BILL ANALYSIS                                                                                                                                                                                                    Ó




           ----------------------------------------------------------------- 
          |SENATE RULES COMMITTEE            |                         SB 19|
          |Office of Senate Floor Analyses   |                              |
          |(916) 651-1520    Fax: (916)      |                              |
          |327-4478                          |                              |
           ----------------------------------------------------------------- 


                                UNFINISHED BUSINESS 


          Bill No:  SB 19
          Author:   Wolk (D), et al.
          Amended:  9/4/15  
          Vote:     21  

           SENATE HEALTH COMMITTEE:  9-0, 4/8/15
           AYES:  Hernandez, Nguyen, Hall, Mitchell, Monning, Nielsen,  
            Pan, Roth, Wolk

           SENATE JUDICIARY COMMITTEE:  6-0, 4/28/15
           AYES:  Jackson, Anderson, Hertzberg, Leno, Monning, Wieckowski
           NO VOTE RECORDED:  Moorlach

           SENATE APPROPRIATIONS COMMITTEE:  7-0, 5/28/15
           AYES:  Lara, Bates, Beall, Hill, Leyva, Mendoza, Nielsen

           SENATE FLOOR:  40-0, 6/3/15
           AYES:  Allen, Anderson, Bates, Beall, Berryhill, Block,  
            Cannella, De León, Fuller, Gaines, Galgiani, Glazer, Hall,  
            Hancock, Hernandez, Hertzberg, Hill, Hueso, Huff, Jackson,  
            Lara, Leno, Leyva, Liu, McGuire, Mendoza, Mitchell, Monning,  
            Moorlach, Morrell, Nguyen, Nielsen, Pan, Pavley, Roth, Runner,  
            Stone, Vidak, Wieckowski, Wolk
           
            ASSEMBLY FLOOR:  64-11, 9/8/15 - See last page for vote

           SUBJECT:   Physician Orders for Life Sustaining Treatment form:  
                     electronic registry pilot.


          SOURCE:    Coalition for Compassionate Care of California

          DIGEST:   This bill establishes a Physician Orders for Life  
          Sustaining Treatment (POLST) eRegistry Pilot operated by the  
          California Emergency Medical Services Authority for the purpose  








                                                                      SB 19  
                                                                    Page  2



          of collecting a POLST form received from a physician, or his or  
          her designee, and disseminating the information in the form to  
          authorized persons.

          Assembly Amendments (1) make this bill a pilot project at the  
          Emergency Medical Services Authority (EMSA); (2) require EMSA to  
          coordinate the registry pilot operated by, and as part of,  
          health information exchange networks, or by an independent  
          contractor, or a combination thereof; (3) adopt guidelines  
          necessary for operation of the pilot exempt from the  
          Administrative Procedures Act, but after seeking input from  
          interested parties and holding at least one public meeting; (4)  
          delete the ability of the physician who signed the POLST form  
          and the patient to review the form after it has been entered  
          into the registry; (5) require EMSA to submit a detailed plan to  
          the Legislature prior to implementation; (6) modify the  
          liability protections with regard to resuscitative measures; (7)  
          limit the health care provider types who can modify or withdraw  
          POLST information on the POLST eRegistry Pilot; (8) require an  
          independent contractor approved by EMSA to perform an  
          evaluation, and (9) sunset the bill on January 1, 2020.

          ANALYSIS:
               
          Existing law:

           1) Requires the Secretary of State to establish a registry  
             system through which a person who has executed a written  
             advance health care directive may register information  
             regarding the advance directive, making that information  
             available upon request to any health care provider, the  
             public guardian, or the legal representative of the  
             registrant. Defines advance health care directive or  
             directive to mean either an individual health care  
             instruction or a power of attorney for health care.  

           2) Establishes the POLST form and medical intervention and  
             procedures, and requires that POLST is explained by a health  
             care provider, as defined. 

           3) Requires POLST to be completed by a health care provider  
             based on patient preferences and medical indications, and  








                                                                      SB 19  
                                                                    Page  3



             signed by a physician and the patient or his or her legally  
             recognized health care decision maker. Requires the health  
             care provider, during the process of completing form, to  
             inform the patient about the difference between an advance  
             health care directive and the POLST form.

           4) Defines "health care provider" for the purposes of health  
             care decisions, as an individual licensed, certified, or  
             otherwise authorized or permitted by the law of this state to  
             provide health care in the ordinary course of business or  
             practice of a profession.  Defines "health care provider" for  
             purposes of  request for resuscitative measures as persons  
             described in the preceding sentence, and emergency response  
             employees, including, but not limited to, firefighters, law  
             enforcement officers, emergency medical technicians I and II,  
             paramedics, and employees and volunteer members of legally  
             organized and recognized volunteer organizations, as  
             specified.

          This bill:

           1) Establishes the California POLST eRegistry Pilot Act, and  
             requires EMSA to make electronic, in addition to other modes  
             of submission and transmission, POLST information available  
             to authorized users, and establish a pilot to operate an  
             electronic registry system on a pilot basis for the purpose  
             of collecting a POLST form received from a physician or  
             physician designee and disseminating the information in the  
             form to an authorized user.

           2) Requires EMSA to implement this bill only after determining  
             that sufficient non-state funds are available to allow for  
             the development of the pilot and any related start-up costs  
             and evaluation.

           3) Requires EMSA to coordinate the pilot, operated by, and as  
             part of, health information exchange networks, or by an  
             independent contractor, or by a combination thereof.  Permits  
             the pilot to operate in a single geographic area or multiple  
             geographic areas and may test various methods of making POLST  
             information available electronically.









                                                                      SB 19 
                                                                    Page  4



           4) Requires EMSA to adopt guidelines necessary for the  
             operation of pilot, and seek input from interested parties  
             and hold at least one public meeting.  Exempts EMSA from the  
             Administrative Procedures Act in adopting these guidelines.

           5) Requires the guidelines include the means to submit initial  
             or subsequent POLST information, or withdraw a form, from the  
             pilot, including a method for electronic delivery and the use  
             of legally sufficient electronic signatures.

           6) Requires the operation of the pilot to comply with state and  
             federal privacy and security laws and regulations including  
             the federal Health Insurance Portability and Accountability  
             Act of 1996.

           7) Requires EMSA to submit a detailed plan to the Legislature  
             that explains how the pilot will operate prior to  
             implementation, and the plan to be submitted in compliance  
             with the law, as specified.

           8) Protects a health care provider who honors a patient's  
             request regarding resuscitative measures obtained from the  
             eRegistry from criminal prosecution, civil liability,  
             discipline for unprofessional conduct, administrative  
             sanction, or any other sanction, if the health care provider  
             believes in good faith that the action or decision is  
             consistent with this part, and has no knowledge that the  
             action or decision would be inconsistent with a health care  
             decision that the individual signing the request would have  
             made on his or her own behalf under like circumstances.

           9) Requires an independent contractor approved by EMSA perform  
             an evaluation of the pilot.

           10)Sunsets this bill on January 1, 2020.

          Comments
          
          1)Author's statement.  According to the author, POLST is a form  
            that contains a doctor's orders to ensure that a patient's  
            wishes are honored regarding medical treatment towards the end  
            of life. Currently, the POLST form is a paper document, and as  








                                                                      SB 19  
                                                                    Page  5



            such, is oftentimes a key barrier to its effectiveness given  
            that it can be misplaced. Furthermore, there isn't a central  
            database or registry that first responders can access in an  
            emergency situation.  An electronic POLST registry in  
            California would help ensure immediate access to vital medical  
            orders by emergency medical personnel.  In an era of  
            ever-increasing technology and federal funding available to  
            specifically support electronic health records. Several states  
            are developing and a few states have already completed a  
            statewide registry to access POLST forms more effectively. 

          2)What is POLST?  POLST is neither an advance directive nor a  
            replacement for advance directives.  However, both documents  
            are helpful for communicating patient wishes when  
            appropriately used. An advance directive is a form in which an  
            individual appoints a person or persons to make health care  
            decisions for the individual if and when the individual loses  
            capacity to make health care decisions (health care power of  
            attorney); and/or provides guidance or instructions for making  
            health care decisions (living will). An advance directive is  
            from the patient, not a medical order.  POLST consists of a  
            set of medical orders that applies to a limited population of  
            patients and addresses a limited number of critical medical  
            decisions. POLST is a complement to advance directives in that  
            it serves as a translation tool and a continuity of care  
            assurance.

          3)POLST in California.  According to Dr. Neil Wenger of UCLA  
            Health Ethics Center at a December 3, 2014 briefing on POLST  
            in California, based on an evaluation by UCLA, POLST is widely  
            used in California but there are challenges with completing  
            the form and making sure it travels with the patient.   
            Additional problems include incomplete or inaccurate  
            information and for emergency medical responders the documents  
            are not always available.  Dr. Wenger suggests a registry is  
            one solution to these challenges.

          4)California pilot project.  In October of 2014, the California  
            HealthCare Foundation (CHCF) issued a request for information  
            to learn about the technical, infrastructure, and cost  
            requirements for developing a POLST registry in a single  
            California community.  CHCF was looking for information from  








                                                                      SB 19  
                                                                    Page  6



            vendors around the technology, operational, and support  
            services necessary to establish a POLST registry and estimates  
            of corresponding costs. The ideal technical solution(s) should  
            receive the POLST information for patients from varied  
            sources, communicate POLST records to emergency responders and  
            other medical professionals, and maintain data accuracy by  
            interfacing with medical and public health information systems  
            (such as the California death registry).  CHCF also requested  
            letters of interest from California communities with the  
            ability to convene acute care hospitals, medical groups,  
            nursing homes, hospices, and emergency medical services to  
            test a registry platform that would make POLST records  
            available to authorized providers telephonically,  
            electronically, or both. The ideal provider community would be  
            able to modify clinical workflows to use the pilot POLST  
            registry, integrate the POLST form into electronic health  
            record systems, and explore a sustainable financing model.  A  
            decision by CHCF to move forward with a pilot is not expected  
            until September.

          FISCAL EFFECT:   Appropriation:    No          Fiscal  
          Com.:YesLocal:   No


          According to the Assembly Appropriations Committee, costs likely  
          exceeding $1 million per year for two years (non-state funds)  
          for system development.  CHCF has commissioned a feasibility  
          report to examine the concept of a POLST registry.  According to  
          a draft of the report, it would cost about $2.5 million to  
          develop a statewide information technology system for an  
          online-accessible registry and set up the program; costs in the  
          hundreds of thousands of dollars per year to staff, maintain,  
          and market the registry pilot for the course of the pilot  
          (General Fund or other unknown fund source); and, unknown  
          potential cost savings due to avoided unwanted medical care  
          (various fund sources).


          SUPPORT:   (Verified9/8/15)


          Coalition for Compassionate Care of California (source)








                                                                      SB 19  
                                                                    Page  7



          AARP
          Alliance of Catholic Health Care
          Arc and United Cerebral Palsy California Collaboration
          Blue Shield of California
          California Accountable Physician Groups
          California American College of Emergency Physicians
          California Assisted Living Association
          California Association of Physician Groups
          California Chapter American College of Emergency Physicians
          California Commission on Aging
          California Hospital Association
          Care Like A Daughter, LLC
          Long Term Care Ombudsman Services of San Luis Obispo County
          Mission Hospital, Laguna Beach
          Mission Hospital, Mission Viejo
          Petaluma Valley Hospital
          Providence Health & Services Southern California
          Queen of the Valley Medical Center, Napa
          Redwood Memorial Hospital, Fortuna
          Riverside Family Physicians
          Santa Rosa Memorial Hospital 
          St. Mary Medical Center, Apple Valley
          St. Joseph Hospital, Orange
          St. Jude Medical Center, Fullerton
          Vynca


          OPPOSITION:   (Verified9/8/15)


          California Advocates for Nursing Home Reform 
          California Right to Life Committee


          ARGUMENTS IN SUPPORT:     According to this bill's sponsor,  
          Coalition for Compassionate Care of California (CCCC), POLST has  
          been widely adopted in California, almost 95% of California  
          hospitals have admitted a patient with a POLST and 87% have  
          blank forms available; 69% of nursing homes had reported  
          admitting a resident with a POLST form and 81% report a staff  
          member had completed a POLST with a resident; and after hearing  
          a description of POLST almost two-thirds of Californians say  








                                                                      SB 19  
                                                                    Page  8



          they would definitely or probably want to complete a POLST form  
          if they were seriously ill.  CCCC states that gaining access to  
          a patient's POLST during a medical crisis is a critical factor  
          in honoring patients' wishes and a statewide registry will  
          eliminate delays in care and confusion.  Hospitals have written  
          that POLST is an important care planning tool, but it does  
          little good if the information is not easily available in a time  
          of crisis.  POLST forms sometimes get lost when patients  
          transition from care settings and a statewide registry would  
          eliminate this problem.  Others write that POLST facilitates  
          free and informed consent required for medical treatments and  
          procedures for persons who are frail and elderly or who have a  
          compromised medical condition.  There are common roadblocks to  
          effective use of POLST but the registry can be a solution.


          ARGUMENTS IN OPPOSITION:     The California Right to Life  
          Committee, Inc. opposes this bill because the organization  
          believes the goals of this bill are directly tied to SB 128.   
          The California Right to Life Committee, Inc. believes this bill  
          is another interjection of the state into the medical field and  
          will result in an authorization of the death industry to heavily  
          pressure ill, elderly or disabled, especially low-income  
          citizens to succumb to their sales pitch and seek to end their  
          own lives.  The California Advocates for Nursing Home Reform  
          (CANHR) believes using state resources to create a POLST  
          registry without including advance health care directives  
          represents a significant missed opportunity and threatens to  
          further relegate advance health care directives to second class  
          status compared to POLST.  CANHR believes the POLST promotion  
          has exacerbated some of the form's problems, namely the form  
          does not need to be signed by patients and can sometimes be used  
          to override their actual wishes.  CANHR writes that advance  
          health care directives are generally superior to POLSTs for  
          advance care planning, but under this bill, advance health care  
          directives will continue to languish in a registry system that  
          is ancient, unused, and virtually useless.

           ASSEMBLY FLOOR:  64-11, 9/8/15
           AYES: Achadjian, Alejo, Baker, Bloom, Bonilla, Bonta, Brown,  
            Burke, Campos, Chang, Chau, Chiu, Chu, Cooley, Cooper,  
            Dababneh, Daly, Dodd, Frazier, Gallagher, Cristina Garcia,  








                                                                      SB 19  
                                                                    Page  9



            Eduardo Garcia, Gatto, Gipson, Gomez, Gonzalez, Gordon, Gray,  
            Hadley, Roger Hernández, Holden, Irwin, Jones, Jones-Sawyer,  
            Lackey, Levine, Linder, Lopez, Low, Maienschein, Mathis,  
            McCarty, Medina, Mullin, Nazarian, Obernolte, O'Donnell,  
            Olsen, Perea, Quirk, Rendon, Ridley-Thomas, Rodriguez, Salas,  
            Santiago, Steinorth, Mark Stone, Thurmond, Ting, Wagner,  
            Weber, Williams, Wood, Atkins
           NOES: Travis Allen, Bigelow, Brough, Dahle, Beth Gaines,  
            Harper, Mayes, Melendez, Patterson, Waldron, Wilk
           NO VOTE RECORDED: Calderon, Chávez, Eggman, Grove, Kim



          Prepared by:Teri Boughton / HEALTH / 
          9/8/15 20:56:40


                                   ****  END  ****