Florida Senate - 2014                        COMMITTEE AMENDMENT
       Bill No. CS for SB 1646
                              LEGISLATIVE ACTION                        
                    Senate             .             House              
                 Comm: UNFAV           .                                
                  04/11/2014           .                                

       recommended the following:
    1         Senate Amendment (with title amendment)
    3         Delete everything after the enacting clause
    4  and insert:
    5         Section 1. Section 456.4501, Florida Statutes, is created
    6  to read:
    7         456.4501Short title.—Sections 456.4501-456.4506 may be
    8  cited as the “Florida Telemedicine Act.”
    9         Section 2. Section 456.4502, Florida Statutes, is created
   10  to read:
   11         456.4502Definitions.—As used in this act, the term:
   12         (1) “Act” means the Florida Telemedicine Act.
   13         (2) “Advanced communications technology” means:
   14         (a) Compressed digital interactive video, audio, or data
   15  transmissions;
   16         (b) Real-time synchronous video- or web-conferencing
   17  communications;
   18         (c) Secure web-based communications;
   19         (d) Still-image capture or asynchronous store and forward;
   20         (e) Health care service transmissions supported by mobile
   21  devices (mHealth); or
   22         (f) Other technology that facilitates access to health care
   23  services or medical specialty expertise.
   24         (3)“Distant site” means the location at which the
   25  telemedicine provider delivering the health care service is
   26  located at the time the service is provided via telemedicine.
   27         (4) “Encounter” means an examination, consultation,
   28  monitoring, or other health care service.
   29         (5) “Health care provider” means a health care practitioner
   30  or out-of-state licensed individual who provides health care
   31  services within the scope of his or her professional license.
   32         (6) “In person” means that a patient is in the physical
   33  presence of the health care provider without regard to whether
   34  portions of the encounter are conducted by other providers.
   35         (7)“Originating site” means the location of the patient
   36  receiving telemedicine services, which site meets the standards
   37  of this act as verified by the telemedicine provider.
   38         (8)“Patient presenter” means an individual who has
   39  clinical background training in the use of advanced
   40  communications technology equipment and who is available at the
   41  originating site to present the patient, manage the cameras or
   42  equipment, and perform any hands-on activity necessary to
   43  successfully complete the telemedicine encounter under the
   44  direction and supervision of a telemedicine provider.
   45         (9)“Store and forward” means the type of telemedicine
   46  encounter that uses still images of patient data for rendering a
   47  medical opinion or diagnosis. The term includes the asynchronous
   48  transmission of clinical data from one site to another.
   49         (10) “Telehealth” means the use of advanced communications
   50  technology to provide access to health assessment, diagnosis,
   51  intervention, consultation, supervision, and information across
   52  distances. The term includes the use of remote patient
   53  monitoring devices that are used to collect and transmit data
   54  for telemonitoring and interpretation.
   55         (11)“Telemedicine” means the use of advanced
   56  communications technology by a telemedicine provider at a
   57  distant or originating site in compliance with federal and state
   58  privacy and confidentiality requirements and encryption
   59  standards. Services provided through telemedicine may include
   60  patient assessment, diagnosis, consultation, treatment,
   61  prescription of medicine, transfer of medical data, or other
   62  medical-related services. The term does not include audio-only
   63  calls, e-mail messages, or facsimile transmissions. Telemedicine
   64  includes telehealth and telemonitoring.
   65         (12) “Telemedicine provider” means a health care
   66  practitioner licensed or certified in this state who provides
   67  telemedicine services.
   68         Section 3. Section 456.4503, Florida Statutes, is created
   69  to read:
   70         456.4503 Telemedicine requirements.—
   71         (1) A health care provider who provides telemedicine across
   72  state lines to a patient physically located in this state must
   73  be licensed or certified in this state.
   74         (2) An out-of-state health care provider is exempt from
   75  subsection (1) if:
   76         (a) The out-of-state health care provider is consulting
   77  with a telemedicine provider licensed to practice in this state;
   78         (b) The telemedicine provider licensed in this state
   79  retains ultimate authority and responsibility for the diagnosis,
   80  treatment, and care of the patient located within this state;
   81  and
   82         (c)The out-of-state health care provider has privileges at
   83  or is on the medical staff of an out-of-state hospital
   84  affiliated with a Florida hospital licensed under chapter 395,
   85  or has an affiliation with an out-of-state health insurer or
   86  health plan that is also authorized to conduct business in this
   87  state pursuant to chapter 627 or chapter 641.
   88         (3) An out-of-state health care provider authorized under
   89  subsection (2) to provide telemedicine services to patients in
   90  this state is subject to appropriate disciplinary action by the
   91  appropriate board in this state or other regulatory entity in
   92  this state which has regulatory jurisdiction over the hospital,
   93  insurer, or health plan affiliated with the health care
   94  practitioner as described in paragraph (2)(c).
   95         (4) A telemedicine provider and a hospital, insurer, or
   96  health plan operating in this state which is affiliated with an
   97  out-of-state health care practitioner as described in paragraph
   98  (2)(c) shall make any pertinent records available upon request
   99  of the appropriate board, the department, or other regulatory
  100  authority as applicable. Failure to comply with such request may
  101  result in the revocation of the provider’s license or
  102  certification or imposition of a fine by the applicable board
  103  or, in the case of an affiliated hospital, insurer, or health
  104  plan, a fine, license restriction, or revocation of an
  105  affiliated entity’s authorization to conduct business in this
  106  state.
  107         (5)Consultations that occur on an emergency basis and that
  108  are conducted via telemedicine are exempt from subsection (1).
  109  As used in this subsection, the term “emergency basis” refers to
  110  the provision of emergency services and care for an emergency
  111  medical condition, as those terms are defined in s. 395.002.
  112         (6) A health care practitioner or patient presenter acting
  113  under the direction and supervision of a telemedicine provider
  114  through the use of telemedicine may not be interpreted as
  115  practicing without a license. However, the health care
  116  practitioner must be trained in, educated on, and knowledgeable
  117  about the procedure and technology and may not perform duties
  118  for which he or she does not have sufficient training,
  119  education, and knowledge. Failure to have adequate training,
  120  education, and knowledge is grounds for disciplinary action by
  121  the appropriate board, or department if there is no board, or
  122  the affiliated regulatory entity for affiliated providers.
  123         (7) Upon license or certification renewal, the health care
  124  practitioner practicing telemedicine shall:
  125         (a)Designate himself or herself as a telemedicine provider
  126  on the practitioner’s profile, if applicable; and
  127         (b) Submit proof of successful completion of a course and
  128  subsequent examination, approved by the applicable regulatory
  129  board, or the department if there is no board, on the standards
  130  of practice in telemedicine. The course must consist of 2 web
  131  based contact hours. The first course and examination must be
  132  offered by October 1, 2014, and shall be conducted at least
  133  annually thereafter. The course and examination shall be
  134  developed and offered by a statewide professional association
  135  accredited to provide educational activities as designated by
  136  the board. The board shall review and approve the content of the
  137  initial course and examination if the board determines that the
  138  course and examination adequately and reliably satisfy the
  139  criteria set forth in this section. Annually thereafter, the
  140  applicable regulatory board shall review the course and
  141  examination and, if the board determines that the content
  142  continues to adequately and reliably satisfy the criteria set
  143  forth in this section, approve them. Successful completion of an
  144  approved course and examination may be used to satisfy 2 hours
  145  of continuing education requirements for the biennial period
  146  during which the approved course and examination are taken. A
  147  health care practitioner who does not complete an approved
  148  course and examination under this section may not provide
  149  telemedicine services.
  150         (8) Venue for a civil or administrative action initiated by
  151  the telemedicine recipient, the department, or the appropriate
  152  board shall be based on the location of the patient or shall be
  153  in Leon County.
  154         (9)The boards may adopt rules to administer the
  155  requirements of this act and must repeal rules that are
  156  inconsistent with this act, including rules that prohibit the
  157  use of telemedicine in this state. The appropriate board may
  158  also develop standards and adopt rules relating to requirements
  159  for patient presenters. Such rules may not require the use of
  160  patient presenters in telemedicine services if special skills or
  161  training is not needed for a patient to participate in the
  162  encounter.
  163         Section 4. Section 456.4504, Florida Statutes, is created
  164  to read:
  165         456.4504 Telemedicine standards.—
  166         (1) The standard of care as provided in s. 766.102 is the
  167  same regardless of whether the health care practitioner provides
  168  health care services in person or by telemedicine. The
  169  applicable board may adopt rules specifically related to the
  170  standard of care for telemedicine.
  171         (2) A telemedicine provider providing telemedicine services
  172  under this act is responsible for the quality of the equipment
  173  and technology employed and for its safe use. Telemedicine
  174  equipment and advanced communications technology must, at a
  175  minimum, be able to provide the same information to the
  176  telemedicine provider as the information that would be obtained
  177  in an in-person encounter with a health care provider and must
  178  enable the telemedicine provider to meet or exceed the
  179  prevailing standard of care for the practice of the profession.
  180         (3) The telemedicine provider is not required to conduct a
  181  patient history or physical examination of the patient before
  182  engaging in a telemedicine encounter if the telemedicine
  183  provider conducts a patient evaluation sufficient to meet the
  184  prevailing standard of care for the services provided.
  185         (4) Before each telemedicine encounter, the identification
  186  and location of the telemedicine provider and all other
  187  individuals present via advanced communications technology who
  188  will view the patient or the patient’s information must be
  189  identified to the patient.
  190         (5) For the purposes of this act, the nonemergency
  191  prescribing of a legend drug based solely on an electronic
  192  questionnaire without a visual examination is considered a
  193  failure to practice with the level of care, skill, and treatment
  194  which is recognized by a reasonably prudent health care
  195  practitioner and is not authorized under this act.
  196         (6) A controlled substance may not be prescribed through
  197  the use of telemedicine for chronic, nonmalignant pain.
  198         (7) Medical records must be kept by each telemedicine
  199  provider that participates in a patient telemedicine encounter
  200  to the same extent as required for an in-person encounter under
  201  state and federal law. Telemedicine providers are encouraged to
  202  create electronic health records to document the encounter and
  203  to transmit information in the most efficient manner possible.
  204         (8) Any medical records generated, including records
  205  maintained via video, audio, electronic, or other means, due to
  206  a telemedicine encounter must conform to the confidentiality and
  207  recordkeeping requirements of federal law and nationally
  208  recognized health care accreditation organizations and the laws
  209  and rules of this state, regardless of where the medical records
  210  of a patient in this state are maintained.
  211         (9) Telemedicine technology used by a telemedicine provider
  212  must be encrypted and must use a recordkeeping program to verify
  213  each interaction.
  214         (10) In those situations in which a telemedicine provider
  215  uses telemedicine technology provided by a third-party vendor,
  216  the telemedicine provider must:
  217         (a) Require a business associate agreement with the third
  218  party vendor; and
  219         (b) Ensure that the third-party vendor complies with the
  220  administrative, physical, and technical safeguards and standards
  221  set forth by the Health Information Technology for Economic and
  222  Clinical Health (HITECH) Act and by federal regulations
  223  implemented pursuant to HITECH.
  224         Section 5. Section 456.4505, Florida Statutes, is created
  225  to read:
  226         456.4505 Telemedicine services to diagnose or treat the
  227  human eye.—
  228         (1)The use of automated equipment, including computer
  229  controlled devices, in the provision of telemedicine services to
  230  diagnose or treat the human eye and its appendages, is
  231  permissible if the following requirements are met at the time
  232  the automated equipment is used:
  233         (a)The automated equipment is approved by the United
  234  States Food and Drug Administration for the intended use;
  235         (b) The automated equipment is designed and operated in a
  236  manner that provides any accommodation required by the federal
  237  ADA Amendments Act of 2008;
  238         (c)The automated equipment and accompanying technology
  239  used for the collection and transmission of information and
  240  data, including photographs and scans, gathers and transmits
  241  protected health information in compliance with the federal
  242  Health Insurance Portability and Accountability Act;
  243         (d)The procedure for which the automated equipment is used
  244  has a recognized Current Procedural Terminology (CPT) code
  245  approved by the Centers for Medicare and Medicaid Services;
  246         (e)The physical location of the automated equipment
  247  prominently displays the name and Florida license number of the
  248  individual who will read and interpret the diagnostic
  249  information and data, including photographs and scans;
  250         (f)Diagnostic information and data, including photographs
  251  and scans, gathered by the automated equipment is read and
  252  interpreted by an optometrist licensed under chapter 463 or a
  253  physician skilled in diseases of the human eye and licensed
  254  under chapter 458 or chapter 459; and
  255         (g)The owner or lessee of the automated equipment
  256  maintains liability insurance in an amount adequate to cover
  257  claims made by individuals diagnosed or treated based on
  258  information and data, including photographs and scans, generated
  259  by the automated equipment.
  260         (2)A prescription for spectacles or contact lens may not
  261  be made based on telemedicine services or based solely on the
  262  refractive error of the human eye generated by a computer
  263  controlled device such as an autorefractor.
  264         Section 6. Section 456.4506, Florida Statutes, is created
  265  to read:
  266         456.4506Telemedicine services under Medicaid.—
  267         (1)The Agency for Health Care Administration may reimburse
  268  for Medicaid services provided through telemedicine in the same
  269  manner and equivalent to Medicaid services provided in-person
  270  under parts III and IV of chapter 409, except as provided in
  271  subsection (7).
  272         (2)Telemedicine services reimbursed under Medicaid must
  273  meet the standards and requirements of this act.
  274         (3)Except as provided in subsection (7), the agency may
  275  not require in-person contact between a telemedicine provider
  276  and Medicaid recipient as a prerequisite for payment for
  277  services appropriately provided through telemedicine in
  278  accordance with generally accepted health care practices and
  279  standards prevailing in the applicable health care community at
  280  the time the services are provided.
  281         (4) Before receipt of telemedicine services, a Medicaid
  282  recipient or the legal representative of a Medicaid recipient
  283  must provide informed consent for telemedicine services. A
  284  Medicaid recipient shall also be provided the opportunity to
  285  receive the same service through an in-person encounter.
  286         (5)A Medicaid service that is provided through a fee-for
  287  service or managed care program may not be denied as a
  288  creditable Medicaid service solely because that service is
  289  provided through telemedicine.
  290         (6)Reimbursement of telemedicine services under Medicaid
  291  shall be the amount negotiated between the parties involved to
  292  the extent permitted under state and federal law. Regardless of
  293  the reimbursement methodology or amount, telemedicine providers
  294  located at the originating site and the distant site should both
  295  receive reimbursement based on the services rendered, if any,
  296  during the telemedicine encounter.
  297         (7)If, after implementation, the agency determines that
  298  the delivery of a particular service through telemedicine is not
  299  cost-effective or does not adequately meet the clinical needs of
  300  recipients and the determination has been documented, the agency
  301  may discontinue Medicaid reimbursement for that telemedicine
  302  service.
  303         (8)The agency shall submit a report on the usage and
  304  costs, including savings, if any, associated with the provision
  305  of health care services through telemedicine under the Medicaid
  306  program by January 1, 2017, to the President of the Senate, the
  307  Speaker of the House of Representatives, and the minority
  308  leaders of the Senate and the House of Representatives.
  309         (9)This section is repealed June 30, 2017.
  310         Section 7. This act shall take effect October 1, 2014.
  312  ================= T I T L E  A M E N D M E N T ================
  313  And the title is amended as follows:
  314         Delete everything before the enacting clause
  315  and insert:
  316                        A bill to be entitled                      
  317         An act relating to telemedicine; creating s. 456.4501,
  318         F.S.; providing a short title; creating s. 456.4502,
  319         F.S.; defining terms applicable to the act; creating
  320         s. 456.4503, F.S.; requiring specified practitioners
  321         providing telemedicine services to patients in this
  322         state to be licensed in this state; providing certain
  323         exceptions for emergency services and consultations;
  324         requiring pertinent records to be made available upon
  325         request; requiring other health care providers to be
  326         supervised by a telemedicine provider; providing
  327         continuing education requirements for telemedicine
  328         providers; establishing venue; authorizing the
  329         licensing boards to adopt rules; creating s. 456.4504,
  330         F.S.; providing standards and prohibitions for the
  331         provision of telemedicine services; prohibiting
  332         nonemergency prescribing of a legend drug without a
  333         physical examination; prohibiting the prescription of
  334         a controlled substance for chronic, nonmalignant pain
  335         using telemedicine; establishing a method for
  336         disciplinary action of out-of-state health providers;
  337         requiring a telemedicine provider to keep medical
  338         records of a patient; requiring the records to conform
  339         to certain requirements; providing duties for a
  340         telemedicine provider that uses telemedicine
  341         technology provided by a third-party vendor; creating
  342         s. 456.4505, F.S.; authorizing the use of telemedicine
  343         services in the diagnosis and treatment of the human
  344         eye; providing requirements for the use of automated
  345         equipment; requiring the owner or lessee of the
  346         automated equipment to maintain specified liability
  347         insurance under certain circumstances; prohibiting
  348         prescriptions for spectacles or contact lens based
  349         solely on the use of an autorefractor; creating s.
  350         456.4506, F.S.; providing requirements for
  351         reimbursement of telemedicine services under the
  352         Medicaid program; requiring a report to the
  353         Legislature on the usage and costs of telemedicine
  354         services under the Medicaid program by a certain date;
  355         providing for future repeal; providing an effective
  356         date.