ARC 6205C

ARC 6205C

NURSING BOARD[655]

Notice of Intended Action

Proposing rule making related to standards of practice for telehealth for advanced registered nurse practitioners (ARNPs) and providing an opportunity for public comment

The Board of Nursing hereby proposes to amend Chapter 7, "Advanced Registered Nurse Practitioners," Iowa Administrative Code.

Legal Authority for Rule Making

This rule making is proposed under the authority provided in Iowa Code section 147.76.

State or Federal Law Implemented

This rule making implements, in whole or in part, Iowa Code chapter 152.

Purpose and Summary

In light of the proliferation of telehealth services, the Board proposes to adopt amendments governing minimum standards of practice for advanced registered nurse practitioners (ARNPs) who provide health care services through telehealth. These proposed amendments provide when an Iowa license is required, instruct that the licensee will be held to the same standard of care as is applicable to in-person settings, instruct when a provider-patient relationship must first be established, require the use of Health Insurance Portability and Accountability Act (HIPAA)-compliant technology, authorize the issuance of prescriptions via telehealth provided such issuance is consistent with the standard of care, require adequate recordkeeping of telehealth encounters, and require referrals for follow-up care when required by the standard of care. These proposed amendments have been reviewed and approved by the Board's ARNP Advisory Committee, which is a committee comprised of 11 ARNPs who work in various settings throughout the state.

Fiscal Impact

This rule making has no fiscal impact to the State of Iowa.

Jobs Impact

Although a precise jobs impact is unclear, these amendments have the potential for creating additional jobs, because the amendments clarify that ARNPs may provide health care services, consistent with ARNPs' scopes of practice and population foci, through telehealth.

Waivers

Any person who believes that the application of the discretionary provisions of this rule making would result in hardship or injustice to that person may petition the Board for a waiver of the discretionary provisions, if any, pursuant to 655—Chapter 15.

Public Comment

Any interested person may submit written comments concerning this proposed rule making. Written comments in response to this rule making must be received by the Board no later than 4:30 p.m. on March 15, 2022. Comments should be directed to:

Public Hearing

A public hearing at which persons may present their views orally or in writing will be held as follows:

Persons who wish to make oral comments at the public hearing may be asked to state their names for the record and to confine their remarks to the subject of this proposed rule making.

Any persons who intend to attend the public hearing and have special requirements, such as those related to hearing or mobility impairments, should contact the Board and advise of specific needs.

Review by Administrative Rules Review Committee

The Administrative Rules Review Committee, a bipartisan legislative committee which oversees rule making by executive branch agencies, may, on its own motion or on written request by any individual or group, review this rule making at its regular monthly meeting or at a special meeting. The Committee's meetings are open to the public, and interested persons may be heard as provided in Iowa Code section 17A.8(6).

The following rule-making actions are proposed:

Item 1. Adopt the following new definitions of "Asynchronous store-and-forward transmission," "Cross-coverage," "Licensee," "On call" and "Telehealth" in rule 655—7.1(17A,124,147,152):

"Asynchronous store-and-forward transmission" means the collection of a patient's relevant health information and the subsequent transmission of the data from an originating site to a health care provider at a distant site without the presence of the patient.

"Cross-coverage" means a licensee who engages in a remote evaluation of a patient, without in-person contact, at the request of another licensed health care provider who has established a proper practitioner-patient relationship with the patient.

"Licensee" means an individual licensed by the board as an advanced registered nurse practitioner.

"On call" means a licensee is available, where necessary, to attend to the urgent and follow-up needs of a patient for whom the licensee has temporarily assumed responsibility, as designated by the patient's primary care licensee or other health care provider of record.

"Telehealth" means the practice of nursing using electronic audiovisual communications and information technologies or other means, including interactive audio with asynchronous store-and-forward transmission, between a licensee in one location and a patient in another location with or without an intervening health care provider. Telehealth includes asynchronous store-and-forward technologies, remote monitoring, and real-time interactive services, including teleradiology and telepathology. Telehealth, for the purposes of this rule, shall not include the provision of nursing services only through an audio-only telephone, email messages, facsimile transmissions, or U.S. mail or other parcel service, or any combination thereof.

Item 2. Adopt the following new rule 655—7.9(152):

655—7.9(152) Standards of practice for telehealth.

7.9(1) Telehealth permitted. A licensee may, in accordance with all applicable laws and rules, provide health care services to a patient through telehealth.

7.9(2) License required. An advanced registered nurse practitioner who provides services through telehealth to a patient physically located in Iowa must be licensed by the board. A licensee who provides services through telehealth to a patient physically located in another state shall be subject to the laws and jurisdiction of the state where the patient is physically located.

7.9(3) Standard of care.

a. A licensee who provides services through telehealth shall be held to the same standard of care as is applicable to in-person settings. A licensee shall not perform any service via telehealth unless the same standard of care can be achieved as if the service was performed in person.

b. Prior to initiating contact with a patient for the purpose of providing services to the patient using telehealth, a licensee shall:

(1)Review the patient's history and all relevant medical records; and

(2)Determine as to each unique patient encounter whether the licensee will be able to provide the same standard of care using telehealth as would be provided if the services were provided in person.

7.9(4) Scope of practice. A licensee who provides services through telehealth must practice within the licensee's respective population foci and ensure the services provided are consistent with the licensee's scope of practice, education, training, and experience.

7.9(5) Practitioner-patient relationship.

a. Prior to providing services through telehealth, the licensee shall first establish a practitioner-patient relationship. A practitioner-patient relationship is established when:

(1)The person with a health-related matter seeks assistance from the licensee;

(2)The licensee agrees to provide services; and

(3)The person agrees to be treated, or the person's legal guardian or legal representative agrees to the person's being treated, by the licensee regardless of whether there has been a previous in-person encounter between the licensee and the person.

b. A practitioner-patient relationship can be established through an in-person encounter, consultation with another licensee or health care provider, or telehealth encounter.

c. Notwithstanding paragraphs 7.9(5)"a" and "b," services may be provided through telehealth without first establishing a practitioner-patient relationship in the following settings or circumstances:

(1)Institutional settings;

(2)Licensed or certified nursing facilities, residential care facilities, intermediate care facilities, assisted living facilities, and hospice settings;

(3)In response to an emergency or disaster;

(4)Informal consultations with another health care provider performed by a licensee outside of the context of a contractual relationship, or on an irregular or infrequent basis, without the expectation or exchange of direct or indirect compensation;

(5)Episodic consultations by a specialist located in another jurisdiction who provides consultation services upon request to a licensee;

(6)A substitute licensee acting on behalf and at the designation of an absent licensee or other health care provider in the same specialty on an on-call or cross-coverage basis; or

(7)When a sexually transmitted disease has been diagnosed in a patient, a licensee prescribes or dispenses antibiotics to the patient's named sexual partner(s) for the treatment of the sexually transmitted disease as recommended by the U.S. Centers for Disease Control and Prevention.

7.9(6) Consent to telehealth. Prior to providing services via telehealth, the licensee shall obtain consent from the patient, or the patient's legal guardian or legal representative, to receive services via telehealth.

7.9(7) Technology. A licensee providing services through telehealth shall utilize technology that is secure and compliant with the Health Information Portability and Accountability Act (HIPAA). The technology must be of sufficient quality, size, resolution, and clarity such that the licensee can safely and effectively provide the telehealth services and abide by the applicable standard of care.

7.9(8) Prescriptions. A licensee providing services through telehealth may issue a prescription to a patient as long as the issuance of such prescription is consistent with the standard of care applicable to the in-person setting.

7.9(9) Records. A licensee who provides services through telehealth shall maintain a record of the care provided to the patient. Such records shall comply with all applicable laws, rules, standards of care for recordkeeping, confidentiality, and disclosure of a patient's medical record.

7.9(10) Follow-up care. A licensee who provides services through telehealth shall refer a patient for follow-up care when required by the standard of care.