co-author of the study said, ““Our initial hope was that we would see a correlation between electronic health records and quality, and when we looked at the subset of patients whose doctors got help from the clinical decision support systems, we'd see an even stronger relationship. Perhaps we need to re-examine the naive assumption that just putting in place an EHR system will make a huge difference.” © 2020 Thomson Reuters. No claim to original U.S. Government Works. -19- Also, there is a 2013 study published in Health Affairs that examined the Rand Corporation's 2005 projection that health information [FN109] technology could save the United States more than $81 billion annually. The authors found that seven years later the empirical data on the technology's impact on health care efficiency and safety are mixed. The authors believe several factors have caused the mixed results. These factors include: (i) the slow adoption of health IT systems, coupled with the choice of systems that are neither interoperable nor easy to use; and (ii) the failure of health care providers and facilities to reengineer care processes to take advantage of the full benefits of health IT. Today, 72% of office-based physicians use some sort of electronic system in their practice, however [FN110] only 40% of practices meet the definition of a “basic” system. According to Dr. Art Kellermann, one of the authors, the ability for doctors to easily share information is the exception in America, not the rule. The authors believe that the original goals for health IT are achievable provided the systems are redesigned by creating more-standardized systems that are easier to use, are truly interoperable, and afford patients more access to and control over their health data. Dr. Kellermann stated, “As we shift American health care and start paying for the best quality care and the best outcomes, rather than who does the most stuff, who orders the most tests or who does the most operations, then I think you'll see IT becoming a tool for efficiency and high performance. Many experts, however, do see a real advantage to EHRs in addition to their ability to prevent medical errors. For example, the Veterans Administration (VA), which has been utilizing electronic health records for over 20 years, is in the process of creating the [FN111] world's largest medical database for research purposes. Part of this project involves obtaining blood samples from 1 million U.S. veterans. Those samples will then be paired with the VA's current mega-database which contains records of laboratory results, vital signs, pharmaceuticals, assessments of depression, post-traumatic stress disorder, suicide screening, alcohol and substances use, and traumatic brain injury. The patient's names will be removed from the database to ensure that the data is anonymous. The VA intends for the database to be used by researchers for such purposes as to better understand why some people are more responsive to certain drugs and why some are more vulnerable to certain diseases. Despite scrubbing the names from the data, VA clinics are reporting that the number one concern of possible participants is privacy and the fear that the information could end up with future employers or insurers. The military is also seeing the advantages of Health IT in caring for its service members. Recently TRICARE Management Activity, a component of the U.S. Military Health System, has awarded LongView International Technology Solutions, Inc. (LongView) a five- year, multi-award contract to develop new information technology systems for the Military Health System's Pacific Joint Information [FN112] Technology Center (JITC) on Maui. The contract's ceiling value is $300 million. The Pacific JITC is center for proof of concept and prototyping of Information Management/Information Technology products and services to support the Department of Defense's medical readiness requirements and the Department's Information Technology modernization needs across the medical continuum of care. The Pacific JITC's mission is to rapidly research, test, and develop warfighter medical solutions and products, through pilots or prototypes that provide mission critical value and actionable information to the Department. Ben Long, President and CEO of LongView, said “As a national security and federal healthcare-focused Service-Disabled Veteran-Owned Small Business, LongView keenly understands the importance the Pacific JITC program plays in advancing the medical IM/IT solutions that support the warfighter, including the prototype development of the Electronic Health Record.” LongView is based in the Washington D.C. area. A study by Stanford University School of Medicine found that the use of a computerized safety checklist that automatically pulls information from patients' electronic medical records resulted in a threefold drop in rates of one serious type of hospital-acquired [FN113] infection . The study, conducted in the Lucille Packard Children's Hospital Stanford's pediatric intensive care unit, targeted bloodstream infections that begin in central lines — catheters inserted into major veins. The checklists, along with a dashboard-style interface used to interact with the checklist, enabled caregivers to quickly and easily follow national guidelines for keeping patients' central lines infection-free. The system checked patients' electronic medical records and pushed alerts to physicians and nurses when a patient's central line was due for care. During the study the rate of central line infections in the hospital's pediatric intensive care unit dropped from 2.6 to 0.7 per 1,000 days of central line use. These infections are a preventable cause of illness and death, and currently hospitals across the country are working to reduce their frequency. Hospitals that have adopted the use of EHRs have been very pleased with the results. In 2012, The Ohio State University Wexner [FN114] Medical received the Stage 7 Award for its four hospitals. Stage 7 is the highest level of implementation on the Electronic Medical Records Adoption Model, which tracks EMR progress at hospitals and health systems. “Our electronic system will allow us to provide more efficient, effective and better coordinated care to our patients. Patient records are in a central, secure location where health providers can access their patients' current health information,” said Steven G. Gabbe, MD, Wexner Medical Center's CEO. HIMSS Analytics developed the EMR Adoption Model in 2005 as a methodology for evaluating the progress and impact of EMR systems for hospitals. The Model has eight stages (0-7) that measure a hospital's implementation and utilization of IT applications. More and more hospitals are receiving the Stage 7 Award. Currently only 1.16 percent of the more than 19,085 U.S. ambulatory clinics in the HIMSS Analytics® Database, have received the Stage 7 Ambulatory Award. In November 2013, HIMSS Analytics recognized [FN115] Atrius Health and also separately its affiliate, Reliant Medical Group, in Worcester, Mass., 50 of Truman Medical Centers (TMC) [FN116] ambulatory clinics, St. Vincent Hospital in Green Bay, Wis., St. Mary's Hospital Medical Center in Green Bay, Wis., and St. Nicholas Hospital in Sheboygan, Wis., part of Hospital Sisters Health System, and 44 of University of Missouri's (MU Health Care)'s [FN117] ambulatory clinics with its State 7 Ambulatory Award. © 2020 Thomson Reuters. No claim to original U.S. Government Works. -20- Atrius Health is a not-for-profit alliance of six community-based medical groups and a home healthcare and hospice agency. The Atrius Health groups include Dedham Medical Associates, Granite Medical Group, Harvard Vanguard Medical Associates, Reliant Medical Group, South Shore Medical Center, Southboro Medical Group, and VNA Care Network & Hospice. The organization represents more than 1,000 physicians and 2,100 other health professionals, with a total of 8,700 employees serving nearly one million patients across eastern and central Massachusetts. Truman Medical Centers is a not-for-profit two acute-care hospital health system in Kansas City, Mo. Recently named one of the nation's top academic medical centers, TMC is the primary teaching hospital for the University of Missouri-Kansas City School of Medicine, Nursing, Pharmacy and Dentistry and specializes in chronic disease management, orthopaedics, family medicine, women's health, and trauma services. St. Vincent Hospital and St. Mary's Hospital Medical Center have been delivering quality health care to Green Bay and its surrounding communities since 1888. Both hospitals have been named one of the “100 Top Hospitals” nationwide and are accredited by the Joint Commission on Accreditation of Healthcare Organizations. St. Nicholas Hospital is a non-profit hospital sponsored by the Hospital Sisters of St. Francis. MU Health Care is one of the most comprehensive health care networks in Missouri, with several hospitals and more than 50 clinics in Columbia, Mo., and throughout the state. Thomas Selva, M.D., chief medical information officer for MU Health said that MU Health's “achievement of this Stage 7 designation means physicians have immediate access to their patients' complete medical records electronically in the hospital and the clinic, helping them provide the best care.” HIMSS announced in October 2013 the opening of the HIMSS Innovation Center as part of the Global Center for Health Innovation, in [FN118] downtown Cleveland, Ohio. The Innovation Center, which covers a 30,000-square-foot space, includes a Health IT Simulation Center testing health IT interoperability and a Healthcare Technology Showcase demonstrating the value of IT and information exchange to patient care, clinician and patient satisfaction, population health, and the bottom line. The Innovation Center is a fully operational, multi-care environment populated with simulated patient demographic, clinical and financial data. It allows members of the health and healthcare communities to interact in real-time to both test and demonstrate scenarios that elicit a specific product's interoperability and other capabilities to improve quality and patient outcomes, cost-effective care coordination, secure data exchange, and better business performance. The pursuit of a comprehensive national health IT system has emerged because of demonstrations showing that digitalizing medical information could outweigh any potential drawbacks in the long run. The Department of Veterans Affairs (VA) has demonstrated benefits to quality of healthcare and significant cost savings from the use of health IT, according to a study published in Health Affairs. [FN119] Researchers from the Center for Information Technology Leadership believe the finding could provide a framework for measuring benefits of federal health IT funding programs. They compared health IT in the VA with private sector systems over a ten-year period from 1997 to 2007 and examined how well providers met clinical guidelines using EHRs and computerized alerts. The study focused on chronic illnesses like diabetes, which affect a quarter of VA patients. The study's authors found that the VA spent more on health IT compared to the private sector and achieved higher levels of health IT adoption and quality of healthcare. Diabetic VA patients showed better compliance with glucose testing, had better controlled cholesterol levels, and underwent timelier retinal exams compared to Medicare counterparts. The elimination of redundant tests and reduction of medical errors resulted in more than 86 percent of the savings of healthcare costs. Reduced workload and operating expenses also led to savings. “VA has seen its investment in health information technology pay off for veterans and taxpayers for many years, and this study provides positive evidence for this correlation,” said VA Secretary Eric K. Shinseki. “The benefits have exceeded [FN120] costs, proving that the implementation of secure, efficient systems of electronic records is a good idea for all our citizens.” State governments are using contests as ways to encourage ideas concerning the use of health information technology. For example, in March 2012, the Maryland Department of Health and Mental Hygiene (DHMH) has partnered with the Chesapeake Regional Information System for Our Patients (CRISP) and the Abell Foundation to launch a contest for practical ideas concerning the innovative [FN121] use of data to address public health challenges facing Maryland. Applicants are encouraged to propose solutions using data from more than 16 existing health-related databases in combination with various other publicly available state and Federal databases. Applicants are encouraged to propose ideas that leverage Maryland's health information exchange infrastructure and lead to significant health gains, while respecting privacy. A total of $5,000 in prize money, provided by the Abell Foundation, will be awarded for the best ideas. To aid providers in effectively engaging patients in choosing how they want their electronic patient health information shared, in September 2013, HHS launched its Meaningful Consent site, an online resource to help health care providers effectively engage [FN122] patients in choosing how they want their electronic patient health information shared. The website includes the laws, policies and issues related to the electronic exchange of health information. In addition, the site is a source of strategies and tools that can be used to engage and educate patients. It is designed for providers, certain health information organizations and other implementers of health information technology. © 2020 Thomson Reuters. No claim to original U.S. Government Works. -21- Because of all the interest in Health IT, the industry itself is thriving. Mercom Capital Group, LLC, a global consulting firm, released a report on funding and mergers & acquisitions in the Health IT Sector showing that globally the second quarter of 2014 was the sector's [FN123] first billion-dollar quarter. Venture Capital funding raised $1.8 billion in 161 deals, which was a 104% increase over $861 million raised in 2014's first quarter. The $2.6 billion raised so far this year is greater than the $2.2 raised in all of 2013. U.S. companies raised $1.6 billion of the $1.8 billion raised globally with a total of 161 deals. Forty-seven of those deals came out of California, 12 were New York, eight in Massachusetts and seven deals each in Texas and Tennessee. The success in the industry is contributing to a positive feeling among the workforce. Healthcare IT Leaders just released the results [FN124] of a survey of healthcare IT professionals completed during May 2014. Of the 446 valid, completed surveys, 198 were by individuals who self-identified as permanent IT employees for a healthcare industry employer and 248 self-identified as IT consultants with healthcare clients. The survey found that 43% of the consultants were “very satisfied” in their jobs and only 2% were “very dissatisfied” while only 19% of the full-time employees said they were very satisfied and 12% reported being very dissatisfied. The survey also found that 40% of the consultants were very satisfied with their pay while only 18% of the full-time employees said they were. Both groups had 54% of the respondents saying that they found their jobs either extremely challenging or very challenging. Both groups also had high numbers of respondents saying their work was either extremely meaningful or very meaningful (72% of full-time employees and 82% of consultants). Only a small minority of both groups said they would not consider a new job, which infers that most would consider changing positions if the job was right. Health IT Leaders recommends that Healthcare IT hiring companies should focus on retention of their IT employees by keeping the team engaged and well-compensated. To assist in growing the workforce to meet future demands, the U.S. Department of Labor, Education and Training Administration [FN125] and Bellevue College have teamed with HIMSS to offer a Veterans Career Initiative. The initiative's goal is to “to welcome [FN126] transitioning military veterans into the health IT field - a growing and promising area for technologically-adept veterans.” The Bureau of Labor Statistics projects that health IT jobs will grow by 21% through 2020. This workforce solution is funded by an $11.7 million grant awarded by the U.S. Department of Labor's Employment and Training Administration. The initiative offers a veteran mentoring program in which military veterans working as health IT professionals assist veterans transitioning to the workforce, a webinar series and a health IT certification program. On Nov. 4, 2014, HHS Secretary Sylvia M. Burwell today named a new member to the Health Information Technology Policy [FN127] Committee (HITPC) and renewed appointments for three members of the Health IT Standards Committee (HITSC). The committees are charged with recommending policies and technologies needed to implement a nationwide health information technology infrastructure and strategic plan. The HHS Secretary, appoints three members of the HITPC with input from the HHS National Coordinator for Health IT, four members are appointed by Congress, the Comptroller General of the United States appoints 13 members and the President appoints the other members. The new member named is Anjum Khurshid, a senior advisor - health systems division, Louisiana Public Health Institute. The continuing members are Floyd Eisenberg, M.D., M.P.H., Leslie Kelly Hall, and Arien Malec. In May 2015, the ONC has announced the availability of online tools and resources designed to help states participating in the State [FN128] Innovation Models initiative improve health care quality and lower costs. The State Innovation Models initiative supports states in planning or implementing a customized, fully developed proposal creating statewide health transformation to improve health care, focusing on Medicare, Medicaid, and Children's Health Insurance Program beneficiaries. Thirty-four states, three territories, and the District of Columbia, representing nearly two-thirds of the U.S. population, are participating in the initiative. Under the initiative ONC has developed tools and resources to help leverage existing health IT infrastructure. These include resources that can help states and health care providers use health IT tools to manage an individual's care for both their primary care and behavioral health needs, ensuring the individual is getting the right care when they need it. Recently CMS announced on its blog that it will update the Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs [FN129] beginning in 2015. The purpose of these changes is to reduce the reporting burden on providers, while at the same time supporting the long-term goals of the program. As of January 2014, over 400,000 eligible providers have joined the numbers of hospitals and professionals that have adopted or are meaningfully using EHRs. CMS intends to propose the new rule this spring. CMS plans for it to be responsive to provider concerns about software implementation and information exchange readiness. In addition, the new role will be reflective of developments in the industry and progress toward program goals achieved since the program began in 2011. Among the proposals CMS is considering are: • to realign hospital EHR reporting periods to the calendar year. This proposal will allow hospitals to incorporate 2014 Edition software into their workflows and to better align with other CMS quality programs. • to modify other parts of the program so that they better align with long-term goals, reduce complexity, and lessen providers' reporting burdens. • to shorten the EHR reporting period to 90 days. In July 2015, the Department of Health and Human Services announced that as part of the effort to create an interoperable learning health system the Office of the National Coordinator for Health Information Technology (ONC) would award twenty entities for three © 2020 Thomson Reuters. No claim to original U.S. Government Works. -22- [FN130] health information technology grant programs totaling about $38 million. The grants build on programs funded from the Health Information Technology and Clinical Health Act (HITECH). These grants will further the Department's efforts to improve the way providers are paid, improve and innovate in care delivery, and share information more broadly to providers, consumers, and others to support better health care decisions while maintaining privacy. The three cooperative agreement programs are: • Advance Interoperable Health Information Technology Services to Support Health Information Exchange. This is a two-year cooperative agreement program that was awarded $29.6 million to support the efforts of 12 states or state designated entities to expand the adoption of health information exchange technology, tools, and services; facilitate and enable the send, receive, find, and use capabilities of health information across organizational, vendor, and geographic boundaries; and increase the integration of health information in interoperable health IT to support care processes and decision making. The organizations selected to participate in this program include: Arkansas Office of Health Information Technology, California Emergency Medical Services Authority, Colorado Department of Health Care Policy and Financing, Delaware Health Information Network, Illinois Health Information Exchange Authority, Nebraska Department of Administrative Services, New Hampshire Health Information Organization Corporation, New Jersey Innovation Institute, Oregon Health Authority, Rhode Island Quality Institute, South Carolina Health Information Partners, Inc., and Utah Health Information Network. • The Community Health Peer Learning Program. This is a two-year cooperative agreement grant award was made to AcademyHealth to work with 15 communities around population health strategies. Communities working with AcademyHealth under this program will be required to identify data solutions, accelerate local progress, disseminate best practices and learning guides, and help inform national strategy around population health challenges. The grant for this program totals $2.2 million. • The Workforce Training Program. This is a two-year cooperative agreement program has awarded seven grantees $6.7 million to update training materials from the original Workforce Curriculum Development program funded under HITECH. In addition to updating training materials, the goal of this program is to train incumbent health care workers to use new health information technologies in a variety of settings, including: team-based care environments, long-term care facilities, patient-centered medical homes, accountable care organizations, hospitals, and clinics. This workforce program will focus on the four key topic areas of: population health, care coordination, new care delivery and payments models, and value based and patient centered care. The organizations selected to participate in this program include: University of Alabama at Birmingham, Bellevue College, Bellevue, Washington, Columbia University, New York City, New York, Johns Hopkins University, Baltimore, Maryland, Normandale Community College, Bloomington, Minnesota, Oregon Health & Science University, Portland, Oregon, and The University of Texas Health Science (Houston). In January 2016, the Centers for Medicare and Medicaid Services requested feedback from the health information technology industry to improve the certification and testing of electronic health records used for reporting quality measures. CMS wants feedback on the following: “how often to require recertification, the number of clinical quality measures a certified health IT module should be required to certify and testing of certified HIT modules ‘in order to reduce the burden and further streamline the process for providers and health IT developers while ensuring such products are certified and tested appropriately for effectiveness.”’ Following the comment period, CMS will determine whether it should update the rules regarding quality reporting programs. The Department of Health and Humans Services' Office of Civil Rights (OCR) issued guidelines on October 7 for HIPPA-covered [FN131] entities that utilize cloud computing solutions. The guidance provides guidance to covered entities and business associates, including cloud service providers (CSPs), with understanding their obligations under HIPAA privacy and security rules when implementing cloud computing solutions. The guidelines clarify that CSPs that lack an encryption key to encrypted date are not exempt CSPs from the obligations of HIPAA because encryption alone does not safeguard ePHI. Thus, CSPs must execute Business Associate Agreements with its covered entity and business associate customers. As a result, the CSP is both contractually liable for meeting the terms of the Business Associate Agreement and directly liable for compliance with the applicable requirements of HIPAA. CSPs cannot argue that they are a conduit and therefore not a business associate. CSPs providing cloud services that involve creating, receiving or maintaining ePHI meet the definition of a business associate, even if the CSP is providing no-view services. CSPs must document security incidents just like any other business associate and must satisfy any breach notification requirements that applies to unencrypted data. Health care providers, other covered entities, and business associates may use mobile devices to access ePHI in the cloud if appropriate physical, administrative, and technical safeguards are in place to protect the confidentiality, integrity, and availability of the ePHI on the mobile device and in the cloud. As is normally the case under HIPAA, CSPs are not required to maintain ePHI for a period beyond when it has finished providing services to a covered entity or business associate. Covered entities and business associates can use CSPs that store ePHI on servers outside the U.S. but should consider the increased risks of hacking or malware that may be present in other countries. Of course, cross-border transfers of ePHI may raise other regulatory issues. HIPAA does not require CSPs to provide documentation or allow auditing of their security practices by their customers. CSPs that receive and maintain only information that has been de-identified in accordance with the HIPAA Privacy Rule will not be considered a business associate. Nearly 87% of physicians in the United States were using electronic health records in 2015 which has nearly doubled since 2007. The increase in use has been spurned by federal incentives and a desire to improve accessibility. However, physicians and patients are still having trouble accessing and sharing the electronic health records. Right now, it appears that there are too many players in creating © 2020 Thomson Reuters. No claim to original U.S. Government Works. -23- the technology for electronic health records that is leading to varied standards, disorganization, and complexity. As a result, “President [FN132] Obama signed new legislation that included provisions designed to help improve interoperability of health records systems. ” RECENT FEDERAL LEGISLATIVE ACTIVITY • 2019 CONG US HR 2296, reported in House September 24, 2019, and 2019 CONG US S 2543, reported in Senate September 25, 2019, would amend 42 USCA § 1395w-104 (Beneficiary protections for qualified prescription drug coverage) requiring Prescription Drug Plan Sponsors and Medicare Advantage Organizations to include Real-time Benefit Information Under Medicare Part D by requiring the took to be capable of integrating electronic prescribing and electronic health record systems for the transmission of formulary and benefit information in real time to prescribing professionals. • 2019 CONG US HR 3525, referred in Senate October 15, 2019, would require the Commissioner of U.S. Customs and Border Protection to establish uniform processes for medical screening of individuals interdicted between ports of entry and would require the Department of Homeland Security to establish within the Department an electronic health record system that can be accessed by all Department components operating along the borders of the United States for individuals in the custody of such components. The bill would also require the CIO and CMO to assess the electronic health records system capacity for improvement and interoperability within 120 days of implementation. • 2019 CONG US HR 5321, introduced in House December 5, 2019, would adopt the Public Health Data System Transformation to expand, enhance, and improve public health data systems including health information technology. It would establish health information technology standards. • 2019 CONG US S 317, introduced in Senate February 4, 2019, would adopt the Advancing Care for Exceptional Kids Act of 2019 to require a State to include in the State plan amendment a proposal for use of health information technology in providing health home services under this section and improving service delivery and coordination across the care continuum (including the use of wireless patient technology to improve coordination and management of care and patient adherence to recommendations made by their provider). • 2019 CONG US S 2897, introduced in Senate November 19, 2019, would adopt the Patient-Centered Outcomes Research Institute Reauthorization Act requiring the Agency for Healthcare Research and Quality, in consultation with relevant medical and clinical associations, to carry out activities to promote the timely implementation of research findings into clinical practices, including by assisting users of health information technology focused on clinical decision support in such implementation, in order to improve quality of care, health outcomes, and population health and to promote the ease of use of such implementation. RECENT STATE LEGISLATIVE ACTIVITY Arizona • 2019 AZ S.B. 1352 (NS), adopted June 7, 2019, amends AZ ST § 36-3201 (Definitions), AZ ST § 36-3291 (Health care directives registry; website), AZ ST § 36-3292 (Filing requirements), AZ ST § 36-3293 (Effect on nonregistration or revocation), AZ ST § 36-3294 (Registration), AZ ST § 36-3295 (Registry information; confidentiality; health care provider access; use and transfer of information; definition), AZ ST § 36-3296 (Liability; limitation), and AZ ST § 36-3297 (Health care directives registry fund) to establish the requirements for qualifying health information exchange organizations. The amendments are effective December 31, 2020. • 2019 AZ S.B. 1532 (NS), engrossed February 28, 2019, would require a patient-engagement mobile application system to can integrate with the mobile application user's electronic health record. Arkansas • 2019 AR H.B. 1072 (NS), introduced January 14, 2019, would adopt AR ST § 25-43-812 (State Health Alliance for Records Exchange -- Duties) providing that the State Health Alliance for Records Exchange to serve as the official health information exchange for the State of Arkansas and establishing the requirements for the Exchange. The bill would also create the Office of Health Information Technology and provide for its purpose and policy. • 2019 AR H.B. 1269 (NS), adopted April 1, 2019, amends AR ST § 17-92-503 (Generic substitutions) to require a pharmacist who dispenses a biological product to communicate to the prescriber the name and manufacturer of the drug within 5 business days following the dispensing of the biological product. The communication shall occur via an entry in an interoperable electronic medical records system, an electronic prescribing technology, a pharmacy benefit management system or a pharmacy record that can be accessed electronically by the prescriber. The amendment is effective August 5, 2019. California 2019 CA A.B. 1175 (NS), enrolled September 12, 2019, would add CA WEL & INST § 14197.06 would require each county mental health plan and managed care health plan to use either (1) an electronic health record system, (2) an electronic health record system or health information exchange that allows the electronic sharing of patient information between the contracted provider and one or more © 2020 Thomson Reuters. No claim to original U.S. Government Works. -24- county mental health plans' electronic health record system, (3) an electronic health record system or health information exchange that allows the electronic sharing of patient information between the contracted provider and one or more Medi-Cal managed care health plans' electronic health record systems, or (4) an electronic health record system or health information exchange that allows the electronic sharing of patient information between the contracted provider and one or more Medi-Cal managed care health plans and county mental health plans, and is interoperable with both entities. The bill was vetoed by Governor Newsom on October 13, 2019. Connecticut • 2019 CT H.B. 5908 (NS), introduced January 23, 2019, would amend CT ST § 17b-59a (Development of uniform information and technology standards and regulations. Health information technology plan. Electronic data standards. State-wide Health Information Exchange. Report) to require the executive director of the Office of Health Strategy to submit reports every quarter on the implementation of the state-wide health information technology plan and the State-wide Health Information Exchange to the joint standing committee of the General Assembly having cognizance of matters relating to public health. • 2019 CT H.B. 6138 (NS), introduced January 24, 2019, would require the Department of Public Health and the Insurance Department to study the optimization of the State-wide Health Information Exchange and the interoperability of electronic health record systems. District of Columbia 2019 DC L.B. 261 (NS), introduced April 23, 2019, would adopt DC CODE § 21-2221.14 (Study of electronic registry) providing that to facilitate the use of cloud-based technology for electronic Medical Orders for Scope of Treatment (“MOST”) Forms, the DOH shall issue a request for proposals from and contract with an electronic MOST service or multiple electronic MOST services to connect with health care providers at the point of care through the State-designated health information exchange. Florida • 2019 FL H.B. 697 (NS), introduced March 5, 2019, would amend FL ST § 638.637 (Care coordination) to provide that care coordination administrative tracking and medical recordkeeping services for members may not be required to use a certified electronic health record, meet any other requirements of the federal Health Information Technology for Economic and Clinical Health Act, enacted under the federal American Recovery and Reinvestment Act of 2009, Pub. L. No. 111-5, or meet certification requirements of the federal Centers for Medicare and Medicaid Services' Electronic Health Records Incentive Programs, including meaningful use requirements. • 2019 FL H.B. 1035 (NS), engrossed April 17, 2019, would amend FL ST § 394.4615 (Clinical records; confidentiality), FL ST § 397.501 (Rights of individuals), and FL ST § 456.057 (Ownership and control of patient records; report of copies of records to be furnished; disclosure of information) and adopt FL ST § 408.833 (Client access to medical records) to require, within 14 working days after receiving a written request from a client or client's legal representative, a provider shall furnish a true and correct copy of all records, including medical, care and treatment, and interdisciplinary records, as applicable, in the possession of the provider. A provider may furnish the requested records in paper form or, upon request, in an electronic format. A provider who maintains an electronic health record system shall furnish the requested records in the manner chosen by the requester which must include electronic format, access through a web-based patient portal, or submission through a patient's electronic personal health record. • 2019 FL S.B. 1544 (NS), introduced March 13, 2109, would adopt FL ST § 408.0522 (Florida Health Data Interoperability Act) to define terms, require certain certified electronic health record (EHR) vendors conducting business in this state to provide interoperability and data integration, require such EHR vendors to make a certain attestation to the agency, require the agency to quarterly publish a certain list of EHR vendors, require licensed health care entities and licensed providers to report EHR vendor information blocking, require the agency to impose a specified fine on an EHR vendor for certain noncompliance or information blocking, provide for the distribution of collected fines, require any integrating partner to meet security requirements for EHR vendors, provide immunity from liability for an EHR vendor under certain circumstances, prohibit discriminatory pricing, clarify that the qualifying entity is responsible for integration, and prohibit EHR vendors from taking certain actions; providing an effective date. Illinois • 2019 IL H.B. 477 (NS), introduced January 18, 2019, and 2019 IL S.B. 803 (NS), filed January 31, 2019, would amend IL ST CH 20 § 3860/1 (Short title) clarifying that the Act may be cited as the Illinois Health Information Exchange and Technology Act. • 2019 IL H.B. 3249 (NS), adopted July 12, 2019, amends IL ST CH 720 § 570/316 (Prescription Monitoring Program) updating the cross-reference to Public Act 100-564 that requires the Department to adopt rules requiring all EHR systems to interface with the Prescription Monitoring Program. The amendment is effective July 12, 2019. Iowa • 2019 IA H.F. 96 (NS), introduced January 24, 2019, would adopt IA ST § 135E.15 (Delivery of care -- participating health care providers) and IA ST § 135E.16 (Delivery of care -- care coordination) to prohibit participating health care providers and care © 2020 Thomson Reuters. No claim to original U.S. Government Works. -25- coordinators from using health information technology or clinical practice guidelines that limit the effective exercise of the professional judgment of a physician or registered nurse and providing exemptions that allow a physician or registered nurse to override health information technology and clinical practice guidelines. • 2019 IA H.S.B. 38 (NS), draft/request January 23, 2019, would amend IA ST § 155A.32 (Drug product selection -- restrictions) to require a pharmacist who dispenses a biological product to communicate to the prescriber the name and manufacturer of the drug within 5 business days following the dispensing of the biological product. The communication shall occur via an entry in an interoperable electronic medical records system, an electronic prescribing technology, a pharmacy benefit management system or a pharmacy record that can be accessed electronically by the prescriber. • 2017 IA S.S.B. 1134 (NS), draft/request February 11, 2019, would adopt IA ST § 155A.28A (Partial dispensing of prescription for opioid medication) to allow a pharmacist to notify the prescriber of the quantity of the opioid medication actually dispensed to do so by a notation on the patient's electronic health record. Kentucky 2019 KY S.B. 167 (NS), adopted March 25, 2019, amends KY ST § 194A.030 (Major organizational units of cabinet) to require the Office of Health Data and Analytics to provide leadership in the redesign of the health care delivery system using electronic information technology to improve patient care and reduce medical errors and duplicative services. The amendment is effective June 28, 2019. Maine • 2019 ME H.P. 480 (NS), adopted April 11, 2019, amends ME ST T. 32 § 13781 (Generic and therapeutically equivalent substitution) to require a pharmacist who dispenses a biological product to communicate to the prescriber the name and manufacturer of the drug within 5 business days following the dispensing of the biological product. The communication shall occur via an entry in an interoperable electronic medical records system, an electronic prescribing technology, a pharmacy benefit management system or a pharmacy record that can be accessed electronically by the prescriber. The bill would also provide that transmission of a facsimile through a proprietary payer portal or by use of an electronic form is not considered electronic transmission. The amendment is effective September 7, 2019.2019 ME S.P. 218 (NS), enrolled March 13, 2019, would amend ME ST T. 24-A § 4304 (Utilization review) requiring, beginning January 1, 2020, that if a health plan provides coverage for prescription drugs, the carrier must accept and respond to prior authorization requests in accordance with subsection 2 through a secure electronic transmission using standards adopted by a national council for prescription drug programs for electronic prescribing transactions. • 2019 ME H.P. 1163 (NS), introduced April 23, 2019, would adopt ME ST T. 24-A § 7510 (Maine Health Board) to require the Board to require that all electronic health records used by providers be fully interoperable with the open-source electronic health records system used by the United States Department of Veteran Affairs. Maryland • 2019 MD H.B. 1087 (NS), introduced February 8, 2019, and 2019 MD S.B. 871 (NS), introduced February 7, 2019, would adopt MD HEALTH GEN § 25-701 to prohibit a health care provider from using health information technology or clinical practice guidelines that limit the effective exercise of the professional judgment of physicians, registered nurses, or other health care providers operating within the scope of practice of the provider under the health occupations article. It would also establish the requirements for a physician, a registered nurse, or any other health care provider to override health information technology and clinical practice guidelines used by a health care provider. • 2019 MD H.B. 1217 (NS), introduced February 8, 2019, and 2019 MD S.B. 497 (NS), introduced February 4, 2019, would adopt MD HEALTH OCCUP § 12-513 to require a pharmacist, after prescribing and dispensing to a patient an aid for the cessation of the use of tobacco products, to record the prescribing and dispensing of the aid for the cessation of the use of tobacco products in any electronic health record maintained for the patient by the pharmacist. • 2019 MD S.B. 577 (NS), introduced February 4, 2019, would amend MD HEALTH OCCUP § 12-509 (Administration of prescribed self-administered drug) to require a pharmacist to record in any electronic or written health record on the patient maintained by the pharmacist the administering of the injectable medication or biological product and any pertinent details about the patient's condition after administering an injectable medication or a biological product. Minnesota • 2019 MN H.F. 400 (NS), enrolled May 22, 2019, would adopt MN ST § 144.348 (Voluntary Nonopiod Directive) to require the Commissioner to adopt rules establishing requirements related to the use of voluntary nonopioid health care directives. The procedures must include the directive in the individual's medical record or interoperable electronic health record. • 2019 MN H.F. 725 (NS), engrossed March 14, 2019, and 2019 MN S.F. 823 (NS), introduced February 4, 2019, would amend MN ST § 256B.0625 (Covered Services) to require the Commissioner to reimburse a federally qualified health center and rural health clinic for acquiring, implementing, and maintaining electronic health records and patient management systems. © 2020 Thomson Reuters. No claim to original U.S. Government Works. -26- • 2019 MN S.F. 751 (NS), engrossed March 20, 2019, would amend MN ST § 152.126 (Prescription monitoring program) to authorize the Board to modify its contract with its vendor to authorize that vendor to provide a service to prescribers and pharmacies that allows them to access prescription monitoring program data from within the electronic health record system or pharmacy software used by those prescribers and pharmacists. • 2019 MN H.F. 1200 (NS), introduced February 14, 2019, and 2019 MN S.F. 1125 (NS), 2019 MN S.F. 1126 (NS), 2019 MN S.F. 1128 (NS), and 2019 MN S.F. 1129 (NS), introduced February 11, 2018, would adopt MN ST § 62W.06 (Minnesota Health Board) to require the Board to require all electronic health records used by providers be fully interoperable with the open source electronic health records system used by the United States Veterans Administration. • 2019 MN H.F. 1250 (NS), introduced February 14, 2019, would adopt MN ST § 256B.0625 (Covered Services) to require the Commissioner to reimburse a certified community behavioral health clinic for acquiring, implementing, and maintaining electronic health records and patient management systems. • 2019 MN H.F. 1281 (NS), engrossed March 14, 2019, would amend MN ST § 256B.0757 (Coordinated care through a health home) to require a behavioral health home services provider to utilize an electronic health record. • 2019 MN S.F. 349 (NS), enrolled May 22, 2019, would amend MN ST § 62J.495 (Electronic health record technology) to eliminate the interoperable electronic health records system mandate. Mississippi • 2019 MS H.B. 803 (NS), introduced January 21, 2019, would reenact MS ST § 41-119 (Health Information Technology Act) to establish the Mississippi Health Information Technology Act and to extend the repealer date to July 1, 2022. • 2019 MS S.B. 2365 (NS), adopted March 21, 2019, amends MS ST § 73-21-117 (Dispensing generic equivalent drugs) to require a pharmacist who dispenses a biological product to communicate to the prescriber the name and manufacturer of the drug within 5 business days following the dispensing of the biological product. The communication shall occur via an entry in an interoperable electronic medical records system, an electronic prescribing technology, a pharmacy benefit management system or a pharmacy record that can be accessed electronically by the prescriber. The amendment is effective July 1, 2019. • 2019 MS S.B. 2427 (NS), amended/substituted February 13, 2019, would amend MS ST § 41-119-21 (Repealer) to extend the automatic repealer on the Health Information Technology Act to July 1, 2024. The bill would also readopt MS ST § 41-119-15 (Definitions) and MS ST § 41-119-19 (Legislative report; contents; deadline) without changes. Montana 2019 MT H.B. 669 (NS), adopted May 8, 2019, amends MT ST 53-6-125 (Physician services reimbursement) to reduce the amount of reimbursement received for physician services to fund the development of health information exchange. The amendment is effective July 1, 2019. New Jersey • 2018 NJ A.B. 5977 (NS), amended/substituted December 5, 2019, and 2019 NJ S.B. 4282 (NS), amended/substituted December 12, 2019, would establish a Regional Health Hub Program as a replacement to the Accountable Care Organization Demonstration Project. The bill would define “health information platform” as a Health Information Exchange (HIE) or other electronic platform that is used to run population-level analytics or exchange health information among various organizations and would establish requirements for the health information platform. • 2018 NJ A.B. 6061 (NS), introduced December 5, 2019, would require the governing body of each county in New Jersey to establish a public body entitled County Inmate Reentry Committee and require the Committee to establish a health information exchange for sharing county inmate health data between the county correctional facility and appropriate medical, mental health, social service, and other providers. New York • 2019 NY S.B. 1564 (NS), introduced January 15, 2019, would adopt NY EDUC § 6534 (Scope of tasks) to allow medical assistants to enter data into electronic health care records. • 2019 NY S.B. 4494 (NS), introduced March 13, 2109, would amend NY PUB HEALTH § 2168 (Statewide immunization information system) to allow a health care provider, registered professional nurse, or a pharmacist to report the administration of an immunization to a person 19 years of age or older to a regional health information organization or other health information exchange to satisfy the reporting requirements if such data is provided by the regional health information organization or health information exchange to the department or citywide immunization registry. Tennessee © 2020 Thomson Reuters. No claim to original U.S. Government Works. -27- 2019 TN H.B. 390 (NS) and 2019 TN S.B. 385 (NS), introduced February 4, 2019, would require the Department of health to study the feasibility of promoting and implementing medical interoperability in Tennessee. Texas • 2019 TX S.B. 813 (NS), introduced February 13, 2019, would adopt TX HEALTH & S § 481.07635 (Prescriptions of Opioids) would require the dispenser to note the partial filing of the prescription in the patient's electronic health record, if they have access to it, no th later than the 7 day after the date the opioid was dispensed. • 2019 TX H.B. 3304 (NS), adopted June 15, 2019, amends TX HEALTH & S § 182.003 (Expiration of Subchapter) and TX HEALTH & S § 182.052 (Expiration of Subchapter) and amend TX HEALTH & S § 182.101 (General Powers and Duties), TX HEALTH & S § 182.102 (Prohibited Acts), TX HEALTH & S § 182.103 (Privacy of Information), TX HEALTH & S § 182.104 (Security Compliance), TX HEALTH & S § 182.105 (Intellectual Property), TX HEALTH & S § 182.106 (Annual Report), TX HEALTH & S § 182.107 (Funding), and TX HEALTH & S § 182.101 (Standards for Electronic Sharing of Protected Health Information; Covered Entity Certification) to remove September 1, 2021 expiration date. The amendments are effective September 1, 2019. Utah 2019 UT S.B. 223 (NS), introduced February 27, 2091, would amend UT ST § 58-17b-605.5 (Interchangeable biological products) to remove requirement that a pharmacist who dispenses a biological product to communicate to the prescriber the name and manufacturer of the drug within 5 business days following the dispensing of the biological product. The bill would also remove the communication shall occur via an entry in an interoperable electronic medical records system, an electronic prescribing technology, a pharmacy benefit management system or a pharmacy record that can be accessed electronically by the prescriber. Vermont 2019 VT S.B. 80 (NS), introduced February 5, 2019, would amend VT ST T. 18 § 9351 (Health Information Technology Plan) would require the Health Information Technology Plan to provide individuals with the opportunity to opt out of having their health information shared with any identified health care provider, or with all health care providers, through the State's health information exchange, except in an emergency situation. Virginia • 2018 VA H.B. 2499 (NS), adopted March 5, 2019, amends VA ST § 53.1-40.10 (Exchange of medical and mental health information and records) requiring the Department to develop policies to improve the exchange of medical and mental health information and records of persons committed to a state correctional facility, including policies to improve access to electronic health records and electronic exchange of information and records for the provision of telemedicine and telepsychiatry. The amendment is effective July 1, 2019. • 2018 VA S.B. 1607 (NS), adopted March 21, 2019, amends VA ST § 38.2-3407.15:2 (Carrier contracts; required provisions regarding prior authorization) would require a carrier, when requiring a prescriber to provide supplemental information that is in the covered individual's health record or electronic health record, to identify the specific information required. The amendment is effective July 1, 2019. Wisconsin 2019 WI A.B. 437 (NS), introduced September 12, 2019, and 2019 WI S.B. 394 (NS), introduced September 16,2 019, would amend WI ST 97.67 (Recreational licenses and fees) clarifying that if the Department requires health services staff to make a record of medication administered or treatment provided to a camper or staff member, the department shall allow such records to be made and maintained electronically, if done in a system that documents each change to the health record and that does not allow previous changes to the health record to be edited or deleted. Washington • 2019 WA H.B. 1331 (NS), amended/substituted February 28, 2019, and 2019 WA S.B. 5380 (NS), amended/substituted February 8, 2019, would adopt a new section in WA ST 70.225 (Prescription Monitoring Program) would require the Department to collaborate with health professional and facility associations to expand integration of prescription monitoring program data into certified electronic health record technologies. • 2019 WA S.B. 5380 (NS), adopted May 8, 2019, adopts a new section in WA ST 70.225 (Prescription Monitoring Program) to require the Department to collaborate with health professional and facility associations to expand integration of prescription monitoring program data into certified electronic health record technologies. The new section is effective July 28, 2019. © 2020 Thomson Reuters. No claim to original U.S. Government Works. -28- • 2019 WA S.B. 5846 (NS), amended/substituted February 28, 2019, would provide that eligible grant activities to include support in becoming proficient in the use of information technology, including computer skills and use of electronic health record technology. West Virginia 2019 WV H.B. 2978 (NS), introduced February 11, 2019, would adopt WV ST § 9-10-4 (Requirements of the smart health card) to require the smart health card, used for the pilot program, to be capable of containing data that can be formatted for direct ingestion into any certified electronic health record operating system, at the point of care, allowing proper reconciliation of the data to be achieved and eliminating erroneous entry of the data into the disparate electronic health record operating system. RECENT STATE REGULATORY ACTIVITY District of Columbia • 2019 DC REG TEXT 514238 (NS), adopted November 14, 2018, amends 22-A DC ADC § 2510 (Individual and Family Support Services) adding that providing consumers with access to their EHR or other clinical information, and providing access to their family members and authorized representatives if the beneficiary provides written authorization to do so is an individual and family support service. The rule was amended via emergency and is effective February 1, 2019. • 2019 DC REG TEXT 511972 (NS), adopted July 10, 2019, adopts new Chapter 87 (District of Columbia Health Information Exchange) of Title 29 (Public Welfare) of the District of Columbia Municipal Regulations (“DCMR”). The regulations establish the District of Columbia Health Information Exchange (“DC HIE”), govern the registration and designation of HIE entities in the District of Columbia, and set out guidance to regulate the efficient and secure transmission of health information according to nationally recognized standards. The regulations are effective July 19, 2019. New sections include: 29 DC ADC § 8700 (General Provisions); 29 DC ADC § 8701 (The District of Columbia's Health Information Exchange (DC HIE)); 29 DC ADC § 8702 (HIE Registration Requirements and Application); 29 DC ADC § 8703 (Registered HIE Entity Protected Health Information Access, Use, and Disclosure Requirements); 29 DC ADC § 8704 (Auditing Requirements for Registered HIE Entities); 29 DC ADC § 8705 (Remedial Actions to Be Taken by a Registered HIE Entity); 29 DC ADC § 8706 (Notice of HIPAA Breach and Non-HIPAA Violation by A Registered HIE Entity); 29 DC ADC § 8707 (Registered HIE Entity Consumer Participation, Access, and Education Requirements); 29 DC ADC § 8708 (HIE Designation Requirements and Application); 29 DC ADC § 8709 (Designated HIE Entity Auditing Requirements); 29 DC ADC § 8710 (Designated HIE Entity Requirements to Promote Consumer Participation, Access, and Education); 29 DC ADC § 8711 (Oversight and Enforcement); 29 DC ADC § 8712 (Exemptions); 29 DC ADC § 8713 (Appeals and Administrative Review); and 29 DC ADC § 8799 (Definitions). Florida 2019 FL REG TEXT 526623 (NS), published November 26, 2019, adopts FL ADC 64K-1.008 (Electronic Health Recordkeeping System Integration) providing definitions and providing the process for approved entities to connect electronic health recordkeeping systems to the Prescription Drug Monitoring Program system. The new rule is effective December 11, 2019. Iowa 2019 IA REG TEXT 5153383 (NS), filed March 20, 2019, adopts IA ADC 657-37.17(124) (Integrated systems) to allow a practitioner or a health care system to integrate its electronic health record system or a pharmacy to integrate its automated data processing system with the PMP using an application programming interface. Also requires the practitioner, health care system, or pharmacy to notify the PMP administrator of any breach in the electronic health record system that may have included PMP information within 72 hours of making the determination that a breach occurred. The rule is effective May 15, 2019. Kentucky 2019 KY REG TEXT 513352 (NS), filed April 1, 2019, amend 900 KY ADC 9:010 (Kentucky Health Information Exchange participation) incorporating new Office and Division names established by EO 2018-325 for overseeing KHIE, updating the material that are incorporated by reference, and clarifying the KHIE capabilities. The amendment is effective March 13, 2019. Massachusetts • 2019 MA REG TEXT 455803 (NS), published August 9, 2019, amends 243 MA ADC 2.01 (Scope and Construction) removing the definition for “Electronic Medical Record (EMR)” and 243 MA ADC 2.07 (General Provisions Governing the Practice of Medicine) requiring physicians to take proactive measures to ensure that their executor or administrator has access to both paper and electronic medical records. The amendments are effective August 9, 2019. • 2019 MA REG TEXT 528585 (NS), filed October 4, 2019, amends 101 MA ADC 20 (Health Information Exchange) making technical changes. The regulations are effective October 4, 2019. © 2020 Thomson Reuters. No claim to original U.S. Government Works. -29- Missouri • 2019 MO REG TEXT 506383 (NS), filed February 15, 2019, renumbers 9 MO ADC 10-5.240 (Health Home) as 9 MO ADC 10-7.035 (Behavioral Health Healthcare Home)) removing the definition for “emergency medical record” and requirement that eligibility for Health Home services be identifiable through the state's comprehensive Medicaid electronic health record. The new rule is effective March 30, 2019. • 2019 MO REG TEXT 522626 (NS), filed March 20, 2019, adopts 9 MO ADC 30-6.010 (Certified Community Behavioral Health Clinics) establishing the requirements for Certified Community Behavioral Health Clinics (CCBHCs) to provide a comprehensive range of mental health and substance use disorder services to people with serious mental illness, serious emotional disturbances, long-term chronic addiction, mild or moderate mental illness and substance use disorders, and complex health conditions. CCBHCs provide services regardless of an individual's ability to pay, including those who are underserved, have low incomes, are insured, uninsured, Medicaid-eligible, and active duty U.S. Armed Forces or veterans. Also requires CCBHCs to maintain a health information technology (HIT) system that includes, but is not limited to, electronic health records of all individuals serviced and requires electronic health record systems to comply with state and federal regulations. The rule was adopted via emergency and is effective from July 1, 2019 to October 30, 2019. Montana 2019 MT REG TEXT 529515 (NS), certified to the Secretary of State October 8, 2019, amends MT ADC 37.86.4420 (Rural Health Clinics and Federally Qualified Health Centers, Alternative Payment Methodologies) providing that, beginning July 1, 2019, RHC or FQHC providers may elect to be reimbursed under an Alternative Payment Methodology (APM) equal to the per-visit cost as calculated utilizing the two most recently completed as-filed Medicare cost reports and/or other requested information. Examples include the Uniform Data Systems report, audited financial statements, and Electronic Health Record visit reconciliation. The amendment is effective October 19, 2019. New Jersey 2019 NJ REG TEXT 526006 (NS), filed October 17, 2019, adopts NJ ADC 13:44H-11.8 (Privacy and notice to patients) requiring licensees who communicate with patients by electronic communications other than telephone or facsimile to establish written privacy practices that are consistent with Federal standards under 45 CFR Parts 160 and 164, as amended and supplemented, which are incorporated herein by reference, relating to privacy of individually identifiable health information. Transmissions, including patient e-mail, prescriptions, and laboratory results must be password protected, encrypted electronic prescriptions, or protected through substantially equivalent authentication techniques. The new rules is effective November 18, 2019. Ohio • 2018 OH REG TEXT 506725 (NS), filed December 31, 2018, adopts OH ADC 5160-1-73 (Behavioral health care coordination) requiring qualified behavioral health entities to, at the time of application, attest that it implements and actively uses an electronic health record. The new rule is effective December 21, 2019. • 2019 OH REG TEXT 526042 (NS), filed October 21, 2019, amends OH ADC 4729:1-6-03 (Standards for managing drug therapy) requiring a hospital, clinic, or other healthcare facility that utilizes managing pharmacists for the purposes of authorizing prescriptions to utilize electronic health records system that provide managing pharmacists and consulting physicians with real-time access to the patient's complete medical record maintained by the consulting physician, including patient lab results and prescriber and pharmacist notes and requiring the electronic health records system to have the capability to allow communication between managing pharmacists and consulting physicians. The amendment is effective November 15, 2019. • 2019 OH REG TEXT 531315 (NS), filed October 21, 2019, amends OH ADC 5122-25-03 (Certification procedure for non-deemed status) and OH ADC 5122-25-04 (Certification procedure for deemed status) requiring the provider to demonstrate clinical readiness to meet the documentation requirements of Chapter 5122-27 by demonstrating it has acquired an electronic health record system that supports documentation to meet these requirements and/or providing samples of paper forms. The amendment is effective October 31, 2019. • 2019 OH REG TEXT 531406 (NS), filed October 30, 2019, replaces OH ADC 5160-57-01 (Medicaid provider incentive program (MPIP): program eligibility requirements) with OH ADC 5160-57-01 (Medicaid provider incentive program (MPIP): program eligibility requirements and payment) updating Medicaid incentive payment criteria for hospitals and professionals using electronic health records. The new rule is effective November 9, 2019. Oklahoma • 2019 OK REG TEXT 512276 (NS), adopted May 28, 2019, amends OK ADC 317-30-3-28 (Electronic Health Records Incentive Program) outlining how to qualify for the Electronic Health Records (EHR) Incentive Program by changing the timeframe in which hospitals must meet SoonerCare patient volume criteria for a continuous 90-day period from the preceding calendar year to the © 2020 Thomson Reuters. No claim to original U.S. Government Works. -30- preceding federal fiscal year. The revisions also add a 30-day time limit for eligible providers to submit documentation or make corrections to avoid denial of their EHR attestation. The amendment is effective September 1, 2019. • 2019 OK REG TEXT 530314 (ND), approved, via emergency, July 1, 2019, adopts OK ADC 317:30-5-265 (Eligible providers) requiring qualifying providers to actively use an Office of National Coordinator (ONC) certified Electronic Health Record (HER) as demonstrated on the ONC Certified Health IT Product List. The new rule is effective July 1, 2019. Texas 2019 TX REG TEXT 524116 (NS), published August 30, 2019, adopts 16 TX ADC § 130.58 (Standards for Prescribing Controlled Substances and Dangerous Drugs) providing that if a podiatrist uses an electronic medical records management system (health information exchange) that integrates a patient's Schedule II, III, IV, and V prescription drug history data from the Texas State Board of Pharmacy's - Texas Prescription Monitoring Program (PMP) database, a review of the electronic medical records management system (health information exchange) with the integrated data shall be deemed compliant with the review of the Texas State Board of Pharmacy's - Texas Prescription Monitoring Program (PMP) database as required under §481.0764(a) of the Texas Health and Safety Code and these rules. The rule is effective September 1, 2019. Utah 2019 UT REG TEXT 509866 (NS), published November 15, 2018, amends UT ADC R156-37f (Controlled Substance Database Act Rule) providing the definition for “EDS,” “EHR,” and “HIE.” The amendment is effective December 27, 2018. West Virginia 2019 WV REG TEXT 526855 (NS), filed via emergency November 22, 2019, amends previous emergency rules WV ADC § 69-14-1 (General), WV ADC § 69-14-2 (Definitions), and WV ADC § 69-14-3 (Overdose Reporting) requiring health care providers, medical examiners, law enforcement agencies, including state, county, and local police departments, emergency response providers, and hospital emergency rooms to report all overdoses to the ODCP within 72 hours after the provider responds to the incident and via an appropriate information technology platform. Defining “information technology platform.” The emergency amendment is effective January 1, 2020. IV. Telehealth/Telemedicine Related to, and utilizing, health IT, telehealth and telemedicine offer ways for providing healthcare over long distances and have the potential to benefit individuals living in remote and medically underserved areas. IMS Research is predicting that the use of telehealth [FN133] will increase dramatically over the next five years. According to their analysis over 1.3 million patients will be receiving telehealth services in 2017. The researchers believe that telehealth will reduce the rate of patient readmissions and in-home care visits. IMS estimates that the revenue from telehealth will increase from $174.5 million in 2012 to $707.9 million in 2017. In May 2015 the American Telemedicine Association did a gap analysis of the physician standards for telemedicine across the United [FN134] States. The analysis graded the states on laws and regulations concerning (i) physician-patient encounter, (ii) telepresenter, (iii) informed consent, and licensure and out-of-state practice. It found that 22 states received high composite scores indicating a supportive environment for telemedicine, 26 and the District of Columbia received average composite scores indicating some room for improvement, and two states, Texas and Alabama, received low scores indicating numerous barriers to the practice of telemedicine. Both states received failing scores for physician-patient encounter and informed consent. However, a 2013 study published in the British Medical Journal found some limitation sot the use of telehealth. The study discussed the effects of a home-based telehealth system on health-related quality of life, anxiety, and depressive symptoms over a 12-month period [FN135] in patients with long-term conditions. The participants all suffered from chronic obstructive pulmonary disease, diabetes, or heart failure. The researchers concluded that the telehealth system was not effective compared with usual care in improving the quality of life or the psychological outcomes for the patients. The researchers believe that while telehealth provides the opportunity for earlier intervention, which may reduce the frequency with which hospital-based care, is required, it should not be introduced with the aim of improving quality of life or psychological outcomes. Seeing the potential for telehealth to help those in areas where there is a shortage of physicians, the Federal government is actively pursuing telehealth. Recently, teams at the Veterans Administration's National Center for Post-Traumatic Stress Disorder (PTSD) and the Department of Defense's National Center for Telehealth and Technology have collaborated to create a mobile app to educate about PTSD, information about professional care, a self-assessment for PTSD, opportunities to find support, and tools that can help [FN136] with managing the stresses of daily life with PTSD. Then, in November 2012, the Veterans Administration (VA) announced that following a two-year pilot program with the University of Kansas it is expanding the program to cover the entire state of Kansas. [FN137] VA officials believe this program will make it easier for veterans to receive mental health services and could be a model for future programs across the country. During the pilot program, the University of Kansas and the VA partnered at a Garden City clinic equipped with a telemedicine site that allowed veterans from western Kansas who have mental health problems to connect with VA doctors in © 2020 Thomson Reuters. No claim to original U.S. Government Works. -31- Wichita. The program will now expand to the 80 telemedicine sites the University of Kansas has around the state. Each site is equipped with high-definition televisions and other equipment that allow patients and their medical providers in relatively remote hospitals to interact with doctors and other specialists at the University Medical Center. The VA intends to use that system to connect veterans with VA providers in Wichita and elsewhere. However, officials said the expansion could be slowed while privacy protocols and other details still are negotiated with officials at each of the telemedicine locations. Each of the telemedicine sites has already agreed to be equipped for following the protocols aimed at protecting patient information. The system will use a secure Internet connection to link the sites with providers elsewhere. Using the Internet will enable VA patient information to be displayed to medical staff in remote locations without permitting them access to the VA's secure patient database. [FN138] According to a 2013 study published by Critical Care Medicine, rural emergency room doctors are benefiting from telemedicine consultations when treating seriously ill or injured young patients. Telehealth enables these doctors to gain access to specialized care [FN139] experts. Telehealth is proving particularly helpful in the treatment of young patients as rural ER doctors typically see very few young patients during a year. The researchers looked at records for 320 patients, including 58 who had telemedicine consultations, 63 who had phone consultations and 199 who had no consultation. The average quality of care rating on a scale of 1 to 7 was 5.76 for patients who received telemedicine consults, 5.38 for patients who received phone consultations, and 5.26 for those who received no consultation. One example of the successful use of telemedicine can be seen in a program using it to improve asthma care for students. Since 2006 the University of Rochester Medical Center has been working with the Rochester City School District to try to improve asthma care for [FN140] the upper New York state's district's students. Also for almost dozen years, University of Rochester Medical Center has been using telemedicine to allow offsite doctors to make quick diagnoses of sick students in city schools. A recent $3.6 Million grant from the National Institutes of Health is allowing the Medical Center to bring those two programs together. In doing so, researchers hope to reduce both student absences and preventable visits to doctor's offices and emergency rooms. The researchers also intend to create a telemedicine-centric asthma treatment program that will be able to be replicated in other locations. As part of the program, with the start of this school year, students with asthma began receiving evaluations in school nurses' offices. After these evaluations the students will be given help in taking their daily asthma medications while in school and be given regular reminders to take their medications at home. After the first six weeks in the program, the students will receive a follow-up visit from a telehealth assistant. This assistant will check their breathing again and send their readings to offsite doctors, who will determine if the medications are working. The researchers are hoping that the five-year program will lower student absences. According to the Centers for Disease Control, for students, especially those from lower-income areas, asthma is a leading cause of school absences. Another successful of use of telemedicine in California's “Virtual Dental Home Demonstration Project.” This project is a $2.5 million [FN141] experiment to provide both dental care and education about dental care to underserved populations. Currently it exists in 50 locations across the state and has 15 specially trained hygienists and dental assistants who work via teledentistry with dentists. These hygienists and dental assistants have all completed a special educational program. They travel to the different locations and, with special permission from the state and perform basic procedures by working online with dentists. It is estimated that for every dollar [FN142] spent on preventative services, the teledentistry program will save $50 on more expensive procedures. A bill pending in the Senate, after passing the Assembly, would expand the Virtual Dental Home approach statewide. The bill would authorize a registered dental assistant who has completed the specified educational program to determine which radiographs to place protective restorations as specified. The bill would also eliminate the requirement for face-to-face contact between a health care provider and a patient under the Medi-Cal program for teledentistry by store and forward. In May 2015, the grocery store chain Wegman's announced that it was testing a new telemedicine service in the pharmacy of one of [FN143] their stores in upstate New York. The service allows customers to make video visits with doctors by using their smartphones. There is also a kiosk with a tablet for customers that do not have smartphones. A video visit with a primary care physician or a pediatrician costs $40, and the first visit is free. The service is to be used by customers with problems like the flu, rashes, sore throats and urinary tract infections. A Wegman's wellness clinical services manager emphasized that it would not be appropriate for chest pains or emergency situations. The service is offered by Doctor on Demand, a San Francisco based company. UnitedHealthcare has included Doctor on Demand in its network as one of its first virtual visit providers. CVS Health announced in August 2015 that it is working with three major telehealth providers, American Well, Doctor On Demand and Teladoc, to find the best ways direct-to-consumer telehealth providers, retail pharmacy and retail clinic providers can collaborate [FN144] to improve patient care. This initiative represents an expansion of CVS Health's existing telehealth approach. Currently CVS provides telehealth services in connection with its over 900 MinuteClinics. Data on MinuteClinic recently published in the Journal of General Internal Medicine showed that 95% of patients were highly satisfied with the quality of care they received, the ease with which telehealth technology was integrated into the visit, and the timeliness and convenience of their care. CVS Health is piloting several different telehealth opportunities, including making telehealth physician care accessible through CVS Health digital properties. CVS Health will also explore enabling MinuteClinic providers to consult with telehealth physicians to expand the scope of care offered at MinuteClinic. In addition, MinuteClinic will continue to provide telehealth care to patients in CVS retail stores and will explore serving as a site for in-person exams to facilitate telehealth medical visits. Andrew Sussman, M.D., executive vice president/associate chief medical officer, CVS Health and president, MinuteClinic, said: “With the increased demand for patient care anticipated in future years © 2020 Thomson Reuters. No claim to original U.S. Government Works. -32- as a result of the expansion of coverage through the Affordable Care Act, the primary care physician shortage, aging of the population and epidemic of chronic disease, telehealth gives us the opportunity to offer high quality care to an expanded group of patients in a variety of convenient and cost-effective locations, The benefits of telemedicine can also be seen in a study in the February 2014 issue of Health Affairs, which looked at the possibility [FN145] that not having a physician present at nursing homes during off hours might contribute to inappropriate hospitalizations. The researchers did a controlled study of eleven nursing homes. They found that switching from on-call to telemedicine physician coverage during off hours could reduce hospitalizations and therefore generate cost savings to Medicare more than the facility's investment in the service. However, the results showed that such savings were evident only when nursing homes used the telemedicine service to a greater extent. The researchers believe that telemedicine service providers and nursing home leaders need to take additional steps to encourage buy-in to the use of telemedicine at nursing homes. Currently hospitalizations of nursing home residents are frequent and result in more than a billion dollars in Medicare expenditures annually. In July 2014 the American Medical Association released its Guiding Principles for Telemedicine and many telemedicine providers are [FN146] expressing support for them. The providers are pleased that the AMA believes that telemedicine can strengthen the physician- patient relationship and that it improves access to health care services. The one guideline that providers tend to disagree with is AMA's belief that a physician should be licensed in each state in which he or she provides services via telemedicine. There are currently two proposals being raised to address that concern. One is reciprocity, where a state recognizes the license of another state for telemedicine purposes, and the other, which originated with the Federation of State Medical Boards, involves the creation of a simplified path to get an out-of-state license to practice via telemedicine. The guiding principles the AMA adopted provide that telemedicine services should be covered and paid where: • a valid patient-physician relationship is established prior to the telemedicine services being provided; • physicians abide by the state licensure and scope of practice laws of the state where the patients are located; • the standards and scope of the services provided are consistent with those for in person patient services; • the services are delivered in a manner that is consistent with the laws regarding patient privacy and the security of their records and in a transparent manner (including advance knowledge of cost sharing responsibilities and any limitations on drugs that can be prescribed); • the patient history is collected, each visit is documented, and a summary of the visit is provided to the patient; and [FN147] • the telemedicine services include coordination with the patient's medical home and/or any treating physicians. [FN148] A November 2014 study by AMN Healthcare looked at trends in hiring clinicians trained in telehealth. Of the 323 respondents, 24% said that they are either currently recruiting or planning to recruit telehealth-trained physicians. In addition, 19% said they are currently recruiting or planning to recruit telehealth nurse practitioners and physician assistants who are trained in telehealth and 21% are similarly for telehealth-trained registered nurses. The survey also found that 17% of the respondents are currently providing telehealth training to physicians, 12% to nurse practitioners/physician assistants and 16% to registered nurses. [FN149] Another November 2014 study, this one by AMN Healthcare, looked at trends in hiring clinicians trained in telehealth. Of the 323 respondents, 24% said that they are either currently recruiting or planning to recruit telehealth-trained physicians. In addition, 19% said they are currently recruiting or planning to recruit telehealth nurse practitioners and physician assistants who are trained in telehealth and 21% are similarly for telehealth-trained registered nurses. The survey also found that 17% of the respondents are currently providing telehealth training to physicians, 12% to nurse practitioners/physician assistants and 16% to registered nurses. The private sector is active in improving the tools that are used in providing telehealth. TeleHealth Services, a leading provider of hospital televisions and interactive patient engagement solutions, in October 2012 announced the launch of the new line of UL ® [FN150] approved and ENERGY STAR 5.3 certified Samsung LED healthcare televisions. The new hospital televisions provide a full- array LED backlight, a more compact cabinet, industry leading energy savings, and enhanced multi-set management capabilities. The new healthcare LED televisions combine the traditional hospital-specific features with new enhancements that promote patient satisfaction, optimize operational efficiency, and improve sustainability. “The patient experience is a growing opportunity for hospitals and patients that are expecting more from healthcare facilities and increasingly want access to modern conveniences in the inpatient setting. We are excited to evolve our partnership with Samsung to deliver LED hospital televisions to enhance patient satisfaction efforts,” said George Fleming, president and CEO of TeleHealth Services. Among the hospital specific features, the healthcare televisions include are: • Pro:Idiom decoding, allowing hospitals to provide patients with a wide variety of high-definition channels; • UL Listing to meet the more requirements for the use in a hospital environment; • universal pillow speaker interface for cross compatibility between multiple pillow speaker brands and pin sets; • autosensing side inputs to allow patients access to external content sources; and © 2020 Thomson Reuters. No claim to original U.S. Government Works. -33- • four energy saving modes that can reduce power consumption by up to 70 percent. On September 1, 2013, HHS Secretary Sebelius announced that HHS was awarding nearly $5.3 million grants that will help to expand [FN151] the rural HIT workforce and the use of telehealth to improve mental health services for veterans in rural areas. Close to $4.4 million will go to rural organizations in 15 states to recruit and train current health care staff, local unemployed workers, rural veterans, and other potential students to meet the technology needs of rural hospitals and clinics. The grants will enable community colleges to work with local rural health care providers to develop rural-focused HIT training programs. Students selected for these programs will gain EHR technology certification, apprenticeship training and the opportunity for employment in rural hospitals and clinics. In addition, Maine, Montana, and Alaska will each receive $300,000 to enhance crisis intervention services through telehealth technologies. Bringham and Women's Hospital in Massachusetts is testing video consults. In Massachusetts, it is still being decided who should foot the bill for virtual medical appointments because hospitals and insurers don't agree. The hospitals want, and lawmakers are considering requiring private insurers to cover the cost of virtual medical appointments if the appointment would be covered if it had been in-person. So far, Bringham and Women's Hospital is not being reimbursed for these video consults. Doctors are currently seeing up to 10 patients per week and are increasing it to 100 patients per week soon. Currently the video consults are only offered to patients who have met their doctor in person and need a follow-up appointment that does not require a physical exam. They have found that patients are more [FN152] likely to attend a video consult than the in-person appointment. Dr. John Radford opened 247 Online Care for individuals in New York. 247 Online Care works in conjunction with the Five Star Urgent Care clinic which provides primary care at the convenience of urgent care but at a reduced cost. 247 Online Care uses the same doctors, physician assistants, and nurse practitioners as Five Star Urgent Care. Patients use the 247 Online Care app to talk to a medical professional about their issues. The call comes into a central portal and then gets assigned to whoever has time. The professional will then sit down at a computer with a webcam to interact with a patient and there is no limit to the time that the visit takes. 247 Online Care has a unique way to charge for these visits. The company charges $49 for a single visit or patients can get unlimited access for $249 a year. This is a more cost-effective way for patients to obtain care since it costs roughly $130 to $195 for self-pay for a [FN153] basic visit to the Five Star Urgent Care clinic. Bon Secours Richmond Health System launched its new app Bon Secours 24/7. The app gives the community access to the health system's medical group providers 24 hours a day, 365 days a year. The app allows you to access their providers “via mobile phone, [FN154] electronic device, or computer….” Visits on the app are $49 and may be covered by some health insurance plans. The app features live video visits with secure messaging and easy access to providers and treats conditions like allergies, colds, flu, sinus infections, pink eye, or urinary tract infections. Accenture estimates that funding for on-demand healthcare companies will reach $1 billion in 2017. On-demand healthcare companies include providing location-based services with near real-time and 24/7 options. On-demand healthcare make physicians exceedingly [FN155] accessible to patients while reducing costs. Investments are increasing because 29 states have created telehealth parity laws. Doctor on Demand received accreditation from the American Telemedicine Association for online patient consultations. Doctor on Demand offers 24/7 direct to consumer healthcare services through its internet-based patient portal. Doctors on Demand offers consumers primary care, psychology, and lactation consulting. American Telemedicine Association Accreditation Program for Online Patient Consultations establishes standard criteria regarding the security of patient information, transparency in pricing and operations, [FN156] qualifications and licensing of providers and clinical practices and guidelines. Analogic Corporation launched an ultrasound-based telehealth initiative. Analogic Corporation acquired Oncura Partners Diagnostics, LLC, a provider of remote, real-time ultrasound imaging and teleconsulting services in the veterinary market. Analogic is using the [FN157] Oncura technology to expand ultrasound telehealth into the human healthcare market. Third Eye Health, a Chicago startup, is working with nursing homes to keep patients out of hospitals by using Google Glass, texts, and live video chats. Third Eye Health builds secure mobile platform for sharing information. The hope is that patients will be able to remotely interact with a nurse instead of making unnecessary trips to the hospital. Third Eye Health partners with the nursing homes to provide the technology but the facilities are responsible for billing Medicare and other insures for reimbursement for services provided [FN158] through their technology. According to a study published in JAMA Internal Medicine, patients who set up virtual visits with physicians are having varied experiences in terms of quality of care. The study found that the diagnosis was correct in 76.5% of cases, the diagnosis was wrong in 14.9% of cases, and no diagnosis was given in 8.7% of cases. The cases also varied in terms of whether the physicians asked all the recommended history questions and carried out all relevant aspects of physical examination. The study also found that there was [FN159] greater variation in consultations for viral pharyngitis and acute rhinosinusitis than other conditions. Four states, New York, Hawaii, Oregon, and Washington, will attempt to make abortion more accessible by allowing women to obtain abortion-inducing drugs through the mail. Women in their first 9 weeks of pregnancy can receive the pills by mail if they live in the same state as the clinic and undergo an ultrasounds and blood test to confirm the pregnancy and rule out risks. A physician will then use [FN160] video conferencing to counsel the women on how to take the pills. © 2020 Thomson Reuters. No claim to original U.S. Government Works. -34- Cigna expanded access and choice to affordable telehealth services for millions of individuals enrolled in Cigna administered medical and behavioral health plans for 2017.Cigna added AMWELL to its telehealth coverage. AMWELL, along with MDLIVE, operate a national network of board-certified physicians that can treat minor medical conditions. Cigna is also planning to add telehealth video [FN161] consultations for behavioral health professionals. RECENT FEDERAL LEGISLATIVE ACTIVITY • 2019 CONG US HR 4243, introduced September 9, 2019, would amend 42 USCA § 254c-14 (Telehealth network and telehealth resource centers grant programs) to include providers and entities involved in maternal care to the requirements for telehealth network and telehealth resource centers grant programs. • 2019 CONG US HR 4900, introduced in House October 29, 2019, would establish a National Telehealth Program to issue guidance on uniform best practices for the provision of telehealth across State lines. • 2019 CONG US HR 5190, introduced in House November 20, 2019, to adopt the Specialty Treatment to Access and Referrals Act of 2019 (STAR Act) allowing the Secretary may award grants to eligible health center controlled networks, health centers, and rural health clinics described in subsection (e) to conduct pilot projects to implement and test the effectiveness of E-Consult services and related telehealth services furnished at such networks, centers, and clinics. • 2019 CONG US HR 5201, introduced in House November 20, 2019, would amend 42 USCA § 1395m (Special payment rules for particular items and services) to define “treatment of mental health services furnished through telehealth.” • 2019 CONG US HR 5257, introduced in House November 22, 2019, would establish the Telehealth Expansion Act of 2019 to require the Commission to establish the Expanding Telehealth Program to (1) support connected care services for low-income individuals, individuals residing in rural areas, and veterans through telehealth services and health care providers, (2) defray the costs of internet services to health care providers to provide connected care services to low-income individuals, individuals residing in rural areas, and veterans with conditions such as behavioral health conditions, opioid dependency, chronic health conditions (such as diabetes, kidney disease, heart disease, stroke recovery, and traumatic brain injury), mental health conditions, cancer, and high-risk pregnancies, (3) promote innovative telehealth services technologies by empowering health care providers to connect directly with patients, and (4) gather data and information on medical conditions, transitions of care services, telehealth services, and health care provider resources or needs that may be considered in potential reforms needed to improve the efficiency or effectiveness of the Program. • 2017 CONG US HR 7391, introduced in House December 21, 2018, would amend 42 USCA § 1395m (Special payment rules for particular items and services) to add a rural emergency access center to the list of locations that are considered an “originating site.” • 2019 CONG US S 2741, introduced in Senate October 30, 2019, would amend title XVIII of the Social Security Act to expand access to telehealth services. RECENT FEDERAL REGULATORY ACTIVITY • 83 FR 67816-01, filed December 31, 2018, adopts 42 CFR § 425.613 (Telehealth services) providing that payment is available for covered telehealth services by a physician or other practitioner billing through the TIN of ACO participant in an applicable ACO. The new rule is effective February 14, 2019. • 84 FR 60648-01, filed November 8, 2019, amends 42 CFR § 410.38 (Durable medical equipment: Scope and conditions) to define “face-to-face encounter” as an in-person or telehealth encounter between the treating practitioner and the beneficiary and to add requirements for a telehealth encounter. The amendment is effective January 1, 2020. RECENT STATE LEGISLATIVE ACTIVITY Alaska 2019 AK H.B. 29 (NS), introduced February 20, 2019, would amend AK ST § 21.42.422 (Coverage for telehealth and mental health benefits) to change the section title to “Coverage for telehealth,” to clarify that an insurer must provide coverage for benefits provided through telehealth, and to define “telehealth”. Arizona • 2019 AZ S.B. 1089 (NS), adopted April 18, 2019, amends AZ ST § 20-1057.13 (Telemedicine; coverage of health care services; definitions), AZ ST § 20-1376.05 (Telemedicine; coverage of health care services; definitions), and AZ ST § 20-1406.05 (Telemedicine; coverage of health care services; definitions) to prohibit insurers from restricting or denying coverage of telemedicine based solely on the communication technology, network or application used to deliver telemedicine services. The amendments are effective December 31, 2020. • 2019 AZ S.B. 1122 (NS), introduced January 22, 2019, would repeal AZ ST § 36-3604 (Use of telemedicine for abortion prohibited; penalty; definition). © 2020 Thomson Reuters. No claim to original U.S. Government Works. -35- Arkansas • 2019 AR H.B. 1220 (NS), engrossed March 14, 2019, would amend AR ST § 17-80-402 (Definitions) update the definition of “professional relationship” to include relationships established by telemedicine. • 2019 AR H.B. 1471 (NS), adopted April 1, 2019, adopts AR ST § 20-47-1005 (Statewide mental health services) develop and implement strategies for ensuring access to culturally affirmative mental health services and linguistically appropriate mental health services by clients in geographic areas where there is a lack or shortage of certified mental health professionals, including without limitation the authorization of treatment through telemedicine or other remote technology that allows a client to be provided culturally affirmative mental health services and linguistically appropriate mental health services from certified mental health professionals. The bill is effective August 5, 2019. • 2019 AR H.B. 1727 (NS), engrossed March 13, 2019, would adopt AR ST § 23-79-1902 (Intraoperative neurophysiological monitoring -- Coverage required) to require a health benefit plan to provide overage and reimbursement for intraoperative neurophysiological monitoring provided through telemedicine under the Telemedicine Act, AR ST § 17-80-401 et seq., per hour, and on the same basis as the health benefit plan provides coverage and reimbursement for health services provided in person. • 2019 AR H.B. 1883 (NS), adopted April 11, 2019, amends AR ST § 17-95-107 (Providing information to credentialing organizations) to provide the definition for “telemedicine physician” and adopt AR ST § 17-95-107 (Providing information to credentialing organizations) to provide the credentialing requirements for telemedicine physicians. The amendment is effective August 5, 2019. California • 2019 CA A.B. 690 (NS), adopted October 9, 2019, amends CA BUS & PROF § 4132 (Pharmacy technicians; qualifications; duties; prohibited actions; supervision) updating the requirements for a registered pharmacy technician to work at a remote dispensing site pharmacy and perform specific tasks under the supervision of a pharmacist at a supervising pharmacy using a telepharmacy system. The amendment is effective October 9, 2019. • 2019 CA A.B. 744 (NS), adopted October 13, 2019, adopts CA HEALTH & S § 1374.14 and CA INS § 10123.855 to require a contract issued, amended, or renewed on or after January 1, 2021, between a health care service plan and a health care provider for the provision of health care services to an enrollee or subscriber, or a contract issued, amended, or renewed on or after January 1, 2020, 2021, between a health insurer and a health care provider for an alternative rate of payment to specify that the health care service plan or health insurer reimburse a health care provider for the diagnosis, consultation, or treatment of an enrollee, subscriber, insured, or policyholder appropriately delivered through telehealth services on the same basis and to the same extent that the health care service plan or health insurer is responsible for reimbursement for the same service through in-person diagnosis, consultation, or treatment. The bill would also authorize a health care service plan or health insurer to offer a contract or policy containing a copayment or coinsurance requirement for a health care service delivered through telehealth services, subject to specified limitations. The bill would require telehealth services covered under a health care service plan contract or policy or health insurance issued, amended, or renewed on or after January 1, 2021, to be subject to the same deductible and annual or lifetime dollar maximum requirements for equivalent services that are not provided through telehealth. These amendments are effective January 1, 2020. • 2019 CA A.B. 798 (NS), amended/substituted June 13, 2019, would adopt CA HEALTH & S § 131120 to establish a pilot program to include a provider-to-provider or patient-to-provider consultation program and utilize telehealth or e-consult technologies. • 2019 CA A.B. 1264 (NS), adopted October 11, 2019, amends CA BUS & PROF § 2242 (Prescribing, dispensing or furnishing dangerous drugs without prior examination and medical indication; unprofessional conduct; exceptions) clarify that an appropriate prior examination does not require a synchronous interaction between the patient and the licensee and can be achieved through the use of telehealth, as specified, provided that the licensee complies with the appropriate standard of care. The amendment if effective October 11, 2019. • 2019 CA A.B. 1494 (NS), adopted October 12, 2019, adopts CA WEL & INST § 14132.724 to require the Department, on or before March 1, 2020, to establish a stakeholder process to assist the department in developing guidance for those entities to facilitate reimbursement for the above-described services, and, on or before July 1, 2020, to issue the specified guidance, including certain instructions on the submission of claims for telehealth or telephonic services. The bill is effective January 1, 2020. • 2019 CA A.B. 1519 (NS), adopted October 13, 2019, amends CA BUS & PROF § 1611.3 (Compliance with provisions requiring licentiates to give notice of licensing to clients or customers; notification and contents of notice) to require notices to be accessible electronically for patients receiving dental services through telehealth and CA BUS & PROF § 2290.5 (Telehealth; definitions; consent; in-person health care delivery services; violations; scope of practice; confidentiality; exceptions; privileges and credentials of telehealth service providers) to provide that all laws and regulations governing professional responsibility, unprofessional conduct, and standards of practice that apply to a health care provider under the health care provider's license must apply to that health care provider while providing telehealth services. The bill would also add CA BUS & PROF § 1683.1 to require any individual, partnership, corporation, or other entity that provides a service authorized under this chapter through teledentistry shall make available the name and state license number of any dentist who will be involved in the provision of services to a patient at any time prior to or during the rendering of services. The amendment is effective January 1, 2020. © 2020 Thomson Reuters. No claim to original U.S. Government Works. -36- • 2019 CA A.B. 1676 (NS), amended/substituted April 22, 2019, would require health care service plans and health insurers, by January 1, 2021, to establish a telehealth consultation program that provides providers who treat children and pregnant and postpartum persons with access to a psychiatrist in order to more quickly diagnose and treat children and pregnant and postpartum persons suffering from mental illness. The bill would require the consultation to be done by telephone or telehealth video and would authorize the consultation to include guidance on providing triage services and referrals to evidence-based treatment options, including psychotherapy. The bill would require health care service plans and insurers to communicate information relating to the telehealth program at least twice a year in writing. • 2019 CA S.B. 24 (NS), adopted October 11, 2019, would require public university student health centers to offer abortion by medication techniques onsite and allows the services to be provided through telehealth services. The amendment is effective January 1, 2020. Colorado • 2019 CO S.B. 10 (NS), adopted May 10, 2019, amends CO ST § 22-96-103 (Behavioral health care professional matching grant program - created – rules) providing that the education provider may use the money to provide direct services or consultation by a school health professional through telehealth technology. The amendment is necessary for the immediate preservation of the public peace, health, and safety and is effective immediately. • 2019 CO S.B. 73 (NS), adopted May 16, 2019, adopts CO ST § 25-51-102 (Statewide system for advance directives created – rules) allowing a qualified provider to meet with the individual or authorized surrogate decision-maker in person or through telehealth. The amendment is effective August 2, 2019. • 2019 CO S.B. 91 (NS), adopted April 23, 2019, adopts CO ST § 16-2.5-403 (Peace officer-involved shooting or fatal use of force policy) to allow for a post-incident intervention with a qualified mental health professional to be conducted through telehealth. The bill is effective August 2, 2019. Connecticut • 2019 CT H.B. 5620 (NS), introduced January 18, 2019, would expand Medicaid coverage for telehealth services to home health telemonitoring. • 2019 CT H.B. 5756 (NS), introduced January 22, 2019, would amend CT ST § 19a-906 (Definitions) to allow telehealth providers in nursing facilities to prescribe controlled substances for the purposes of pain control and comfort-oriented care. • 2019 CT H.B. 6532 (NS), introduced January 28, 2019, would require Connecticut to join the Psychology Interjurisdictional Compact and allow (1) a psychologist licensed in a state that participates in the compact to practice telehealth in Connecticut without requiring that the psychologist be licensed under chapter 383 of the general statutes, and (2) a psychologist licensed under chapter 383 of the general statutes to practice telehealth in another state that participates in the compact without requiring that the psychologist be licensed in that state. • 2019 CT H.B. 6681 (NS), introduced January 29, 2019, would require the Commissioner of Social Services to develop a Medicaid- funded pilot program to test the benefits of telemedicine in an eastern Connecticut rural district where access to service is hampered by inadequate transportation. • 2019 CT S.B. 307 (NS) and 2019 CT S.B. 293 (NS), introduced January 23, 2019, would require the Commissioner of Social Services to integrate telehealth services into the medical assistance program, provide Medicaid reimbursement for such services and seek any federal approval necessary. • 2019 CT S.B. 542 (NS), introduced January 24, 2019, would require the Department of Social Services to integrate telemedicine into the medical assistance program and to update telemedicine definitions to more accurately serve rural areas. • 2019 CT S.B. 920 (NS), adopted July 9, 2019, 2019, would amend CT ST § 19a-906 (Telehealth services) to update the definition of “telehealth provider.” The amendment is effective July 1, 2019. • 2019 CT S.B. 1052 (NS), adopted June 28, 2019, amends CT ST § 17b-245e (Telehealth services provided under the Medicaid program. Report) to require the Commissioner of Social Services to expand Medicaid coverage of telehealth services statewide whenever such coverage meets federal Medicaid requirements for efficiency, economy, and quality of care. The amendment is effective July 1, 2019. Delaware 2019 DE H.B. 172 (NS), adopted June 27, 2019, adopts the Psychology Interjurisdictional Compact to regulate the date to day practice of telepsychology by psychologists across state boundaries in the performance of their psychological practice. The bill is effective June 27, 2019. Florida © 2020 Thomson Reuters. No claim to original U.S. Government Works. -37- • 2019 FL H.B. 23 (NS), adopted June 25, 2019, adopts FL ST § 456.47 (Use of telehealth to provider services) to provide definitions, establish a standard of care for telehealth providers, authorize telehealth providers to use telehealth to perform patient evaluations, provide that telehealth providers, under certain circumstances, are not required to research a patient's history or conduct physical examinations before providing services through telehealth, authorize certain telehealth providers to use telehealth to prescribe specified controlled substances under certain circumstances, provide that a nonphysician telehealth provider using telehealth and acting within his or her relevant scope of practice is not deemed to be practicing medicine without a license, provide recordkeeping requirements for telehealth providers, provide registration requirements for out-of-state telehealth providers, require the Department of Health to publish certain information on its website, and authorizing a board or the department if there is no board to revoke a telehealth provider's registration under certain circumstances. The bill is effective July 1, 2019. • 2019 FL H.B. 931 (NS) and 2019 FL S.B. 1182 (NS), introduced March 5, 2019, would amend FL ST § 401.35 (Rules) to require the Department to adopt rules that provide at least minimum standards governing option use of telemedicine by licensees. • 2019 FL H.B. 947 (NS), amended March 5, 2019, would adopt FL ST § 456.4501 (Use of telehealth to provider services) to establishes standard of care for telehealth providers, authorize use of telehealth to perform patient evaluations, provide that telehealth providers, under certain circumstances, are not required to research patient's history or conduct physical exam before providing services, provide situations when use of telehealth is not deemed to be practicing medicine without a license, and authorize certain providers to use telehealth to prescribe specified controlled substances. • 2019 FL H.B. 7067 (NS), enrolled April 29, 2019, would amend FL ST § 456.47 (Use of telehealth to provide services) to require an applicant for registration of out-of-state telehealth providers to pay an initial registration fee of $150 and to require each registrant to pay a biennial registration renewal fee of $150 with a completed application for renewal. • 2019 FL S.B. 1062 (NS), filed November 26, 2019, would FL ST § 1011.62 (Funds for operation of schools) requiring that, in a student crisis situation, school or law enforcement personnel must contract the local mobile crisis response service before initiating an involuntary examination and providing that the contact may be done by using telehealth. • 2019 FL S.B. 1526 (NS), amended/substituted April 18, 2019, would amend FL ST § 409.967 (Managed care plan accountability) to prohibit a plan from using providers who exclusively provide services through telehealth as a way to achieve network adequacy and FL ST § 641.31 (Health maintenance contracts) to prohibit a health maintenance organization from requiring a subscriber to consult with, seek approval from, or obtain any type of referral or authorization by way of telehealth from a telehealth provider. The bill would also adopt FL ST § 456.4501 (Use of telehealth to provide services), FL ST § 627.42393 (Requirements for insurer reimbursement of telehealth services), and FL ST § 641.31093 (Requirements for reimbursement by health maintenance organization for telehealth services) to define the terms “telehealth” and “telehealth provider”, establish certain practice standards for telehealth providers, prohibit a telehealth provider from using telehealth to prescribe a controlled substance, provide exceptions, clarify that prescribing medications based solely on answers to an electronic medical questionnaire constitutes a certain failure to practice medicine, specify equipment and technology requirements for telehealth providers, provide recordkeeping requirements, provide reimbursement requirements for health insurers relating to telehealth services, and provide reimbursement requirements for health maintenance organizations relating to telehealth services. • 2019 FL S.B. 1790 (NS), introduced March 13, 2019, and 2019 FL H.B. 1317 (NS), introduced March 5, 2019, would amend FL ST § 627.736 (Required personal injury protection benefits; exclusions; priority; claims) to allow for reimbursement for services and care rendered via telemedicine. Georgia • 2019 GA H.B. 26 (NS), adopted April 23, 2019, would establish the Psychology Interjurisdictional Compact to regulate the date to day practice of telepsychology by psychologists across state boundaries in the performance of their psychological practice. The bill is effective April 23, 2019. • 2019 GA S.B. 118 (NS), adopted May 6, 2019, amends GA ST § 33-24-56.4 (Georgia Telehealth Act) to update the Act title from Georgia Telemedicine Act to Georgia Telehealth Act, update definitions, prohibit insurers from requiring insureds to use telemedicine, and provide for pay equity for providers using telemedicine. The amendment is effective January 1, 2020. • 2019 GA H.B. 253 (NS), adopted May 7, 2019, amends GA ST § 43-28-3 (Definitions) to include telehealth in the practice of occupational therapy. The amendment is effective July 1, 2019. • 2019 GA S.B. 133 (NS), adopted May 2, 2019, amends GA ST § 33-24-56.4 (Georgia Telemedicine Act) to update the definition for “health benefit policy” and “insurer.” The amendment is effective July 1, 2019. Hawaii • 2019 HI H.B. 490 (NS), amended/substituted February 15, 2019, and 2019 HI S.B. 1033 (NS), introduced January 18, 2019, would adopt new chapter (Midwives) to define “telehealth” and to allow a licensed midwife to provide midwifery services via telehealth. © 2020 Thomson Reuters. No claim to original U.S. Government Works. -38- • 2019 HI H.B. 935 (NS), amended/substituted February 8, 2019, would adopt new sections in HI ST § 453 (Medicine and Surgery) to define “distant site,” “originating site,” “telehealth,” and “telemedicine.” The bill would also amend HI ST § 453-1.3 (Practice of telemedicine) and HI ST § 453-2 (License required; exceptions) to update terminology to use “telemedicine” instead of “telehealth” and to allow physician assistants to practice telemedicine. • 2019 HI H.B. 1453 (NS), adopted June 25, 2019, establishes the community paramedicine program to require the Department to employ telehealth to enhance access and improve the patient experience. The Act is effective July 1, 2019. • 2019 HI H.B. 935 (NS), amended/substituted February 8, 2019, and 2019 HI H.B. 1560 (NS), introduced January 24, 2019, would adopt new sections in HI ST § 453 (Medicine and Surgery) to define “distant site,” “originating site,” “telehealth,” and “telemedicine.” The bill would also amend HI ST § 453-1.3 (Practice of telemedicine) and HI ST § 453-2 (License required; exceptions) to update terminology to use “telemedicine” instead of “telehealth” and to allow physician assistants to practice telemedicine. • 2019 HI S.B. 1246 (NS), adopted June 25, 2019, establishes goals for the adoption and proliferation of telehealth to increase health care access and establish the Strategic Telehealth Advisory Council and permanent full-time State Telehealth Coordinator position. The Act is effective July 1, 2019. Illinois • 2019 IL H.B. 1282 (NS), introduced January 29, 2019, would amend IL ST CH 225 § 150/1 (Short title) clarifying that the Act may be cited at the Telehealth Act. • 2019 IL H.B. 2152 (NS), adopted August 9, 2019, adopts the Mental Health Early Action on Campus Act to define telehealth and to require through a combination of on-campus capacity, off-campus linkage agreements with mental health service providers, and contracted telehealth therapy services, each public college or university must maintain a ratio of one clinical, non-student staff member to 1,250 students. The Act is effective July 1, 2020. • 2019 IL H.B. 2895 (NS), adopted August 16, 2019, adopts IL ST CH 20 § 2310/2310-223 (Obstetric hemorrhage and hypertension training) allowing birth facilities to use telemedicine for consultation on management and follow-up. The bill is effective January 1, 2020. • 2019 IL S.B. 27 (NS), filed January 10, 2019, would amend IL ST CH 215 § 5/356z.22 (Coverage for telehealth services) to prohibit insurers from excluding from coverage a medically necessary health care service or procedure delivered by certain providers solely because the service or procedure is provided through telehealth. Also, to update the coverage requirements for telehealth services to include telehealth services delivered by licensed dietitians and nutritionists and certified diabetes educators. The bill would also adopt IL ST CH 305 § 5/5-5.25a (Telehealth services) to establish the payment, reimbursement, and service requirements for telehealth services provided under the Medical Assistance program. • 2019 IL S.B. 167 (NS), adopted July 26, 2019, amends IL ST CH 225 § 25/4 (Definitions) to define “teledentistry.” The amendment is effective July 26, 2019. • 2019 IL S.B. 1135 (NS), adopted July 19, 2019, amends IL ST CH 225 § 15/4.3 (Written collaborative agreements) to allow physicians to provide collaboration and consultation with prescribing psychologists via telehealth. The amendment is effective July 19, 2019. Indiana • 2019 IN H.B. 1200 (NS), adopted April 29, 2019, adopts IN ST 25-33-3 (Telepsychology) to allow a psychologist and a health service provider who meets certain requirements (supervisee) to use telepsychology. The new section is effective July 1, 2019. • 2019 IN H.B. 1535 (NS), introduced January 17, 2019, would prohibit physical examinations to be performed via telemedicine to certify a debilitating medical condition for a qualifying patient to obtain a prescription for the medicinal use of cannabis. • 2019 IN H.B. 1246 (NS), adopted May 5, 2019, adopts IN ST 25-26-13.5-6.5 to require an application for registration of an automated dispensing system to include a description of the automated dispensing system being used at the facility, including telepharmacy communication, electronic record keeping, and electronic verification systems. The new section is effective July 1, 2019. • 2019 IN S.B. 242 (NS), introduced January 3, 2019, would amend IN ST 25-1-9-5.8 (Issuance of prescription through telemedicine; requirements) to allow a provider to prescribe ophthalmic devices through telemedicine and adopt IN ST 25-24-1-1.5 to prohibit the Board from setting standards for the practice of ocular telemedicine or ocular telehealth that are more restrictive than the standards established for in person practice. • 2019 IN S.B. 586 (NS), adopted May 1, 2019, amends IN ST 25-27-1-1 (Definitions) to provide the definition for “telemedicine” and adopt IN ST 25-27-1-3.3 to exempt a physical therapist who is licensed in another state if the person is providing a professional or expert opinion or advice by telemedicine to a physician therapist of personal health care provider from the licensure and certification requirements in Indiana. The amendment is effective July 1, 2019. Iowa © 2020 Thomson Reuters. No claim to original U.S. Government Works. -39- • 2019 IA H.F. 722 (NS), introduced March 12, 2019, would amend IA ST § 125.74 (Preapplication screening assessment--program) and IA ST § 229.5A (Preapplication screening assessment--program) to allow preapplication screening assessments to be delivered through telehealth. • 2019 IA S.S.B. 1160 (NS), draft/request February 14, 2019, would adopt IA ST § 514C.31 (Telehealth coverage) to provide definitions and establishing the insurance coverage requirements for telehealth. • 2019 IA S.F. 63 (NS), introduced January 16, 2019, would adopt IA ST § 216.8C (Finding of disability and need for an assistance animal or service animal in housing) to allow a licensee to meet with the patient or client in person or via telemedicine for the purpose of determining if an individual is a person with a disability who needs an assistance animal or service animal as a reasonable accommodation in housing. • 2019 IA S.F. 341 (NS), adopted May 2, 2019, adopts IA ST § 216.8C (Finding of disability and need for an assistance animal or service animal in housing) to allow a licensee to make a written finding of an individual's disability via telemedicine. The bill is effective May 2, 2019. • 2019 IA S.F. 536 (NS), introduced March 7, 2019, and 2019 IA H.S.B. 173 (NS), introduced February 14, 2019, would amend IA ST § 155A.13 (Pharmacy license) to update the requirements for telepharmacies. Maine • 2019 ME H.P. 1191 (NS), introduced April 30, 2019, would amend ME ST T. 22 § 3173-H (Services delivered through telehealth) to require the Department to provide reimbursement for telehealth or telemonitoring private duty nursing, home health services and personal care services for an adult MaineCare member with a physical disability or an adult who is elderly who is receiving MaineCare services under a waiver granted by the federal Department of Health and Human Services, Centers for Medicare and Medicaid Services for home-based and community-based services or state-funded home-based and community-based support services. • 2019 ME S.P. 383 (NS), adopted June 13, 2109, amends ME ST T. 24 § 2904 (Immunity from civil liability for volunteer activities) to allow providers to provide services through telehealth and ME ST T. 24-A § 4316 (Coverage for telemedicine services) to require carriers that offer health plans in this State to provide coverage for health care services provided through telehealth services in the same manner as coverage is provided for services provided in person and sets forth certain standards for coverage of telehealth. The requirements of the bill apply to all policies, contracts, and certificates executed, delivered, issued for delivery, continued or renewed on or after January 1, 2020. Massachusetts 2019 MA H.B. 4134 (NS), introduced October 18, 2019, would adopt new MA ST Pt. I, T. XVII, Ch. 118I (Health Information Technology) to establish a health information technology council within the Executive Office to advise the Executive Office on design, implementation, operation, and use of statewide health information exchange. The bill would also add new section would define “telehealth” and providing coverage, utilization review, and reimbursement requirements for the provision of services via telehealth. Maryland • 2019 MD H.B. 605 (NS), adopted May 13, 2019, amends MD HEALTH GEN § 15-105.2 (Reimbursement of health care providers) to allow a psychiatric nurse practitioner to provide services through telemedicine. The amendment is effective October 1, 2019. • 2019 MD H.B. 1200 (NS), introduced February 8, 2019, and 2019 MD S.B. 524 (NS), introduced February 4, 2019, would amend MD HEALTH GEN § 15-105.2 (Reimbursement of health care providers) to clarify the definition for “telepsychiatry” and requiring reimbursement for psychiatric health care service provided through telepsychiatry. • 2019 MD H.B. 570 (NS) and 2019 MD S.B. 178 (NS), adopted April 30, 2019, would amend MD HEALTH GEN § 7.5-402 (Regulations) to provide that any requirements for the governance of a behavioral health program to include a provision authorizing a behavioral health program licensed as an outpatient mental health center to satisfy any regulatory requirement that the medical director be on-site through the use of telehealth by the director. The amendment is effective October 1, 2019. Michigan • 2019 MI S.B. 128 (NS), adopted July 8, 2019, amends MI ST 333.7104 (Definitions; terms commencing “b” to “e”) providing the definition for “bona fide prescriber-patient relationship” which allows for evaluation through telehealth. The amendment is effective July 8, 2019. • 2019 MI S.B. 340 (NS), engrossed December 11, 2019, would amend MI ST 333.17707 (Definitions; terms commencing “p”) providing the definition for “parent pharmacy,” MI ST 333.17709 (Definitions; terms commencing “s” to “w” providing the definition for “telepharmacy system,” and MI ST 333.17748 (Licensure as pharmacy, manufacturer, or wholesale distributor; requirement; renewal; designation of pharmacist in charge or facility manager; exemption; report of change in ownership, management, location, or designated PIC or facility manager; duties of PIC; criminal history check; investigation or inspection of out-of-state applicant or © 2020 Thomson Reuters. No claim to original U.S. Government Works. -40- compounding pharmacy) providing that the PIC of a remote pharmacy is not required to be physically present at the remote pharmacy to satisfy the hour requirement described in this subsection, but may satisfy the requirement through the use of a telepharmacy system. The bill would adopt MI ST 333.17742b establishing the requirements for operation of a remote pharmacy that is overseen through the use of a telepharmacy system by a pharmacist. Minnesota • 2019 MN H.F. 551 (NS), engrossed March 18, 2019, would amend MN ST § 62D.124 (Geographic accessibility) and MN ST § 62K.10 (Geographic accessibility; provider network adequacy) to grant allow waivers for a health maintenance organization, insurer, or preferred provider organization demonstrates to the commissioner that there are no providers of a specific type or specialty in a county, the commissioner may approve a waiver in which the health maintenance organization is allowed to address network inadequacy in that county by providing for patient access to providers of that type or specialty via telemedicine. • 2019 MN H.F. 610 (NS) and 2019 MN S.F. 682 (NS), introduced January 31, 2019, would require the Council of Health Boards to convene a work group to study and make recommendations on increasing access to the clinical experience required as part of postsecondary educational programs that relate to counseling by utilizing telehealth technologies including, but not limited to, high- fidelity simulation and teleconferencing to replace a portion of the program's traditional clinical experience requirements. • 2019 MN H.F. 766 (NS), engrossed March 11, 2019, and 2019 MN S.F. 1070 (NS), introduced February 11, 2019, would amend MN ST § 152.28 (Healthcare practitioner duties) to allow a health care practitioner to conduct a patient assessment to issue a recertification via telemedicine. • 2019 MN H.F. 2150 (NS) and 2019 MN S.F. 2184 (NS), introduced March 7, 2019, would amend MN ST § 151.37 (Legend drugs, who may prescribe, possess) to allow telemedicine evaluations to be used to prescribe medications for erectile dysfunction. • 2019 MN H.F. 2414 (NS), engrossed May 1, 2019, would amend MN ST § 256B.0757 (Coordinated care through a health home) to require a behavioral health home services provider to utilize an electronic health record. The bill would also amend MN ST § 155.15 (Compounding drugs unlawful under certain conditions) establishing the conditions for when a pharmacist, who is not present within a licensed pharmacy, may accept a written, verbal, or electronic prescription drug order from a practitioner. The bill would also amend MN ST § 256B.0625 (Covered Services) to provide that the limit on coverage of 3 telemedicine services per enrollee per calendar week does not apply if the telemedicine services provided by the licensed health care provider are for the treatment and control of tuberculosis and the services are provided in a manner consistent with the recommendations and best practices specified by the CDC and the Commissioner of Health. MN ST § 152.28 (Health care practitioner duties) allowing a health care practitioner to conduct a patient assessment to issue a recertification via telemedicine. Mississippi • 2019 MS H.B. 738 (NS), introduced January 17, 2019, would amend MS ST § 83-9-351 (Telemedicine services coverage) and MS ST § 83-9-353 (Requirement to provide coverage and reimburse for telemedicine and remote patient monitoring services) to prohibit insurers from placing geographic restrictions on coverage for, or the delivery of, telemedicine to insureds. • 2019 MS H.B. 881 (NS) and 2019 MS S.B. 2745 (NS), introduced January 21, 2019, would amend MS ST § 41-127-1 (Medical treatment via electronic means) to allow telemedicine provides to provide treatment for substance use disorders, including medication assisted treatment. • 2019 MS S.B. 2828 (NS), adopted April 16, 2019, would adopt the Mississippi Guardianship and Conservatorship Act which would allow personal examination to occur via telemedicine, but any telemedicine examination must be made using an audio-visual connection by a physician licensed in this state. The bill is effective January 1, 2020. • 2019 MS S.B. 2064 (NS), introduced January 8, 2019, would amend MS ST § 83-9-351 (Care and services covered; discontinuation of optional services) to authorize Medicaid reimbursement to physicians providing telemedicine medical services to students in a school-based setting. • 2019 MS S.B. 2367 (NS), introduced January 21, 2019, would amend MS ST § 83-41-409 (Requirements for managed care plan certification) would prohibit a managed care plan must not require a participating provider to comply with any requirements for reimbursement of telemedicine services other than those provided for in Chapter 9, Title 83, Mississippi Code of 1972. • 2019 MS S.B. 2689 (NS) and 2019 MS S.B. 2690 (NS), introduced January 21, 2019, would amend MS ST § 83-9-351 (Telemedicine services coverage) and MS ST § 83-9-353 (Requirement to provide coverage and reimburse for telemedicine and remote patient monitoring services) to provide that store and forward telemedicine services and remote patient monitoring services must not be unduly restricted based on the patient's geographic proximity to a network provider. Missouri 2019 MO H.B. 693 (NS), introduced January 24, 2019, would amend MO ST 335.175 (Utilization of telehealth by nurses established-- definition of telehealth--rulemaking authority--sunset provision) to remove requirement that an advanced practice registered nurse © 2020 Thomson Reuters. No claim to original U.S. Government Works. -41- (APRN) providing nursing services under a collaborative practice arrangement under MO ST 334.104 (Collaborative practice arrangements, form, contents, delegation of authority--rules, approval, restrictions--disciplinary actions--notice of collaborative practice or physician assistant agreements to board, when--certain nurses may provide anesthesia services, when--contract limitations) may provide such services outside the geographic proximity requirements of MO ST 334.104 (Collaborative practice arrangements, form, contents, delegation of authority-- rules, approval, restrictions--disciplinary actions--notice of collaborative practice or physician assistant agreements to board, when--certain nurses may provide anesthesia services, when--contract limitations) if the collaborating physician and advanced practice registered nurse utilize telehealth in the care of the patient and if the services are provided in a rural area of need. Montana • 2019 MT H.B. 5128 (NS), adopted April 18, 2019, amends MT ST 37-11-105 (Supervision of physical therapist assistant, physical therapy aide, physical therapy student, or physical therapist assistant student) allowing physical therapists to supervise physical therapy assistants by means of telemedicine. The amendment is effective March 30, 2019. • 2019 MT S.B. 265 (NS), adopted May 3, 2019, would amend MT ST 50-46-302 (Definitions) to provide the definition for “telemedicine” and MT ST 50-46-310 (Written certification – accompanying statements) to allow use of telemedicine for written certifications. Nebraska 2019 NE L.B. 29 (NS), adopted March 21, 2019, would allow any credential holder under the Uniform Credentialing Act to establish a provider-patient relationship through telehealth and to prescribe the patient a drug while providing a telehealth service. The bill is effective September 6, 2019. Nevada • 2019 NV A.B. 47 (NS), introduced February 4, 2019, would establish a pilot program to respond to persons suffering from mental health crises in counties whose population is less than 55,000. The program must have a mental health professional to work in partnership with the emergency medical attendants or law enforcement officers in person or through telehealth during the initial response to a person suffering from a mental health crisis. The bill would also define “telehealth.” • 2019 NV S.B. 359 (NS), introduced March 19, 2019, would prohibits a health care provider from altering the previously approved prescription for treatment of a chronic condition without first performing an in-person or telehealth examination of the insured and authorizes the revision of coverage by an insurer or pharmacy benefit manager after providing for an in-person or telehealth examination of the insured by the provider of health care for the insured. • 2019 NV S.B. 366 (NS), adopted June 8, 2019, establishes the profession and practice of dental therapy, define teledentistry, and allow dental therapists to make use of teledentistry. The bill is effective January 1, 2020. New Hampshire • 2019 NH S.B. 258 (NS), adopted August 12, 2019, NH ST § 167:4-d (Medicaid Coverage of Telehealth Services) providing that it is the intent of this section to recognize the application of telehealth for covered services provided within the scope of practice of a physician or other health care provider as a method of delivery of medical care by which an individual at an originating site shall receive medical services which are clinically appropriate for delivery through telehealth from a health care provider at a distant site without in-person contact with the provider. Adds definitions for “Distant site”, “Originating site”, “Remote patient monitoring” and “Store and forward”. Provides that telemedicine services for primary care, remote patient monitoring, and substance use disorder services shall only be covered in the event that the patient has already established care at an originating site via face-to-face in-person service. Also makes other clarifying and conforming changes. Amends, effective January 1, 2020, NH ST § 415-J:2 (Definitions) adding definitions for “Remote patient monitoring” and “Store and forward”. The bill is effective October 11, 2019. • 2019 NH H.B. 483 (NS), introduced January 3, 2019, would establish the Psychology Interjurisdictional Compact to regulate the date to day practice of telepsychology by psychologists across state boundaries in the performance of their psychological practice. • 2019 NH S.B. 308 (NS), amended/substituted March 27, 2019, would amend NH ST § 167:4-d (Medicaid Coverage of Telehealth Services), NH ST § 167:3-c (Rulemaking), NH ST § 415-J:2 (Definitions), and NH ST § 415-J:3 (Coverage for Telemedicine Services) to update definitions and update the coverage requirements for telemedicine. New Jersey • 2018 NJ A.B. 2444 (NS), amended/substituted December 12, 2019, would amend NJ ST 30:4D-6 (Basic medical care and services) would require comprehensive tobacco cessation benefits to individual who is 18 years of age or older, or who is pregnant, and the coverage must include counseling via telemedicine. © 2020 Thomson Reuters. No claim to original U.S. Government Works. -42- • 2019 NJ A.B. 5986 (NS), introduced November 25, 2019, would amend NJ ST 24:6I-5.1 (Authorizing patients for the medical use of cannabis; registry) allowing a health care practitioner to authorize a patient who is a child, resident of a long-term care facility, developmentally disabled, terminally ill, receiving hospice care, or housebound as certified by the patient's physician, for the medical use of cannabis in the course of the health care practitioner's practice of telemedicine or telehealth and defining “telehealth” and “telemedicine.” • 2019 NJ S.B. 4171 (NS), introduced November 7, 2019, would amend NJ ST 24:6I-5.1 (Authorizing patients for the medical use of cannabis; registry) and NJ ST 24:6I-10 (Health care practitioner's written instructions; duration of time to be dispensed) to authorize the dispensing of medical marijuana through telemedicine and telehealth. New Mexico • 2019 NM H.B. 90 (NS), introduced January 16, 2019, and 2019 NM S.B. 153 (NS), introduced January 15, 2019, would establish the Elizabeth Whitefield End of Life Options Act. The Act would define telemedicine and would allow a mental health professional and health care professional to examine the individual in person or through telemedicine to determining if an individual has the capacity to make end of life decisions. • 2019 NM H.B. 308 (NS), enrolled March 28, 2019, would amend NM ST § 61-5A-3 (Definitions) to update the definition for “teledentistry.” • 2019 NM S.B. 141 (NS), introduced January 15, 2019, would establish the Psychology Interjurisdictional Compact to regulate the date to day practice of telepsychology by psychologists across state boundaries in the performance of their psychological practice. • 2019 NM S.B. 339 (NS), introduced January 24, 2019, would add a new section (Medicaid--Tobacco Use Cessation Coverage) to provide medical assistance coverage individual or group counseling, provided in person, through telemedicine services or by telephone, of at least 10 minutes per counseling session per week for tobacco use cessation. • 2019 NM S.B. 354 (NS), engrossed April 4, 2019, would amend NM ST § 13-7-14 (Coverage for telemedicine services), NM ST § 59A-22-49.3 (Coverage for telemedicine services), NM ST § 59A-23-7.12 (Coverage for telemedicine services), NM ST § 59A-46-50.3 (Coverage for telemedicine services), and NM ST § 59A-47-45.3 (Coverage for telemedicine services) to update the requirements for coverage of services provided via telemedicine. • 2019 NM S.B. 406 (NS), enrolled April 4, 2019, NM ST § 26-2B-3 (Definitions) providing the definition for “telemedicine.” New York • 2019 NY A.B. 2120 (NS), introduced January 22, 2019, would amend NY ELDER § 214 (Community services for the elderly) to allow for telehealth services to be provided under the senior care choices program. • 2019 NY A.B. 3060 (NS), introduced January 28, 2019, would add a new section NY PUB HEALTH § 2805-ii (Sexual assault forensic examination telemedicine pilot program) to establish the sexual assault forensic examination telemedicine pilot program and add a new section. • 2019 NY A.B. 4888 (NS), introduced February 5, 2019, would amend NY EDUC § 6802 (Definitions) to define “remote site,” “satellite consultation site,” “telepharmacy,” and “telepharmacy in hospitals,” and adopt NY EDUC § 6832 (Telepharmacy) to establish the requirements for telepharmacy practice. • 2019 NY A.B. 6530 (NS), introduced March 11, 2019, would adopt NY PUB HEALTH § 2703 (Delivery of gerontologic services and senior health care) to require the Commission to study the utilization of telehealth and telemedicine in senior populations. • 2019 NY A.B. 8442 (NS), introduced July 8, 2019, would enact the Orthodontic Tele-Dentistry Consumer Protection Act to establish requirements on licensed dental procedures entities and licensed dentists who perform cosmetic dental procedures including the posting of specific notices. • 2019 NY S.B. 879 (NS), introduced January 9, 2019, would amend NY INS § 5102 (Definitions) and NY WORK COMP § 13 (Treatment and care of injured employees) to require comprehensive motor vehicle reparations and workers' compensation coverage of health care services delivered by means of telehealth. • 2019 NY S.B. 888 (NS), introduced January 9, 2019, would amend NY PUB HEALTH § 2999-cc (Definitions), NY INS § 1117 (Health insurance plans for long term care), NY INS § 3217-h (Telehealth delivery of services), NY INS § 3229 (Minimum benefit standards for certain long term care plans), NY INS § 4306-g (Telehealth delivery of services), and NY PUB HEALTH § 4406-g (Telehealth delivery of services) to allow for home care services to be delivered via telemedicine or telehealth. • 2019 NY S.B. 1043 (NS), introduced January 10, 2019, would amend NY PUB HEALTH § 2999-dd (Telehealth delivery of services), NY INS § 3217-h (Telehealth delivery of services), NY INS § 4306-g (Telehealth delivery of services), and NY PUB HEALTH § 4406- g (Telehealth delivery of services) to require reimbursement for covered services delivered via telehealth on the same basis and at the same rate as established for the same service when not delivered via telehealth. © 2020 Thomson Reuters. No claim to original U.S. Government Works. -43- • 2019 NY S.B. 5477 (NS), introduced May 2, 2019, would amend NY MENT HYG § 7.41 (Geriatric service demonstration program) to allow grants to be awarded for the purpose of telepsychiatry and requiring a Department study to provide recommendations on effective identification of social isolation, including specific recommendations for health care practitioners, intervention techniques, and the development of telehealth, telemedicine, and telepsychiatry programs to meet the needs of homebound and socially isolated geriatric patients who may be suffering from depression, mental illness, or other health consequences. North Carolina • 2019 NC H.B. 106 (NS), adopted July 19, 2019, establishes a telemedicine pilot program to provide physical health services to inmates in remote correctional facilities. The bill is effective July 19, 2019. • 2019 NC H.B. 297 (NS), introduced March 7, 2091, would establish the Psychology Interjurisdictional Licensure Compact to regulate the date to day practice of telepsychology by psychologists across state boundaries in the performance of their psychological practice. • 2019 NC H.B. 555 (NS), amended/substituted May 2, 2019, would require the Department of Health and Human Services (DHHS) make changes to the Medicaid and NC Health Choice Clinical Coverage Policy No. 1H, Telemedicine and Telepsychiatry to increase access to services, evolve with the latest technology, and align with best practices. • 2019 NC H.B. 721 (NS), amended/substituted May 6, 2019, would require the Department of Health and Human Services to ensure that Medicaid and NC Health Choice coverage of telemedicine and telepsychiatry services are consistent with this act and shall amend Clinical Coverage Policy No: 1H. Also update terminology to use “telehealth” instead of “telemedicine.” The bill would also adopt NC ST § 58-50-305 (Coverage for telehealth services) to require health benefit plans to provide coverage for telehealth services. • 2019 NC H.B. 884 (NS), introduced April 22, 2019, would require Medicaid and NC Health Choice reimbursement to federally qualified health centers for telemedicine and telepsychiatry services. • 2019 NC S.B. 361 (NS), engrossed August 12, 2019, would establish the Psychology Interjurisdictional Compact to regulate the date to day practice of telepsychology by psychologists across state boundaries in the performance of their psychological practice. North Dakota • 2019 ND H.B. 1343 (NS), introduced January 9, 2019, would establish the Psychology Interjurisdictional Compact to regulate the date to day practice of telepsychology by psychologists across state boundaries in the performance of their psychological practice. • 2019 ND H.C.R. 3036 (NS), introduced January 24, 2019, would require the Legislative management to study a multidisciplinary approach to chronic pain which focuses on the patient's medical condition, comorbidities, and various aspects of care, and consideration of innovative solutions to pain management such as telemedicine, telementoring, and mobile applications for behavioral and psychological skills, and whether newer medicines and medical devices should be utilized as part of the overall approach to pain management. • 2019 ND S.B. 2094 (NS), adopted April 24, 2019, amends ND ST 43-17-01 (Definitions) to provide the definition for “telemedicine” and adopt ND ST 43-17-44 (Standard of care and professional ethics) to provide that a licensee is held to the same standard of care and same ethical standards, whether practicing traditional in-person medicine or telemedicine and establish the standard of care and ethical standards applicable to the practice of telemedicine, and ND ST 43-17-45 (Prescribing – Controlled substance) to allow a licensee who has performed a telemedicine examination or evaluation to prescribe medications, except for opioids. The amendments are effective August 1, 2019. • 2019 ND S.B. 2125 (NS), adopted March 28, 2019, would amend ND ST 43-26.1-01 (Definitions) to provide the definition for “telehealth.” The amendment is effective August 1, 2019. Ohio 2019 OH H.B. 435 (NS), introduced December 4, 2019, would adopt OH ST § 3738.20 to define “telemedicine” and to allow a hospital or freestanding birthing center to use telemedicine services for the pregnant or postpartum women in the emergency department to have timely consultation with an obstetrician, certified nurse-midwife, or physician assistant with obstetric expertise to provide input on patient management and follow-up. Oklahoma • 2019 OK H.B. 2081 (NS), introduced February 4, 2019, would amend OK ST T. 59 § 888.3 (Definitions) to provide the definition for “telehealth,” “telemedicine,” and “telerehabilitation.” • 2019 OK H.B. 1057 (NS), adopted April 29, 2019, would establish the Psychology Interjurisdictional Compact to regulate the date to day practice of telepsychology by psychologists across state boundaries in the performance of their psychological practice. The bill is effective November 1, 2019. © 2020 Thomson Reuters. No claim to original U.S. Government Works. -44- • 2019 OK H.B. 2614 (NS), engrossed April 25, 2019, would amend OK ST T. 63 § 420 (Medical marijuana license--Permissions-- Application--Caregiver license) to prohibit the physical examination required prior to issuing a medical marijuana recommendation from being performed via telemedicine. • 2019 OK H.B. 2639 (NS), amended/substituted April 2, 2019, would adopt a new section to provide that A sexual victims' assault victim has the right to consult, either in person or via telemedicine, with a sexual assault victims' advocate during any medical evidentiary or physical examination and during any interview by law enforcement authorities or district attorneys, asexual assault victim retains this right even if the victim has waived the right in a previous examination or interview, and where a sexual assault victims' advocate is not available for an in-person consultation, consultations via telemedicine must be provided. • 2019 OK S.B. 575 (NS), adopted May 9, 2019, amends OK ST T. 25 § 2004 (Written consent required for medical treatment of minors--Exceptions—Penalties) and OK ST T. 25 § 2005 (Written consent required for mental health treatment of minors--Exceptions-- Penalties) to exempt health care professionals providing assessment or treatment through telemedicine from being required to make verification that the parent is at the site. The amendment is effective July 1, 2019. • 2019 OK S.B. 767 (NS), amended/substituted April 2, 2019, would amend OK ST T. 63 § 420 (Medical marijuana license-- Permissions--Application-- Caregiver license) to prohibit a physical examination for a medical marijuana recommendation to be performed by remote means, including telemedicine. • 2019 OK S.B. 1038 (NS), adopted May 14, 2019, amends OK ST T. 59 § 888.3 (Definitions) to define “telehealth” and “telemedicine.” The amendment is effective November 1, 2019. Oregon • 2019 OR S.B. 1 (NS), adopted July 23, 2019, adopts a new section requiring an interdisciplinary assessment team to increase telemedicine evaluation with specific emphasis on increasing access to psychiatric and developmental assessments in communities that lack sufficient access to providers. The bill is effective January 1, 2020. • 2019 OR S.B. 129 (NS), adopted June 4, 2019, adopts new section to define “telemedicine” and allow a licensed optometrist to engage in the practice of telemedicine and amend OR ST § 683.010 (Definitions) to amend the definition of “practice of optometry” to include the use of telemedicine. The bill is necessary for the immediate preservation of the public peace, health, and safety, an emergency is declared, and the bill is effective June 4, 2019. • 2019 OR S.B. 130 (NS), engrossed April 4, 2019, would authorize school nurses associated with school-based health center to engage in practice of telehealth. Pennsylvania • 2019 PA H.B. 15 (NS), introduced March 5, 2019, would adopt the Telemedicine Act to provide definitions related to telemedicine, authorize the regulation of telemedicine by professional licensing boards, and provide for insurance coverage of telemedicine. • 2019 PA S.B. 67 (NS), introduced January 24, 2019, would authorize Pennsylvania to join the Psychology Interjurisdictional Compact, providing for the form of the compact, and imposing additional powers and duties on the Governor, the Secretary of the Commonwealth and the Compact. • 2019 PA S.B. 857 (NS), amended/substituted November 18, 2019, would enact the Telemedicine Act to provide definitions related to telemedicine, authorize the regulation of telemedicine by professional licensing boards, and provide for insurance coverage of telemedicine. South Carolina • 2019 SC S.B. 132 (NS), adopted May 13, 2019, amends SC ST § 40-47-955 (Scope of physician assistant's practice; physical presence requirements of supervising physician; practices in separate locations; granting of exceptions) to allow physician assistants to perform medical acts via telemedicine. The amendment is effective August 11, 2019. • 2019 SC S.B. 366 (NS), introduced January 15, 2019, would enact the South Carolina Compassionate Care Act. The Act would allow follow-up appointments to be conducted through telemedicine and require dispensaries to have a pharmacist, physician assistant, or clinical practice nurse available to advise and educate patients, in person or by telemedicine. South Dakota • 2019 SD S.B. 136 (NS), adopted March 27, 2019, would establish the requirements for health care professionals to utilize telehealth. The bill is effective July 1, 2019. • 2019 SD S.B. 137 (NS), adopted March 27, 2019, provides for the payment of claims for covered services provided by a health care professional via telehealth. The bill is effective July 1, 2019. © 2020 Thomson Reuters. No claim to original U.S. Government Works. -45- Tennessee 2019 TN S.B. 1169 (NS), introduced February 7, 2019, and 2019 TN H.B. 753 (NS), introduced February 6, 2019, would amend TN ST § 56-7-1002 (Healthcare services delivered through telehealth encounter) to allow patients to receive telehealth services covered by health insurance at their residence and place of employment, if equipped to engaged in telehealth communications, and prohibits insurers from distinguishing among geographic locations in the reimbursement for telehealth services. Texas • 2019 TX H.B. 10 (NS), engrossed April 16, 2019, would adopt TX EDUC § 104A.001 (Definitions) to define “telepsychiatry” and TX EDUC § 104A.001 (Powers and Duties) to require the Institute to improve the quality and accessibility of care in local communities by establishing child psychiatry access lines for peer-to-peer consultation support for direct care providers who use telepsychiatry and create a program to provide students access to telepsychiatry through the use of child psychiatry access lines to support public school personnel who are assisting students with behavioral health concerns. • 2019 TX H.B. 12 (NS), engrossed May 12, 2019, 2019 TX H.B. 1295 (NS), amended/substituted March 7, 2019, and 2019 TX S.B. 2225 (NS), introduced March 9, 2019, would establish the Tele-Connective Pilot Program to develop and implement a pilot program to provide early childhood intervention services under Chapter 73 to eligible children through the provision of telehealth and telemedicine medical services delivered using access points established in school districts selected to participate in the program. • 2019 TX H.B. 870 (NS), amended/substituted April 22, 2019, would amend TX GOVT § 531.0216 (Participation and Reimbursement of Telemedicine Medical Service Providers and Telehealth Service Providers Under Medicaid) to require managed care organizations to provide reimbursement for health care services provided to Medicaid recipients via telemedicine or telehealth if it would be covered if it had been provided in-person. • 2019 TX H.B. 871 (NS), adopted May 28, 2019, adopts TX HEALTH & S § 773.1151 (Use of Telemedicine Medical Service by Certain Trauma Facilities) to authorize a Level IV trauma facility to utilize telemedicine. The bill is effective September 1, 2019. • 2019 TX H.B. 1111 (NS), engrossed April 30, 2019, would adopt TX GOVT § 531.02163 (Study on Providing Certain Maternal Care Medicaid Services Through Telemedicine Medical Services and Telehealth Services) to require the Commission to conduct a study on the benefits and costs of permitting reimbursement under Medicaid for prenatal and postpartum care delivered through telemedicine medical services and telehealth services. The bill would also adopt TX HEALTH & S § 34.020 (Program to Deliver Prenatal and Postpartum Care Through Telehealth or Telemedicine Medical services in Certain Counties) to require the Commission to develop a program to deliver prenatal and postpartum care through telehealth services or telemedicine medical services to pregnant women with a low risk of experiencing pregnancy-related complications. • 2019 TX H.B. 1448 (NS), introduced February 6, 2019, would adopt TX HEALTH & S § 113.0051 (Establishment; Purpose) establishing the Texas Mental Health Care Consortium to facilitate access to mental health care services through telemedicine and other cost-effective, evidence-based programs, TX HEALTH & S § 113.0151 (General Duties) to require the consortium to ensure that evidence-based tools, including telemedicine, are used to help expand the delivery of mental health care services, and TX HEALTH & S § 113.0152 (Comprehensive Child Psychiatry Access Centers) to require the a center to collaborate with community mental health providers to better care for children and youth with behavioral health needs by establishing or expanding a telemedicine or telehealth program for identifying and assessing behavioral health needs and providing access to mental health care services. • 2019 TX H.B. 1501 (NS), adopted June 10, 2019, adopts the Psychology Interjurisdictional Compact, providing for the form of the compact, and imposing additional powers and duties on the Governor, the Secretary of the Commonwealth and the Compact. The bill is effective September 1, 2019. • 2019 TX H.B. 1738 (NS), introduced February 13, 2019, would adopt TX GOVT § 531.02177 (Study Concerning Home Telemonitoring and Telehealth Services Fraud, Waste, and Abuse) to require the Commission to conduct a study to identify patterns or instances of fraud, waste, or abuse committed by providers of Medicaid home telemonitoring services and telehealth services and based on the finding, the Executive Commissioner may adopt rules necessary to prevent or reduce fraud, waste, and abuse by providers of Medicaid home telemonitoring services and telehealth services. The bill also amends TX OCC § 111.001 (Definitions) to update the definition for “telehealth service.” • 2019 TX H.B. 1756 (NS), introduced February 13, 2019, and 2019 TX S.B. 792 (NS), amended/substituted April 26, 2019, would amend TX OCC § 111.001 (Definitions), TX OCC § 111.002 (Informed Consent), TX OCC § 111.003 (Confidentiality), TX OCC § 111.004 (Rules), TX OCC § 111.005 (Practitioner-Patient Relationship for Telemedicine Medical Services), TX OCC § 111.006 (Coordination to Adopt Rules That Determine Valid Prescription), TX OCC § 111.007 (Standard of Care for Telemedicine Medical Services and Telehealth Services), TX OCC § 262.1515 (Delegation of Duties to Dental Hygienist Practicing in Certain Facilities), TX OCC § 562.056 (Practitioner-Patient Relationship Required), TX GOVT § 531.001 (Definitions), TX GOVT § 531.0216 (Participation and Reimbursement of Telemedicine Medical Service Providers and Telehealth Service Providers Under Medicaid), TX GOVT § 531.02161 (Telemedicine, Telehealth, and Home Telemonitoring Technology Standards), TX GOVT § 531.02162 (Medicaid Services Provided Through Telemedicine Medical Services and Telehealth Services to Children With Special Health Care Needs), TX HEALTH & S § 62.157 (Telemedicine Medical Services and Telehealth Services for Children With Special Health Care Needs), TX HEALTH & S © 2020 Thomson Reuters. No claim to original U.S. Government Works. -46- § 62.1571 (Telemedicine Medical Services), TX INS § 1455.001 (Definitions), TX INS § 1455.004 (Coverage for Telemedicine Medical Services and Telehealth Services), and TX INS § 1455.006 (Telemedicine Medical Services and Telehealth Services Statement) and adopting TX OCC § 111.009 (Certain Prescriptions Prohibited) and TX GOVT § 531.02172 (Reimbursement for Teledentistry Dental Services) providing definitions, adding teledentistry to the practice of telemedicine, and requiring reimbursement for services provided via teledentistry. 2019 TX H.B. 1782 (NS), engrossed May 9, 2019, would adopt TX GOVT § 531.021611 (Action Plan to Expand Telemedicine Medical Services and Telehealth Services) to require the Commission to develop and implement an action plan to expand the use of and increase access to telemedicine medical services, telehealth services, and related mobile applications for those services by health care providers for the residents of this state. • 2019 TX H.B. 3269 (NS), introduced March 5, 2019, would adopt TX HEALTH & S § 241.1835 (Use of telehealth services and telemedicine medical services at certain hospitals) to prohibit the Commission from excluding or prohibiting the use of telehealth services or telemedical services by a physician providing on-call services at a hospital located in a rural area of this state that is assigned a Level I, II, or III level of care designation. • 2019 TX H.B. 3285 (NS), enrolled May 25, 2019, would adopt TX GOVT § 531.02253 (Telehealth Treatment for Substance Use Disorders) to require the Executive Commissioner to, by rule, establish a program to increase opportunities and expand access to telehealth treatment for substance use disorders in Texas. • 2019 TX H.B. 3345 (NS), adopted June 14, 2019, amends TX INS § 1455.004 (Coverage for Telemedicine Medical Services and Telehealth Services) to require a health benefit plan to provide coverage for a covered health care service or procedure delivered by a preferred or contracted health professional to a covered patient as a telemedicine medical service or telehealth service on the same basis and to the same extent that the plan provides coverage for the service or procedure in an in-person setting. The amendment is effective September 1, 2019. • 2019 TX H.B. 4455 (NS), adopted June 14, 2019, adopts TX OCC § 113.002 (Patient located outside of state) would allow a health care professional to provide a mental health service that is within the scope of the professional's license through the use of a telemedicine medical service or a telehealth service to a patient who is located outside of Texas, subject to applicable laws and regulations of the patient's jurisdiction. The bill is effective September 1, 2019. • 2019 TX S.B. 10 (NS), amended/substituted May 16, 2019, would adopt TX HEALTH & S § 113.0051 (Establishment; Purpose) establishing the Texas Mental Health Care Consortium to facilitate access to mental health care services through telemedicine and other cost-effective, evidence-based programs, TX HEALTH & S § 113.0151 (General Duties) to require the consortium to ensure that evidence-based tools, including telemedicine, are used to help expand the delivery of mental health care services, and TX HEALTH & S § 113.0152 (Comprehensive Child Psychiatry Access Centers) to require the a center to collaborate with community mental health providers to better care for children and youth with behavioral health needs by establishing or expanding a telemedicine or telehealth program for identifying and assessing behavioral health needs and providing access to mental health care services. • 2019 TX S.B. 71 (NS), adopted June 4, 2019, would establish a Statewide Telehealth Center for Sexual Assault Forensic Medical Examination. The bill is effective September 1, 2019. • 2019 TX S.B. 562 (NS), adopted June 14, 2019, amends TX CRIM PRO Art. 46B.073 (Commitment for Restoration to Competency) and TX CRIM PRO Art. 46B.105 (Transfer Following Civil Commitment Placement) to allow a defendant's competency and commitment to be determined through telepsychiatry. The amendments are effective September 1, 2019. • 2019 TX S.B. 670 (NS), adopted June 14, 2019, amends TX GOVT § 531.0216 (Participation and Reimbursement of Telemedicine Medical Service Providers and Telehealth Service Providers Under Medicaid) to require managed care organizations to provide reimbursement for health care services provided to Medicaid recipients via telemedicine or telehealth if it would be covered if it had been provided in-person. The amendment is effective September 1, 2019. • 2019 TX S.B. 749 (NS), adopted June 10, 2019, adopts TX HEALTH & S § 241.1835 (Use of Telehealth Services and Telemedicine Medical Services at Certain Hospitals) to provide the definition for “telehealth service” and “telemedicine medical service” and prohibiting the Executive Commissioner from excluding or prohibiting the use of telehealth services or telemedicine medical services by a physician providing on-call services at a hospital located in a rural area of this state, as defined by executive commissioner rule, that is assigned a Level I, II, or III level of care designation. The bill is effective September 1, 2019. • 2019 TX S.B. 1657 (NS), introduced March 6, 2019, would adopt TX HEALTH & S § 241.1831 (Level of care designations for maternal care in rural hospitals) to define telemedicine, require a rural hospital to have available a family medicine physician, an obstetrics and gynecology physician, or a maternal fetal medicine physician a viable for consolation either in person or as a telemedicine medical service. • 2019 TX S.B. 1666 (NS), introduced March 6, 2019, and 2019 TX H.B. 1706 (NS), introduced February 13, 2019, would amend TX OCC § 562.110 (Telepharmacy Systems) allowing federally qualified health centers, ambulatory surgical centers, birth centers, community health centers, hospitals, outpatient clinics, and public health clinics to utilize a telepharmacy system. Utah © 2020 Thomson Reuters. No claim to original U.S. Government Works. -47- 2019 UT H.B. 392 (NS), adopted March 25, 2019, would amend UT ST § 26-18-13.5 (Mental health telehealth services-- Reimbursement--Reporting-- Telepsychiatric consultations), UT ST § 26-60-105 (Study by Public Utilities, Energy, and Technology Interim Committee and Health Reform Task Force), and UT ST § 49-20-414 (Mental health telemedicine services-- Reimbursement-- Reporting) to require the Medicaid program to reimburse for certain telemedicine services at rates set by the Medicaid program, require the Public Employees' Benefit and Insurance Program to reimburse for certain telemedicine services at commercially reasonable rates, and update telemedicine reporting and study requirements. The amendment is effective May 14, 2019. Virginia • 2018 VA H.B. 1970 (NS) and 2018 VA S.B. 1221 (NS), adopted March 5, 2019, amends VA ST § 32.1-325 (Board to submit plan for medical assistance services to U.S. Secretary of Health and Human Services pursuant to federal law; administration of plan; contracts with health care providers) to require insurers, corporations, or health maintenance organizations to cover remote patient monitoring services as part of their coverage of telemedicine services to the full extent that these services are available., VA ST § 38.2-3418.16 (Coverage for telemedicine services) to define “remote patient monitoring services” and update the definition for “telemedicine services”, VA ST § 54.1-2901 (Exceptions and exemptions, generally) to provide that provisions of the Code of Virginia regulating health professions regulated by the Board of Medicine do not prevent or prohibit any practitioner of one of such professions who is located in another state and is in good standing with the applicable regulatory agency in such state from providing telemedicine services within the scope of his practice to a patient located in Virginia, and VA ST § 54.1-2903 (What constitutes practice) to provide that in cases in which a practitioner of the healing arts is providing telemedicine services, such practice is deemed to occur where the practitioner is located at the time of provision. The amendment is effective July 1, 2019. • 2018 VA H.B. 2128 (NS) and 2018 VA S.B. 1124 (NS), introduced January 9, 2019, would amend VA ST § 54.1-2901 (Exceptions and exemptions, generally) to authorize a person licensed to practice medicine or osteopathy who is in good standing with the applicable regulatory agency of a jurisdiction that is contiguous to the Commonwealth to provide health care services to patients located in the Commonwealth through use of telemedicine services. • 2019 VA S.B. 122 (NS), prefiled December 16, 2019, would amend VA ST § 54.1-2700 (Definitions), VA ST § 54.1-2711 (Practice of dentistry), and VA ST § 54.1-2719 (Persons engaged in construction and repair of appliances) defining “teledentistry,” establishing requirements for the practice of teledentistry, establishing requirements for the taking of dental scans for use in teledentistry by dental scan technicians, and clarifies requirements related to the use of digital work orders for dental appliances in the practice of teledentistry. The bill would also require the Board of Dentistry to review all applications for renewal of a license to identify those applicants who are engaged in the practice of teledentistry and report such information annually, by October 1, to the Chairmen of the House Committee on Health, Welfare and Institutions, the Senate Committee on Education and Health, and the Joint Commission on Health Care. • 2019 VA S.B. 52 (NS), prefiled November 18, 2019, would adopt VA ST § 37.2-310.1 (Opioid addiction treatment and recover services; pilot program) requiring the Department, in partnership with community services boards, a hospital licensed in the Commonwealth, and telemedicine networks, including the Center for Telehealth at the University of Virginia and the Virginia Telemedicine Network, to establish a two-year pilot program designed to provide comprehensive treatment and recovery services to uninsured or underinsured individuals suffering from opioid addiction or opioid-related disorders. The Department, together with the partnering hospital, community services boards, and telemedicine networks must develop an evidence-based treatment and recovery program that may include withdrawal management, medication-assisted treatment, behavioral and cognitive interventions, housing assistance, transportation assistance, and other community supports. Washington • 2019 WA H.B. 1593 (NS), adopted May 9, 2019, adopts a new section in WA ST 28B.20 (University of Washington) to expand the telepsychiatry consultation program at the University of Washington. The bill is effective July 27, 2019. • 2019 WA H.B. 1094 (NS), adopted April 30, 2019, amends WA ST 69.51A.030 (Acts not constituting crimes or unprofessional conduct--Health care professionals not subject to penalties or liabilities) to allow, for the authorization of the use of marijuana for medical purposes, a subsequent physician examination for the proposes of reviewing an authorization may occur through the use of telemedicine technology if the health care professional determines that requiring the qualifying patient to attend a physical examination in person to renew an authorization would likely result in severe hardship to the qualifying patient because of the qualifying patient's physical or emotional condition. The amendment is effective November 1, 2019. • 2019 WA S.B. 5385 (NS), amended/substituted February 22, 2019, would amend WA ST 48.43.735 (Reimbursement of health care services provided through telemedicine or store and forward technology), WA ST 41.05.700 (Reimbursement of health care services provided through telemedicine or store and forward technology), and WA ST 74.09.325 (Reimbursement of a health care service provided through telemedicine or store and forward technology--Report to the legislature) to require reimbursement for telemedicine or store and forward technology to be at the same rate as if the service was provided in person by the provider. • 2019 WA S.B. 5387 (NS), adopted April 17, 2019, amends WA ST 70.41.230 (Duty of hospital to request information on physicians granted privileges) to require physicians providing telemedicine or store and forward services at the distant site hospital to be fully credentialed and privileged to provide such services by the distant site hospital. The amendment is effective July 27, 2019. © 2020 Thomson Reuters. No claim to original U.S. Government Works. -48- • 2019 WA S.B. 5386 (NS), adopted April 17, 2019, adds a new section in WA ST 43.70 (Department of Health) would require a health care professional who provides clinical services through telemedicine shall complete telemedicine training and attest acknowledgment and understanding, and maintain documentation of training and attestation, prior to providing services through telemedicine to patients located in Washington. The bill is effective July 27, 2019. • 2019 WA S.B. 5498 (NS), amended/substituted February 12, 2019, would amend WA ST 69.51A.030 (Acts not constituting crimes or unprofessional conduct--Health care professionals not subject to penalties or liabilities) to allow, for the authorization of the use of marijuana for medical purposes, a subsequent physician examination for the proposes of reviewing an authorization may occur through the use of telemedicine technology if the health care professional determines that requiring the qualifying patient to attend a physical examination in person to renew an authorization would likely result in severe hardship to the qualifying patient because of the qualifying patient's physical or emotional condition. • 2019 WA S.B. 5511 (NS), adopted May 13, 2019, adopts a new section in WA ST 43.155 (Public Works Projects) would require the Board to give priority to applications that facilitate the use of telemedicine and electronic health records, especially in the delivery of behavioral health services and services to veterans. Medical interoperability is defined as a means of healthcare technology systems communicating and sharing data, including all data involved in patient care, from a patient's medical history to the real-time data that can be transmitted by medical devices directly to electronic health records. The amendment is effective July 27, 2019. • 2019 WA S.B. 5648 (NS), introduced January 25, 2019, would amend WA ST 70.41.230 (Duty of hospital to request information on physicians granted privileges) to include physician assistants and advanced registered nurse practitioners to the requirements for telemedicine. West Virginia • 2019 WV H.B. 3019 (NS), introduced February 12, 2019, would adopt WV ST § 33-15-4s (Additional mandatory policy provision) to require the insurer to contain an access plan to include how the use of telemedicine or telehealth or other technology may be used to meet network access standards. • 2019 WV H.B. 3089 (NS), introduced February 12, 2019, would amend WV ST § 30-3-13a (Telemedicine practice; requirements; exceptions; definitions; rule-making) to update the definition for “telemedicine” and “telemedicine technologies” and to update the licensing requirements for the practice of telemedicine and surgery or podiatry. • 2019 WV S.B. 464 (NS), amended/substituted February 23, 2019, would amend WV ST § 30-3-13 (Licensing requirements for the practice of medicine and surgery or podiatry; exceptions; unauthorized practice; notice; criminal penalties) and WV ST § 30-3-13a (Telemedicine practice; requirements; exceptions; definitions; rule-making) to update definitions and to update the requirements for the practice of telemedicine. Wisconsin • 2019 WI A.B. 56 (NS), adopted July 3, 2019, amends WI ST 49.45 (Medical assistance; administration) to update the definition for “telehealth.” The amendment is effective July 4, 2019. • Assistance program for any benefit that is covered under the Medical Assistance program, delivered by a certified Medical Assistance program, and provided through interactive telehealth. • 2019 WI A.B. 410 (NS), introduced September 5, 2019, and 2019 WI S.B. 380 (NS, introduced August 29, 2019, would amend WI ST 49.45 (Medical assistance; administration) and WI ST 49.46 (Medical assistance; recipients of social security aids) requiring the Department to provide reimbursement under the Medical Assistance program for any benefit that is covered under the Medical Assistance program, delivered by a certified Medical Assistance program, and provided through interactive telehealth. • 2019 WI S.B. 593 (NS), introduced November 27, 2019, and 2019 WI A.B. 654 (NS), introduced December 5, 2019, would require the Department of Correction to expand telehealth mental health treatment to offenders under community supervision in division of community corrections regions 4, 6, and 8. Wyoming 2019 WY S.F. 133 (NS), introduced January 24, 2019, would require the Department of Health to study the current quality and availability of telemedicine in Wyoming and strategies for improving this service. RECENT STATE REGULATORY ACTIVITY Alaska 2019 AK REG TEXT 522725 (NS), filed July 22, 2019, adopts 12 AK ADC 07.020 (Telemedicine), 12 AK ADC 07.030 (Consent to send records), and 12 AK ADC 07.090 (Definitions) establishing the requirements for the practice of telemedicine by audiologists, speech- © 2020 Thomson Reuters. No claim to original U.S. Government Works. -49- language pathologists, and speech-language pathology assistants and providing related definitions. The new rules are effective August 21, 2019. Alabama • 2019 AL REG TEXT 528188 (NS), filed June 20, 2019, amends AL ADC 850-X-2-.01 (Definitions of Terms) providing the definition for “telehealth.” The amendment is effective October 1, 2019. • 2019 AL REG TEXT 533312 (NS), filed August 20, 2019, adopts AL ADC 850-X-2-.04 (Telehealth) to establish the requirements for licensees providing social work via telehealth to a client located in Alabama. The rule is effective January 13, 2020. Colorado • 2019 CO REG TEXT 529675 (NS), published September 25, 2019, renumbers 3 CO ADC 713-7:400-2 (Extent and Manner in which a Physician Assistant May Perform Delegated Tasks Constituting the Practice of Medicine Under Personal and Responsible Direction and Supervision) as 3 CO ADC 713-7:400-7.1 (Extent and Manner in which a Physician Assistant May Perform Delegated Tasks Constituting the Practice of Medicine Under Personal and Responsible Direction and Supervision). The regulation is effective October 15, 2019. • 2019 CO REG TEXT 531167 (NS), filed, via emergency, August 2, 2019, amends 3 CO ADC 713-7:400-7.1 (Extent and Manner in Which a Physician Assistant May Perform Delegated Tasks Constituting the Practice of Medicine Under Personal and Responsible Direction and Supervision) clarifying that practicing medicine based primarily on telecommunication devices or other telehealth technologies does not constitute “actively practicing medicine in Colorado” for the purpose of requirements for supervising physicians. The amendments are effective August 2, 2019. • 2019 CO REG TEXT 531168 (NS), adopted July 17, 2019, amends 5 CO ADC 1006-2:1 (Establishment and confidentiality of the registry for the medical use of marijuana) clarifying that an “appropriate personal physical examination” for purposes of establishing a “bona fide physician-patient relationship” cannot be performed by remote means, including telemedicine. The amendment is effective August 2, 2019. District of Columbia • 2019 DC REG TEXT 429827 (NS), adopted, via emergency rulemaking, July 26, 2019, adopts 29 DC ADC § 910 (Medicaid- Reimbursable Telemedicine Services) establishing the eligibility criteria for the receipt of telemedicine services and conditions of participation for providers who deliver telemedicine services as part of the District of Columbia's Medicaid program. The rule is effective July 26, 2019. • 2019 DC REG TEXT 429827 (NS), published December 13, 2019, adopts 9 DC ADC § 910 (Medicaid-Reimbursable Telemedicine Services) establishing eligibility standards for Medicaid beneficiaries receiving telemedicine services under the Medicaid fee-for- service program. Also, establishes conditions of participation and reimbursement policies for providers. This rulemaking was previously adopted by emergency rule with certain changes. The rule is effective December 13, 2019. Florida • 2019 FL REG TEXT 470616 (NS), published August 13, 2019, amends FL ADC 65D-30.002 (Definitions) updating definition for “telehealth,” adopts FL ADC 65D-30.0036 (Licensure Application and Renewal) establishing telehealth requirements for license applicants, and FL ADC 65D-30.004 (Common Licensing Standards) establishing the requirements for the provision of telehealth services. The rules are effective August 29, 2019. • 2019 FL REG TEXT 532000 (NS), published October 1, 2019, repeals FL ADC 64B8-9.0141 (Standards for Telemedicine Practice) effective October 14, 2019. • 2019 FL REG TEXT 533108 (NS), published October 8, 2019, repeals FL ADC 64B15-14.0081 (Standards for Telemedicine Practice) effective October 24, 2019. Kansas 2019 KS REG TEXT 513401 (NS), filed January 3, 2019, adopts KS ADC 100-77-1 (Definitions) providing that the definitions for “distant site,” “healthcare provider,” “originating site,” “physician,” “telemedicine,” and “telehealth” have the same meaning as specified in KS ST 40-2,211 (Same; definitions), KS ADC 100-77.2 (Telemedicine deemed rendered at location of patient) providing that the delivery of healthcare services is deemed to occur at the originating site, and KS ADC 100-77-3 (Prescribing drugs by means of telemedicine) providing that the same laws and regulations that apply to a healthcare provider prescribing drugs, including controlled substances, by means of in-person contact with a patient shall apply to prescribing drugs, including controlled substances, by means of telemedicine. The new rules are effective December 28, 2018. © 2020 Thomson Reuters. No claim to original U.S. Government Works. -50- Georgia 2019 GA REG TEXT 538742 (NS), filed November 4, 2019, adopts GA ADC 511-5-13-.04 (Designation Criteria for Maternal Centers) and GA ADC 511-5-13-.05 (Designation Criteria for Neonatal Centers) establish separate criteria for three maternal and three neonatal levels of care and procedures by which a perinatal facility may request approval to be a designated facility which has achieved a particular DPH designated level of care. Includes requirements for telemedicine. The new rules are effective November 14, 2019. Indiana 2019 IN REG TEXT 505512 (NS), filed August 14, 2019, adopts 410 IN ADC 39-4-3 (Obstetric Level III facility requirements) and 410 IN ADC 39-8-5 (Support services) establishing the telemedicine requirements for Obstetric Level III facilities and perinatal centers. The rules are effective September 13, 2019. Iowa • 2019 IA REG TEXT 501163 (NS), filed January 2, 2019, amends IA ADC 441-25.1(331) (Definitions) adding the definition for “face-to- face.” The amendment is effective March 1, 2019. • 2019 IA REG TEXT 520055 (NS), filed November 6, 2019, adopts IA ADC 650-27.12(153) (Teledentistry) establishing the standards of practice for teledentistry. The new rule is effective December 11, 2019. • 2019 IA REG TEXT 531154 (NS), filed November 8, 2019, amends IA ADC 657-13.4(155A) (Responsible parties), IA ADC 657-13.8(124,155A) (General requirements for telepharmacy site), IA ADC 657-13.9(155A) (General requirements for managing pharmacy), IA ADC 657-13.11(155A) (General requirements for telepharmacy technician), IA ADC 657-13.16(124,155A) (Telepharmacy site-initial application), IA ADC 657-13.17(124,155A) (Changes to telepharmacy site or managing pharmacy), and IA ADC 657-13.21(124,155A) (Policies and procedures) allowing the pharmacist in charge (PIC) of a managing pharmacy to designate another pharmacist to serve as PIC of a telepharmacy site, requiring the PIC of the telepharmacy site to be employed by the managing pharmacy and to be identified on the pharmacy license of the telepharmacy site, allowing training of telepharmacy technicians at the managing pharmacy or at another pharmacy that uses the same audiovisual technology system, and requiring the display at the telepharmacy site of the original license to practice pharmacy in Iowa of the telepharmacy site's PIC and the current license renewal certificates of the telepharmacy site's PIC and of any pharmacist who may provide counseling to patients at the telepharmacy site. The rules are effective January 8, 2020. Kentucky • 2019 KY REG TEXT 527620 (NS), filed with the Legislative Research Commission June 14, 2019, adopts 907 KY ADC 3:170E (Telehealth service coverage and reimbursement) to amend 907 KY ADC 3:170 (Telehealth consultation coverage and reimbursement) changing the regulation title, removing outdated definitions, and providing the definition for “telehealth,” “telehealth service,” “place of service,” and “telehealth care provider.” Provides that telehealth reimbursement is at the same level of reimbursement for comparable services provided in-person. Establishes cost-sharing requirements for telehealth services. Requires providers to appropriately denote telehealth services and to document them in the patient's medical record. Clarifies that referral requirements are the same as for in- person services. Removes outdated provisions. The amendment is effective June 14, 2019. • 2019 KY REG TEXT 530165 (NS), filed June 28, 2019, adopts emergency rule 902 KY ADC 20:430E (Facilities specifications, operation and services; behavioral health services organizations for mental health treatment) to amend 902 KY ADC 20:430 (Facilities specifications, operation and services; behavioral health services organizations) providing the definition for “telehealth” and allowing services, screenings, and assessments to be provided via telehealth. The emergency rule is effective June 28, 2019. • 2019 KY REG TEXT 530167 (NS), filed June 28, 2019, adopts emergency rule 907 KY ADC 15:005E (Definitions for 907 KAR Chapter 15) to amend 907 KY ADC 15:005 (Definitions for 907 KAR Chapter 15) providing the definition for “telehealth.” The emergency rule is effective July 1, 2019. • 2019 KY REG TEXT 530168 (NS), filed June 28, 2019, adopts emergency rule 907 KY ADC 15:010E (Coverage provisions and requirements regarding behavioral health services provided by individual approved behavioral health practitioners, behavioral health provider groups, and behavioral health multi-specialty groups) to amend 902 KY ADC 15:010 (Coverage provisions and requirements regarding behavioral health services provided by individual behavioral health providers, behavioral health provider groups, and behavioral health multi-specialty groups) allowing services, screenings, and assessments to be provided via telehealth. The emergency rule is effective July 1, 2019. • 2019 KY REG TEXT 530170 (NS), filed June 28, 2019, adopts emergency rule 907 KY ADC 15:020E (Coverage provisions and requirements regarding services provided by behavioral health services organizations for mental health treatment) to amend 902 KY ADC 20:020 (Coverage provisions and requirements regarding services provided by behavioral health services organizations) allowing services, screenings, and assessments to be provided via telehealth. The emergency rule is effective July 1, 2019. © 2020 Thomson Reuters. No claim to original U.S. Government Works. -51- • 2019 KY REG TEXT 530170 (NS), filed June 28, 2019, adopts emergency rule 907 KY ADC 15:022E (Coverage provisions and requirements regarding services provided by behavioral health services organizations for substance use disorder treatment and co- occurring disorders) allowing services, screenings, and assessments to be provided via telehealth. The emergency rule is effective July 1, 2019. Louisiana • 2019 LA REG TEXT 498658 (NS), published March 20, 2019, amends 46 LA ADC Pt LXIX, § 101 (Definitions) providing the definition for “telenutrition” and adopts 46 LA ADC Pt LXIX, § 105 (Licensing of Dieticians/Nutritionists Practicing Telenutrition) establishing the licensing requirements for dieticians/nutritionists practicing telenutrition. The rules are effective March 20, 2019 • 2019 LA REG TEXT 501399 (NS), published March 20, 2019, amends 46 LA ADC Pt LXXV, § 135 (Telehealth) to correct errors made in the previous rulemaking. Specifically, updates terminology to use “telehealth” instead of “telepractice.” The rule is effective March 20, 2019. • 2019 LA REG TEXT 512533 (NS), published March 20, 2019, adopts new 46 LA ADC Pt LX, § 505 (Teletherapy Guidelines for Licensees) to establish the licensure requirements, fees, and exemptions for teletherapy. The rule is effective March 20, 2019. • 2019 LA REG TEXT 522099 (NS), published October 20, 2019, amends 46 LA ADC Pt XLV, § 7705 (Definitions) defining “consult or consultation” to allow the consultation to be obtained in person or by telephone, telemedicine, or electronic mail, provided it affords for medical/health information privacy and security. The rule is effective October 20, 2019. • 2019 LA REG TEXT 522100 (NS), published August 20, 2019, amends 46 LA ADC Pt XLV, § 7505 (Patient Relationship; Standard of Care; Location of Participants) clarifying that a patient receiving medical services by telemedicine may be in any location at the time that the services are received by removing requirements that the patient be located “in this state.” The amendment is effective August 20, 2019. Maine 2019 ME REG TEXT 527867 (NS), published September 25, 2019, amends ME ADC 10-144 Ch. 101, Ch. II, § 28 (Rehabilitative and Community Support Services for Children with Cognitive Impairments and Functional Limitations) allowing telemedicine to be utilized as clinically appropriate. The amendment is effective September 23, 2019. Maryland • 2018 MD REG TEXT 50910 (NS), adopted November 29, 2018, amends MD ADC 10.09.59.04 (Provider Requirements for Participation) allowing a psychiatrist in Assertive Community Treatment (ACT) and Mobile Treatment to provide services via telehealth. The amendment is effective December 31, 2018. • 2019 MD REG TEXT 521670 (NS), adopted July 22, 2019, adopts new chapter MD ADC 10.32.05 (Telemedicine) to improve patient safety, to authorize other health occupations under the Board's jurisdiction to do telehealth, and to reflect technological innovations and the increasing use of telehealth in more settings. The regulations are effective August 12, 2019. New sections include: MD ADC 10.32.05.02 (Definitions); MD ADC 10.32.05.03 (Licensure); MD ADC 10.32.05.04 (Standards Related to Telemedicine); MD ADC 10.32.05.05 (Patient Evaluation); and MD ADC 10.32.05.06 (Standard of Quality of Care). • 2019 MD REG TEXT 525785 (NS), adopted September 5, 2019, renumbers and amends MD ADC 10.09.49.05 (Covered Services) as MD ADC 10.09.49.04 (Covered Services); MD ADC 10.09.49.07 (Provider Conditions for Participation) as MD ADC 10.09.49.06 (Provider Conditions for Participation); MD ADC 10.09.49.10 (Limitations) as MD ADC 10.09.49.09 (Limitations) and MD ADC 10.09.49.11 (Reimbursement) as MD ADC 10.09.49.10 (Reimbursement) removing certain restrictions regarding services delivered via telehealth so that all provider types can receive Medicaid reimbursement if their licensing board includes telehealth in its scope of practice. Renumbers MD ADC 10.09.49.09 (Confidentiality) as MD ADC 10.09.49.08 (Confidentiality). The regulations are effective October 7, 2019. • 2019 MD REG TEXT 537938 (NS), filed October 25, 2019, renumbers MD ADC 10.09.67.31 (Benefits – Telemedicine Services) as MD ADC 10.67.06.31 (Benefits – Telemedicine Services) without changes. The amendment is effective December 11, 2019. Massachusetts 2019 MA REG TEXT 521052 (NS), published July 12, 2019, amends 104 MA ADC 27.12 (Prevention of Restraint and Seclusion and Requirements When Used) providing that the requirement for examination pursuant to 104 MA ADC 27.12(8)(d)(4) may be satisfied through utilization of telemedicine or other technology pursuant to protocols approved by the Department that assure verbal and visual observation and communication between the patient and an off-premises authorized physician and adequate on-premises clinical staff provided that a physician, registered nurse or certified physician assistant as assessed the patient and determined that: the medication restraint has taken effect and the patient is not in need of further restraint; the patient has not experienced side effects of the medication restraint; there are no apparent medical or physical conditions related to the medication restraint that require an in-person examination; © 2020 Thomson Reuters. No claim to original U.S. Government Works. -52- and initiation of Mechanical Restraint, Physical Restraint or Seclusion. Providing that the requirement for examination pursuant to 104 MA ADC 27.12(8)(e)(2)(d) may be satisfied through utilization of telemedicine or other technology pursuant to protocols approved by the Department that assure verbal and visual observation and communication between the patient and an off-premises authorized physician and adequate on-premises clinical staff provided that the restraint or seclusion episode has ended and the patient has been permanently released from restraint or seclusion in accordance with 104 MA ADC 27.12(h)(8). The amendment is effective July 12, 2019. Michigan 2019 MI REG TEXT 519863 (NS), filed with the Secretary of State on November 19, 2019, adopts MI ADC R 338.306 (Telehealth services; requirements) establishing the standard of care requirements for an optometrist who provides telehealth services. The rule is effective November 19, 2019. Mississippi 2019 MS REG TEXT 517903 (NS), filed October 25, 2019, adopts 30 MS ADC Pt. 3103, R. 3.2 (Telehealth) establishing the requirements fort the use of telehealth by physical therapists/physical therapist assistants. The rule is effective November 25, 2019. Missouri 2019 MO REG TEXT 520093 (NS), filed February 22, 2019, amends 20 MO ADC 2150-7.135 (Physician Assistant Supervision Agreements) providing that if the collaborating physician and physician assistant are utilizing telehealth in providing services in a medically underserved area no mileage limitation apply and that if the collaborating physician and physician assistant are not utilizing telehealth in providing services in the medically underserved area, the practice location where the collaborating physician, or other physician designated in the collaborative practice agreement, must be no further than seventy-five (75) miles by road, using the most direct route available, from the collaborating physician assistant. The rule was adopted via emergency rule and is effective March 4, 2019 and expires August 30, 2019. Nevada 2019 NV REG TEXT 516404 (NS), filed October 30, 2019, amends NV ADC 639.250 (Restrictions on supervision) authorizing a pharmacist to supervise more than 1 pharmaceutical technician in any telepharmacy, remote site, or satellite consultation site. The amendment is effective October 30, 2019. New Jersey 2019 NJ REG TEXT 522892 (NS), filed October 15, 2019, adopts NJ ADC 13:34D-8.1 (Purpose and Scope) and NJ ADC 13:34D-8.2 (Standard of Care) authorizing art therapists to engage in telemedicine and telehealth and establishing the standard of care for providing services through telemedicine or telehealth. The rules are effective November 18, 2019. New Mexico 2019 NM REG TEXT 525908 (NS), published August 27, 2019, amends NM ADC 7.34.2 (Advisory Board Responsibilities and Duties) and NM ADC 7.34.4 (Licensing Requirements for Produces, Couriers, Manufacturers and Laboratories) providing the definition for “telemedicine” and NM ADC 7.34.3 (Registry Identification Cards) providing the definition for “telemedicine” and providing that a practitioner may only issue a written certification on the basis of an evaluation conducted via telemedicine if the practitioner has previously examined the patient in person. The amendments are effective August 27, 2019. New York 2019 NY REG TEXT 515158 (NS), filed June 17, 2019, amends 14 NY ADC 596.4 (Definitions), 14 NY ADC 596.5 (Approval to Utilize Telemental Health Services), 14 NY ADC 596.6 (Requirements for Telemental Health Services) and 14 NY ADC 596.7 (Reimbursement for Telemental Health Services) to update the requirements related to telemental health services. New definitions are added, and the terminology is updated to use “telemental health” instead of “telepsychiatry”. Updates the general requirements, the protocols and procedures, and adds requirements for telemental health services to be delivered in a Personalized Recovery Oriented Services (“PROS”) setting. Provides that the Commissioner may direct the provider to immediately suspend the provision of telemental health services pending review of a decision to revoke if there is reason to believe the safety or privacy of any patient has been compromised because of telemental health service provision. Also makes other clarifying and conforming changes. The amendments are effective July 3, 2019. Oklahoma © 2020 Thomson Reuters. No claim to original U.S. Government Works. -53- 2019 OK REG TEXT 541069 (NS), filed October 31, 2019, amends, via emergency, OK ADC 317:30-3-27 (Telehealth) adding requirements for certain designated telehealth services to be provided in a primary or secondary school setting. Provides that a telehealth service is subject to the same SoonerCare program restrictions, limitations, and coverage which exist for the service when not provided through telehealth; provided, however, that only certain telehealth codes are reimbursable by SoonerCare. Also, updates the definitions, adds requirements for physical therapy, occupational therapy, and/or speech and hearing services and makes other clarifying and conforming changes. The rule is effective October 25, 2019 and expires September 15, 2019, unless superseded by another rule or disapproved by the Legislature. Oregon • 2019 OR REG TEXT 513703 (NS), filed August 1, 2019, amends OR ADC 335-005-0010 (Definitions) providing the definition for “telepractice,” “patient” or “client,” “telepractice service,” client/patient site,” and “clinician site” and adopts OR ADC 335-005-0016 (Tele- practice) establishing the requirements for audiologists and speech-language pathologists to participate in telepractice. The rules are effective September 5, 2019. • 2019 OR REG TEXT 530589 (NS), filed July 16, 2019, amends, via temporary rule, OR ADC 309-088-0125 (CMHP Responsibilities) clarifying that consultations must occur through a face-to-face meeting, either in-person or via telehealth, as clinically appropriate. The amendment is effective July 16, 2019. Pennsylvania 2019 PA REG TEXT 465308 (NS), filed October 11, 2019, amends 55 PA ADC § 1153.2 (Definitions) and 55 PA ADC § 5200.3 (Definitions) providing the definition for “tele-behavioral health,” 55 PA ADC § 1153.14 (Noncovered services) clarifying that payment will not be made for a covered psychiatric outpatient clinic, MMHT or partial hospitalization outpatient service conducted over the telephone, 55 PA ADC § 1153.51 (General payment policy) requiring the Department to publish procedures for the use of tele- behavioral health to provide compensable psychiatric outpatient clinic or psychiatric partial hospitalization services in the Pennsylvania Bulletin, and 55 PA ADC § 5200.22 (Staffing pattern) clarifying that 50% of the psychiatric time may be provided by a psychiatrist off- site by the use of tele-behavioral health. The regulations are effective October 12, 2019. Texas 2019 TX REG TEXT 512595 (NS), filed June 10, 2019, amends 40 TX ADC § 108.403 (Definitions), 40 TX ADC § 108.501 (Specialized Rehabilitative Services), and 40 TX ADC § 108.1104 (Early Childhood Intervention Services Delivery) to allow case management services, specialized rehabilitative services, and early childhood intervention services to be provided via telehealth with the prior written consent of the parent. The amendments are effective June 30, 2019. Vermont 2019 VT REG TEXT 498203 (NS), filed December 20, 2018, adopts VT ADC 12-9-3.101 (Telehealth) establishing the criteria for Medicaid coverage and reimbursement for Telehealth, including telemedicine, store and forward, and telemonitoring, under Vermont's Medicaid program. The new rule is effective January 7, 2019. Virginia • 2018 VA REG TEXT 458397 (NS), filed November 21, 2018, amends 18 VA ADC 110-20-690 (Persons or entities authorized or required to obtain a controlled substances registration) authorizing issuance of a controlled substances registration to (i) persons who have been trained in the administration of naloxone in order to possess and dispense the drug to persons receiving training and (ii) an entity for the purpose of establishing a bona fide practitioner-patient relationship for prescribing when treatment is provided by telemedicine in accordance with federal rules. The amendment is effective January 23, 2019. • 2019 VA REG TEXT 464888 (NS), filed June 14, 2019, adopts 18 VA ADC 110-60-30 (Requirements for a practitioner issuing a certification) prohibiting a practitioner, using a certification for cannabidiol oil or THC-A oil for any diagnosed condition or disease, to use telemedicine for patient care and evaluation for the first year of certification. The amendment is effective August 7, 2019. • 2019 VA REG TEXT 541682 (NS), November 13, 2019, amends 12 VA ADC 30-70-271 (Payment for capital costs) providing that effective July 1, 2019, inpatient capital rates for critical access hospitals shall be 100% of cost reimbursement. The rule is effective January 8, 2020. Washington • 2019 WA REG TEXT 526504 (NS), filed September 25, 2019, amends WA ADC 182-535-1050 (Definitions) providing the definition for “distant site (location of dental provider),” “originating site (location of client),” and “teledentistry.” The amendment is effective October 26, 2019. © 2020 Thomson Reuters. No claim to original U.S. Government Works. -54- • 2019 WA REG TEXT 531841 (NS), filed November 1, 2019, amends WA ADC 246-71-010 (Definitions) adding the definition for “telemedicine.” The rule is effective November 1, 2019. Wyoming • 2019 WY REG TEXT 520147 (NS), published July 18, 2019, adopts WY ADC 083.0001.3 § 4 (Telehealth) establishing the requirements for occupational services to be provided via telehealth. The new section is effective July 12, 2019. • 2019 WY REG TEXT 531222 (NS), adopted, via emergency, August 13, 2019, WY ADC 052.0001.1 § 3 (Definitions) allowing a physician-patient relationship to be established through telemedicine. The amendment is effective August 13, 2019. V. E-Prescribing and E-Prescription Monitoring Programs Proponents tout the usefulness and benefits of electronic prescribing technology in reducing drug prescribing errors, largely attributed to illegible prescription orders, and increasing efficiencies in delivering prescription drugs to patients. The use of electronic prescriptions has grown dramatically in recent years. In December 2008 only 7% of U.S. physicians were using e- [FN162] prescriptions. That number rose to 48% by June 2012 with Iowa, Minnesota, New Hampshire, and North Dakota experiencing the greatest growth. During that same time the number of community pharmacies that can accept e-prescriptions rose from 76% to 94%. There was also during that time a ten-fold increase in the growth of new and renewal e-prescriptions. The states with the highest volume of e-prescriptions are California, Texas, New York, and Florida. Several studies have found benefits in e-prescriptions. In September 2010 Partners Healthcare released a study showing that automated text messages to patients that include reminders about medication and educational information about their ailment improve [FN163] a patient's compliance with the prescribed treatment. The patients in the study suffered from atopic dermatitis. At the start of the project 92% of the patients reported that sometimes they forgot to take or apply their medication and 88% reported that often they stopped using their medication when their skin appeared to improve. However, at the end of the study 72% improved their compliance to treatment and 98% reported an improvement in at least one self-care behavior A study released in July 2011 from George Washington University, “Effect of Electronic Prescription on Cholesterol Goals,” found that while clinical end points supporting the use of e-prescribing were lacking, the use of e-prescriptions improves low-density lipoprotein [FN164] (LDL) goals. The researchers looked at electronic medical records of a multispecialty outpatient academic medical practice in order to identify patient encounters during which consecutive lipid panels were drawn in 2007. Logistic regression was then used to examine whether the odds of reaching LDL goal were influenced using e-prescriptions. The researchers found that patients with an e- prescription which included formulary decision support, a tool to inform physicians of drug costs, were 59% more likely to achieve their LDL goals than those with a manual prescription. The researchers concluded that, “[E]-prescribing can deliver tangible clinical gains to patients, likely from improved adherence to more affordable treatment.” A study published in November 2011 in the Journal of the American Medical Informatics Association, shows that physician practices and pharmacies generally view electronic prescribing as an important tool to improve patient safety and save time, but both groups face [FN165] barriers to realizing the technology's full benefit. The study looked at a key aspect of e-prescribing: the electronic exchange of prescription data between physician practices and pharmacies, which can save time and money by streamlining the way in which new [FN166] prescriptions and renewals are processed. The study found that physician practices and pharmacies generally were positive about the electronic transmission of new prescriptions. However, prescription renewals, the connectivity between physician offices and mail-order pharmacies, and the manual entry of certain prescription information by pharmacists, particularly drug name, dosage form, quantity, and patient instructions, continue to pose problems. In producing the study, which was fully-funded by the Department of Health and Human Services, Researchers at the Center for Studying Health System Change, Washington, D.C., researchers conducted 114 interviews with representatives of 24 physician practices, 48 community pharmacies and three mail-order pharmacies using e-prescribing. Community pharmacies were divided between local and national companies. The study also found that physician practices and pharmacies used e-prescribing features for electronic renewals much less often than for new prescriptions. More than a quarter of the community pharmacies reported that they did not send electronic renewal requests to physicians. Similarly, one-third of physician practices had e-prescribing systems that were not set up to receive electronic renewals or only received them infrequently. Among the findings of the study are: • About three-quarters of physician practices reported problems sending new prescriptions and renewals electronically to mail-order pharmacies. Many practices were unsure which mail-order pharmacies accepted e-prescriptions and believed that, even when a mail- order company did accept them, the process was unreliable. • Pharmacies noted the need to sometimes manually edit certain prescription information, such as drug name, dosage and quantity. One common cause reported by both physicians and pharmacists was that physicians must select medications with more specificity when e-prescribing and make decisions about such factors as packaging and drug form. Previously pharmacists had made such decisions from handwritten prescriptions. © 2020 Thomson Reuters. No claim to original U.S. Government Works. -55- • Nearly half of pharmacies reported that patient instructions typically had to be rewritten for patients to understand them. Most recently, a 2012 study published in PLoS Medicine found that when hospitals switch to using electronic prescriptions they can [FN167] see a 60% drop in error rate. This is particularly significant since it has been estimated that 1 in 7 hospital patients suffers from some form of error. According to the annual study by the Leapfrog Group, only 17% of the responding U.S. hospitals have employed a system for electronic prescriptions. The study did note, however, that a computerized system could cause errors as well due to software design. However, the researchers concluded that while system-related errors require close attention, as they are frequent, they are [FN168] potentially remediable by system redesign and user training. [FN169] In the fall of 2014, CMS released its “User Guide: 2013 Electronic Prescribing (eRx) Incentives Feedback Reports.” According to the CMS the report is designed to assist eligible professionals, group practices and their authorized users in interpreting the 2013 eRx Incentives Feedback Reports. The report reflects data from the Medicare Part B Physician Fee Schedule claims received for the dates of service January 1, 2013 – December 31, 2013 that were processed into National Claims History (NCH) by February 28, 2014. Additionally, quality data was received from qualified registries and EHR systems for purposes of the eRx Incentive Program. The 2013 eRx incentive payment is scheduled to be distributed in the fall of 2014. Participation in the 2013 eRx Incentive Program was defined as individual EPs or group practices participating via eRx GPRO submitting at least one eRx quality-data code (QDC) via claims or quality data via qualified registry, or qualified EHR submission methods. Much like past years, security and the prevention of fraud and abuse related to prescriptions are important themes as lawmakers propose strict prerequisites for issuing electronic prescription orders and the establishment or enhancement of electronic monitoring programs to track controlled substances. Beginning March 27, 2016, all prescriptions written in New York must be transmitted electronically from the prescriber directly to the [FN170] pharmacy. This requirement is a component of New York's I-STOP Act. I-STOP aims to reduce the number of deaths caused by opioid addiction and the over-prescription of painkillers by implementing improved electronic monitoring methods. I-STOP was passed in 2012 as part of New York's continuing effort to lead the way in programs to track, monitor and protect against drug abuse. The first process in the I-STOP Act went in to effect August 27, 2013 requiring all prescribers to consult the Prescription Monitoring Program (PMP) Registry when writing a prescription for a Schedule II, III, and IV controlled substance. I-STOP is intended to help practitioners better evaluate their patients being treating with controlled substance and prevent prescription drug abuse and overdose, prescription fraud, prescription errors, and double doctoring/doctor shopping. By moving to a 100% electronic prescription system, paper prescription pads can no longer be stolen, forged, or alter to illegally obtain a prescription drug. There is limited exception to the I-STOP Act. I-STOP does not apply to veterinarians. All other prescribers of controlled substances require the prescription to be transmitted electronically, regardless of the amount of supply. An exception to this rule, is that a paper or oral prescription may be issued for a controlled substance that does not exceed a 5-day supply, only if the practitioner determines that it would be impractical for the patient to obtain substances prescribed by electronic prescription in a timely manner, and such delay would adversely impact the patient's medical condition. RECENT FEDERAL LEGISLATIVE ACTIVITY • 2019 CONG US HR 19, introduced in House December 9, 2019, would amend 42 USCA § 1395w-104 (Beneficiary protections for qualified prescription drug coverage) requiring, not later than January 1, 2021, the program shall implement real-time benefit tools that are capable of integrating with a prescribing health care professional's electronic prescribing or electronic health record system for the transmission of formulary and benefit information in real time to prescribing health care professionals. With respect to a covered part D drug, such tools shall be capable of transmitting such information specific to an individual enrolled in a prescription drug plan. • 2019 CONG US HR 2115, referred in Senate October 29, 2019, would amend 42 USCA § 1395w-104 (Beneficiary protections for qualified prescription drug coverage) to require, by January 1, 2021, the program to implement real-time benefit tools that are capable of integrating with a prescribing health care professional's electronic prescribing or electronic health record system for the transmission of formulary and benefit information in real time to prescribing health care professionals. RECENT STATE LEGISLATIVE ACTIVITY Alabama 2019 AL H.B. 69 (NS), adopted June 7, 2019, amends AL ST § 34-23-8 (Substitution of drugs or brands of drugs) to provide that an electronic prescription from a practitioner specify whether a generic product may be dispensed. The bill is effective September 1, 2019. Arizona 2019 AZ H.B. 2075 (NS), adopted February 14, 2019, amends AZ ST § 36-2525 (Prescription orders; labels; packaging; definition) adding exceptions to the electronic prescription requirement during any period in which an established electronic prescribing system is © 2020 Thomson Reuters. No claim to original U.S. Government Works. -56- not operational or available in a timely manner. If the electronic prescribing system is not operational or available, the pharmacist may dispense a prescription order that is written or received pursuant to subsection E of this section for a schedule II-controlled substance that is an opioid. The amendment is necessary to preserve the public peace, health, or safety and is effective immediately. Arkansas • 2019 AR H.B. 1269 (NS), adopted April 1, 2019, amends AR ST § 17-92-503 (Generic substitutions) to require a pharmacist who dispenses a biological product to communicate to the prescriber the name and manufacturer of the drug within 5 business days following the dispensing of the biological product. The communication shall occur via an entry in an interoperable electronic medical records system, an electronic prescribing technology, a pharmacy benefit management system or a pharmacy record that can be accessed electronically by the prescriber. The amendment is effective August 6, 2019. • 2019 AR S.B. 174 (NS), adopted March 13, 2019, amends AR ST § 5-64-308 (Prescriptions) to require mandatory electronic prescribing for controlled substances. The amendment is effective August 6, 2019. Colorado 2019 CO S.B. 79 (NS), adopted April 8, 2019, adopts CO ST § 10-32-107.7 (Electronic prescribing of controlled substances - exceptions - rules - definition), CO ST § 12-35-114.5 (Electronic prescribing of controlled substances - exceptions - rules), CO ST § 12-36-117.9 (Electronic prescribing of controlled substances - exceptions - rules – definition), CO ST § 12-38-111.7 (Electronic prescribing of controlled substances - exceptions - rules – definition), and CO ST § 12-40-109.9 (Electronic prescribing of controlled substances - exceptions - rules – definition) to establish electronic prescribing requirements for controlled substances and providing exceptions. The bill would also amend CO ST § 12-22-122 (Prescription required--exception--dispensing opiate antagonists-- definitions) to exempt pharmacists from verifying the applicability of an exception to electronic prescribing of controlled substances. The bill is effective August 2, 2019 Connecticut • 2019 CT H.B. 5144 (NS), introduced January 10, 2019, would amend CT ST § 21a-254 (Designation of restricted drugs or substances by regulations. Records required by chapter. Electronic prescription drug monitoring program) to require physicians to check the electronic prescription drug monitoring program prior to writing prescriptions. • 2019 CT H.B. 7159 (NS), adopted July 9, 2019, amends CT ST § 21a-254 (Designation of restricted drugs or substances by regulations. Records required by chapter. Electronic prescription drug monitoring program) to allow pharmacists to designate a pharmacy technician to access the electronic prescription drug monitoring program and patient-controlled substance prescription information after the supervising pharmacist provides training. The amendment is effective July 9, 2019. • 2019 CT H.B. 7395 (NS), amended/substituted April 29, 2019, would amend CT ST § 21a-254 (Designation of restricted drugs or substances by regulations. Records required by chapter. Electronic prescription drug monitoring program) add opioid antagonists to drugs monitored as part of the electronic prescription drug monitoring program. Delaware • 2019 DE H.B. 115 (NS), adopted June 27, 2019, amends DE ST TI 24 § 502 (Definitions), DE ST TI 24 § 1101 (Definitions), DE ST TI 24 § 1702 (Definitions), and DE ST TI 24 § 1902 (Definitions) to provide the definition for “electronic prescription,” DE ST TI 24 § 518A (Prescription requirements), DE ST TI 24 § 1137 (Prescription requirements), DE ST TI 24 § 1764A (Prescription requirements), and DE ST TI 24 § 1927 (Prescription requirements) requiring prescriptions to made by electronic prescription and providing for exceptions. The bill would also amend DE ST TI 24 § 2122 (Prescription requirements) to provide the definition for “electronic prescription” and require prescriptions to be made by electronic prescription and providing for exceptions. The bill is effective June 27, 2019. • 2019 DE H.B. 233 (NS), introduced June 18, 2019, would amend DE ST TI 16 § 4701 (Definitions) updating the definition of “prescription drug order” to include electronic prescribing. District of Columbia 2019 DC L.B. 430 (NS), introduced September 17, 2019, would require a pharmacist who dispenses a biological product to communicate to the prescriber the name and manufacturer of the drug within 5 business days following the dispensing of the biological product. The communication shall occur via an entry in an interoperable electronic medical records system, an electronic prescribing technology, a pharmacy benefit management system or a pharmacy record that can be accessed electronically by the prescriber. Florida • 2019 FL H.B. 731 (NS), filed November 21, 2019, would amend FL ST § 408.0611 (Electronic prescribing clearinghouse) to remove requirement that the agency monitor and report on the implementation of electronic prescribing. © 2020 Thomson Reuters. No claim to original U.S. Government Works. -57- • 2019 FL H.B. 831 (NS), adopted June 18, 2019, amends FL ST § 456.42 (Written prescriptions for medicinal drugs), FL ST § 459.0137 (Pain-management clinics), and FL ST § 459.015 (Grounds for disciplinary action; action by the board and department) to prohibit electronic prescribing from interfering with patient's freedom to choose pharmacy, provide restrictions for electronic prescribing software, authorize electronic prescribing software to display information regarding payor's formulary. The bill also repeals FL ST § 456.43 (Electronic prescribing for medicinal drugs). The bill is effective January 1, 2020. Georgia 2019 GA S.B. 195 (NS), amended/substituted March 28, 2019, would adopt GA ST § 33-65-6 to require the Commissioner to consider requiring an insurer and a pharmacy benefits manager to exchange prior authorization requests electronically with a prescriber who has e-prescribing capability and who initiates a request electronically. Hawaii • 2019 HI H.B. 665 (NS), adopted July 5, 2019, would amend HI ST § 329-38.2 (Prescriptions; additional restrictions) to exempt a health care provider from requirement to consult the electronic prescription accountability system for patients when the prescription will be directly administered under the supervision of a health care provider or for patients who qualify for hospice care. The amendment is effective July 1, 2019. • 2019 HI H.B. 667 (NS), amended/substituted February 14, 2019, would amend HI ST § 329-38.2 (Prescriptions) to allow either words or figures to indicate the amount of controlled substance to be dispensed on an electronic prescription. • 2019 HI S.B. 536 (NS), adopted July 5, 2019, amends HI ST § 329-38.2 (Prescriptions; additional restrictions) to exempt a health care provider from requirement to consult the electronic prescription accountability system for patients when the prescription will be directly administered under the supervision of a health care provider or for patients who are receiving hospice or other palliative care. The amendment is effective July 5, 2019. • 2019 HI S.B. 1263 (NS), adopted June 7, 2019, amends HI ST § 329-38 (Prescriptions) to allow either words or figures to indicate the amount of controlled substance to be dispensed on an electronic prescription. The amendment is effective June 7, 2019. Illinois 2019 IL S.B. 2104 (NS), enrolled November 14, 2019, would adopt IL ST CH 225 § 85/22c (Automated prescription refills) requiring, beginning January 1, 2021, a pharmacy using the National Council for Prescription Drug Programs' SCRIPT standard for receiving electronic prescriptions to enable, activate, and maintain the ability to receive transmissions of electronic prescription cancellation and to transmit cancellation response transactions. Indiana • 2019 IN S.B. 146 (NS), introduced January 3, 2018, would adopted a new section to require the Medical Licensing Board to study and determine whether a waiver is necessary for the electronic prescription requirement. • 2019 IN H.B. 1294 (NS), adopted April 18, 2019, adopts IN ST 25-26-24 (Central Repository for Controlled Substances Data) to establish the Indiana scheduled prescription electronic collection and tracking program data base (INSPECT data base) and allow a practitioner to obtain information about a patient directly through the INSPECT data base or through the patient's integrated health record. The new section chapter is effective upon passage. Kansas • 2019 KS H.B. 2119 (NS), adopted April 18, 2019, would adopt new section to require electronic prescriptions for controlled substance in schedules II-IV that contain an opiate. • 2019 KS H.B. 2389 (NS), introduced March 20, 2019, would adopt a new section requiring electronic prescription for certain controlled substances and providing exceptions. Kentucky • 2019 KY H.B. 342 (NS), adopted March 26, 2019, adopts a new section to require, beginning January 1, 2021, perceptions be made by electronic prescription and making exemptions. • 2019 KY S.B. 54 (NS), adopted March 26, 2019, amends KY ST § 217.211 (Electronic prescribing) and KY ST § 218A.171 (Electronic prescribing) to provide that If electronic prescribing software does show information regarding a payor's formulary, payments, or benefit plan under paragraph (a) of this subsection, the information shall be updated at least quarterly to ensure its accuracy. The amendments are effective January 1, 2020. Maryland © 2020 Thomson Reuters. No claim to original U.S. Government Works. -58- 2019 MD H.B. 409 (NS), introduced January 9, 2019, would amend MD HEALTH GEN § 21-220 (Prescription required to dispense drugs) to provide exceptions to the electronica prescription requirements. Missouri • 2019 MO H.B. 872 (NS), introduced February 11, 2019, would amend MO ST 195.550 to require, beginning January 1, 2021, perceptions be made by electronic prescription and making exemptions. • 2019 MO S.B. 262 (NS), introduced January 16, 2019, and 2019 MO H.B. 293 (NS), introduced January 9, 2019, would adopt MO ST 195.550 to require prescriptions be made by electronic prescriptions and providing for exceptions. • 2019 MO S.B. 514 (NS), adopted July 11, 2019, adopts MO ST 195.550 requiring Schedule II, III, or IV controlled substances to be made by electronic prescription and providing exceptions. The bill is effective August 28, 2019. Minnesota • 2019 MN H.F. 90 (NS), enrolled May 22, 2019, would adopt MN ST § 144I.17 (Medication Management) to require when a written or electronic prescription is received, the written or electronic prescription must be communicated to the registered nurse in charge and recorded or placed in the resident's record. • 2019 MN H.F. 1718 (NS), engrossed March 18, 2019, would amend MN ST § 151.15 (Compounding drugs unlawful under certain conditions) to allow a pharmacist, when that pharmacist is not present within a licensed pharmacy, to accept a written, verbal, or electronic prescription drug order under certain circumstances. • 2019 MN H.F. 2414 (NS), engrossed May 1, 2019, would amend MN ST § 256B.0757 (Coordinated care through a health home) to require a behavioral health home services provider to utilize an electronic health record. The bill would also amend MN ST § 155.15 (Compounding drugs unlawful under certain conditions) establishing the conditions for when a pharmacist, who is not present within a licensed pharmacy, may accept a written, verbal, or electronic prescription drug order from a practitioner. The bill would also amend MN ST § 256B.0625 (Covered Services) to provide that the limit on coverage of 3 telemedicine services per enrollee per calendar week does not apply if the telemedicine services provided by the licensed health care provider are for the treatment and control of tuberculosis and the services are provided in a manner consistent with the recommendations and best practices specified by the CDC and the Commissioner of Health. MN ST § 152.28 (Health care practitioner duties) allowing a health care practitioner to conduct a patient assessment to issue a recertification via telemedicine. New York • 2019 NY S.B. 4183 (NS), introduced March 4, 2019, would amend NY PUB HEALTH § 281 (Official New York state prescription forms) and NY EDUC § 6810 (Prescriptions) to add exceptions to requirements for electronic prescriptions. • 2019 NY S.B. 6818 (NS), introduced October 28, 2019, would amend NY PENAL § 220.00 (Controlled substances; definitions) to update the definition for “prescription for a controlled substance” to include an electronic prescription. North Carolina 2019 NC S.B. 556 (NS), adopted July 1, 2019, amends NC ST § 90-106 (Prescriptions and labeling) clarifying that no Schedule II substance may be dispensed pursuant to a written or electronic prescription more than 6 months after the date it was prescribed. The amendment is effective October 1, 2019. South Carolina 2019 SC S.B. 136 (NS), amended/substituted March 20, 2019, would amend SC ST § 44-53-360 (Prescriptions) to require a practitioner to electronically prescribe any targeted controlled substance and providing exemptions. Texas • 2019 TX H.B. 2174 (NS), adopted June 14, 2019, amends TX HEALTH & S § 481.074 (Prescriptions) clarifying that except in an emergency, a person may not dispense or administer a controlled substance without an electronic prescription. Also clarifies that a prescribing practitioner must cause an electronic prescription to be delivered to the dispensing pharmacist at the pharmacy where the prescription was dispensed within 7 days after the date a prescribing practitioner authorizes an emergency oral or telephonically communicated prescription. The amendment is effective September 1, 2019. • 2019 TX H.B. 3284 (NS), enrolled May 27, 2019, 2019 TX H.B. 2766 (NS), engrossed May 3, 2019, and 2019 TX S.B. 1233 (NS), introduced February 27, 2019, would adopt TX HEALTH & S § 481.0755 (Written, Oral, and Telephonically Communicated Prescriptions) to establish the requirements for when a prescription for a controlled substance must be issued electronically. Utah © 2020 Thomson Reuters. No claim to original U.S. Government Works. -59- 2019 UT H.B. 121 (NS), introduced January 28, 2019, would adopt UT ST § 75-2c-106 (Attending physician responsibilities) to require attending physicians to, with the patient's consent, personally contact a pharmacist and inform the pharmacist of the prescription and personally deliver a written prescription or personally send an electronic prescription to the pharmacist, who will dispense the medication to either the patient, the attending physician, or an expressly identified agent of the patient. Virginia • 2018 VA H.B. 1839 (NS), adopted March 21, 2019, amends VA ST § 54.1-3401 (Definitions) to add the definition for “electronic prescription.” The amendment is effective March 21, 2019. • 2018 VA H.B. 2559 (NS), adopted March 21, 2019, amends VA ST § 54.1-3408.02 (Transmission of prescriptions) to require any prescription for a controlled substance containing an opioid to be issued via an electronic pre204scription. The amendment is effective July 1, 2020. Washington 2019 WA S.B. 5446 (NS), introduced January 21, 2019, would adopt a new section in WA ST 69.50 (Uniform Controlled Substances Act) to require, beginning January 1, 2020, to require prescription medications issued in Washington must be electronically communicated to a pharmacy of a patient's choice using the national council for prescription drug programs prescriber/pharmacist interface SCRIPT standard for electronic prescribing. West Virginia • 2019 WV H.B. 2849 (NS), adopted March 26, 2019, amends WV ST § 30-5-12 (Scope practice for registered pharmacy technician) to allow a registered pharmacy technician who has obtained a nuclear pharmacy technician endorsement, to under the direct supervision of the licensed nuclear pharmacist, to receive new written or electronic prescription drug orders. The amendment is effective June 7, 2019 • 2019 WV H.B. 3042 (NS), introduced February 12, 2019, would adopt WV ST § 30-5-12d (Mandatory e-prescribing; exceptions) to, beginning July 1, 2019, require prescriptions to be made by electronic prescription and to provide exceptions. Wyoming 2019 WY S.F. 47 (NS), adopted February 28, 2019, would amend WY ST § 35-347.30 (Prescriptions required in certain instances) to prohibit a controlled substance from being dispensed without an electronic prescription from a practitioner. The amendment is effective July 1, 2019. RECENT STATE REGULATORY ACTIVITY FLORIDA 2019 FL REG TEXT 533106 (NS), published November 5, 2019, amends 64 FL ADC 64B15-19.002 (Violations and Penalties) providing that failing to timely notify the Department of a breach of an osteopathic physician's electronic prescribing software within 24 hours in disciplinary action including fine, probation, suspension, or revocation. The amendment is effective November 11, 2019. Indiana 2018 IN REG TEXT 504630 (NS), filed November 21, 2018, readopts 805 IN ADC 1-40-1 (“Board” defined), 805 IN ADC 1-40-2 (“Electronically transmitted” or “electronic transmission” defined), 805 IN ADC 1-40-3 (“Electronic data intermediary” or “EDI” defined), 805 IN ADC 1-40-4 (“Practitioner” defined), 805 IN ADC 1-40-5 (“Prescription” defined), 805 IN ADC 1-40-6 (Equipment), 805 IN ADC 1-40-7 (Electronic transmission), 805 IN ADC 1-40-8 (Electronic data intermediary requirements), 805 IN ADC 1-40-9 (Electronic data intermediary standards), 805 IN ADC 1-40-10 (Electronic prescription prohibitions) in anticipation of their expiration on January 1, 2019. The readoption is effective December 20, 2018. Iowa • 2019 IA REG TEXT 516872 (NS), adopted April 5, 2019, adopts IA ADC 650-16.4(153) (Prescription requirements) providing that prior to January 1, 2020, a prescription drug order may be written or transmitted to a pharmacy orally, by fax, or through electronic prescribing in accordance with applicable federal and state laws. A dentist shall take adequate measures to prevent prescription forgery from occurring. Beginning January 1, 2020, all prescription drug orders, including prescriptions for controlled substances, must be electronically prescribed unless exempted. Beginning January 1, 2020, a dentist who fails to comply with the electronic prescription mandate may be subject to a nondisciplinary administrative penalty of $250 per violation, up to a maximum of $5,000 per calendar year. A dentist shall securely maintain the unique authentication credentials issued to the dentist for utilization of the electronic prescription application and authentication of the dentist's electronic signature. The rule is effective May 29, 2019. © 2020 Thomson Reuters. No claim to original U.S. Government Works. -60- • 2019 IA REG TEXT 521212 (NS), filed July 31, 2019, adopting IA ADC 657-8.18(124,155A) (Electronic prescription mandate), IA ADC 657-21.8(124,155A) (Electronic prescription mandate and exemptions), and IA ADC 657-21.9(124,155A) (Exemption from electronic prescription mandate-petition) and amends IA ADC 657-8.19(124,126,155A) (Manner of issuance of a prescription drug or medication order), IA ADC 657-10.24(124,126,155A) (Prescription requirements), and IA ADC 657-21.6 (Electronic prescription applications) requiring, beginning January 1, 2020, all prescription to be transmitted electronically to a pharmacy, with exceptions. The regulations are effective September 4, 2019. • 2019 IA REG TEXT 521210 (NS), filed September 25, 2019, amends IA ADC 653-13.2(124,148,272C) (Standards of practice- appropriate pain management) requiring, beginning January 1, 2020, all prescriptions (controlled and controlled substances) to be transmitted electronically as electronic prescriptions pursuant to IA ST § 124.308 (Prescriptions). Requiring a prescription to be transmitted to a pharmacy by the physician or the physician's authorized agent in compliance with federal law and regulation for electronic prescriptions of controlled substances. The regulation is effective November 27, 2019. Missouri • 2019 MO REG TEXT 506394 (NS), published February 15, 2019, amends 19 MO ADC 30-1.064 (Partial Filing of Controlled Substance Prescriptions) to allow partial filing of a prescription for controlled substances listed in Schedules II, III, IV, or V is permissible if the pharmacy documents the date and quantity dispensed on the original prescription record or their approved electronic computer applications, provided that the electronic system meets all of the federal requirements for handling of electronic prescriptions for controlled substances, including the ability to retrieve the information pertaining to partially filled controlled substances. The amendment is effective March 30, 2019. • 2019 MO REG TEXT 525964 (NS), published October 1, 2019, amends 20 MO ADC 2220-2.080 (Electronic Prescription Records) removing unnecessary/duplicative rule language and modernizing rule language governing electronic prescription records. The amendment is effective November 30, 2019. New Jersey 2019 NJ REG TEXT 506178 (NS), filed March 25, 2019, adopts NJ ADC 13:45A-35.6A (Access to prescription monitoring information; electronic health record system) to allow the Division to make prescription monitoring information available on electronic systems that collect and display health information, such as an electronic system that connects hospital emergency departments for the purpose of transmitting and obtaining patient health data from multiple sources, or an electronic system that notifies practitioners of information pertaining to the treatment of overdoses, provided that the Division determines that any such electronic system has appropriate security protections in place. Also provides that practitioners who are required to access prescription monitoring information pursuant to NJ ADC 13:45A-35.9 (Mandatory look-up), may discharge that responsibility by accessing one or more authorized electronic systems into which the prescription monitoring information maintained by the Division has been integrated. The rule is effective May 6, 2019. Rhode Island 2019 RI REG TEXT 524231 (NS), filed August 16, 2019, amends 216 RI ADC 20-20-4.3 (Definitions) providing the definition for “electronic prescription” and 216 RI ADC 20-20-4.4 (Pain Management and Prescribing) requiring, effective January 2, 2020, to review, sign, transmit, and file prescription electronically for controlled substances in Schedules II, III, IV, and V. The regulations are effective January 2, 2020. Virginia 2019 VA REG TEXT 535190 (NS), filed September 18, 2019, adopts via emergency 18 VA ADC 85-21-21 (Regulations Governing Prescribing of Opioids and Buprenorphine) requiring July 1, 2020, prescriptions for controlled substances that contain an opioid to be issued by electronic prescription and providing requirements for a one-time waiver of the requirement. The emergency regulation is effective September 18, 2019 through March 17, 2021. Washington 2019 WA REG TEXT 510078 (NS), filed March 5, 2019, amends WA ADC 246-887-020 (Uniform Controlled Substances Act) providing that an emergency exists when the immediate administration of the drug is necessary for proper treatment, no alternative treatment is available, and it is not possible for the physician to provide a written or electronic prescription for the schedule II drug and because of this emergency a dispenser is not required to have a signed prescription in his possession prior to dispensing the Schedule II drug. The amendment is effective April 5, 2019. Wyoming • 2018 WY REG TEXT 505187 (NS), filed December 20, 2018, amends WY ADC 059.0002.6 § 4 (Definitions), WY ADC 059.0002.6 § 7 (Manner of Issuance of Written, Typed or Computer Generated Prescriptions) WY ADC 059.0002.6 § 12 (Electronic Prescriptions), © 2020 Thomson Reuters. No claim to original U.S. Government Works. -61- WY ADC 059.0002.6 § 13 (Requirement of Prescription for Schedule II Substances), WY ADC 059.0002.6 § 18 (Filing of Prescription – Schedule II), and WY ADC 059.0002.6 § 19 (Requirement of Prescription for Schedule III and IV Substances) to clarify partial filing of prescriptions for Schedule II controlled substances. The amendments are effective December 11, 2018. • 2019 WY REG TEXT 505188 (NS), filed January 3, 2019, would adopt new WY ADC 059.0001.2 s 20 (Electronic Prescription Transmission) establishing the requirements for electronic prescriptions. The new rule is effective December 19, 2018. VI. Conclusion Both patients and health care professionals have become comfortable with and more dependent on the use of healthcare technology. Funds from the American Recovery and Reinvestment Act for health IT helped the states to begin the process of achieving the important national objective of having comprehensive digital medical information systems. In addition, federal funds have enabled many healthcare providers to adopt the use of health IT. An increasing number of state legislatures are requiring that insurance companies recognize the importance of health IT and cover treatments appropriately done by telemedicine. As American healthcare systems strive toward implementing digital technology, lawmakers and policymakers will continue to address cost and security concerns to encourage more widespread adoption of health IT by healthcare providers and facilities. In addition, professional organizations are issuing guidelines for healthcare providers in their use of social media. This Issue Brief contains information on introduced and pending legislation. Subscribers to Legislation To Watch can view the full text of these bills, along with related information and actions. If you do not have access to Legislation To Watch or for information about other HPTS products, please contact 1-800-WESTLAW (1-800-937-8529), for information about subscribing to Westlaw. © Copyright Thomson/West - NETSCAN's Health Policy Tracking Service [FN1] . Executive Order 13410, “Promoting Quality and Efficient Health Care in Federal Government Administered or Sponsored Health Care Programs,” 71 FR 51089, 2006 WL 2463679 (Aug. 22, 2006). [FN2] . “Top 12 Legislative Issues of 2012”, NCSL News, National Conference of State Legislatures, Jan. 3, 2012, available at: http:// www.ncsl.org/?tabid=24021. [FN3] . Erin McCann, “Former UConn Employee Breached Health Records,” Government Health IT, Privacy and Security, March 14, 2013, available at: http://www.govhealthit.com/news/former-uconn-employee-breaches-health-records. [FN4] . Erin McCann, “HIPAA Breach for 34K After Staff Slipup,” HealthcareITNews, June 13, 2014, available at: http:// www.healthcareitnews.com/news/HIPAA-breach-34K-after-staff-slipup. [FN5] . Bob Mayo, “Class Action Lawsuit Filed Against UPMC Over Data Breach,” Pittsburgh's Action 4 News, WTAE, May 9, 2014, available at: http://www.wtae.com/news/class-action-lawsuit-filed-against-upmc-over-data-breach/25902550. [FN6] . Alex Nixon, “UPMC Health Plan Breach Affects Over 700 Clients,” Tribune-Review July 14, 2015, available at: http://triblive.com/ business/headlines/8738254-74/health-breach-upmc#axzz3fxxNIzo5. [FN7] . Reed Abelson and Matthew Goldstein, “Millions of Anthem Customers Targeted in Cyberattack,” The New York Times, Feb. 5, 2015, available at: http://www.nytimes.com/2015/02/05/business/hackers-breached-data-of-millions-insurer-says.html? hp&action=click&pgtype=Homepage&module=first-column-region&region=top-news&WT.nav=top-news&_r=0. [FN8] . “Premera Blue Cross Announces Cyberattack, Offers Protection for Affected Individuals,” A Premera Blue Cross Press Release, Marcy 17, 2015, available at: http://www.prnewswire.com/news-releases/premera-blue-cross-announces-cyberattack-offers-protection- for-affected-individuals-300051918.html. © 2020 Thomson Reuters. No claim to original U.S. Government Works. -62- [FN9] . Coral Garnick, “Deadline approaches for Premera's security-breach victims to seek credit monitoring,” Seattle Times, Sept. 24, 2015, available at: http://www.seattletimes.com/business/premera-sued-over-security-breaches/. [FN10] . “Redspin Issues Annual Healthcare Data Breach Report,” Redspin, Inc. Press Release via PR Newswire, February 24, 2015, available at: http://www.prnewswire.com/news-releases/redspin-issues-annual-healthcare-data-breach-report-300039794.html. [FN11] . “MDCH Notifying Individuals Regarding Protected Health Information Breach,” Michigan Department of Community Health Press Release, April 3, 2014, available at: http://www.michigan.gov/mdch/0,4612,7-132-8347-325431--m,00.html. [FN12] . “Bulletin: HIPAA Settlement Underscores the Vulnerability of Unpatched and Unsupported Software, “Department of Health & Human Services, Office of Civil Rights, December 2014, available at: http://www.hhs.gov/ocr/privacy/hipaa/enforcement/examples/acmhs/ acmhsbulletin.pdf. [FN13] . Chad Terhune, “Health Database Cal Index Must Address Privacy, Consumer Group Says,” Los Angeles Times, December 14, 2014, available at: http://www.latimes.com/business/la-fi-insurers-patient-privacy-20141217-story.html. [FN14] . Jason Miller, “Contractors Security Flaw Puts Data of 7,000 Veterans At Risk,” Federal News Radio, Dec. 24, 2014, available at: http:// www.federalnewsradio.com/1177/3769129/Contractor-security-flaw-puts-data-of-7000-veterans-at-risk. [FN15] . Erin McCann, “Hackers swipe health data of 405k,” HealthcareITNews, Feb. 5, 2014, available at: http://www.healthcareitnews.com/ news/hackers-swipe-health-data-405k. [FN16] . “2014 Trustwave Global Security Report,” May 2014, Trustwave Holdings, Inc., available at: http://www2.trustwave.com/rs/trustwave/ images/2014_Trustwave_Global_Security_Report.pdf?aliId=18259011. [FN17] . David Vogel, “Top 10 HIPAA Data Breaches of 2013,” Layeredtech, Jan. 7, 2014, available at: http://www.layeredtech.com/blog/ top-10hipaa-data-breaches-of-2013/. [FN18] . Helen Gregg, “5 Top Causes of Data Breaches in 2013,” Becker's Hospital Review, December 11, 2013, available at: http:// www.beckershospitalreview.com/healthcare-information-technology/5-top-causes-of-data-breaches-in-2013.html. [FN19] . “6th Annual HIMSS Security Survey,” HIMSS, February 19, 2014, available at: http://himss.files.cms- plus.com/2013_HIMSS_Security_Survey.pdf. [FN20] . Pamela Lewis Dolan, “Passwords Make Doctors Vulnerable, But Solutions Are Easy,” Amednews.com, American Medical News, Nov. 12, 2012, available at: http://www.ama-assn.org/amednews/2012/11/12/bil21112.htm. [FN21] . “2012 Data Breach Investigations Report,” a study conducted by the Verizon RISK Team with cooperation from the Australian Federal Police, Dutch National High Tech Crime Unit, Irish Reporting, and Information Security Services, Police Central e-Crime Unit, and United States Secret Service, October 2012, available at: http://www.verizonbusiness.com/about/events/2012dbir/. [FN22] . Healthcare Vendors Identified as the “Unlocked Backdoor to Healthcare Data,” CORL Technologies Press Release, June 27, 2014, available at: http://www.prweb.com/releases/2014/06/prweb11977024.htm. © 2020 Thomson Reuters. No claim to original U.S. Government Works. -63- [FN23] . Mary Mosquera, “HHS: Patients Should Receive Easily Understood HIE Privacy Notices,” Government Health IT, Oct. 18, 2010, available at: http://www.govhealthit.com/newsitem.aspx?nid=74873. For more information on the recommendations of the panel accesshttp://healthit.hhs.gov/portal/server.pt? open=512&objID=1814&parentname=CommunityPage&parentid=18&mode=2&in_hi_userid=11673&cached=true#102010. [FN24] . Personal Health Record (PHR) Model Privacy Notice, The Office of the National Coordinator for Health Technology, September 2011 available at: http://healthit.hhs.gov/portal/server.pt/community/healthit_hhs_gov__phr_model_privacy_notice/1176. [FN25] . “New Tools to Help providers Protect Patient Data on Mobile Devices,” Department of Health and Human Services Press Release, December 12, 2012, available at: http://www.hhs.gov/news/press/2012pres/12/20121212a.html. [FN26] . “HHS Releases Security Risk Assessment Tool to Help Providers with HIPAA Compliance,” Department of Health & Human Services Press Release, March 28, 2014, available at: http://www.hhs.gov/news/press/2014pres/03/20140328a.html. [FN27] . Pamela Lewis Dolan, “Data Breach Insurance Goes Mainstream in Health Care,” Amednews.com, Aug. 19, 2013, available at: http:// www.amednews.com/article/20130819/business/130819963/2/. [FN28] . “Medicare Information Technology: Centers for Medicare and Medicaid Services Needs to Pursue a Solution for Removing Social Security Numbers from Medicare Cards,” United States Government Accountability Office, Sept 10, 2013, GAO-13-761, available at: http://www.gao.gov/products/GAO-13-761. [FN29] . “Not All Recommended Fraud Safeguards Have Been Implemented in Hospital EHR Technology,” Office of Inspector General of the Department of Health & Human Services, Report (OEI-01-11-00570), Dec. 9, 2013, available at: http://oig.hhs.gov/oei/reports/ oei-01-11-00570.asp [FN30] . “CMS and Its Contractors Have Adopted Few Program Integrity Practices to Address Vulnerabilities in EHRs,” Office of Inspector General of the Department of Health & Human Services, Report (OEI-01-11-00571), Jan. 8, 2014, available at: https://oig.hhs.gov/oei/ reports/oei-01-11-00571.pdf. [FN31] . “Not All Recommended Fraud Safeguards Have Been Implemented in Hospital EHR Technology,” Office of Inspector General of the Department of Health & Human Services, Report (OEI-01-11-00570), Dec. 9, 2013, available at: http://oig.hhs.gov/oei/reports/ oei-01-11-00570.asp. This report is discussed in the HPTS Healthcare Information Technology Issue Brief published December 30, 2013 (HPTS Issue Brief 12-30-13.7). [FN32] . Transcript of Podcast “Fraud Safeguards in Electronic Health Records,” Office of Inspector General of the Department of Health & Human Services, January 8, 2014, available at: https://oig.hhs.gov/newsroom/podcasts/reports.asp#ehr14. [FN33] . “LogRhythm and FairWarning® Team to Deliver Cyber Threat Defense, Detection and Response to Healthcare Organizations,” Press Release, Market Watch The Wall Street Journal, March 27, 2012, available at: http://www.marketwatch.com/story/logrhythm-and- fairwarning-team-to-deliver-cyber-threat-defense-detection-and-response-to-healthcare-organizations-2012-03-27. [FN34] . “States Prepare for Seamless Exchange of Health Records After Disasters,” Department of Health & Human Services Press Release, July 11, 2013, available at http://www.hhs.gov/news/press/2013pres/07/20130711a.html. [FN35] © 2020 Thomson Reuters. No claim to original U.S. Government Works. -64- . Anne Brynolf, et al., “Virtual Colleagues, Virtually Colleagues-- Physicians' Use of Twitter: A Population Observational Study, British Medical Journal Open, Col 3, Issue 7, BMJ Open 2013;3:e002988 doi:10.1136/bmjopen-2013-002988. [FN36] . “Physicians on Twitter,” JAMA, Feb. 9, 2011, JAMA. 2011;305(6):566-568. doi:10.1001/jama.2011.68, available at: http:// jama.jamanetwork.com/article.aspx?articleid=893850. [FN37] . Jeanne M. Farnan MD., MHPE, et al., “Online Medical Professionalism: Patient and Public Relationships: Policy Statement From the American College of Physicians and the Federation of State Medical Boards,” Ann Intern Med. 16 April 2013;158(8):620-627, available at: http://annals.org/article.aspx?articleid=1675927. [FN38] . “Rhode Island Board of Medical Licensure and Discipline Policy Guidelines for the Appropriate Use of Social Media and Social Networking in Medical Practice,” Rhode Island Department of Health, September 2013, available at: http://www.health.ri.gov/ publications/guidelines/AppropriateUseOfSocialMediaAndSocialNetw [FN39] . In the Matter of LabMD, Inc., a corporation, 2014 WL 253518 (F.T.C., Jan. 16, 2014). [FN40] . “Actions Needed to Address Weaknesses in Information Security and Privacy Controls,” U.S. Government Accountability Office Report, Sept. 16, 2014, available at: http://www.gao.gov/products/GAO-14-730. [FN41] . Joseph Goedert, “HIPAA Violations Lead to $1.55 Million Fine of Hospital System,” Information Management (March 18, 2016) available at: 2016 WLNR 8434561. [FN42] . Carrie Teegardin, “Data drives on nearly 1M people missing Centene is parent company of Peach State Health Plan,” Atlanta Journal and Constitution (January 27, 2016), available at: 2016 WLNR 2568343. [FN43] . Eric D. Fader, “GAO Report Critical of HHS Cybersecurity Guidance and Oversight,” Monday (September 28, 2016), available at 2016 WLNR 29615508. [FN44] . Joe Davidson, “Cyberattacks on personal health records growing ‘exponentially’,” The Washington Post (September 28, 2016), available at 2016 WLNR 29622964. [FN45] . Greg Slabodkin, “HHS Security, Privacy Guidance Said to Fall Short of Fed Guidelines,” Information Management (September 28, 2016), available at 2016 WLNR 29619013. [FN46] . “ELECTRONIC HEALTH INFORMATION: HHS Needs to Strengthen Security and Privacy Guidance and Oversight,” GAO report number GAO-16-771 (U.S. Government Accountability Office, September 26, 2016), available at http://www.gao.gov/products/ GAO-16-771. [FN47] . David Blumenthal MD and David Squires, “2014 The Health Care Year in Review,” The Commonwealth Fund, Dec. 23, 2014, available at: http://www.commonwealthfund.org/publications/blog/2014/dec/2014-health-care-year. [FN48] . Data and Program Reports, EHR Incentive Programs, U.S. Department of Health and Human Services, last updated Sept. 3, 2014, available at: http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/DataAndReports.html. [FN49] © 2020 Thomson Reuters. No claim to original U.S. Government Works. -65- . “Doctors and Hospitals' Use of Health IT More Than Doubles Since 2012,” Department of Health & Human Services Press Release, May 22, 2013, available at: http://www.cms.gov/Newsroom/MediaReleaseDatabase/Press-Releases/2013-Press-Releases- Items/2013-05-22.html. [FN50] . Mike Mallard, “Americans Want Docs to be Online,” Healthcare IT News published in partnership with HIMSS, Healthcare IT News, March 3, 2011, available at: http://www.healthcareitnews.com/news/americans-want-docs-be-online. [FN51] . Joy L. Lee PhD, MS, MS, et al., “Patient Use of Email, Facebook, and Physician Websites to Communicate with Physicians: A National Online Survey of Retail Pharmacy Users,” Journal of General Internal Medicine, June 24, 2015, DOI 10.1007/ s11606-015-3374-7, available at: http://link.springer.com/article/10.1007®s11606-015-3374-7. [FN52] . “MDLIVE Survey: Young ‘Invincibles' Favor Mobile Healthcare,” MDLIVE Press Release, May 14, 204, available at: https:// www.mdlive.com/news/press_05142014b.html. [FN53] . “Research: Consumers eager to use online health care tools, but physicians report health IT systems lag,” an Optum Institute Press Release, Sept. 20, 2012, available at http://www.optuminsight.com/news-events/press-releases/2012/sept-20-2012/. [FN54] . “Physicians Practice 2015 Tech Survey, sponsored by Kareo Go Practice”, July 2015, available at: http://imaging.ubmmedica.com/all/ editorial/physicianspractice/pdfs/2015-Tech-Survey-Results.pdf. [FN55] . “Healthgrades Partners With Athenahealth to Provide Easier Access to Online Appointment Scheduling,” Healthgrades' Press Release, July 25, 2014, available at: http://www.healthgrades.com/about/press/healthgrades-partners-with-athenahealth-to-provide- easier-access-to-online-appointment-scheduling. [FN56] . “Booking a Trip to the ER on Your Smartphone? It's a Breeze,” The Associated Press, Jan 15, 2015, available at: http:// www.nytimes.com/aponline/2015/01/15/us/ap-us-er-reservations.html. [FN57] . Martijn van der Eijk, MSc et al., “Using Online Health Communities to Deliver Patient-Centered Care to People with Chronic Conditions,” Journal of Medical Internet Research, June 25, 2013, Vol. 15, No. 6, (J Med Internet Res 2013;15(6):e115J Med Internet Res 2013;15(6):e115) doi:10.2196/jmir.2476, available at: http://www.jmir.org/2013/6/e115/. [FN58] . 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