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Maheu CAPP Legal & Ethical Telehealth Issues, Online Therapy & Online Counseling CEUs

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Dr. Marlene Maheu delivered 6-hours of a professional training workshop to the Cincinnati Academy of Professional Psychology (CAPP) on April 27, 2012. ...

Dr. Marlene Maheu delivered 6-hours of a professional training workshop to the Cincinnati Academy of Professional Psychology (CAPP) on April 27, 2012.

The above event is sponsored by the TeleMental Health Institute, Inc. We are the premier professional training site for professionals seeking training in telehealth. Our courses are offered in a state-of-the-art, 100% online learning environment that is fully mobile compatible. Professional training is now available from your desktop of mobile device, 24/7, at your home or office.

To receive our FREE monthly newsletter related to telemental health, telecounseling, online therapy, telepsychology or telepsychiatry and telenursing, send an email to: tmhinews@aweber.com You will also receive notices of our bonuses and discounts for professional training for CEUs and CMEs.

See other offerings at www.telehealth.org
Send questions or comments to us at www.support.telehealth.org
Contact Dr. Maheu to speak at your next workshop or conference at: www.support.telehealth.org

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  • How many of you are psychotherapists? Consider yourselves professional communicators?
  • How many of you have had this unfortunate experience as you try to find a needed document or navigate the information superhighway?
  • At times, we all have probably had this experience, too, where technology makes what was once impossible a breeze.
  • Let me show you a glimpse of what the future may hold for us. How many of you know someone who is using technology in psychology?How many of you personally are already using video in your practices? Good for you – because you’re already in the ballgame, and that’s what I’m here to talk about today.
  • Our evidence base had made it clear…technology is here to stay because it ….
  • Patientedication often occurs during the informed consent process / agreement.
  • Then again, msybe you didn’t keeop records, and can just blame your computer when you can’t find a record if supeoned?
  • Yes we can help him
  • Medicare documents name psychologists as covered entities. Guest editor for telehealth, expanded to technology, expected 6 submissions, received 60 – tremendous amount of research waiting to be published

Maheu CAPP Legal & Ethical Telehealth Issues, Online Therapy & Online Counseling CEUs Maheu CAPP Legal & Ethical Telehealth Issues, Online Therapy & Online Counseling CEUs Presentation Transcript

  • CAPPSuccess Strategies forLegally & EthicallyExpanding YourPractice Online Using21st Century ToolsApril 27, 2012Marlene M. Maheu, Ph.D. 1
  • Disclaimer• WHO I AM: I am a licensed psychologist, not an attorney, physician, marketing or information technology (IT) professional. The content of my presentations covers a wide range of technical, clinical, risk management, legal and ethical issues from my perspective of a psychologist. These areas are in rapid flux.• MY GOAL: My goal is educational only. I will outline the issues and alert you to whats happening in a way to help think through the issues, help you move forward, and protect yourself as well as your clients or patients. No warranty, guarantee, or representation is made as to the accuracy or sufficiency of the information contained in my presentation for your specific circumstance. Therefore, I assume no responsibility in connection therewith.• YOUR PART: You are encouraged to seek specific advice from your specific legal, regulatory, ethical and malpractice bodies before offering any online services or programs to consumers. Get all such opinions in writing, and have your informed, trusted, local, legal counsel review them for their full significance with your particular business requirements, and the specific populations you serve. – If you ask questions, please protect the identify of the patients and clients you may mention. Copyright 2012 TeleMental Health Institute, Inc. All rights reserved.
  • Inspire You• What’s Happening• Myths vs. Realities• Opportunities for Us and Our Clients
  • Goals • What’s the Problem? • Definitions • What’s Happening • Legal/Ethical: Online Clinical Practice Management (OCPM) • Training • Referrals • Patient Ed • Legalities • Assessment • Direct Care • Reimbursement • Possible Solutions?
  • Learning Objectives• 1. ETHICS: Describe 3 ethical dilemmas related to Skype, Google and Facebook, blogging and the ethical codes that help practitioners think through those dilemmas.• 2. LEGAL ISSUES: Discuss the legal issues related to practicing over state lines or international borders, HIPAA and informed consent when practicing online.• 3. RISK MANAGEMENT: Outline 3 key elements of a risk management plan for working online with clients to deliver care.
  • Benefits of Telehealth• Increased client satisfaction• Decreased travel time• Decreased travel, child & elder-care costs• Increased access to underserved populations• Improved accessibility to specialists• Reduced emergency care costs• Faster decision-making time• Increased productivity / decreased lost wages• Improved operational efficiency
  • The Is Video Teleconferencing (VTC) Effective?• Yes – Medicare & Medicaid required to pay • Client satisfaction very high • Provider satisfaction is high • Outcomes are relatively comparable, especially for follow-up care (intakes are still a matter of state law) • Literature for specialty groups is sparser, but positive (pediatrics) – Also effective for supervision – Can improve some ways service is rendered – See www.telehealth.ORG/bibliography• BUT, traditional VTC isn’t the same as Skype Copyright 2012 TeleMental Health Institute, Inc. All rights reserved.
  • With everythingwe know in thetelehealthliterature, whenis it acceptable to have an“accident”as a treatingprofessional?
  • Existing TeleMental Health Guidelines• American Medical Association. (2000). Guidelines for Patient-Physician Electronic Mail• American Counseling Association. (1999) (2005). ACA Code of Ethics• American Mental Health Counselors Association. (2000). Code of Ethics of the American Mental Health CounselorsAssociation, Principle 14, Internet On-Line Counseling• American Psychological Association. (1997). APA Statement on Services by Telephone, Teleconferencing, and Internet, Astatement by the Ethics Committee of the American Psychological Association• American Psychological Association. (2010). Ethical principles of psychologists and code of conduct• American Telemedicine Association. (2009). Evidence-Based Practice for Telemental Health• American Telemedicine Association. (2009). Practice Guidelines for Videoconferencing-Based Telemental Health• Australian Psychological Society. (2004). Guidelines for Providing Psychological Services and Products on the Internet• British Psychological Society. (2009). The Provision of Psychological Services via the Internet and Other Non-direct Means• Canadian Psychological Association. (2006). Ethical Guidelines for Psychologists Providing Psychological Services viaElectronic Media• Federation of State Medical Boards of the United States, Inc., Report of the Special Committee on Professional Conduct andEthics. (2002) Model guidelines for the appropriate use of the Internet in medical practice• National Association of Social Workers. (1999) (2008). Code of Ethics• National Board for Certified Counselors and Center for Credentialing and Education, (2001). The Practice of InternetCounseling. (2001)• New Zealand Psychological Psychologists Board (2011). Draft Guidelines: Psychology services delivered via the internet andother electronic media• Ohio Psychological Association. (2010). Telepsychology Guidelines• Winkler, M., Flanagin, A., Chi-Lum, B., White, J., Andrews, K., Kennett, R., DeAngelis, C. & Musacchio, R. (2000). Guidelines formedical and health information sites on the Internet. Journal of the American Medical Association, March 22/29, 283(12), pp.1600-1606
  • 2010 OPA Telepsychology Guidelines• http://www.ohpsych.org/psy chologists/files/2011/06/O PATelepsychologyGuideline s41710.pdf
  • Ohio Board of Psychology Telepsychology Rules• http://www.psychology.ohi o.gov/pdfs/ALL%20NEW%2 0TELEPSYCH%20RULES%20 FOR%20WEB.pdf
  • What is happening?
  • We Are Re-toolingCopyright 2012 TeleMental Health Institute, Inc. All rights reserved.
  • Accelerating Paceof Developing Tools• Stone Implements  Iron• Hunting & Gathering  Farming• Scribes  Printing Press  Typewriters  Microsoft WORD• Horses (100 years ago)  Automobiles  Jets• In-person  Distance via Information & Communication Technology (ICT), mHealth & Medical Homes
  • Types of Health Care TechnologyWith permission from Teri Louden of the Louden Network and Adapted from: Biology, Bioconvergence, Information and Enterprise:Taking the Broad View, May 20, 2004, Alan Barrel
  • Effective Conversations?• Terminology is Evolving in Scientific Literature: – Ehealth – Telehealth – Telemedicine – Telemental Health – Telepsychology – Behavioral Telehealth – Online Counseling – Online Therapy
  • Effective Conversations?• Email• Chat• Text Messaging• Telephone / VoIP• Video Chat• Smartphone• Tablet PC• Peripherals• VPN / Cloud Video
  • Effective Conversations?• 50 Different State Boards, Each State w/ 3 or 4 Different Regulatory Boards: – Medical Boards • Specialty Boards – Psychology Boards – Boards of Behavioral Sciences • Social Workers • Counselors • MFTs • Substance Abuse
  • Future StudiesMoores Law vs.Single Atom 1 LifetimeTransmitter• The number of transistors that can be placed on a processor will double approximately every 18 months.• The latest Intel chip, the "Sandy Bridge," uses a manufacturing process to place 2.3 billion transistors 32 nanometers apart. Reprinted with permission from Ray Kurzweil, 2005
  • Copyright 2012 TeleMental Health Institute, Inc. All rights reserved.
  • Remote doctor examines a patient’s Patient in rural ER gets benefit of localinner ear from a remote location. care plus remote consultation with specialists. Copyright 2012 TeleMental Health Institute, Inc. All rights reserved.
  • Copyright 2012 TeleMental Health Institute, Inc. All rights reserved.
  • Copyright 2012 TeleMental Health Institute, Inc. All rights reserved.
  • Wearable Computers (Glasses)
  • Virtual Worlds
  • ROBOTS
  • Our Primary Focus: What is theservice we are delivering?
  • Coming next… What do mental health consumers Want online?Copyright 2012 TeleMental Health Institute, Inc. All rights reserved.
  • Copyright 2012 TeleMental Health Institute, Inc. All rights reserved.
  • PEW: Social networking sites and our lives (June 16, 2011) • The number of people using social networking sites has nearly doubled since 2008, and the population of SNS users has gotten older. Copyright 2012 TeleMental Health Institute, Inc. All rights reserved.
  • Psychoeducation• Anywhere, anytime• Serve more people• Part time• Practice generator• Lower risk• Non-therapeutic relationship• Clearer legal/ethical mandates Copyright 2012 TeleMental Health Institute, Inc. All rights reserved.
  • Consumer Demand
  • Practitioner Adoption?• Over 1/2 million Google search results: – “online counseling” = 210,000 + searches – “online therapy” = 143,000 + searches – “online counselling” = 83,100 + searches – “online therapy” = 65,900 + searches• --------------• = 502,200 searches
  • Question is No Longer “If” but “How”Table of Contents for Psychological Services, Volume: 9 Issue: 2Regular Articles• Videoconferencing Psychotherapy: A Systematic Review• Acceptability and Cost Effectiveness of Military Telehealth Mental Health Screening• Telehealth for persons with severe functional disabilities and their caregivers: Facilitating self-care management in the home setting• A Telehealth Intervention for Veterans on Antiviral Treatment for the Hepatitis C Virus• Interactive Voice Response for Relapse Prevention Following Cognitive Behavioral Therapy for Alcohol Use Disorders: A Pilot Study• Assessing Daily Fluctuations in Posttraumatic Stress Disorder Symptoms and Substance Use With Interactive Voice Response Technology: Protocol Compliance and ReactionsBrief Program Articles• Lessons Learned From Studies of Psychotherapy for Posttraumatic Stress Disorder via Video Teleconferencing• Tele-Pain Management: Use of video-conferencing technology in the delivery of an integrated cognitive-behavioral and physical therapy group intervention• The VA Maryland Health Care Systems Telemental Health Program• Uniting Veterans across Distance through a Telephone-Based Reminiscence Group Therapy Intervention• VA Puget Sound Telemental Health Service to Rural Veterans: A Growing Program• Web-based, Psychosocial Treatment for Substance Use Disorders in Community Treatment Settings• The Use of Internet Technology for Psychoeducation and Support With Dementia Caregivers• Telephone-delivered Psychotherapy for Late-life Anxiety• Improving clinical outcomes in psychiatric care with touch-screen technology• Using an Online Viewing System for Parent-Child Interaction Therapy Consulting with Professionals• A Web-Based Intervention for Elementary School Teachers of Students with Attention-Deficit/Hyperactivity Disorder
  • Online Norm vs. Standard of Care• Mostly Email & Chat vs. Video• Anonymity / No Patient Records• Avoid Responsibility w/ Website Disclaimers• No Clear Channels for Mandated Reporting No Contact with Other Treating Clinicians No Authentication of Consumer / Professional No Emergency Backup Procedures Misunderstanding of Clinical Processes (suicide)
  • Benefits of Telehealth• Increased client satisfaction• Decreased travel time• Lower travel, child & elder-care costs• Increased access to unserved populations• Improved accessibility to specialists• Reduced emergency care costs• Faster decision-making time• Increased productivity / decreased lost wages• Improved operational efficiency
  • Is Video Teleconferencing (VTC) Effective?• Yes – Medicare & Medicaid required to pay • Client satisfaction very high • Provider satisfaction is high • Outcomes are relatively comparable, especially for follow-up care (intakes are still a matter of state law) • Literature for specialty groups is sparser, but positive (pediatrics) – Also effective for supervision – Can improve some ways service is rendered Copyright 2012 TeleMental Health Institute, Inc. All rights reserved.
  • Get the legal & ethicaltraining you aremandated to getStudy the evidence-based models$150 to $30 a month
  • OCPM: Online ClinicalPractice Model Online Clinical Practice Management (OCPM)Step 1: TrainingStep 2: ReferralsStep 3: Patient EducationStep 4: LegalitiesStep 5: AssessmentStep 6: Direct CareStep 7: Reimbursement Copyright 2012 TeleMental Health Institute, Inc. All rights reserved.
  • OCPM: Online ClinicalPractice Model Online Clinical Practice Management (OCPM)Step 1: TrainingStep 2: ReferralsStep 3: Patient EducationStep 4: LegalitiesStep 5: AssessmentStep 6: Direct CareStep 7: Reimbursement Copyright 2012 TeleMental Health Institute, Inc. All rights reserved.
  • Training• (i) A psychologist shall not practice outside his or her particular field or fields of competence as established by his or her education, training, continuing education, and experience. Cal. Bus. & Prof. Code 2915. Copyright 2012 TeleMental Health Institute, Inc. All rights reserved.
  • Boundaries of CompetenceCopyright 2012 TeleMental Health Institute, Inc. All rights reserved.
  • Is Skype avideoplatform or asocial mediaplatform? Copyright 2012 TeleMental Health Institute, Inc. All rights reserved .
  • Lighting & Other A / V Issues?
  • ACA Code of Ethics (2005)• Discuss time zone differences, local customs, and cultural or language differences that might impact service delivery. Copyright 2012 TeleMental Health Institute, Inc. All rights reserved.
  • American Psychological Association, Ethical Principles & Standards (2002)• Psychologists must be aware of multicultural and diversity issues.
  • Linguistic & Cultural Diversity Copyright 2012 TeleMental Health Institute, Inc. All rights reserved.
  • Multicultural/Multilingual Issues (1) SelfhelpMagazine.com• Canada • Singapore• Netherlands • Greece• United Kingdom • South Africa• Australia • Malaysia• Japan • Israel• Germany • Belgium• New Zealand • Sweden Copyright 2012 TeleMental Health Institute, Inc. All rights reserved.
  • Multicultural/Multilingual Issues (2) SelfhelpMagazine.com• Malaysia • Ireland• Israel • France• Belgium • Russia• Sweden • Spain• Mexico • Brazil• Finland • Austria• Saudi Arabia • Poland
  • Multicultural/Multilingual Issues (3) SelfhelpMagazine.com• Denmark • Thailand• Argentina • Croatia• Turkey • Indonesia• Philippines • Norway• Portugal • Romania• Peru • Italy• Hong Kong • United Arab Emirates• Pakistan • Cyprus
  • Multicultural/Multilingual Issues (4) SelfhelpMagazine.com• Brunei Darussalam • Bulgaria• Latvia • Uruguay• Ecuador • Former USSR• Venezuela • Lithuania• Mauritius • Kazakhstan• Bosnia-Herzegovina • Ukraine• Slovak Republic • Zimbabwe• South Korea • Georgia
  • Multicultural/Multilingual Issues (5) SelfhelpMagazine.com• Iran • Aruba• Nicaragua • Qatar• Guatemala • El Salvador Jordan• Virgin Islands (USA) • Kenya • Papua New Guinea• Macedonia • Dominica• Netherlands Antilles • Madagascar• Botswana • Malta• Oman • Namibia
  • Multicultural/Multilingual Issues (6) SelfhelpMagazine.com• Andorra • Iceland• Jamaica • Egypt• Maldives • China• Sri Lanka • Chile• Faroe Islands • Czech Republic• Zambia • Luxembourg• Estonia • India• Trinidad and Tobago • Colombia Copyright 2012 TeleMental Health Institute, Inc. All rights reserved.
  • Multicultural/Multilingual Issues (7) SelfhelpMagazine.com• Taiwan • Moldavia• Lebanon • Yemen• Dominican Republic • Switzerland• Yugoslavia • Bolivia• Bermuda • Ethiopia• Slovenia • Burkina Faso• Hungary • Bahamas• Costa Rica • Belarus
  • Practitioner Adoption?• Over 1/2 million Google search results: – “online counseling” = 210,000+ searches – “online therapy” = 143,000+ searches – “online counselling” = 83,100+ searches – “online therapy” = 65,900+ searches• --------------• = 502,200 searches
  • ACA Code of Ethics (2005)• A.12.c. Inappropriate Services – When technology-assisted distance counseling services are deemed inappropriate by the counselor or client, counselors consider delivering services face to face. – How do you decide what’s appropriate? Copyright 2012 TeleMental Health Institute, Inc. All rights reserved.
  • Australian Psychological Society (2011 revision of Internet Guidelines)• Research-based protocols – 1.6 “Psychologists using the internet to provide a psychological service should be aware of the extent to which therapeutic interventions via the internet are supported by research or may be contra-indicated ….” Copyright 2012 TeleMental Health Institute, Inc. All rights reserved.
  • OCPM Step 1: Training • Where do you find research? – http://telehealth.org/ bibliography • Look at: – funding sources – meta-analyses Copyright 2012 TeleMental Health Institute, Inc. All rights reserved.
  • Training• Choice of Communication Channel (modality) – Responsibility of Professional?• Technology specific training/proficiency for each modality + combination of modalities• Confidentiality for each modality• Client authentication for each modality• Practitioner authentication for each modality Copyright 2012 TeleMental Health Institute, Inc. All rights reserved.
  • Google Drive• "When you upload or otherwise submit content to our Services, you give Google (and those we work with) a worldwide license to use, host, store, reproduce, modify, create derivative works (such as those resulting from translations, adaptations or other changes we make so that your content works better with our Services), communicate, publish, publicly perform, publicly display and distribute such content. The rights you grant in this license are for the limited purpose of operating, promoting, and improving our Services, and to develop new ones. This license continues even if you stop using our Services..."
  • OCPM: Online ClinicalPractice Model Online Clinical Practice Management (OCPM)Step 1: TrainingStep 2: ReferralsStep 3: Patient EducationStep 4: LegalitiesStep 5: AssessmentStep 6: Direct CareStep 7: Reimbursement Copyright 2012 TeleMental Health Institute, Inc. All rights reserved.
  • OCPM Step 2: Referrals or Internet Marketing (IM) • Provider lists • Colleagues with telehealth training • Professional websites, blogs, appsCopyright 2012 TeleMental Health Institute, Inc.
  • ACES TECHNICAL COMPENTENCIES• TECHNICAL COMPETENCIES FOR COUNSELOR EDUCATION: RECOMMENDED GUIDELINES FOR PROGRAM DEVELOPMENT• http://files.acesonline.net/doc/2007_aces_tec hnology_competencies.pdf Copyright 2012 TeleMental Health Institute, Inc. All rights reserved.
  • Social Networking
  • OCPM: Online ClinicalPractice Model Online Clinical Practice Management (OCPM)Step 1: TrainingStep 2: ReferralsStep 3: Patient EducationStep 4: LegalitiesStep 5: AssessmentStep 6: Direct CareStep 7: Reimbursement Copyright 2012 TeleMental Health Institute, Inc. All rights reserved.
  • Patient Education• Email /Texting• Social networking• File exchange• Computer repair• Clinical records• Insurance• Reports• Lateness / Missed sessions• Non-compliance/Avoidance
  • ACA Code of Ethics (2005)• A.12.a. Benefits and Limitations• Counselors inform clients of the benefits and limitations of using information technology applications in the counseling process and in business/ billing procedures. Such technologies include, but are not limited to, computer hardware and software, telephones, the World Wide Web, the Internet, online assessment instruments and other communication devices. Copyright 2012 TeleMental Health Institute, Inc. All rights reserved.
  • ACA Code of Ethics (2005)• A.12.g. Technology and Informed Consent• As part of the process of establishing informed consent, counselors do the following: – 1. Address issues related to the difficulty of maintaining the confidentiality of electronically transmitted communications. – 2. Inform clients of all colleagues, supervisors, and employees, such as Informational Technology (IT) administrators, who might have authorized or unauthorized access to electronic transmissions. Copyright 2012 TeleMental Health Institute, Inc. All rights reserved.
  • Rating Sites: Yelp (Keely Kolmes, Psy.D.)• Your right /Gently discourage for these reasons: 1. The American Psychological Associations Ethics Code states that it is unethical for psychologists to solicit testimonials: Principle 5.05 "Psychologists do not solicit testimonials from current therapy clients/patients or other persons who because of their particular circumstances are vulnerable to undue influence." Since you may decide to return to therapy with me at a later date, I do not request testimonials from people who have ended therapy with me. Copyright 2012 TeleMental Health Institute, Inc. All rights reserved.
  • Rating Sites: Yelp (Keely Kolmes, Psy.D.)• 2. Unlike other business owners who may respond to their Yelp reviews, as a psychologist, I must provide confidentiality to my clients.• This means I am restricted from responding in any way that acknowledges whether someone has been in my care.• Thus, I do not intend to respond to any reviews. Copyright 2012 TeleMental Health Institute, Inc. All rights reserved.
  • Rating Sites: Yelp (Keely Kolmes, Psy.D.)• 3. I hope that if we work together, we can discuss your feelings about our work directly and in person.• This may not always feel comfortable, but the discussion of positive and negative reactions to our process can be an important part of your therapy.• If it is simply a matter of poor fit, Im always happy to help you find a therapist who is a better match. Copyright 2012 TeleMental Health Institute, Inc. All rights reserved.
  • Rating Sites: Yelp (Keely Kolmes, Psy.D.)• 4. If you still choose to write something about my practice on Yelp, remember that this is a public forum and you may be sharing personally revealing information with a wide range of readers.• To preserve your privacy, consider using a pseudonym that is not linked to your regular email address or friend networks.
  • Internet Ratings: Where are we going? • Expect ratings and quality surveys by healthcare providers to become standard operating procedure by smartphone app users. • Yelp – Consumers can rate you, but you can’t fully defend yourself without violating confidentiality
  • Informed Consent & Social Media Policy Samples • http://telehealth.ORG/sites/def ault/files/Informed_Consent.pd f • http://drkkolmes.com/for- clinicians/social-media-policy/ Copyright 2012 TeleMental Health Institute, Inc. All rights reserved.
  • OCPM: Online ClinicalPractice Model Online Clinical Practice Management (OCPM)Step 1: TrainingStep 2: ReferralsStep 3: Patient EducationStep 4: Legal IssuesStep 5: AssessmentStep 6: Direct CareStep 7: Reimbursement
  • AllExistingLegalandEthicalRulesApply
  • Duty to Report / Duty to Warn• (v) Failing to comply with the child abuse reporting requirements of Section 11166 of the Penal Code.• (w) Failing to comply with the elder and adult dependent abuse reporting requirements of Section 15630 of the Welfare and Institutions Code. CA Business and Professions Code Sections 4989.54 (cont.)
  • ATA Guidelines - Emergencies• A patient site • Emergency protocols assessment shall be shall be created with undertaken, including clear explanation of obtaining information roles & responsibilities on local regulations & in emergencies emergency resources, and identification of potential local collaborators to help with emergencies
  • ATA Guidelines - Emergencies• Determine outside • Be familiar with local emergency coverage civil commitment• Establish guidelines for regulations and have determining at what arrangements where point other staff and possible to work with resources should be local staff to recruited to help initiate/assist with civil manage emergencies commitments
  • ATA Guidelines - Emergencies• Be aware of the impact • Be aware of safety issues of remote care on with patients displaying provider’s perception of strong affective or control (or lack thereof) behavioral states upon over the clinical conclusion of a interaction, and how session, and how this might impact patients may then provider’s management. interact with remote site inhabitants
  • Sources of HIPAA Risks• 79% of breaches caused by employees• 18% by a third-party partner• the increasing use of mobile devises2012 HIMSS Analytics Report• http://www.krollcybersecurity.com/white- papers/himss-2012-report.aspx
  • HIPAA Risks Increasing• Interconnectedness and information sharing a ‘must have’ competency• EHR mandated by 2013 or penalties will start being applied in terms of reductions• Security and privacy risks are increasing proportionally
  • 17 HIPAA Risk Solutions1. Encrypt• If data is encrypted, there is no duty under the Notification Rule to notify clients if a breach occurs (“safe harbor” clause).• While HIPAA requires data is encrypted at 178 bits, your software provider may offer 256-bit encryption which is considerably more secure
  • 17 HIPAA Risk Solutions2. Authentication – Change passwords / symbols & characters / biometrics / access controls (need-to-know access)3. Have “best practices” policies and procedures – Include sanctions for employees in violation – Monitor 3rd party partners – Incident response and planning4. Create awareness of risk of human error – No laptops in trunks of cars or cybercafés – No passwords on post-it notes
  • 17 HIPAA Risk Solutions5. Create failed log-in’s after a certain number of attempts6. Vulnerability testing of your system7. Use firewalls9. Digital signatures10. Perform yearly logical penetration test,11. Provide free credit monitoring to clients12. Perform risk assessments on a regular basis13. Review and update audit trails regularly14. Install tools to shut down the system if hacking is detected15. Establish building and computer room security16. Learn how to repair and dispose of your old hardware17. Screen third parties carefully
  • Is Skype HIPAA-Compliant?• Skype doesnt claim HIPAA compliance – it doesn’t have to - professionals do• Difficult for us to know Unless a company makes a statement for which they are liable • Changing quickly • Microsoft Copyright 2012 TeleMental Health Institute, Inc. All rights reserved .
  • Which Technologies to Use?• No Guesswork Needed – HIPAA “compliant” or “compatible” – Practitioners need to be compliant, not technology – Look for documentation of compatibility with HIPAA standards
  • Business Asscoaites and HITECH• All Business Associates in health care must sign an agreement stating their adherence to HIPAA standards • Transactions • Security • Privacy• True for any service you hire • Billing, janitorial, computer repair, e-mail, or video conferencing, etc.• Not a matter of opinion  it is now enforced by the HITECH ACT Copyright 2012 TeleMental Health Institute, Inc. All rights reserved.
  • What else do healthcare professionals need to know to be compliant with HIPAA regulations today?• We are mandated to use HIPAA compliant technologies and processes – Document policies • Security & privacy policies – Repairs – Staff training – Breaches, etc. Copyright 2012 TeleMental Health Institute, Inc. All rights reserved.
  • Practicing OverState Lines Copyright 2012 TeleMental Health Institute, Inc. All rights reserved.
  • LicensureRequirements • We need to be licensed in our state(s) to practice • Common: We need to be licensed in the state of residency of the patient (e.g., Florida, Texas, Utah, Vermont ) • Also Possible: Both laws may exist
  • Licensing Suggestions• Know laws in relevant states• Decline patients where not licensed• Require prospective patient to legally represent he’s a citizen of a state – Use authentication services – Use traditional proof of residency
  • Cross-Border Practice• Licensing Boards that may assert jurisdiction: – The one in your state – The one in the patient’s state – Both• Safest: – Provide services only where licensed – Require pt to attest to his or her citizenship there Copyright 2012 TeleMental Health Institute, Inc. All rights reserved.
  • Question• What can we do to move licensing forward with the authorities? – Contact them – Volunteer if they need help – Get their newsletters – Follow the literature – Get trained so you know which questions to ask Copyright 2012 TeleMental Health Institute, Inc. All rights reserved.
  • Question• I’m ok if my malpractice carrier says they cover me online, right? Copyright 2012 TeleMental Health Institute, Inc. All rights reserved.
  • APA Ethical Principles of Psychologists• Principle B: Fidelity and Responsibility – Psychologists establish relationships of trust with those with whom they work. They are aware of their professional and scientific responsibilities to society and to the specific communities in which they work. • "Cardiologists fined $100,000 for Internet privacy violations“ (Arizona Republic, April 17, 2012) – Online calendar, no written policies & procedures, no documented staff training, no risk analysis, no security official • New York State Social Worker Copyright 2012 TeleMental Health Institute, Inc. All rights reserved.
  • Legal Suggestions (TMH Institute)• Study & understand the • Communicate often to your scientific literature local, state and national• Get broad-based and professional associations specific telehealth training • Write to your malpractice• Save all proof of training or carrier and ask them to consultation clearly tell you what will• Document, document, docu happen if you get in trouble ment • Consider that a lawsuit can• Don’t refer to peers who involve a year or two of you suspect are practicing your life, without pay illegally or unethically online Copyright 2012 TeleMental Health Institute, Inc. All rights reserved.
  • OCPM: Online ClinicalPractice Model Online Clinical Practice Management (OCPM)Step 1: TrainingStep 2: ReferralsStep 3: Patient EducationStep 4: LegalitiesStep 5: AssessmentStep 6: Direct CareStep 7: Reimbursement
  • OCPM: Online ClinicalPractice Model Online Clinical Practice Management (OCPM)Step 1: TrainingStep 2: ReferralsStep 3: Patient EducationStep 4: LegalitiesStep 5: AssessmentStep 6: Direct CareStep 7: Reimbursement
  • ACA Code of Ethics (2005)• A.1.b. Records• Counselors maintain records necessary for rendering professional services to their clients and as required by laws, regulations, or agency or institution procedures.• Counselors include sufficient and timely documentation in their client records to facilitate the delivery and continuity of needed services. Counselors take reasonable steps to ensure that documentation in records accurately reflects client progress and services provided. Copyright 2012 TeleMental Health Institute, Inc. All rights reserved.
  • What’s the Problem? • Differences, Confusion & Disagreement • Institutional vs. Independents • No IT staff, nurses, admins • No time for it all • Costs – free video chat • Technology • Unreliable systems • HIPAA? • Practical • Clarify Roles •Legal/Regulatory (what’s what?) • Ethical – associations • Reimbursement • Deception – loss of trust • Technical • Anonymity / duty to report • Malpractice carriers
  • Solutions: Anxiety Reduction  Education •Professionals • Blueprint (legal/ethical) • Licensing • Malpractice • Reimbursement • Practical (work flow) • Control / Authority • Predictable • Peaceful • Patients • Authentication • Reliability • Payment / Reimbursement Models • Negotiate with Employers • Creative Marketing  Positive
  • OCPM Step 6: Direct Clinical CareExplain & sign informed consent documentConduct a formal intake – no shortcuts Meet in-person or video, take full history, medications, illnesses, abuse, stressors, support system, use of other technology, drug/alcohol use, suicide/homicide intent, mental status Decide if, then which technology is appropriate Obtain names of all other key providers, get all appropriate releases and send reports as usualContract for short, protocol-driven txAuthenticate & set ground rules at every sessionEnforce boundaries (privacy, family, social media)Have backup emergency planEvaluate at regular intervals
  • Is Skype Reliable?Its free, but then again, so is a park bench… is a park bench adequate for yourwork?Skype tiles & pixelates, the audio getstinny, echoes develop, and often callsdrop entirely. Sometimes consumers cansee you and hear you, without yourawareness.How will the most dysfunctional of yourclients and patients react to a droppedcall?Do you have a back-up emergencyplan, and full knowledge of localresources in case you need to actimmediately?Most of the literature has a “champion” inthe local community of the patient. Copyright 2012 TeleMental Health Institute, Inc. All rights reserved.
  • Do you see well enough?•Image Resolution • ATA GuidelinesAre you conducting an intakeor follow-up?• Most of the scientific literaturedescribed VTC as being used forfollow-up care after a primaryphysician or other licensedprofessional does an intake.• Can you properly assess glassyeyes, tremors, gaitdisturbance, sweaty palms, bodyodor, other signs of poor hygiene? Copyright 2012 TeleMental Health Institute, Inc. All rights reserved .
  • Skype does not provide an audit trail, which is afoundational HIPAA requirement
  • What if you just askconsumer to sign adisclaimer?You can ask, but most courts will notsupport your having asked avulnerable patient to sign away theirbasic U.S. rights -- such as the rightto privacy.
  • What if I claimBeneficence vs.Malfeasance?• Are you in an emergencysituation?• Did you document your rationaleadequately to defend yourself ifsomething goes wrong?• Did you run your rationale byyour own local attorney?• Did you describe your rationalein writing to your licensingboard, ethics boards and othercolleagues?• Are you sure your malpracticecarrier will cover your civil as wellas regulatory risk? Get it in writing.
  • What’s Microsoft Doing to Improve Skype’s Functionality?• For developers, the .NET Framework provides a comprehensive and consistent programming model for building applications that have visually stunning user experiences and seamless and secure communication. http://www.microsoft.com/net Copyright 2012 TeleMental Health Institute, Inc. All rights reserved.
  • Implications of Microsofts actions for Skype in mental health? • Very positive – Future of bringing mental health care to the hip pocket is more and more of a reality Copyright 2012 TeleMental Health Institute, Inc. All rights reserved.
  • #1. VTC is moving to the smart device
  • •Nursing Homes
  • Schools
  • Rural Hospitals
  • Hospitals
  • Home Health
  • Military & Veteran’s Migration ModelAdministration
  • CorrectionaFacilities
  • mHealth• Mobile phones are the predominant form of communication in 3rd world countries – landlines are extremely limited – broadband lags behind in development Copyright 2012 TeleMental Health Institute, Inc. All rights reserved.
  • 49.7% of all Americans have a smartphone (Neilson, Feb. 2012)What does that mean for psychotherapy?Insurance reimbursement is right around the corner… patients and clients will choosebetween you and someone else who is trained, skilled and available via technology Copyright 2012 TeleMental Health Institute, Inc. All rights reserved.
  • OCPM: Online ClinicalPractice Model Online Clinical Practice Management (OCPM)Step 1: TrainingStep 2: ReferralsStep 3: Patient EducationStep 4: LegalitiesStep 5: AssessmentStep 6: Direct CareStep 7: Reimbursement
  • Reimbursement?• Medicare & Medicaid already pay for VTC. Many 3rd party carriers do, too. • Require HIPAA compliance • Designated sites • Rural areas • Not to the home yet, but such reimbursement is coming • Get Telemedicine Reimbursement Handbook or TMI Institute course Copyright 2012 TeleMental Health Institute, Inc. All rights reserved.
  • Which features do mental health professionals need to deliver effective care with VTC?• Depends on population served – General adult – Pediatrics (room, table top – Gerontology (adaptive devices) – Correctional facilities (videophones)• White boards, show desktop & access Internet Copyright 2012 TeleMental Health Institute, Inc. All rights reserved.
  • Special Mental Health FeaturesDepend on servicesdelivered White board Access desktop or web Neuropsych testing– Supervision– Might also want secured email, instant messaging, cloud storage, etc.– Virtual reality goggles– Apps Copyright 2012 TeleMental Health Institute, Inc. All rights reserved.
  • Internet-based, VTC Companies* Claiming HIPAA Compliance• Access Psychiatry • Interactive Care• Adobe Connect • iTel• Behavior Imaging Solutions • IVE (cloud)• Breakthrough • Lifesize (Logitech)• Brighter Day Health • MyTherapyNet• CaliforniaLiveVisit • Pass• CopeToday • Revation• Consult a Doctor • Secure Telehealth• Counsol.com • Secure Video Conference• EasyShare VC • Shepell fgi• eCounseling • Smart House Calls• E Mental Health Center • Soltrite• Forefront Telecare • Via3• GEMS • VisHealth (Visual Telehealth)• GoToMeeting • VSee• iCouch * TMH Institute has partnered with some of these companies and will receive a referral fee if you mention TMHI. You may also get an added discount. Copyright 2012 TeleMental Health Institute, Inc. All rights reserved.
  • Some 3rd partycarriers insist thatremote care must be“medicallynecessary.”Should the deliverysystem be medicallynecessary -- or shouldwe focus on theservice?.
  • Resources• www.telehealth.ORG/bibliography
  • Learning Objectives• 1. ETHICS: – Skype, Google, Facebook, Assessment, Records, Testimonia ls, use established treatment protocols• 2. LEGAL ISSUES: – practicing over state lines, HIPAA, informed consent• 3. RISK MANAGEMENT: – Abide by your ethical code, know your state law, hire a local attorney
  • We can dothis if wejointogether
  • Wish List of Next Steps• Recognize Essential Differences: – Traditional telepsychiatry vs. how most psychologists are using telehealth – Outline clear statements of needed technology-based competencies – Develop psychology protocols for treatment in “unsupervised settings” • Find malpractice carriers who will carry our entire risk (both civil & regulatory)• Expand training options for responsible technology-based practice• Advocate for our regulatory boards to – Post clear statements about, & enforce existing laws – Require technology-competencies be demonstrated as a condition for licensure• Focus on other areas in addition to direct-care• Start developing online group practices & our own online ACOs• Join us in forming a Division at the APA devoted exclusively to advancing the use of technology -- and thereby growing the APA
  • Questions?Marlene M. Maheu, Ph.D.TeleMental Health Institute, Inc.Phone: 619-255-2788Email: mmaheu@telehealth.ORG Copyright 2012 TeleMental Health Institute, Inc. All rights reserved.