BILL NUMBER: AB 1224 ENROLLED
BILL TEXT
PASSED THE SENATE AUGUST 30, 2007
PASSED THE ASSEMBLY SEPTEMBER 4, 2007
AMENDED IN SENATE JUNE 26, 2007
AMENDED IN ASSEMBLY APRIL 10, 2007
INTRODUCED BY Assembly Member Hernandez
FEBRUARY 23, 2007
An act to amend Sections 2290.5 and 3041 of the Business and
Professions Code, relating to healing arts.
LEGISLATIVE COUNSEL'S DIGEST
AB 1224, Hernandez. Optometrists: telemedicine.
Existing law, the Optometry Practice Act, creates the State Board
of Optometry, which licenses optometrists and regulates their
practice. The act defines the practice of optometry as including the
treatment of primary open-angle glaucoma with the participation, as
specified, of a collaborating ophthalmologist. Existing law, the
Medical Practice Act, regulates the practice of telemedicine, defined
as the practice of health care delivery, diagnosis, consultation,
treatment, transfer of medical data, and education using interactive
audio, video, or data communications, by a health care practitioner,
as defined. A violation of the provisions governing telemedicine is
unprofessional conduct.
This bill would make a licensed optometrist subject to these
telemedicine provisions and would define collaborating
ophthalmologist for purposes of his or her participation in treating
primary open angle glaucoma.
THE PEOPLE OF THE STATE OF CALIFORNIA DO ENACT AS FOLLOWS:
SECTION 1. Section 2290.5 of the Business and Professions Code is
amended to read:
2290.5. (a) (1) For the purposes of this section, "telemedicine"
means the practice of health care delivery, diagnosis, consultation,
treatment, transfer of medical data, and education using interactive
audio, video, or data communications. Neither a telephone
conversation nor an electronic mail message between a health care
practitioner and patient constitutes "telemedicine" for purposes of
this section.
(2) For purposes of this section, "interactive" means an audio,
video, or data communication involving a real time (synchronous) or
near real time (asynchronous) two-way transfer of medical data and
information.
(b) For the purposes of this section, "health care practitioner"
has the same meaning as "licentiate" as defined in paragraph (2) of
subdivision (a) of Section 805 and also includes a person licensed as
an optometrist pursuant to Chapter 7 (commencing with Section 3000).
(c) Prior to the delivery of health care via telemedicine, the
health care practitioner who has ultimate authority over the care or
primary diagnosis of the patient shall obtain verbal and written
informed consent from the patient or the patient's legal
representative. The informed consent procedure shall ensure that at
least all of the following information is given to the patient or the
patient's legal representative verbally and in writing:
(1) The patient or the patient's legal representative retains the
option to withhold or withdraw consent at any time without affecting
the right to future care or treatment nor risking the loss or
withdrawal of any program benefits to which the patient or the
patient's legal representative would otherwise be entitled.
(2) A description of the potential risks, consequences, and
benefits of telemedicine.
(3) All existing confidentiality protections apply.
(4) All existing laws regarding patient access to medical
information and copies of medical records apply.
(5) Dissemination of any patient identifiable images or
information from the telemedicine interaction to researchers or other
entities shall not occur without the consent of the patient.
(d) A patient or the patient's legal representative shall sign a
written statement prior to the delivery of health care via
telemedicine, indicating that the patient or the patient's legal
representative understands the written information provided pursuant
to subdivision (a), and that this information has been discussed with
the health care practitioner, or his or her designee.
(e) The written consent statement signed by the patient or the
patient's legal representative shall become part of the patient's
medical record.
(f) The failure of a health care practitioner to comply with this
section shall constitute unprofessional conduct. Section 2314 shall
not apply to this section.
(g) All existing laws regarding surrogate decisionmaking shall
apply. For purposes of this section, "surrogate decisionmaking" means
any decision made in the practice of medicine by a parent or legal
representative for a minor or an incapacitated or incompetent
individual.
(h) Except as provided in paragraph (3) of subdivision (c), this
section shall not apply when the patient is not directly involved in
the telemedicine interaction, for example when one health care
practitioner consults with another health care practitioner.
(i) This section shall not apply in an emergency situation in
which a patient is unable to give informed consent and the
representative of that patient is not available in a timely manner.
(j) This section shall not apply to a patient under the
jurisdiction of the Department of Corrections or any other
correctional facility.
(k) This section shall not be construed to alter the scope of
practice of any health care provider or authorize the delivery of
health care services in a setting, or in a manner, not otherwise
authorized by law.
SEC. 2. Section 3041 of the Business and Professions Code is
amended to read:
3041. (a) The practice of optometry includes the prevention and
diagnosis of disorders and dysfunctions of the visual system, and the
treatment and management of certain disorders and dysfunctions of
the visual system, as well as the provision of rehabilitative
optometric services, and is the doing of any or all of the following:
(1) The examination of the human eye or eyes, or its or their
appendages, and the analysis of the human vision system, either
subjectively or objectively.
(2) The determination of the powers or range of human vision and
the accommodative and refractive states of the human eye or eyes,
including the scope of its or their functions and general condition.
(3) The prescribing or directing the use of, or using, any optical
device in connection with ocular exercises, visual training, vision
training, or orthoptics.
(4) The prescribing of contact and spectacle lenses for, or the
fitting or adaptation of contact and spectacle lenses to, the human
eye, including lenses which may be classified as drugs or devices by
any law of the United States or of this state.
(5) The use of topical pharmaceutical agents for the sole purpose
of the examination of the human eye or eyes for any disease or
pathological condition. The topical pharmaceutical agents shall
include mydriatics, cycloplegics, anesthetics, and agents for the
reversal of mydriasis.
(b) (1) An optometrist who is certified to use therapeutic
pharmaceutical agents, pursuant to Section 3041.3, may also diagnose
and exclusively treat the human eye or eyes, or any of its
appendages, for all of the following conditions:
(A) Through medical treatment, infections of the anterior segment
and adnexa, excluding the lacrimal gland, the lacrimal drainage
system and the sclera. Nothing in this section shall authorize any
optometrist to treat a person with AIDS for ocular infections.
(B) Ocular allergies of the anterior segment and adnexa.
(C) Ocular inflammation, nonsurgical in cause, limited to
inflammation resulting from traumatic iritis, peripheral corneal
inflammatory keratitis, episcleritis, and unilateral nonrecurrent
nongranulomatous idiopathic iritis in patients over 18 years of age.
Unilateral nongranulomatous idiopathic iritis recurring within one
year of the initial occurrence shall be referred to an
ophthalmologist. An optometrist shall consult with an ophthalmologist
if a patient has a recurrent case of episcleritis within one year of
the initial occurrence. An optometrist shall consult with an
ophthalmologist if a patient has a recurrent case of peripheral
corneal inflammatory keratitis within one year of the initial
occurrence.
(D) Traumatic or recurrent conjunctival or corneal abrasions and
erosions.
(E) Corneal surface disease and dry eyes.
(F) Ocular pain, not related to surgery, associated with
conditions optometrists are authorized to treat.
(G) Pursuant to subdivision (f), primary open-angle glaucoma in
patients over 18 years of age.
(2) For purposes of this section, "treat" means the use of
therapeutic pharmaceutical agents, as described in subdivision (c),
and the procedures described in subdivision (e).
(c) In diagnosing and treating the conditions listed in
subdivision (b), an optometrist certified to use therapeutic
pharmaceutical agents pursuant to Section 3041.3, may use all of the
following therapeutic pharmaceutical agents exclusively:
(1) All of the topical pharmaceutical agents listed in paragraph
(5) of subdivision (a) as well as topical miotics for diagnostic
purposes.
(2) Topical lubricants.
(3) Topical antiallergy agents. In using topical steroid
medication for the treatment of ocular allergies, an optometrist
shall do the following:
(A) Consult with an ophthalmologist if the patient's condition
worsens 72 hours after diagnosis.
(B) Consult with an ophthalmologist if the inflammation is still
present three weeks after diagnosis.
(C) Refer the patient to an ophthalmologist if the patient is
still on the medication six weeks after diagnosis.
(D) Refer the patient to an ophthalmologist if the patient's
condition recurs within three months.
(4) Topical antiinflammatories. In using topical steroid
medication for:
(A) Unilateral nonrecurrent nongranulomatous idiopathic iritis or
episcleritis, an optometrist shall consult with an ophthalmologist if
the patient's condition worsens 72 hours after the diagnosis, or if
the patient's condition has not resolved three weeks after diagnosis.
If the patient is still receiving medication for these conditions
six weeks after diagnosis, the optometrist shall refer the patient to
an ophthalmologist.
(B) Peripheral corneal inflammatory keratitis, excluding Moorens
and Terriens diseases, an optometrist shall consult with an
ophthalmologist if the patient's condition worsens 48 hours after
diagnosis. If the patient is still receiving the medication two weeks
after diagnosis, the optometrist shall refer the patient to an
ophthalmologist.
(C) Traumatic iritis, an optometrist shall consult with an
ophthalmologist if the patient's condition worsens 72 hours after
diagnosis and shall refer the patient to an ophthalmologist if the
patient's condition has not resolved one week after diagnosis.
(5) Topical antibiotic agents.
(6) Topical hyperosmotics.
(7) Topical antiglaucoma agents pursuant to the certification
process defined in subdivision (f).
(A) The optometrist shall not use more than two concurrent topical
medications in treating the patient for primary open-angle glaucoma.
A single combination medication that contains two pharmacological
agents shall be considered as two medications.
(B) The optometrist shall refer the patient to an ophthalmologist
if requested by the patient, if treatment goals are not achieved with
the use of two topical medications or if indications of narrow-angle
or secondary glaucoma develop.
(C) If the glaucoma patient also has diabetes, the optometrist
shall consult in writing with the physician treating the patient's
diabetes in developing the glaucoma treatment plan and shall notify
the physician in writing of any changes in the patient's glaucoma
medication. The physician shall provide written confirmation of those
consultations and notifications.
(8) Nonprescription medications used for the rational treatment of
an ocular disorder.
(9) Oral antihistamines. In using oral antihistamines for the
treatment of ocular allergies, the optometrist shall refer the
patient to an ophthalmologist if the patient's condition has not
resolved two weeks after diagnosis.
(10) Prescription oral nonsteroidal antiinflammatory agents. The
agents shall be limited to three days' use. If the patient's
condition has not resolved three days after diagnosis, the
optometrist shall refer the patient to an ophthalmologist.
(11) The following oral antibiotics for medical treatment as set
forth in subparagraph (A) of paragraph (1) of subdivision (b):
tetracyclines, dicloxacillin, amoxicillin, amoxicillin with
clavulanate, erythromycin, clarythromycin, cephalexin, cephadroxil,
cefaclor, trimethoprim with sulfamethoxazole, ciprofloxacin, and
azithromycin. The use of azithromycin shall be limited to the
treatment of eyelid infections and chlamydial disease manifesting in
the eyes.
(A) If the patient has been diagnosed with a central corneal ulcer
and the condition has not improved 24 hours after diagnosis, the
optometrist shall consult with an ophthalmologist. If the central
corneal ulcer has not improved 48 hours after diagnosis, the
optometrist shall refer the patient to an ophthalmologist. If the
patient is still receiving antibiotics 10 days after diagnosis, the
optometrist shall refer the patient to an ophthalmologist.
(B) If the patient has been diagnosed with preseptal cellulitis or
dacryocystitis and the condition has not improved 72 hours after
diagnosis, the optometrist shall refer the patient to an
ophthalmologist. If a patient with preseptal cellulitis or
dacryocystitis is still receiving oral antibiotics 10 days after
diagnosis, the optometrist shall refer the patient to an
ophthalmologist.
(C) If the patient has been diagnosed with blepharitis and the
patient's condition does not improve after six weeks of treatment,
the optometrist shall consult with an ophthalmologist.
(D) For the medical treatment of all other medical conditions as
set forth in subparagraph (A) of paragraph (1) of subdivision (b), if
the patient's condition worsens 72 hours after diagnosis, the
optometrist shall consult with an ophthalmologist. If the patient's
condition has not resolved 10 days after diagnosis, the optometrist
shall refer the patient to an ophthalmologist.
(12) Topical antiviral medication and oral acyclovir for the
medical treatment of the following: herpes simplex viral keratitis,
herpes simplex viral conjunctivitis, and periocular herpes simplex
viral dermatitis; and varicella zoster viral keratitis, varicella
zoster viral conjunctivitis, and periocular varicella zoster viral
dermatitis.
(A) If the patient has been diagnosed with herpes simplex
keratitis or varicella zoster viral keratitis and the patient's
condition has not improved seven days after diagnosis, the
optometrist shall refer the patient to an ophthalmologist. If a
patient's condition has not resolved three weeks after diagnosis, the
optometrist shall refer the patient to an ophthalmologist.
(B) If the patient has been diagnosed with herpes simplex viral
conjunctivitis, herpes simplex viral dermatitis, varicella zoster
viral conjunctivitis, or varicella zoster viral dermatitis, and if
the patient's condition worsens seven days after diagnosis, the
optometrist shall consult with an ophthalmologist. If the patient's
condition has not resolved three weeks after diagnosis, the
optometrist shall refer the patient to an ophthalmologist.
(C) In all cases, the use of topical antiviral medication shall be
limited to three weeks, and the use of oral acyclovir shall be
limited to 10 days.
(13) Oral analgesics that are not controlled substances.
(14) Codeine with compounds and hydrocodone with compounds as
listed in the California Uniform Controlled Substances Act (Section
11000 of the Health and Safety Code et seq.) and the United States
Uniform Controlled Substances Act (21 U.S.C. Sec. 801 et seq.). The
use of these agents shall be limited to three days, with a referral
to an ophthalmologist if the pain persists.
(d) In any case where this chapter requires that an optometrist
consult with an ophthalmologist, the optometrist shall maintain a
written record in the patient's file of the information provided to
the ophthalmologist, the ophthalmologist's response and any other
relevant information. Upon the consulting ophthalmologist's request,
the optometrist shall furnish a copy of the record to the
ophthalmologist.
(e) An optometrist who is certified to use therapeutic
pharmaceutical agents pursuant to Section 3041.3 may also perform all
of the following:
(1) Mechanical epilation.
(2) Ordering of smears, cultures, sensitivities, complete blood
count, mycobacterial culture, acid fast stain, and urinalysis.
(3) Punctal occlusion by plugs, excluding laser, cautery,
diathermy, cryotherapy, or other means constituting surgery as
defined in this chapter.
(4) The prescription of therapeutic contact lenses.
(5) Removal of foreign bodies from the cornea, eyelid, and
conjunctiva. Corneal foreign bodies shall be nonperforating, be no
deeper than the anterior stroma, and require no surgical repair upon
removal. Within the central three millimeters of the cornea, the use
of sharp instruments is prohibited.
(6) For patients over 12 years of age, lacrimal irrigation and
dilation, excluding probing of the nasal lacrimal tract. The State
Board of Optometry shall certify an optometrist to perform this
procedure after completing 10 of the procedures under the supervision
of an ophthalmologist as confirmed by the ophthalmologist.
(7) No injections other than the use of an auto-injector to
counter anaphylaxis.
(f) The State Board of Optometry shall grant a certificate to an
optometrist certified pursuant to Section 3041.3 for the treatment of
primary open-angle glaucoma in patients over 18 years of age only
after the optometrist meets the following requirements:
(1) Satisfactory completion of a didactic course of not less than
24 hours in the diagnosis, pharmacological and other treatment and
management of glaucoma. The 24-hour glaucoma curriculum shall be
developed by an accredited California school of optometry. Any
applicant who graduated from an accredited California school of
optometry on or after May 1, 2000, shall be exempt from the 24-hour
didactic course requirement contained in this paragraph.
(2) After completion of the requirement contained in paragraph
(1), collaborative treatment of 50 glaucoma patients for a period of
two years for each patient under the following terms:
(A) After the optometrist makes a provisional diagnosis of
glaucoma, the optometrist and the patient shall identify a
collaborating ophthalmologist.
(B) The optometrist shall develop a treatment plan that considers
for each patient target intraocular pressures, optic nerve appearance
and visual field testing for each eye, and an initial proposal for
therapy.
(C) The optometrist shall transmit relevant information from the
examination and history taken of the patient along with the treatment
plan to the collaborating ophthalmologist. The collaborating
ophthalmologist shall confirm or refute the glaucoma diagnosis within
30 days. To accomplish this, the collaborating ophthalmologist shall
perform a physical examination of the patient.
(D) Once the collaborating ophthalmologist confirms the diagnosis
and approves the treatment plan in writing, the optometrist may begin
treatment.
(E) The optometrist shall use no more than two concurrent topical
medications in treating the patient for glaucoma. A single
combination medication that contains two pharmacologic agents shall
be considered as two medications. The optometrist shall notify the
collaborating ophthalmologist in writing if there is any change in
the medication used to treat the patient for glaucoma.
(F) Annually after commencing treatment, the optometrist shall
provide a written report to the collaborating ophthalmologist about
the achievement of goals contained in the treatment plan. The
collaborating ophthalmologist shall acknowledge receipt of the report
in writing to the optometrist within 10 days.
(G) The optometrist shall refer the patient to an ophthalmologist
if requested by the patient, if treatment goals are not achieved with
the use of two topical medications, or if indications of secondary
glaucoma develop. At his or her discretion, the collaborating
ophthalmologist may periodically examine the patient.
(H) If the glaucoma patient also has diabetes, the optometrist
shall consult in writing with the physician treating the patient's
diabetes in preparation of the treatment plan and shall notify the
physician in writing if there is any change in the patient's glaucoma
medication. The physician shall provide written confirmation of the
consultations and notifications.
(I) The optometrist shall provide the following information to the
patient in writing: nature of the working or suspected diagnosis,
consultation evaluation by a collaborating ophthalmologist, treatment
plan goals, expected followup care, and a description of the
referral requirements. The document containing the information shall
be signed and dated by both the optometrist and the ophthalmologist
and maintained in their files.
(3) When the requirements contained in paragraphs (1) and (2) have
been satisfied, the optometrist shall submit proof of completion to
the State Board of Optometry and apply for a certificate to treat
primary open-angle glaucoma. That proof shall include corroborating
information from the collaborating ophthalmologist. If the
ophthalmologist fails to respond within 60 days of a request for
information from the State Board of Optometry, the board may act on
the optometrist's application without that corroborating information.
(4) After an optometrist has treated a total of 50 patients for a
period of two years each and has received certification from the
State Board of Optometry, the optometrist may treat the original 50
collaboratively treated patients independently, with the written
consent of the patient. However, any glaucoma patients seen by the
optometrist before the two-year period has expired for each of the 50
patients shall be treated under the collaboration protocols
described in this section.
(5) For purposes of this subdivision, "collaborating
ophthalmologist" means a physician and surgeon who is licensed by the
state and in the active practice of ophthalmology in this state.
(g) Notwithstanding any other provision of law, an optometrist
shall not treat children under one year of age with therapeutic
pharmaceutical agents.
(h) Any dispensing of a therapeutic pharmaceutical agent by an
optometrist shall be without charge.
(i) Notwithstanding any other provision of law, the practice of
optometry does not include performing surgery. "Surgery" means any
procedure in which human tissue is cut, altered, or otherwise
infiltrated by mechanical or laser means in a manner not specifically
authorized by this chapter. Nothing in the act amending this section
shall limit an optometrist's authority, as it existed prior to the
effective date of the act amending this section, to utilize
diagnostic laser and ultrasound technology.
(j) All collaborations, consultations, and referrals made by an
optometrist pursuant to this section shall be to an ophthalmologist
located geographically appropriate to the patient.
(k) An optometrist licensed under this chapter is subject to the
provisions of Section 2290.5 for purposes of practicing telemedicine.