BILL ANALYSIS �
SENATE COMMITTEE ON HEALTH
Senator Ed Hernandez, O.D., Chair
BILL NO: SB 1357
AUTHOR: Wolk
AMENDED: April 21, 2014
HEARING DATE: April 24, 2014
CONSULTANT: Boughton
SUBJECT : Physician Orders for Life Sustaining Treatment form:
state-wide registry.
SUMMARY : Establishes a Physician Orders for Life Sustaining
Treatment registry at the California Health and Human Services
Agency.
Existing law:
1.Defines advanced health care directive or advance directive to
mean either an individual health care instruction or a power
of attorney for health care. Establishes a process and form
for an individual to give instructions about health care
decision making and designating an agent to make decisions on
his or her behalf.
2.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 in a central information
center, 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.
3.Requires the Secretary of State to establish procedures to
verify the identities of health care providers, the public
guardian, and other authorized persons requesting information
from the registry system. Prohibits a fee from being charged
to any health care provider, the public guardian, or other
authorized person requesting information from the registry
system.
4.Prohibits failure to register with the Secretary of State from
affecting the validity of any advance health care directive.
5.Requires the Secretary of State to work with the State
Department of Health Services (DHCS) and the office of the
Attorney General (AG) to develop information about end of life
Continued---
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care, advance health care directives, and registration of the
advance health care directives at the registry. Requires links
to this information and to the registry to be available on the
Web sites of the Secretary of State, DHCS, the office of the
AG, the Department of Managed Health Care, the Department of
Insurance, the Board of Registered Nursing, and the Medical
Board of California.
6.Establishes the Physician Orders for Life Sustaining Treatment
(POLST) form and medical intervention and procedures offered
by the form, and requires that it be explained by a health
care provider, defined 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.
7.Requires the form to be completed by a health care provider
based on patient preferences and medical indications, and
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.
8.Requires a request regarding resuscitative orders to be made
by an Emergency Medical Services Authority (EMSA) developed
prehospital "Do Not Resuscitate" or other substantially
similar form or, an EMSA approved POLST form.
This bill:
1.Requires the California Health and Human Services Agency
(CHHS) to establish and operate a statewide registry system,
to be known as the California POLST Registry, for the purpose
of collecting a POLST form, as defined, received from a health
care provider and disseminating the information in the form to
an authorized user. Authorizes the registry to be operated
and maintained by a contractor of CHHS. Requires CHHS to
adopt all rules necessary for the operation of the registry.
2.Requires the rules to include:
a. The means by which a POLST form may be
submitted to the registry, revised, and revoked and
include a method for electronic delivery of this
information and the use of legally sufficient
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electronic signature;
b. Appropriate and timely methods by which the
information in the registry may be disseminated to an
authorized user;
c. Procedures for verifying the identity of an
authorized user; and,
d. Procedures to ensure the accuracy of and to
appropriately protect the confidentiality of POLST
forms submitted to the registry.
3.Makes the registry and the information it contains the
property of the state and any disclosure of information in
POLST forms received by the registry to be made in a manner
consistent with the federal Health Insurance Portability and
Accountability Act of 1996.
4.Requires a health care provider who completes a POLST with a
patient or his or her legally recognized health care
decision-maker to submit a copy of the POLST to the registry
unless the patient or the decision-maker chooses not to
participate in the registry.
5.Indicates that an authorized user acting upon information
obtained from the registry is not subject to criminal
prosecution, civil liability, discipline for unprofessional
conduct, administrative sanction, or any other sanction if
that person acted in good faith and had 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.
6.Defines "authorized user" as a person authorized by CHHS to
submit information to, or to receive information from, the
POLST registry, including health care providers.
FISCAL EFFECT : This bill has not been analyzed by a fiscal
committee.
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
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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.
A statewide 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? According to the POLST Legislative Guide,
approved February 28, 2014 by the National POLST Paradigm Task
Force, the POLST Paradigm is a clinical process designed to
facilitate communication between health care professionals and
patients with serious illness or frailty (or their authorized
surrogate) where the health care professional would not be
surprised if the patient died within the next year. The
process encourages shared, informed medical decision-making
leading to a set of portable medical orders that respects the
patient's goals for care in regard to the use of
cardiopulmonary resuscitation and other medical interventions,
is applicable across health care settings, and can be reviewed
and revised as needed. The POLST paradigm promotes the use of
a highly visible, portable medical form that transfers from
one setting to another with the patient. It functions as a Do
Not Resuscitate order and provides treatment direction for
multiple situations. The form itself is outcome neutral. Its
options range from full treatment to comfort care only.
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
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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. As published in an August 10, 2012
article in the Journal of General Internal Medicine,
Implementation of Physician Orders for Life Sustaining
Treatment in Nursing Homes in California: Evaluation of a
Novel Statewide Dissemination Mechanism, 546 California
nursing homes were surveyed and in 82 percent of responding
nursing homes, staff received POLST education and 59 percent
reported having a formal policy on POLST. Two-thirds had
admitted a resident with a POLST and 15 percent of newly
admitted residents over the past month had a POLST. Few
nursing homes reported difficulty following POLST orders, but
38 percent noted difficulty involving physicians in POLST
completion. A 2013 article in the Journal of American
Geriatrics Society, Implementing Physician Orders for
Life-Sustaining Treatment in California Hospitals: Factors
Associated with Adoption, indicates of 349 hospitals surveyed,
81.9 percent responded. Sixty-five percent of hospitals had a
policy on POLST, 87 percent had available POLST forms, 84
percent had educated staff, and 94 percent reported handling
POLST properly in the emergency department on admission.
Although POLST is widely used in California, a significant
minority of hospitals remain unprepared three years after
implementation.
4.Other Registries.
a. Advance Health Care Directive Registry . The
Secretary of State maintains the Advance Health Care
Directive Registry as required by law which allows a
person who has executed an advance health care directive
to register information regarding the directive with the
Secretary of State. This information is made available
upon request to the registrant's health care provider,
public guardian, or legal representative. A request for
information must state the need for the information. An
advance health care directive can be made a part of the
Secretary of State's registry by attaching a copy of the
advance health care directive to the Registration of
Written Advance Health Care Directive filed with the
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Secretary of State. As an alternative to providing a copy
of the written directive to the Secretary of State, its
location can be indicated on the registration form. As
of March 24, 2014, the registry had 4,464 records in the
registry. The Secretary of State receives an average of
35 filings per month and an average of 40 requests per
month from providers to receive advance health care
information. The Secretary of State does not perform
marketing activities for the registry other than the
information on their Internet Website. The Secretary of
State's office indicates that the registry is an odd fit
for the Business Program Division and that many health
care providers would not think to look for it at the
Secretary of State's office. The annual cost to maintain
the registry is approximately $45,000, excluding overhead
costs. There is a $10 registration fee but the registry
is maintained along with all other Business Programs
Division filings through an annual appropriation from the
Business Fees Fund.
b. California Cancer Registry . According to the
California Department of Public Health, California Cancer
Registry (CCR) is California's statewide population-based
cancer surveillance system. The CCR collects information
about all cancers diagnosed in California (except basal
and squamous cell carcinoma of the skin and carcinoma in
situ of the cervix). In 1985, statewide,
population-based cancer reporting was required by law.
The CCR is now recognized as one of the leading cancer
registries in the world. Due to the size and diversity of
the California population, more is now known about the
occurrence of cancer in diverse populations than ever
before. The CCR has proven to be the cornerstone of a
substantial amount of cancer research in the California
population.
c. California Immunization Information Registry (CAIR).
CAIR is a collaborative effort involving local health
departments, the California Department of Public Health,
Immunization Branch, and a spectrum of key stakeholders
across the state. There are seven regional registries
managed by department staff. CAIR is working to develop
an integrated, statewide computerized registry to network
each child's full immunization history.
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Health care providers and other authorized users log in
to the registry using a user ID and password. In
addition to accessing patient immunization information,
users can utilize the integrated vaccine algorithm to
determine vaccinations due, enter new patients or vaccine
doses administered, manage vaccine inventory, run patient
or inventory reports, or run reminder/recalls on their
patients. New patients or vaccine doses can either be
entered directly into CAIR using the web interface or can
be submitted electronically as aggregated data files
(e.g. exported from their EHR systems) for upload to
CAIR. Many prominent private and public health care
entities already share data electronically with CAIR.
Statewide there are 14.9 million patients with 160
million vaccines registered. In 2010 state General Fund
support for the registries (approximately $3.5 million)
was withdrawn and efforts to integrate the registries
were put on hold. Support to users and system
enhancements were diminished.
5.Lessons Learned. Pathways to POLST Registry Development:
Lessons Learned by Zive and Schmidt, October 2012, examined
POLST Paradigm registry systems in seven different states
(California, which has no current registry, Idaho, New York,
Oregon, Utah, Washington State, and West Virginia). Five of
the states studied had either an active registry or an
Electronic Form Completion System. Several key findings
emerged: 1) Defining the registry's purpose is essential. 2)
A mature, widespread POLST program supports more rapid
population of the registry. 3) Strong leadership is
essential. 4) Integrating into existing health care systems
and Electronic Medical Records increases use and economizes
resources. 5) Volume of submissions is impacted by the
process for submission and who can submit. 6) Launching a
registry prematurely can divert resources from other aspects
of establishing a successful POLST program. 7) Sustaining
funding for registry operations is vital to long-term success.
According to the 2012 study, California's POLST is relatively
new. Since California is such a large and diverse state,
statewide coordination including interaction and communication
with local health care leaders has been extremely important.
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Much of the focus is on quality implementation. Because
emergency responders are overseen by 32 local emergency
medical authorities rather than a single statewide entity
there is no logical centralized home for a registry.
Additionally, the desire to share information electronically
expands to health care information beyond POLST, and the state
of health information technology is in flux. The registry
needs to interface with future health information technology.
6.Oregon. The Oregon registry is a model for other states. The
registry is housed in the Oregon Health Authority and operated
on contract with the Oregon Health and Science University
Department of Emergency Medicine, which already had a 24-hour
Emergency Communication Center. Legislation adopted in Oregon
mandated that all completed POLST forms be submitted to the
registry by the signer unless the patient opts out. Vynca, a
web-based platform for the completion, storage and rapid
access of advance care planning forms is being piloted at
Oregon Health and Science University and the Oregon POLST
registry, supported by the California HealthCare Foundation,
and is currently under evaluation for purchase at sites across
northern California.
7.Double referral. This bill is double referred. Should it pass
out of this committee it will be referred to the Senate
Judiciary Committee.
8.Related legislation. AB 2452 (Pan) would require, commencing
on January 1, 2016, the Secretary of State to establish and
maintain access, as specified, to a secure portion of the
Secretary of State's Internet Web site that provides an
electronic reproduction of an advance health care directive
and other specified documents submitted to the registry
system. This bill is currently pending in the Assembly Health
Committee.
AB 1683 (Jones) would require the Department of Public Health
to inform all patients diagnosed with, or being treated for
cancer that their case has been reported to the Ken Maddy CCR
within six months of their case being reported. This bill is
currently pending in the Assembly Appropriations Committee.
9.Prior legislation. AB 3000 (Wolk), Chapter 266, Statutes of
2008, created POLST in California, which is a standardized
form to reflect a broader vision of resuscitative or life
sustaining requests and to encourage the use of POLST orders
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to better handle resuscitative or life sustaining treatment
consistent with a patient's wishes.
AB 1676 (Richman and Nation), Chapter 434, Statutes of 2005,
created the Advance Directives and Terminal Illness Decisions
Program, which requires the Secretary of State to work with
the Department of Health Services (now DHCS) and the AG to
develop information about end of life care, advance health
care directives, and registration of the advance health care
directives at the Advance Health Care Directive Registry. This
act also requires links to be provided for this information on
the websites of the Secretary of State, DHCS, the AG,
Department of Managed Health Care, Department of Insurance,
Board of Registered Nursing, and the Medical Board of
California.
AB 2442 (Canciamilla), Chapter 882, Statutes of 2004, requires
the Secretary of State, as part of the duties associated with
the Advance Health Care Directive Registry, to receive and
release a person's advance health care directive and transmit
the information to the registry of another jurisdiction upon
request. It requires the Secretary of State to respond by the
close of business on the next business day to a request for
information received from the emergency department of a
general acute care hospital.
AB 891 (Alquist), Chapter 658, Statutes of 2000, established
the Health Care Decisions Law which also governs advance
health care directives.
SB 1857 (Watson), Chapter 1280, Statutes of 1994, requires the
Secretary of State to establish a central registry for power
of attorney for health care or a Natural Death Act
declaration. This legislation was repealed and replaced by
the Health Care Decisions Law.
AB 48 (Cedillo), Chapter 368, Statutes of 2000, renamed the
California Cancer Registry the Ken Maddy CCR.
AB 136 (Connelly), Chapter 841, Statutes of 1985, established
California Cancer Registry.
10.Support. The California Chapter of the American College of
Emergency Physicians writes in support that the POLST document
does not always travel with the patient. The emergency
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department is often the place the end of life decisions a
patient set out in their POLST are put into practice.
However, many patients arrive in the emergency department
without the POLST form. Having POLST forms available online
makes it possible for an emergency physician to quickly access
the form and honor the patient's wishes. Without a POLST
form, emergency physicians will resuscitate. This bill helps
ensure that a patient isn't resuscitated if that is not what
the person truly wants. The Coalition for Compassionate Care
of California (CCCC) writes in support that now that POLST
adoption is widespread in California, it is appropriate for
California to consider establishing an electronic registry for
POLST. Use of health information technology to enhance
availability of medical records and other information has
increased dramatically in recent years, and the landscape of
health information technology continues to evolve. An
electronic registry of POLST forms will ensure that
information is available to healthcare professionals that will
allow them to follow the stated wishes of patients regarding
medical treatment during serious illness, even when patients
are not able to communicate these wishes and there is no one
else to speak on their behalf. For the past year and half,
CCCC has been actively exploring options for and issues around
establishing a successful electronic registry. CCCC and the
Institute for Population Health at UC Davis are looking to
piloting an electronic registry in two communities in
California. Likewise, the California HealthCare Foundation is
conducting a feasibility study to examine what it would take
to implement a successful POLST registry in California and
ensure its sustainability.
11.Oppose. The California Right to Life Committee, Inc., writes
in opposition to POLST because they consider a POLST form does
not guarantee the individual person's total control over
possible treatment therapies and this bill would further embed
the use of POLST in the legal, medical, and social fabric of
California.
12.Where should it go? Is the California Health and Human
Services Agency the appropriate entity to house the registry?
Would the Agency delegate to one of the departments under its
jurisdiction? Should the POLST registry be housed together
with the Advance Health Care Directive Registry? The low
uptake of the Advance Health Care Directive Registry suggests
that the Secretary of State may not be the appropriate place
to house a POLST registry. Will a POLST registry have better
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uptake? The Department of Public Health has some experience
with other registries. Since Advance Directives and POLST
forms complement one another perhaps the registries should be
housed together.
13.Are we ready? According to the October 2012 lessons learned
report there were a number of issues raised that suggested
California wasn't quite ready for a POLST registry. What has
changed since that report was published? Has California's
POLST program matured enough? Is there leadership at the
state level? Does California have the resources now to
support this activity?
14.Technical Amendment. Page 2, line 9, "department" should be
replaced with "agency"
SUPPORT AND OPPOSITION :
Support: California Chapter of the American College of
Emergency Physicians
California Long-Term Care Ombudsman Association
Coalition for Compassionate Care of California
Congress of California Seniors
Long Term Care Ombudsman Services of San Luis Obispo
County
WISE and Healthy Aging Long-Term Care Ombudsman
Program
Oppose: California Right to Life Committee, Inc.
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