California Senate Bill SB492 Amended / Bill

 BILL NUMBER: SB 492AMENDED BILL TEXT AMENDED IN SENATE APRIL 24, 2013 AMENDED IN SENATE APRIL 16, 2013 AMENDED IN SENATE APRIL 1, 2013 INTRODUCED BY Senator Hernandez FEBRUARY 21, 2013 An act to  repeal and add Sections 3041 and 3041.2   amend Sections 3041 and 3041.1  of the Business and Professions Code, relating to optometry. LEGISLATIVE COUNSEL'S DIGEST SB 492, as amended, Hernandez. Optometrist: practice: licensure. The Optometry Practice Act creates the State Board of Optometry, which licenses optometrists and regulates their practice. Existing law defines the practice of optometry to include, among other things, 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 doing certain things, including, but not limited to, the examination of the human eyes, the determination of the powers or range of human vision, and the prescribing of contact and spectacle lenses.  Existing law provides that the State Board of Optometry is required, by regulation, to establish educational and examination requirements for licensure to ensure the competence of optometrists to practice.   Existing law authorizes an optometrist certified to use therapeutic pharmaceutical agents to diagnose and treat specified conditions, use specified pharmaceutical agents, and order specified diagnostic tests.  Any violation of the act is a crime.  This bill would delete the definition of the practice of optometry and would instead provide that a licensed optometrist would be authorized to perform certain health-related services, including, but not limited to, examining, preventing, diagnosing, and treating any disease, condition, or disorder of the visual system, the human eye, and adjacent and related structures of the visual system, prescribing appropriate drugs, including narcotics, and administering immunizations and to diagnose other common primary care conditions that have ocular manifestations. The bill would also authorize an optometrist, who is operating under a protocol with a physician and surgeon or a health care facility, or participating in a specified system of care in which the patient is being otherwise treated, to initiate treatment and manage medications for those diagnosed conditions. The bill would require the board to require applicants for licensure to successfully complete specified examinations, and would authorize the board to require the passage of additional examinations with regard to competency to utilize diagnostic and therapeutic pharmaceutical agents, if not covered by the required examinations.   This bill would add the provision of habilitative optometric services to the definition of the practice of optometry. The bill would expand the practice parameters of optometrists who are certified to use therapeutic pharmaceutical agents by removing certain limitations on their practice and adding certain responsibilities, including, but not limited to, the ability to immunize and treat certain diseases, and deleting the specified drugs the optometrist would be authorized to use, and authorizing the optometrist to use all therapeutic pharmaceutical agents approved by the United States Food and Drug Administration, as provided. The bill would also delete limitations on what kinds of diagnostic tests an optometrist could order and instead would authorize an optometrist to order appropriate laboratory and diagnostic imaging tests.   Existing law requires optometrists in diagnosing or treating eye disease to be held to the same standard of care as physicians and surgeons and osteopathic physicians and surgeons.   This bill would expand this requirement to include other diseases, and would require an optometrist to consult with and, if necessary, refer to a physician and surgeon or other appropriate health care provider if a situation or condition was beyond the optometrist's education and training.  Because this bill would change the definition of a crime, it would create a state-mandated local program. The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement. This bill would provide that no reimbursement is required by this act for a specified reason. Vote: majority. Appropriation: no. Fiscal committee: yes. State-mandated local program: yes. THE PEOPLE OF THE STATE OF CALIFORNIA DO ENACT AS FOLLOWS:  SECTION 1.   Sec   tion 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  habilitative or  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 that 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 purpose of the examination of the human eye or eyes for any disease or pathological condition. (b) (1) An optometrist who is certified to use therapeutic pharmaceutical agents, pursuant to Section 3041.3, may also diagnose and treat the human eye or eyes, or any of its or their 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 in patients under 12 years of age.   adnexa.  (B) Ocular allergies of the anterior segment and adnexa. (C) Ocular  inflammation, nonsurgical in cause except when comanaged with the treating physician and surgeon, 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 or appropriate physician and surgeon if a patient has a recurrent case of episcleritis within one year of the initial occurrence. An optometrist shall consult with an ophthalmologist or appropriate physician and surgeon if a patient has a recurrent case of peripheral corneal inflammatory keratitis within one year of the initial occurrence.   inflammation.  (D) Traumatic or recurrent conjunctival or corneal abrasions and erosions. (E) Corneal surface disease and dry eyes. (F) Ocular  pain, nonsurgical in cause except when comanaged with the treating physician and surgeon, associated with conditions optometrists are authorized to treat.   pain.  (G) Pursuant to subdivision  (f),   (e),  glaucoma in patients over 18 years of age, as described in subdivision  (j).   (i).   (H) Eyelid disorders.  (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)   (d)  . (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:   therapeutic pharmaceutical agents approved by the United States Food and Drug Administration for use in treating eye conditions set forth in this chapter, including narcotic substances other than those listed in Schedule I.   (1) Pharmaceutical agents as described in paragraph (5) of subdivision (a), as well as topical miotics.   (2) Topical lubricants.   (3) Antiallergy agents. In using topical steroid medication for the treatment of ocular allergies, an optometrist shall consult with an ophthalmologist if the patient's condition worsens 21 days after diagnosis.   (4) Topical and oral anti-inflammatories. In using steroid medication for:   (A) Unilateral nonrecurrent nongranulomatous idiopathic iritis or episcleritis, an optometrist shall consult with an ophthalmologist or appropriate physician and surgeon 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 or appropriate physician and surgeon.   (B) Peripheral corneal inflammatory keratitis, excluding Moorens and Terriens diseases, an optometrist shall consult with an ophthalmologist or appropriate physician and surgeon if the patient's condition worsens 72 hours after diagnosis.   (C) Traumatic iritis, an optometrist shall consult with an ophthalmologist or appropriate physician and surgeon if the patient's condition worsens 72 hours after diagnosis and shall refer the patient to an ophthalmologist or appropriate physician and surgeon if the patient's condition has not resolved one week after diagnosis.   (5) Topical antibiotic agents.   (6) Topical hyperosmotics.   (7) Topical and oral antiglaucoma agents pursuant to the certification process defined in subdivision (f).   (A) The optometrist shall refer the patient to an ophthalmologist if requested by the patient or if angle closure glaucoma develops.   (B) If the glaucoma patient also has diabetes, the optometrist shall consult with the physician treating the patient's diabetes in developing the glaucoma treatment plan and shall inform the physician in writing of any changes in the patient's glaucoma medication.   (8) Nonprescription medications used for the rational treatment of an ocular disorder.   (9) Oral antihistamines.   (10) Prescription oral nonsteroidal anti-inflammatory agents.   (11) Oral antibiotics for medical treatment of ocular disease.   (A) If the patient has been diagnosed with a central corneal ulcer and the central corneal ulcer has not improved 48 hours 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 48 hours after diagnosis, the optometrist shall refer the patient to an ophthalmologist.   (12) Topical and oral antiviral medication 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.   (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 (Division 10 (commencing with Section 11000) of the Health and Safety Code) 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 and with the patient's consent, the optometrist shall furnish a copy of the record to the ophthalmologist.   (e)   (d)  An optometrist who is certified to use therapeutic pharmaceutical agents pursuant to Section 3041.3 may also perform all of the following: (1) Corneal scraping with cultures. (2) Debridement of corneal epithelia. (3) Mechanical epilation. (4) Venipuncture for testing patients suspected of having diabetes. (5) Suture removal  , with prior consultation with the treating physician and surgeon  . (6) Treatment or removal of sebaceous cysts by expression. (7) Administration of oral fluorescein  to patients suspected as having diabetic retinopathy  . (8) Use of an auto-injector to counter anaphylaxis. (9) Ordering of  smears, cultures, sensitivities, complete blood count, mycobacterial culture, acid fast stain, urinalysis, tear fluid analysis, and X-rays necessary for the diagnosis of conditions or diseases of the eye or adnexa. An optometrist may order other types of images subject to prior consultation with an ophthalmologist or appropriate physician and surgeon   appropriate laboratory and diagnostic imaging tests  .  (10) A clinical laboratory test or examination classified as waived under CLIA and designated as waived in paragraph (9) necessary for the diagnosis of conditions and diseases of the eye or adnexa, or if otherwise specifically authorized by this chapter.   (11)   (10)  Punctal occlusion by plugs, excluding laser, diathermy, cryotherapy, or other means constituting surgery as defined in this chapter.  (12)   (11)  The prescription of therapeutic contact lenses, including lenses or devices that incorporate a medication or therapy the optometrist is certified to prescribe or provide.  (13)   (12)  Removal of foreign bodies from the cornea, eyelid, and conjunctiva with any appropriate instrument other than a scalpel  or needle  . Corneal foreign bodies shall be nonperforating, be no deeper than the midstroma, and require no surgical repair upon removal.  (14)   (13)  For patients over 12 years of age, lacrimal irrigation and dilation, excluding probing of the nasal lacrimal tract. The board shall certify any optometrist who graduated from an accredited school of optometry before May 1, 2000, to perform this procedure after submitting proof of satisfactory completion of 10 procedures under the supervision of an ophthalmologist as confirmed by the ophthalmologist. Any optometrist who graduated from an accredited school of optometry on or after May 1, 2000, shall be exempt from the certification requirement contained in this paragraph.  (14) Immunizations for influenza and shingles and additional immunizations that may be necessary to protect public health during a declared disaster or public health emergency.   (15) In addition to diagnosing and treating conditions of the visual system pursuant to subdivision (a), diagnoses of diabetes mellitus, hypertension, and hyperlipidemia.   (f)   (e)  The board shall grant a certificate to an optometrist certified pursuant to Section 3041.3 for the treatment of glaucoma, as described in subdivision  (j)   (i)  , in patients over 18 years of age after the optometrist meets the following applicable requirements: (1) For licensees who graduated from an accredited school of optometry on or after May 1, 2008, submission of proof of graduation from that institution. (2) For licensees who were certified to treat glaucoma under this section prior to January 1, 2009, submission of proof of completion of that certification program. (3) For licensees who have substantially completed the certification requirements pursuant to this section in effect between January 1, 2001, and December 31, 2008, submission of proof of completion of those requirements on or before December 31, 2009. "Substantially completed" means both of the following: (A) Satisfactory completion of a didactic course of not less than 24 hours in the diagnosis, pharmacological, and other treatment and management of glaucoma. (B) Treatment of 50 glaucoma patients with a collaborating ophthalmologist for a period of two years for each patient that will conclude on or before December 31, 2009. (4) For licensees who completed a didactic course of not less than 24 hours in the diagnosis, pharmacological, and other treatment and management of glaucoma, submission of proof of satisfactory completion of the case management requirements for certification established by the board pursuant to Section 3041.10. (5) For licensees who graduated from an accredited school of optometry on or before May 1, 2008, and not described in paragraph (2), (3), or (4), submission of proof of satisfactory completion of the requirements for certification established by the board pursuant to Section 3041.10.  (g)  (f)  Other than for prescription ophthalmic devices described in subdivision (b) of Section 2541, any dispensing of a therapeutic pharmaceutical agent by an optometrist shall be without charge.  (h)   (g)  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. "Surgery" does not include those procedures specified in subdivision  (e)   (d)  . Nothing in this section shall limit an optometrist's authority to utilize diagnostic laser and ultrasound technology within his or her scope of practice.  (i)   (h)  An optometrist licensed under this chapter is subject to the provisions of Section 2290.5 for purposes of practicing telehealth.  (j)   (i)  For purposes of this chapter, "glaucoma" means either of the following: (1) All primary open-angle glaucoma. (2) Exfoliation and pigmentary glaucoma.  (k)   (j)  For purposes of this chapter, "adnexa" means ocular adnexa.  (l)   (k)  In an emergency, an optometrist shall stabilize, if possible, and immediately refer any patient who has an acute attack of angle closure to an ophthalmologist.  SEC. 2.   Section 3041.1 of the  Business and Professions Code   is amended to read:  3041.1. With respect to the practices set forth in  subdivisions (b), (d), and (e) of  Section 3041, optometrists diagnosing or treating eye  disease   or other diseases  shall be held to the same standard of care to which physicians and surgeons and osteopathic physicians and surgeons are held.  An optometrist shall consult with and, if necessary, refer to a physician and surgeon or other appropriate health care provider if a situation or condition occurs that is   beyond the optometrist's education and training.   SECTION 1.   Section 3041 of the Business and Professions Code is repealed.   SEC. 2.   Section 3041 is added to the Business and Professions Code, to read: 3041. (a) An optometrist license authorizes the holder to do all of the following: (1) Examine, prevent, diagnose, and treat any disease, condition, or disorder of the visual system, the human eye, and adjacent and related structures of the visual system. (2) The use or prescription of appropriate drugs, including narcotic substances other than those listed in Schedule 1. (3) The performance of minor surgical and nonsurgical primary eye care procedures requiring no more than topical or local anesthetic, or both, consistent with an optometrist's education and training. (4) The use or prescription of visual therapy, ocular exercises or vision habilitation, and rehabilitation services. (5) The performance or ordering of appropriate laboratory and diagnostic imaging tests. (b) An optometrist may administer immunizations. (c) In addition to diagnosing and treating conditions of the visual system pursuant to subdivision (a), an optometrist may diagnose other common primary care conditions that have ocular manifestations. (d) In addition to the authority provided in subdivisions (a) to (c), inclusive, an optometrist who is operating under a protocol with a physician and surgeon or a health care facility, or participating in a medical home, accountable care organization, or other system of care in which the patient is being otherwise treated, may initiate treatment and manage medications for conditions diagnosed pursuant to subdivision (c).   SEC. 3.   Section 3041.2 of the Business and Professions Code is repealed.   SEC. 4.   Section 3041.2 is added to the Business and Professions Code, to read: 3041.2. (a) The State Board of Optometry shall establish, by regulation, educational and examination requirements for licensure to ensure the competence of optometrists to practice. (b) On and after January 1, 2014, the board shall require each applicant for licensure to successfully complete the Part I, Part II, and Part III examinations of the National Board of Examiners in Optometry. (c) On and after January 1, 2014, the board shall require each applicant for licensure to successfully complete an examination in California law and ethics developed and administered by the board. (d) On and after January 1, 2014, the board may require passage of additional examinations to ensure the competency of licentiates to utilize diagnostic and therapeutic pharmaceutical agents, if not otherwise covered by the examinations required pursuant to subdivisions (a) and (b).   SEC. 5.  SEC. 3.  No reimbursement is required by this act pursuant to Section 6 of Article XIII B of the California Constitution because the only costs that may be incurred by a local agency or school district will be incurred because this act creates a new crime or infraction, eliminates a crime or infraction, or changes the penalty for a crime or infraction, within the meaning of Section 17556 of the Government Code, or changes the definition of a crime within the meaning of Section 6 of Article XIII B of the California Constitution.