This articles talks about how teletherapy is becoming much more mainstream – fast. Also notable is that more states are requiring health insurers to cover telemedicine, or virtual doctor visits by phone, text, or video link.
When you need help with depression, anxiety, or any other mental health condition, finding affordable care can be a challenge. A shortage of qualified doctors and therapists means just getting an appointment can be tough. Plus, since finding in-network care can be harder than it is for medical care, you may have to shoulder a hefty portion of the price of your treatment. Now an emerging trend in health care may offer some relief.
More and more states are requiring health insurers to cover telemedicine—doctor visits that are conducted by phone, text, or video link—and more companies are adding the service as an employee benefit. Almost all large employers will offer telemedicine over the next four years, according to a recent National Business Group on Health survey.
Last year UnitedHealthcare, the nation’s largest insurer, announced that it would offer “virtual physician visits.” The Department of Veterans Affairs has invested $1 billion in tele-health.
Telemedicine increasingly includes mental illness treatment. In May, Walgreens teamed with Mental Health America and MDLive to create a portal where you can access more than 1,000 mental health providers. Consultations start at $60, and you can use the video chat service from anywhere.
“Virtual therapy can be as effective as traditional therapy,” says Willis Towers Watson senior health management consultant Allan Khoury, especially for people who don’t want to be seen walking into a therapist’s office, or don’t have one nearby.
A 2011 study out of the University of Amsterdam that was published in Studies in Health Technology and Informatics found that “online cognitive behavioral treatment is a viable and effective alternative to face-to-face treatment.” A 2015 large-scale review of various tele-health practices by the Cochrane Effective Practice and Organisation of Care Group reported that outcomes for those seeking mental health treatment remotely—along with other medical conditions—were no different than for those who got in-person care.
With employers still determining coverage levels, costs are evolving, says Khoury, who has seen an initial 90-minute session go for $200, with subsequent 30-minute follow-ups priced at $90, similar to in-person costs.
One reason people go without therapy is that there are simply are not enough qualified doctors and nurses to treat mental illness. Nearly 103 million Americans live in area designated as having a shortage of mental health professionals. That’s 63% more than those who don’t live near a primary care doctor, and twice as many as those without speedy access to a dentist, according to the U.S. Department of Health and Human Services.
This course is focused upon the ethical principles that are called into play with the use of e-therapy. Among them the most obvious concern is for privacy and confidentiality. Yet these are not the only ethical principles that will be challenged by the increasing use of e-therapy. The others include interjurisdictional issues (crossing state lines), informed consent, competence and scope of practice, boundaries and multiple relationships, and record keeping.In addition to outlining potential ethical problems and HIPAA challenges, this course includes recommended resources and sets of specific guidelines and best practices that have been established and published by various professional organizations.
Ethics and Social Media is a 2-hour online continuing education (CE) course that examines the use of Social Networking Services (SNS) on both our personal and professional lives. Is it useful or appropriate (or ethical or therapeutic) for a therapist and a client to share the kinds of information that are routinely posted on SNS like Facebook, Twitter, and others? How are psychotherapists to handle “Friending” requests from clients? What are the threats to confidentiality and therapeutic boundaries that are posed by the use of social media sites, texts, or tweets in therapist-client communication?
Ethics & Boundaries in Psychotherapy is a 3-hour online continuing education (CE) course intended to give psychotherapists the tools they need to resolve the common and not-so-common ethical and boundary issues and dilemmas that they may expect to encounter in their everyday professional practice in the 21st century. Among the topics discussed are definitions of boundaries; resolving conflicts between ethics and the law; boundary crossings vs. boundary violations; multiple relationships; sexual misconduct; privacy and confidentiality in the age of HIPAA and the Patriot Act; ethics issues with dangerous clients; boundary issues in clinical supervision; ethics and cultural competency; ethical boundaries in use of social media; ethical practice in teletherapy; fees and financial relationships; and a 17-step model for ethical decision making.
Professional Development Resources is a nonprofit educational corporation 501(c)(3) organized in 1992. Our purpose is to provide high quality online continuing education (CE) courses on topics relevant to members of the healthcare professions we serve. We strive to keep our carbon footprint small by being completely paperless, allowing telecommuting, recycling, using energy-efficient lights and powering off electronics when not in use. We provide online CE courses to allow our colleagues to earn credits from the comfort of their own home or office so we can all be as green as possible (no paper, no shipping or handling, no travel expenses, etc.). Sustainability isn’t part of our work – it’s a guiding influence for all of our work.
We are approved to sponsor continuing education by the American Psychological Association (APA); the National Board of Certified Counselors (NBCC); the Association of Social Work Boards (ASWB); the American Occupational Therapy Association (AOTA); the American Speech-Language-Hearing Association (ASHA); the Commission on Dietetic Registration (CDR); the Alabama State Board of Occupational Therapy; the Florida Boards of Social Work, Mental Health Counseling and Marriage and Family Therapy, Psychology & School Psychology, Dietetics & Nutrition, Speech-Language Pathology and Audiology, and Occupational Therapy Practice; the Ohio Counselor, Social Worker & MFT Board and Board of Speech-Language Pathology and Audiology; the South Carolina Board of Professional Counselors & MFTs; the Texas Board of Examiners of Marriage & Family Therapists and State Board of Social Worker Examiners; and are CE Broker compliant (all courses are reported within one week of completion).
First, potential telemedicine providers need to understand what legal limits apply. Many states impose requirements on the treatment of patients. Therefore, it is critical that providers understand all applicable legal limits.
Having established the parameters of the telemedicine practice, providers must also ensure that they hold the proper medical licenses.
Because telemedicine permits the treating provider and the patient to be in different locations, and, in many instances, in different states, there is the question as to where the provider must be licensed in order to properly treat the patient via telemedicine. Although there are some efforts in Congress to allow a physician licensed in one state to treat a patient in another state, state laws generally require a physician treating a patient via telemedicine to be licensed by the medical board of the state where the patient resides.
A telemedicine provider must conform to the standard of care applicable and equivalent to what is expected for in-person care as appropriate to the patient’s age and presenting condition.
Many times, in order to correctly diagnose and treat the patient, the telemedicine provider will need to use diagnostic testing, through the use of peripheral devices appropriate to the patient’s condition.
There is still the question of which standard of care the telemedicine provider must meet. Typically, the provider would be held to the standard of care of the community where he or she practices. However, courts have increasingly recognized standards promulgated by associations such as the American Telemedicine Association as the appropriate standard of care for telemedicine encounters, even if it conflicts with the provider’s local standard of care.
Inquire about Malpractice Coverage
Providers should also check their malpractice insurance coverage. Many providers assume incorrectly that their current professional liability insurance coverage will extend to cover their practice of telemedicine since it is an extension of their current medical practice. However, most professional liability insurance coverage will exclude coverage for telemedicine services. Providers should work with their insurance brokers to secure separate professional liability insurance coverage for telemedicine.
Communicate with Patients
Providers should ensure that patients understand the risks, such as a power failure that could cause a loss of communication or a loss of records, and potential exposure of medical records to outside hackers. This discussion can minimize potential issues that may arise.
As a psychologist who’s been researching/writing/practicing/consulting/training online for years, I’m often asked, “Where can psychologists get guidance and training for practicing online?”
Just as frequently, I encounter well-intentioned, ethical colleagues who blithely undertake an online practice without considering their legal and ethical obligations or competencies. In hopes of helping readers avoid many potential landmines, I’ll outline how current guidelines, ethical standards and state regulations can be used to help you avoid trouble and reap long-term benefits of growing your practice with technology.
A joint task force of representatives of the American Psychological Association, the American Psychological Association Insurance Trust and the Association of State and Provincial Psychology Boards has developed telepsychology guidelines.
Guidelines developed by other professional associations can be of benefit to psychologists, but state regulations and guidelines of licensure also must be taken into consideration.
Despite the proliferation of health care technology in the last two decades, including the Internet, many professional associations have struggled to allocate the needed resources to develop clear and timely practice standards or guidelines. Even when they have been clear, many fail to address the current range of technology used in behavioral practice.
For instance, they might refer to telecommunication technologies for direct care, but neglect the rapid expansion of services delivered as psycho-educational products online, text messaging, virtual reality, robotics, mobile health (mhealth) such as “apps” used with smart devices and other areas.
Some associations are making significant progress; others have barely begun. A number of psychologists are attempting to form a new APA division to address the growing areas that need to be expanded in the definition of psychology and grow the association with vibrant new ideas and enthusiasm.
See the many areas of focus addressed by the proposed Society for Technology and Psychology (http://stp-apa.net) and consider how they are changing traditional in-person care. (Support this movement by signing the petition for inclusion in the APA.)
Even though technology may be outstripping the abilities of professional associations to “keep up,” associations have a responsibility to “catch up.” While many countries are far ahead of the U.S.-based professional associations in both the timeliness and scope of their standards, guidelines or statements of best practice, the following are available online for the psychologist looking for immediate guidance:
For a regularly updated list of currently published standards, guidelines and best practices in behavioral telehealth and telemental health, see Telemental Health Standards, Guidelines and Statements: http://telehealth.org/ethical-statements.
Keep Up On State Laws, Regulations
Despite the best research on recommended standards for the use of technology in psychology, practitioners must also carefully consider the strictures of state licensing regulations.
Licenses are awarded by states and therefore their scopes of practice are defined by the specific states(s) of licensure. Federal laws exempt military and federal government practitioners but otherwise state licensing laws define professional work. From one state to another, laws and regulations can differ substantially, be contradictory or outdated in terms of application to online practice. A number of states are working on updating regulations but they are moving forward in a hodgepodge and piecemeal manner rather than a unified plan. Potential penalties for violating licensing laws include fines, community service, public humiliation or suspension of licensure. In some states, certain laws can be considered “criminal offenses” and lead to the forfeiture of malpractice benefits. Examples include insurance fraud or treating a client in a state where the psychologist is not licensed.
Many psychologists fail to understand that being licensed in one state does not grant them the right to practice in another state or the repercussions of making such uninformed decisions. For example, Vermont and Utah carry $5,000 fines for practicing in their states without a license. Disengaging from treatment with remote clients after learning of such regulatory laws can also create thorny clinical dilemmas.
Role of Professional Associations
In addition to other benefits, professional associations can try to intervene to influence state law. They also typically develop and publish ethical standards and guidelines that not only require that a practitioner adhere to state and federal law but the association’s own rules. Ethical standards are the most stringent and are mandatory. They outline appropriate behavior and set the bar for membership.
For professional associations and practitioners alike, keeping abreast of technological demands is important because an existing set of standards, whether outdated or current, creates a standard of due care.
This Standard in Turn Helps Define Malpractice
Similarly, if professionals do not adhere to standards accepted by their national association, they may be responsible for malpractice in tort. Therefore, it is incumbent upon the elected and staff leaders of professional associations to allocate the needed resources to develop adequate standards and guidelines to protect practitioners in a timely manner. The penalty for failing to adhere to a set of standards is most often censorship or removal from the association.
Guidelines, on the other hand, are aspirational and therefore not required. They usually involve a distillation of the relevant literature and provide guidance in the form of suggestions. But, in many states aspirational guidelines by psychological association are incorporated by reference into licensing regulations and have a long history of being used by prosecutors to establish negligence on the part of practitioners.
Professionals, then, may want to be mindful of and carefully document any departure from both standards and guidelines issued by professional associations. If they don’t agree with standards or guidelines as promulgated by any professional association, they can work within the association to change them or leave the association.
Practitioners attempting to operate innovative technology-based programs within the bounds of vague or outdated ethical standards and guidelines are at risk of being at a distinct disadvantage before an equally vague or outdated licensing board or jury. Unclear standards, guidelines and regulatory law leave the innovative practitioner with many opportunities but not enough direction. Formal professional training is warranted to help forward-thinking psychologists access the strong evidence base that reflects reliable approaches to risk management.
Professional Development Resources is approved to offer continuing education by the American Psychological Association (APA); the National Board of Certified Counselors (NBCC); the Association of Social Work Boards (ASWB); the American Occupational Therapy Association (AOTA); the American Speech-Language-Hearing Association (ASHA); the Commission on Dietetic Registration (CDR); the California Board of Behavioral Sciences; the Florida Boards of Social Work, Mental Health Counseling and Marriage and Family Therapy, Psychology & School Psychology, Dietetics & Nutrition, Speech-Language Pathology and Audiology, and Occupational Therapy Practice; the Ohio Counselor, Social Worker & MFT Board; the South Carolina Board of Professional Counselors & MFTs; and by the Texas Board of Examiners of Marriage & Family Therapists and State Board of Social Worker Examiners.
The trend toward telepsychology — the use of communication technologies in the provision of psychological services — has the potential to reduce hospitalizations, increase access to mental health care and save lives. But there are also limitations and restrictions on the use of telepsychology. Statutes and regulations governing the provision of telepsychology services vary greatly from state to state.
Over the past few years, a growing number of states have passed or updated laws or rules governing telepsychology practice. The increasing volume of laws pertain to both delivery of and payment for telepsychology services.
In light of these developments, the APA Practice Directorate’s Office of Legal & Regulatory Affairs has updated the Telepsychology 50-state review (previously called the Telehealth 50-state review) to guide psychologists in navigating the regulations and provisions in their state.
At its late July 2013 meeting, the APA Council of Representatives approved new Guidelines for the Practice of Telepsychology. A Joint Task Force on the Development of Telepsychology Guidelines for Psychologists, comprised of members representing APA, the Association of State and Provincial Psychology Boards and the American Psychological Association Insurance Trust (APAIT), was formed in 2011 to create guidelines for the practice of telepsychology.
Demand for doctors – whether in person or via a computer screen – is expected to surge as millions more Americans become insured under the Affordable Care Act. About 10 million people already rely on telemedicine, often from doctors who live in another state.
As a result, more physicians are applying for medical licenses in multiple states – a costly and time-consuming proposition for some. Without a license to practice medicine in the patient’s state of residence, both doctors and patients may be at legal risk.
Many states are embracing telemedicine by encouraging it in their Medicaid programs and requiring private insurers to pay for it. But they have made little progress in removing medical licensing barriers that proponents of the technology say have kept doctors and hospitals from expanding even more.
Telemedicine was once the purview of small town doctors who needed to consult with specialists available only in larger urban areas. Today, telemedicine technology is even being used to conduct surgeries using robotics, typically only in emergency situations such as during war.
Most telemedicine consists of video teleconferencing between a doctor and a patient. Doctors also routinely use telemedicine technology to transmit and discuss diagnostic images and to remotely monitor patients with chronic diseases so they don’t have to leave their homes or nursing facilities.
For some consumers, it is the primary way they receive medical care. Using Skype on a computer or FaceTime on an iPhone, patients discuss their symptoms and show their doctors any visible evidence of their conditions, such as a swollen eye or skin rash. Patients most often conduct these consultations from home or their workplace. In some cases, patients go to a medical facility and use high-end, secure equipment to teleconference with a doctor in another location.
Much of the growth in telemedicine is expected to be in remote monitoring of patients with heart and lung diseases and diabetes, who have recently been discharged from a hospital. The aim is to detect health problems early enough to prevent them from being sent back to the hospital.
States have argued that easing licensing requirements could jeopardize patient safety. If doctors practice in a state without obtaining a license there, regulators maintain that they have no power to conduct an investigation or explore a consumer complaint. Also, these doctors would not benefit from any legal protections the state may have against malpractice lawsuits.
Proponents of telemedicine argue that since doctors take standardized national exams and most requirements are set by federal agencies such as the U.S. Department of Health and Human Services, states should recognize other state licenses. They say state medical boards are simply trying to shield doctors from out-of-state competition and preserve state revenues from licensing fees.