I 116th CONGRESS 1st Session H. R. 5190 IN THE HOUSE OF REPRESENTATIVES November 20, 2019 Mr. Harder of California (for himself, Mr. Young , Mr. Fortenberry , Ms. Torres Small of New Mexico , and Mr. Steube ) introduced the following bill; which was referred to the Committee on Energy and Commerce A BILL To amend the Public Health Service Act to provide assistance for health centers and rural health clinics to implement electronic provider consultation and related telemedicine services.

1. Short title This Act may be cited as the Specialty Treatment to Access and Referrals Act of 2019 or the STAR Act . 2. Findings Congress finds the following: (1) Telemedicine involving the delivery of safe, effective, quality health care services by a health care provider using electronic information technology as the mode of care delivery is a clinically appropriate and efficient method of furnishing many health care services. (2) Consultations between health care providers utilizing electronic information technology (in this section referred to as E–Consult services ) are feasible in a variety of settings, flexible in their application, and particularly useful in facilitating the timely provision of information from a clinician with specialized knowledge of a relevant medical subject matter to a treating clinician in order to improve care quality. (3) E–Consult services formalize the role of medical specialists, can be undertaken entirely within electronic exchange platforms that are private and secure, and do not require synchronous communication between providers. (4) E–Consult services conducted in advance of a telemedicine service can improve the effectiveness of the subsequent telemedicine service. (5) E–Consult services are being utilized extensively by the Veterans Health Administration and by a growing number of academic medical centers and other public and private health care settings both in the United States and internationally. (6) There is a need for additional extensive and rigorous research studies to determine best practices and processes for E–Consult services and to validate the impact on access to specialty medical care, costs, and clinical outcomes. (7) Providing the expertise and technical assistance necessary to implement E–Consult services in primary care settings could improve access to specialty care at relatively low cost while simultaneously providing a testbed to evaluate the merits of varying approaches to E–Consult services, ascertain the value of such programs, and experiment with service reimbursement strategies in fee-for-service environments, including value-based care delivery arrangements such as through accountable care organizations. 3. E–Consult services and related telehealth assistance pilot program Title III of the Public Health Service Act is amended by inserting after section 330M ( 42 U.S.C. 254c–19 ) the following new section: 330N. E–Consult services and related telehealth assistance pilot program (a) In general The Secretary may award grants to eligible health center controlled networks, health centers, and rural health clinics described in subsection (e) to conduct pilot projects to implement and test the effectiveness of E–Consult services and related telehealth services furnished at such networks, centers, and clinics for purposes of addressing the goals described in subsection (b). (b) Objectives A pilot project conducted pursuant to a grant awarded under subsection (a) shall address the following goals: (1) Improvement in patient access to specialty care. (2) Reduction in specialty care patient wait times. (3) Reduction in patient specialty referrals. (4) Reduction in patient miles traveled for specialty care consultations. (5) Increased support for primary care providers as demonstrated by job satisfaction measures. (6) Increased patient satisfaction as demonstrated by quality surveys. (7) Health care cost savings. (8) Such other goals as the Secretary may identify. (c) Duration; amount (1) Duration A grant awarded under subsection (a) shall be for a term of no more than 5 years. (2) Amount In the case of a grant made under subsection (a) directly to an eligible health center or rural health clinic, the amount provided may not exceed $200,000 for each center or clinic facility location. In the case of an award to an eligible health center controlled network, the amount provided may not exceed $5,000,000, and the value of the amount of assistance provided by such network to any individual participating health center or rural clinic facility location may not exceed $200,000. (d) Use of funds Funds provided under a grant pursuant to this section may only be used for the following, with respect to a pilot project conducted by a health center controlled network, health center, or rural health clinic: (1) Conducting assessments of a participating facility’s infrastructure (such as broadband, equipment, and software), clinical objectives, and staffing plans. (2) Based on assessment findings, developing and assisting in the execution of equipment and software procurement, defining clinical objectives, developing adequate staffing plans, and implementing E–Consult services and related telehealth services program plan. (3) Training participating facility staff to properly utilize technology and implement programs. (4) Providing clinical workflow training to support program implementation. (5) Providing integrated certified EHR technology capabilities to support live video (where applicable) and E–Consult services. (6) Integrating the facility with live E–Consult service support providers and networks that meet the patient goals of the network, center, or clinic. (7) Procuring appropriate information technology and undertaking minor alterations of physical space. (8) Otherwise carrying out the pilot project to address the objectives described in subsection (b). (e) Participating facilities; Eligible entities (1) Participating Facilities A location of a health center or rural health clinic shall qualify to participate in a pilot program established pursuant to this section if the center or clinic demonstrates in a manner determined by the Secretary that such location— (A) lacks sufficient access to care provided by medical specialists, as determined by the Secretary; and (B) has not already implemented a program of E–Consult services and related telehealth services similar to that described in this section. (2) Requirements to be eligible to receive a grant To be eligible to receive a grant under subsection (a), an entity must— (A) be— (i) a health center controlled network that demonstrates to the satisfaction of the Secretary— (I) sufficient expertise and experience in the successful provision of the technical and other assistance required under for health centers and rural health clinics to conduct a pilot project in accordance with this section; (II) evidence of sufficient binding participation commitments received from eligible health centers and rural health clinics; (III) the ability to assist eligible health centers and rural health clinics to conduct E–Consult services with medical specialists and related telehealth services; and (IV) a likelihood of successfully accomplishing the program objectives as identified in subsection (b); or (ii) a qualifying health center or rural health clinic that demonstrates to the satisfaction of the Secretary— (I) sufficient expertise and ability to implement on its own behalf the technical and other assistance described in subparagraph (A)(i); (II) a likelihood of successfully implementing a program of E–Consult services with medical specialists and related telehealth services; and (III) a likelihood of successfully accomplishing the program objectives as identified in subsection (b); and (B) submit an application described in paragraph (3) to the Secretary in such form and manner, and in accordance with such timing, as specified by the Secretary. (3) Application For purposes of paragraph (2)(B), an application described in this paragraph, with respect to an applicant, is an application that demonstrates to the satisfaction of the Secretary— (A) in the case of an applicant that is a health center controlled network, the intention of a sufficient minimum number of eligible health centers to participate in the program through the network and a plan for recruiting additional centers to participate; (B) the qualification of proposed facility locations to participate in the program; (C) requisite experience, expertise, and capacity; (D) likelihood of meeting program objectives described in subsection (b); and (E) internal program metrics that will be employed to demonstrate satisfaction of program objectives and information to be collected and provided to the Secretary as necessary to conduct program evaluation. (f) Evaluation; report Not later than 180 days after the date of the completion of the last pilot projects funded under this section, the Secretary shall submit to Congress a report, including an evaluation, on the projects that addresses the following: (1) An overview of supported projects and identification of areas of success and failure. (2) Policies, practices, and organizational approaches that either facilitate or impede the effective use of E–Consult services (including personnel training and support, technology usability, workflow, and provider communication). (3) Relative effectiveness of consultations provided by Medical Specialists in improving outcomes, quality of care and efficiency with respect to different specialties, clinical conditions, complexity, patient types, or other issues. (4) The extent to which information shared in the E–Consult services process is sufficient, accurate, and actionable in order to effectively facilitate care improvement, and whether such bi-directional information flows can be standardized. (5) The extent to which E–Consults facilitate continuity of care. (6) Any issues arising related to maintaining the privacy of personal health information, ensuring cybersecurity, and other information security issues. (7) The extent to which E–Consult services contribute to improved health outcomes and metrics that can facilitate such evaluation. (8) Any unintended or adverse results from utilizing E–Consult services. (g) Definitions For purposes of this section: (1) Certified EHR technology The term certified EHR technology has the meaning given such term in section 3000(1). (2) E–Consult service The term E–Consult service means synchronous or asynchronous, consultative, health-care-provider-to-health-care-provider communications that occur within a shared certified EHR technology or secure internet-based platform and are primarily intended to provide specialty expertise to treating clinicians (who are often primary care providers) without requiring a direct interaction between the patient and the medical specialist. Such consultation ordinarily involves a treating clinician sending information regarding the patient and a consultation request to a medical specialist who may then respond in any of a number of ways, including providing requested feedback, asking for additional information, recommending certain studies or examinations, or initiating the scheduling of an appointment. (3) Health center The term health center has the meaning given such term in section 330(a). (4) Health Center Controlled Network The term health center controlled network means a network that is owned and controlled by constituent health centers as described in section 330(e)(1)(C). (5) Primary Care Provider The term primary care provider means a licensed health professional (as defined in section 1819(b)(5)(G) of the Social Security Act) or a licensed provider of behavioral health services who customarily provides services described in paragraph (1) or (2) of section 330(b) to patients. (6) Medical Specialist The term medical specialist means a licensed physician or a nurse practitioner who has completed advanced education and clinical training in a one or more specific areas of medicine and focuses their medical practice on such area or areas. Such term may, if specified by the Secretary, include a licensed provider of behavioral health services. (7) Related Telehealth Services The term related telehealth services means telehealth services arising out of or incident to an E–Consult service, such as laboratory tests, diagnostic imaging, or a subsequent interaction between a medical specialist and a patient. (8) Rural Health Clinic The term rural health clinic has the meaning give such term in section 1861(aa)(2) of the Social Security Act. (9) Telehealth The term telehealth means the use of electronic information and telecommunications technologies (including vi­de­o­con­fer­enc­ing, the internet, store-and-forward imaging, streaming media, and terrestrial and wireless communications) to support and promote long-distance clinical health care, patient and professional health-related education, public health, and health administration. (h) Authorization of appropriations There are authorized to be appropriated to carry out this section $12,000,000 for each of fiscal years 2021 through 2025. .