SUPERVISION, MOBILITY ANDTELEPSYCH: THE NEXT FRONTIER TO       PSYCHOLOGICAL PRACTICE                 ALEX M. SIEGEL, J.D....
Disclaimer and           Acknowledgement   It is PAST October 17, 2011 yet.   DPA for ASPPB   APA/ASPPB/APAIT JOINT TF...
WHAT IS ASPPB Association of State and Provincial Psychology  Boards    64 State/provincial/territorial psychology     r...
PURPOSE OF PRESENTATION Identify benefits and problems with an internet practice of  psychology Compare electronic pract...
Psychology   A Regulated Profession Canada - by province/territory   10 Provinces   Northwest Territories United State...
Registration/LicensureOverview of Requirements Graduate degree in psychology Supervised professional experience (SPE)  ...
Sequence of Training         Leading to     Licensure   Academic Program       Practicum       Dissertation/Thesis…       ...
Entry to Independent           Practice:         United States Most (49) states require a doctoral degree for  licensure ...
Entry to Independent         PracticeAcademic Degree: Canada Five jurisdictions (BC, MB, ON, NB, QC)    Psychologist: do...
Psychologist      Graduate Degree Must be a recognized psychology program (accredited/designatated Specific courses may ...
Pennsylvania Requirements 41.31(5) First time applicants who were enrolled in  doctoral program prior to March 23,  1991...
 Old 41.31(b) prior to June 30, 2008 REQUIREMENTS Education     1) Program Director completes the  Verification of Doc...
IF NOT APA OR ASPPB Must demonstrate applicant’s satisfactory  completion of core, specialty, practicum  and internship:...
   Competence 4 Substantive Content Areas:    Biological Bases of Behavior    Cognitive-Affective Bases of Behavior   ...
RESIDENCY Each degree candidate complete a minimum  of two consecutive academic semesters as a  matriculated student phys...
41.31(4)  First time applicants who enrolled in a  graduate degree program in psychology or  field related to psychology o...
Psychologist: Supervised  Professional Experience Two years (3,000 hours) of supervised  experience typically required, u...
 Some states include APPIC most don’t Some include APA/CPA most don’t Advantage of APPIC/APA is program has  been peer ...
Hours   Number of Jurisdictions•2000           11•1900            2•1800            6•1750            5•1600            1•...
Pennsylvania Requirements Practicum hours NOT Counted (OLD) Predoc Internship   Supervised training for at least 450 ho...
 New Regs do not define internship  requirements since it is part of the doctoral  program requirements
POST DOC1500 hours is defined as a year (37.5 weeks)At least one half of experience in direct  servicesMust be supervised ...
Not Acceptable Experience Independent Private practice as a Qualified  member of another recognized profession Independe...
New 41.31 Shall complete 1 year of acceptable post doc  supervised experience First time applicants who commence post do...
EXPERIENCE AT MORE       THAN 1 PLACE Experience is obtained for each entity for a  minimum of 6 consecutive months Expe...
 Acceptable Experience 1) practice at entity consistent with  psychologist’s education and training 2) No experience ma...
 All experience must be obtained under  supervision of a primary supervision Primary – if obtained from more than 1  sup...
TELEPSYCH
Scope of Issue 10% growth in telehealth annually $500 million spent in US annually Federal health care law provides $1b...
 “The technology has improved to the point  where the experience of both the doctor and  patient are close to the same as...
 Overwhelming research indicates that face  to face therapy is no better(or worse) than  telepsych as measured by satisfa...
China American Analytic Association organized a 2 year program with seminars, supervision and psychoanalysis through Skype.
Numbers of users 73% American adults are internet users (Madden  2006) 5% broadband internet at home (Horrigan, 2008) 8...
 69% of psychologist admit to providing services by  phone(Vandenbos & Williams 2000) 75% have offered services to resid...
WHY NOWPsychologist are being hit hard by lowering  reimbursement rates and increasing restrictionsElectronic Communicatio...
 Psychologist are uniquely positioned to  become the leading profession in this area. Consensus on the need to solve the...
Telehealth, Telemedicine,Telemental Health or Telepsych WHAT TO CALL IT. APA ETHICS, PA STATE BOARD OF  PSYCHOLOGY( LAWS...
TELEPSYCH Wikipedia: The delivery of health-related services  and information via telecommunication  technologies. THE U...
APA ETHICS Ethics Committee Opinion on Remote Therapy  • The APA has not chosen to address teletherapy directly in    its...
APA ETHICS CODE 2010 Beneficence (Principle A) Nonmaleficence (Principle A) Autonomy (Principle E) Justice (Principle ...
2.01 Boundaries of Competence (a) psychologists provide services only within theboundaries of their competence (c) Psychol...
3.10(a) Informed Consent When psychologists conduct research or provide  assessment, therapy, counseling, or consulting  ...
4.0 Privacy and Confidentiality 4.01 Psychologists have a primary obligation  and take reasonable precautions to protect ...
OTHER KEY APA SECTIONS   1.02 Resolving Ethical Conflicts   2.02 Providing Services in Emergencies   3.05 Multiple Rela...
PA State Board of Psychology LAW Rules and Regulations Within the Commonwealth
Is Remote Therapy Equivalent• Intuitively, to most practitioners, in-person  treatment is superior because of the importan...
Is Remote Therapy Equivalent ?Traditional therapy has a great deal of variation.   • Remote therapy has advantages of incr...
RISK MANAGEMENT Have a good working knowledge of ethics  code and legal standards governing practice Conduct a conservat...
Three keys to Success Provide Comprehensive Informed Consent Seek Appropriate Consultation Develop good record-keeping ...
APA/ASPPB/APAIT TF   1 COMPETENCE   2 MULTIPLE RELATIONSHIPS   3 INFORMED CONSENT   4 CONFIDENTIALITY AND PRIVACY   5...
 10 LEGAL ISSUES 11 INTERJURISDICTIONAL 12 INFORMATION COLLECTION,  COMMUNICATION AND STORAGE 13 CONSULTATION AND I/0...
WHAT ARE OTHERS DOING   ACPRO IN CANADA   AUSTRALIA   ASPPB   EU -EUROPSYC   Other states
INFORMED CONSENT Just as you all use an informed consent with all  your face to face patients, need one for telepsych: L...
COMPETENCE Before engaging in the remote delivery of  mental health services via electronic means,  practitioners should ...
Practical Competency Have you done internet therapy -confidentiality Why in this case- benefits vs. risk Type of Patien...
   Entertaining? Is it like TV. boring? Avatars   How much do you get from nonverbal cues   Conditions which might chan...
WEB THERAPY
Technological Competence Do you know how to use the internet, do you  know what you don’t know Broad Band Width, asynchr...
Inter Jurisdictional 10th amendment-- state rights Different states adopt different regulations Licensing Boards are co...
ISSUES Where does the electronic interstate  transaction take place?  a) where the consumer resides--distant  b) where th...
Where the Practitioner Resides? Is physically located in a state where he/she is  licensed. Reside or domicile? Psycholo...
• Federal Government Policy: Health Licensing  Board Report to Congress, HRSA, HHS,  2011 (HSRA) Federal government has r...
Health Licensing Board Report  to Congress HRSA, HHS 2011 “ if collaboration between states is unable to  develop effecti...
HRSA 2011 “ In the absence of specific agreements…  states may not discipline healthcare  providers not licensed in their...
 State licensing authority cannot interfere  with the regulatory authority of the  federal government such as interstate ...
State Licensing Boards States have taken the position that the transaction takes  place in forum state no matter where th...
Minimal Contact Rule The state where the patient resides (the forum  state) can assert jurisdiction over an out-of-state ...
Prince v. Urban Three principles of decision    Was the doctor-patient relationship created because     of a continuing ...
 The essence of the relationship was that the California  patient sought out the Illinois doctors in Illinois. [The  plai...
Tentative Conclusions by APAIT Unless a psychologist actively promotes services  in an interstate manner, forum ( pt resi...
Other View Licensing Board could issue a cease and  desist order and due to laws of comity have  it enforced in another j...
Hypotheticals Psychologist in PA, patient in PA Psych in NJ, patient in PA Psych in PA, patient in New Orleans, LA. Ps...
 Even though the distant( pt resides)  jurisdiction might not have jurisdiction,  home jurisdiction(where psych is licens...
My Fantasy Registry for all who want to practice telepsych  inter jurisdictionally. Benefit:      One license      Lik...
 Problems    1) need to know distant laws, PA v.TX    2) need to abide by stricter standards,  records    3) emergencies ...
Confidentiality: Communications      Voicemail   Websites   Email   Text Messaging   Social Networking      Facebook ...
Clinical Communication Direct Care      Telepsych     Coaching     Assessment     I/O Consultation     Forensic
Administrative   Billing; Insurance, credit or otherwise   Scheduling   Record Keeping and other documentation   Infor...
Points to Consider   Resolution and Picture Quality   Real time Audio   Reliability of technology   Ease of Use   Cos...
SKYPE   It is not HIPAA Compliant   Sells information to others- confidentiality   Public part of profile can be seen b...
 Public parts of your Skype profile can be seen by  everyone else on Skype. Do not put details in your  profile that you ...
 Skype may disclose personal information to  respond to legal requirements, to protect Skype’s  interests, to enforce our...
Voice Mail, Email, Texting Convenience and efficiency Duty to Care Alternative Backups WHAT ARE YOU RESPONSIBLE FOR?
Holmes v. Petrovich Gina Holmes sued her employer  based on allegations of pregnancy  disability discriminations. Holmes...
 The Court reasoned that the e-mails sent  through her company computer were  “akin to consulting her lawyer in her  empl...
 The Court emphasized that an email  communication does not lose its privileged  character solely because it is communica...
Informed Consent with Patient Do not SMS or use social network site No Wall postings, @replies or other on line    Not ...
FACEBOOK Is constantly changing, hard to keep up with  all the changes. Business page now can be post on a page. mashab...
 Is friending a patient a multiple relationship? If you friend someone are friending all of their  friends as well Avoi...
Privacy “This Ethics Code applies only to psychologists  activities that are part of their scientific,  educational, or p...
 In the age of Google, the concept of privacy has  changed. We all practice in small communities and need to  figure out...
GOOGLED OR YELPED? How many of you think you patients have googled  you? Patients will review sites and other means of  ...
 How many of you have googled a patient?   Informed consent   Do you have to let them know   Difference in forensic ca...
Security,Record Keeping and             Storage Same applicability trigger: electronic transmission  in covered transacti...
 Conduct a documented risk analysis which must  be kept with other HIPAA compliance records. Modify your policies and pr...
 Develop specific policies for data access to all  electronic devices that store data. (Scalable Issues)    Includes not...
 Train all employees in the Security Rule. Have policies for dealing with security  breaches including specific sanction...
 Have appropriate facility access controls    Only staff should be able to reach place where     EPHI is stored.    Spe...
2007 APA Recording Keeping          Guidelines Electronic records, like paper records,  should be created and maintained ...
PA PSYCH REGULATIONS       Section 41.57(c) A psychologist shall store and dispose of  written, electronic and other reco...
Onsite Back Up External Hard Drive Flash Drives Back up Drives   Tape   Flash Memory   Paper
Off Site Storage   http://www.carbonite.com/   http://www.mozy.com/   http://www.backblaze.com/   http://www.crashplan...
ENCRYPTION Stanford Hospital $20M Class Action Law for  data breach involving 20,000 patients(San Jose  Mercury News) 4....
What is Encryption Definition: Encryption is the conversion of  data into a form, called a hypertext that cannot  be easi...
Do You Need Encryption? If you don’t encrypt and there is a breach, you must  inform your clients. Unencrypted data brea...
 TrueCrypt (http://www.truecrypt.org/) BestCrypt Enterprise (  http://www.jetico.com/data-protection-encryption  ) PGP ...
MOBILITY AND PORTIBILITY
PASS RATE ON EPPP   Doctoral degree first-time takers: 83%   APA/CPA accredited graduates: 78%   NON APA/CPA graduates:...
 For those already licensed/registered with no  disciplinary sanctions Mechanisms to facilitate mobility:   Certificate...
 Most new practitioners will relocate at least once in  their career Slight variations in registration and licensure  re...
Certificate of professional      Qualification (CPQ) Program of ASPPB Individual must meet requirements for CPQ Include...
 Accepted by 44 jurisdictions in Canada &  United States 3 more jurisdictions in the process of  accepting the CPQ for l...
Accepting CPQ Jurisdictions in Canada: all 10 provinces Jurisdictions in the United States: AZ, AR, CA, CO, CT, DE, DC, ...
 These jurisdictions have “voted” to accept CPQ,  and are in process of making legislative or  administrative changes for...
Recognize CPQ These jurisdictions may waive at least one  requirement for applications who hold a  CPQ. US   IA, MD, MA...
Not Accepting CPQ US   NY, FL, AL, IN, IL, KS, PR, VI, GU
ASPPB Agreement of          Reciprocity 11 jurisdictions (2 provinces, 9 states) Jurisdiction must meet requirements of ...
 Jurisdictions in Canada MB, ON Jurisdictions in the United States AR, KY, MO, MS, NV, NH, OK, TX, WI
Interjurisdictional Practice           Certificate (IPC) Accept IPC     Idaho     Georgia     South Carolina     Kent...
National Register The National Register credential is approved  or in process of approval in 46 jurisdictions in  the US ...
ABPP
THANK YOU. ASIEGEL@ASPPB.ORG 610 668 4240 in Narberth, PA Pa Licensing Board     ST-PSYCHOLOGY@PA.GOV     717 783 7155...
Supervision, Mobility & Telepsychology: The Next Frontier of Psychological Practice
Upcoming SlideShare
Loading in...5
×

Supervision, Mobility & Telepsychology: The Next Frontier of Psychological Practice

2,308

Published on

By Alex M Siegel

Published in: Health & Medicine
0 Comments
0 Likes
Statistics
Notes
  • Be the first to comment

  • Be the first to like this

No Downloads
Views
Total Views
2,308
On Slideshare
0
From Embeds
0
Number of Embeds
0
Actions
Shares
0
Downloads
15
Comments
0
Likes
0
Embeds 0
No embeds

No notes for slide

Supervision, Mobility & Telepsychology: The Next Frontier of Psychological Practice

  1. 1. SUPERVISION, MOBILITY ANDTELEPSYCH: THE NEXT FRONTIER TO PSYCHOLOGICAL PRACTICE ALEX M. SIEGEL, J.D.,PH.D. ASSOCIATION OF STATE AND PROVINCIAL PSYCHOLOGY BOARDS NOVEMBER 18, 2011
  2. 2. Disclaimer and Acknowledgement It is PAST October 17, 2011 yet. DPA for ASPPB APA/ASPPB/APAIT JOINT TF I am a reluctant digital immigrant APAIT TRUST Presentation with Eric Harris and Jeff Younggren, Risk Management in the Electronic Age
  3. 3. WHAT IS ASPPB Association of State and Provincial Psychology Boards  64 State/provincial/territorial psychology regulatory boards/colleges US and Canada  Services to licensing boards, applicants for licensure/registration, licensed psychologists  Goal is to be the international source of information and offer model programs on regulation of psychologists
  4. 4. PURPOSE OF PRESENTATION Identify benefits and problems with an internet practice of psychology Compare electronic practice with portability and mobility of your license What you will need to do as a practitioner for telepsych and or mobility Discuss the changes in supervision requirements in PA
  5. 5. Psychology A Regulated Profession Canada - by province/territory  10 Provinces  Northwest Territories United States - by state/territory  50 States  Virgin Islands, Puerto Rico, Guam  District of Columbia
  6. 6. Registration/LicensureOverview of Requirements Graduate degree in psychology Supervised professional experience (SPE)  1500 to 6000 hours of SPE Examinations  Examination for Professional Practice in Psychology (EPPP)  Jurisprudence and/or Ethics Exam  Oral Examination
  7. 7. Sequence of Training Leading to Licensure Academic Program Practicum Dissertation/Thesis… Internship Graduation Postdoctoral Experience Testing Licensure
  8. 8. Entry to Independent Practice: United States Most (49) states require a doctoral degree for licensure as a Psychologist One (1) state (West Virginia) requires a masters degree for licensure as a Psychologist Two (2) jurisdictions also license at masters level for independent practice, different title:  Oregon: Psychological Associate  Vermont: Psychologist - Master
  9. 9. Entry to Independent PracticeAcademic Degree: Canada Five jurisdictions (BC, MB, ON, NB, QC)  Psychologist: doctoral degree  Psychological Associate: masters degree Six jurisdictions (AB, SK, NS, PE, NL, NWT)  Psychologist: doctoral or masters degree
  10. 10. Psychologist Graduate Degree Must be a recognized psychology program (accredited/designatated Specific courses may be required CPA/APA accredited doctoral program may meet all degree requirements
  11. 11. Pennsylvania Requirements 41.31(5) First time applicants who were enrolled in doctoral program prior to March 23, 1991will have their educational credentials evaluated under regulations in effect at that time. If apply under 41.42(b)[reapplication] will have credentials evaluated under regulations in effect at time of reapplication
  12. 12.  Old 41.31(b) prior to June 30, 2008 REQUIREMENTS Education 1) Program Director completes the Verification of Doctoral Program Approval Status reflecting APA or CPA Accreditation or 2) ASPPB/NR Designation or Within 1 year from the award of Doctoral Degree
  13. 13. IF NOT APA OR ASPPB Must demonstrate applicant’s satisfactory completion of core, specialty, practicum and internship: 1)Recognized Sequence within the overall program or department 2) Comprises Integrated, Organized Sequence of Study Ethics Research Design and Methodology
  14. 14.  Competence 4 Substantive Content Areas: Biological Bases of Behavior Cognitive-Affective Bases of Behavior Social Bases of Behavior Individual Differences Specialty Courses, Practicum, Internship At least 60 graduate hours of above
  15. 15. RESIDENCY Each degree candidate complete a minimum of two consecutive academic semesters as a matriculated student physically present at the institution grating the degree
  16. 16. 41.31(4) First time applicants who enrolled in a graduate degree program in psychology or field related to psychology on or after July 1, 2008 will be evaluated under theses regulations. MUST BE FROM APA or CPA ACCREDITED OR ASPPB/NR DESIGNATED PROGRAM
  17. 17. Psychologist: Supervised Professional Experience Two years (3,000 hours) of supervised experience typically required, usually one of these must be postdoctoral
  18. 18.  Some states include APPIC most don’t Some include APA/CPA most don’t Advantage of APPIC/APA is program has been peer reviewed and meets minimal standards Have some recourse if problems occur
  19. 19. Hours Number of Jurisdictions•2000 11•1900 2•1800 6•1750 5•1600 1•1500 14
  20. 20. Pennsylvania Requirements Practicum hours NOT Counted (OLD) Predoc Internship  Supervised training for at least 450 hours  Learning activities for an average of 2 hours a week  Interact formally and informally with students  For 1 year and 1500 hours with 25%(375) in direct patient contact and no more than 25% in research  Part time for 2 year half time
  21. 21.  New Regs do not define internship requirements since it is part of the doctoral program requirements
  22. 22. POST DOC1500 hours is defined as a year (37.5 weeks)At least one half of experience in direct servicesMust be supervised by psychologist hold current licenseSupervisor meets individually for an average of 2 hours a weekMay delegate 1 hour
  23. 23. Not Acceptable Experience Independent Private practice as a Qualified member of another recognized profession Independent practice as a certified school psychologist
  24. 24. New 41.31 Shall complete 1 year of acceptable post doc supervised experience First time applicants who commence post doc as of December 6, 2010  1 year is calculated as at least 12 months consisting of 1750 hours  No more than 45 hours and no less than 15 hours may be counted each week  At least 50% direct services
  25. 25. EXPERIENCE AT MORE THAN 1 PLACE Experience is obtained for each entity for a minimum of 6 consecutive months Experience occurs for a minimum of 15 hours per week at each setting Total experience for all settings does not exceed 45 hours
  26. 26.  Acceptable Experience 1) practice at entity consistent with psychologist’s education and training 2) No experience may be obtained if psychology resident acts independently
  27. 27.  All experience must be obtained under supervision of a primary supervision Primary – if obtained from more than 1 supervisor, hall have a primary supervisor at each entity. Delegated- may delegate supervision for up to 1 hour per week
  28. 28. TELEPSYCH
  29. 29. Scope of Issue 10% growth in telehealth annually $500 million spent in US annually Federal health care law provides $1billion a year to study telehealth Insurance plans starting to market to large employers
  30. 30.  “The technology has improved to the point where the experience of both the doctor and patient are close to the same as in-person visits, and in some cases better,” Dr. Kaveh Safari, head of global health care for Cisco Systems, NY Times, 05/28/10
  31. 31.  Overwhelming research indicates that face to face therapy is no better(or worse) than telepsych as measured by satisfaction of consumers 983 articles since 1993, 2/3 of them since 2008 A Comprehensive Review and a Meta-Analyisis of the Effectiveness of Internet-Based Psychotherapeutic Interventions in J of Technology in Human Services Vol 26, pages 109-160, 2008
  32. 32. China American Analytic Association organized a 2 year program with seminars, supervision and psychoanalysis through Skype.
  33. 33. Numbers of users 73% American adults are internet users (Madden 2006) 5% broadband internet at home (Horrigan, 2008) 85% college students report own computer and 72% check email at least once a day( Jones 2002) 82% of college student use social networks (Caruso & Salaway 2007)
  34. 34.  69% of psychologist admit to providing services by phone(Vandenbos & Williams 2000) 75% have offered services to residents of another jurisdiction where they are not licensed or registered Office of Advancement of Telemedicine(HHS) identified licensure as a major barrier of telemedicine Both nursing(compact) and medicine have plan to deal with interstate practice issues on a national scope
  35. 35. WHY NOWPsychologist are being hit hard by lowering reimbursement rates and increasing restrictionsElectronic Communications are already a part of professional practice of psychology (HIPAA and HITECH). For example in 2012 all billing will have to be electronic. IN 2014 all records will be electronic.Since 75% are providing service, it is the wild west.No guidelines or regulations.
  36. 36.  Psychologist are uniquely positioned to become the leading profession in this area. Consensus on the need to solve the interjurisdictional issue Opportunity to offer services to individuals or communities that are under served Expand practice Digital natives think differently than us
  37. 37. Telehealth, Telemedicine,Telemental Health or Telepsych WHAT TO CALL IT. APA ETHICS, PA STATE BOARD OF PSYCHOLOGY( LAWS AND REGS) WHAT DO YOU NEED TO KNOW OR BE COMPETENT TO PROVIDE INTERNET SERVICES RISK MANAGEMENT APA/ASPPB/APAIT JOINT TF
  38. 38. TELEPSYCH Wikipedia: The delivery of health-related services and information via telecommunication technologies. THE U: The remote provision of health care services and health education, mediated by technology. Includes: Internet text based Telephone Videoconferencing- education and treatment
  39. 39. APA ETHICS Ethics Committee Opinion on Remote Therapy • The APA has not chosen to address teletherapy directly in its ethics code and by this intentional omission has created no rules prohibiting such services. The APA Ethics Committee has consistently stated a willingness to address complaints regarding such services on a case-by- case basis, while directing clinicians to apply the same standards used in ‘‘emerging areas in which generally recognized standards for preparatory training do not yet exist,’’ by taking ‘‘reasonable steps to ensure the competence of their work and to protect patients, clients, students, research participants, and others from harm’’ (American Psychological Association, 2002, 2.01e). ..
  40. 40. APA ETHICS CODE 2010 Beneficence (Principle A) Nonmaleficence (Principle A) Autonomy (Principle E) Justice (Principle D) Fidelity (Principle B) Integrity (Principle C)
  41. 41. 2.01 Boundaries of Competence (a) psychologists provide services only within theboundaries of their competence (c) Psychologists planning to provide services…involvingtechniques and technologies new to them undertake relevanteducation, training, supervised experience, consultation orstudy. (e) In those emerging areas in which generally recognizedstandards for preparatory training do not yet exist,psychologists nevertheless take reasonable steps to ensurethe competence of their work and to protect clients/patients,students, supervisees, research participants, organizationalclients, and others from harm.
  42. 42. 3.10(a) Informed Consent When psychologists conduct research or provide assessment, therapy, counseling, or consulting services in person or via electronic transmission or other forms of communication, they obtain the informed consent of the individual or individuals using language that is reasonably understandable to that person or persons except when conducting such activities without consent is mandated by law or governmental regulation or as otherwise provided in this Ethics Code.
  43. 43. 4.0 Privacy and Confidentiality 4.01 Psychologists have a primary obligation and take reasonable precautions to protect confidential information obtained through or stored in any medium… 4.02 Psychologists discuss with persons…(1) the relevant limitations to confidentiality
  44. 44. OTHER KEY APA SECTIONS 1.02 Resolving Ethical Conflicts 2.02 Providing Services in Emergencies 3.05 Multiple Relationships 3.12 Interruption of Psychological Services 5.01 Avoidance of False or Deceptive ST’T 6.01 Documentation of Records 9.01 Assessment 10.01 Informed consent to therapy
  45. 45. PA State Board of Psychology LAW Rules and Regulations Within the Commonwealth
  46. 46. Is Remote Therapy Equivalent• Intuitively, to most practitioners, in-person treatment is superior because of the importance of non verbal cues and other non quantifiable relationship superiorities.• Some research shows that the closer a communication is to in-person, the more efficacious it is, but there is evidence that supports efficacy of voice and text only.• There is considerable research that establishes equivalency in terms of outcomes and consumer satisfaction
  47. 47. Is Remote Therapy Equivalent ?Traditional therapy has a great deal of variation. • Remote therapy has advantages of increased flexibility, access, and administrative convenience. • There are some treatment situations where remote treatment has clear advantages Providing there is good informed consent, there is no reason to prohibit or differently regulate remote treatment if both the adequately trained licensed psychologist and his/her client agree and all parties are within the Commonwealth. Not violating other laws, ie insurance
  48. 48. RISK MANAGEMENT Have a good working knowledge of ethics code and legal standards governing practice Conduct a conservative evaluation of your competence to perform  Intellectual competence  Technical competence  Emotional competence Keep your knowledge base up to date Avoid professional isolation
  49. 49. Three keys to Success Provide Comprehensive Informed Consent Seek Appropriate Consultation Develop good record-keeping practices and strategies DOCUMENT DOCUMENT DOCUMENT Eric Harris
  50. 50. APA/ASPPB/APAIT TF 1 COMPETENCE 2 MULTIPLE RELATIONSHIPS 3 INFORMED CONSENT 4 CONFIDENTIALITY AND PRIVACY 5 RECORD KEEPING/ BILLING 6 EDUCATION, SUPERVISION AND CE 7 ASSESSMENT AND TESTING 8 ACCESS TO CARE 9 STANDARDS OF CARE
  51. 51.  10 LEGAL ISSUES 11 INTERJURISDICTIONAL 12 INFORMATION COLLECTION, COMMUNICATION AND STORAGE 13 CONSULTATION AND I/0 14 ADVERTISING
  52. 52. WHAT ARE OTHERS DOING ACPRO IN CANADA AUSTRALIA ASPPB EU -EUROPSYC Other states
  53. 53. INFORMED CONSENT Just as you all use an informed consent with all your face to face patients, need one for telepsych: Limitations of confidentiality, privacy Interjurisdictional and other state laws Duty to report Tarisoff, Emeric or nothing Child Abuse Standards -no immunity Record keeping- what is part of the record, emails How will Emergencies be handled How available will you be to the patient Billing --90806 ? Payment-- paypal, insurance
  54. 54. COMPETENCE Before engaging in the remote delivery of mental health services via electronic means, practitioners should carefully access their competence to offer the particular services and consider the limitations of efficacy and effectiveness that may be a function of remote delivery. On Calif. Board’s website(Koocher)
  55. 55. Practical Competency Have you done internet therapy -confidentiality Why in this case- benefits vs. risk Type of Patient-diagnosis,age,condition,resources Patient wants to do it vs you want to do it Is there a difference with a patient who goes away for a month vs. a new patient vs. patient from website Is patient who they say they are, does it matter Emergencies how do you handle them-- ND position vs KY position vs. head in sand
  56. 56.  Entertaining? Is it like TV. boring? Avatars How much do you get from nonverbal cues Conditions which might change the medium Narcissism of psychologist Intervention you are competent to do Therapy vs assessment vs psychoeducational vs forensic
  57. 57. WEB THERAPY
  58. 58. Technological Competence Do you know how to use the internet, do you know what you don’t know Broad Band Width, asynchronis vs synchronis Confidentiality is anything confidential? Skype is not HIPAA compliant, sell info? When technical difficulties happen Skype vs. texting vs emailing vs videoconferencing How to secure records --encryption, back ups CLOUD in PC vs MAC?
  59. 59. Inter Jurisdictional 10th amendment-- state rights Different states adopt different regulations Licensing Boards are conservative by nature Need to protect the citizens of the jurisdiction, not concerned with citizens of other states since Board does not have jurisdiction(authority) in other state.
  60. 60. ISSUES Where does the electronic interstate transaction take place? a) where the consumer resides--distant b) where the psychologist is providing the services in the home office of the licensed jurisdiction-- home c) in cyberspace
  61. 61. Where the Practitioner Resides? Is physically located in a state where he/she is licensed. Reside or domicile? Psychologist has not set foot in the consumer’s state Psychologist has not attempted to do business there(traditional manner or internet). Psychologist can be regulated by the state where they are licensed or on interstate basis.
  62. 62. • Federal Government Policy: Health Licensing Board Report to Congress, HRSA, HHS, 2011 (HSRA) Federal government has recognized the importance of use of electronic technology and provision of telehealth services.  Federal Agencies Efforts to promote telehealth  Fed benefits for remote services Medicaid, Medicare  Interstate practice is essential for full benefits  Best way to accomplish this is by voluntary compact between state licensing boards
  63. 63. Health Licensing Board Report to Congress HRSA, HHS 2011 “ if collaboration between states is unable to develop effective licensure policies to reduce barriers to electronic practice across state lines within the next 18 months, then Congress should intervene to ensure Medicare and Medicaid beneficiaries are not denied the benefits of e-care.”
  64. 64. HRSA 2011 “ In the absence of specific agreements… states may not discipline healthcare providers not licensed in their state if patient harm occurs as the result of the provision of health care services by an out of state practitioner.”
  65. 65.  State licensing authority cannot interfere with the regulatory authority of the federal government such as interstate commerce or an effective military.  Military or VA Psychologists  Health Care is interstate commerce Anti Trust Cases Erisa v. state mandates Current dispute over health care
  66. 66. State Licensing Boards States have taken the position that the transaction takes place in forum state no matter where the patient resides.  California  Massachusetts  Wisconsin  Kentucky  North Dakota  Minnesota  Florida  Pennsylvania- temp 14 days
  67. 67. Minimal Contact Rule The state where the patient resides (the forum state) can assert jurisdiction over an out-of-state provider, only when that provider has made a purposeful attempt to promote or provide services in the forum state or has otherwise availed him/herself of the laws of the forum state to his/her advantage. Wright vs. Yackley (1972), 459 F. 2nd (United States Court of Appeals, Ninth Circuit, 1971) .
  68. 68. Prince v. Urban Three principles of decision  Was the doctor-patient relationship created because of a continuing effort of the doctors to provide services in California or was the location of the client incidental to the services?  Were the doctors services “grounded” in any relationship [they had] in California”?  Even if the above tests are met, the court needed to balance the state’s interest in securing good medical care for its citizens against the potential and severity of the anticipated harm.  Prince v. Urban (1996) 49 Cal.App.4th 1056 [57 Cal.Rptr.2d 181]
  69. 69.  The essence of the relationship was that the California patient sought out the Illinois doctors in Illinois. [The plaintiff’s] residence was irrelevant and incidental to the services rendered by her physicians. If anything [the plaintiff’s] residence hampered the doctor-patient relationship which existed despite the half continent of separation between the parties. A state’s dominant interest on behalf of its citizens in such a case as this is not that they should be free from injury by out-of-state doctors, but rather that they should be able to secure adequate medical services to meet their needs wherever they may go. In the case of personal services, focus must be on the place where the services are rendered, since this is the place of the patient’s need. They are directed to no place but to the needy person herself.
  70. 70. Tentative Conclusions by APAIT Unless a psychologist actively promotes services in an interstate manner, forum ( pt resides) state licensing boards will be unable to gain jurisdiction. What level of marketing is required to give a forum state jurisdiction is not yet clear. Websites are unlikely to be seen as promotional. Psychologists who actively market themselves on an interstate basis are taking risk. Extradition is very unlikely.
  71. 71. Other View Licensing Board could issue a cease and desist order and due to laws of comity have it enforced in another jurisdiction How lucky do you feel? Do you want to be the test case?
  72. 72. Hypotheticals Psychologist in PA, patient in PA Psych in NJ, patient in PA Psych in PA, patient in New Orleans, LA. Psych’s PA pt. on trip in Texas, call emergency Psych’s PA pt. now attending college at Michigan Psych’s PA pt. in winter in Florida Psych’s pt. on sabbatical in New Zealand Psych’s pt. in PA, psych in Florida or Psych’s pt is in Florida and psych is at meeting in Florida. Psych’s pt. at Michigan goes to Calif during
  73. 73.  Even though the distant( pt resides) jurisdiction might not have jurisdiction, home jurisdiction(where psych is licensed) could always bring action against your license
  74. 74. My Fantasy Registry for all who want to practice telepsych inter jurisdictionally. Benefit:  One license  Like military and VA  Lets states know who is practicing in the state  Protects the citizens of the distant state  Moving toward a similar standard across jurisdictions  Psych to provide services where they are needed
  75. 75.  Problems 1) need to know distant laws, PA v.TX 2) need to abide by stricter standards, records 3) emergencies 4) conflicts of law, child abuse
  76. 76. Confidentiality: Communications Voicemail  Websites  Email  Text Messaging  Social Networking  Facebook  MySpace  Blogging  Virtual worlds- 2nd Life Synchronous v Asynchronous
  77. 77. Clinical Communication Direct Care  Telepsych  Coaching  Assessment  I/O Consultation  Forensic
  78. 78. Administrative Billing; Insurance, credit or otherwise Scheduling Record Keeping and other documentation Information Storage and Transmission
  79. 79. Points to Consider Resolution and Picture Quality Real time Audio Reliability of technology Ease of Use Cost Differences from In Person Communication Privacy
  80. 80. SKYPE It is not HIPAA Compliant Sells information to others- confidentiality Public part of profile can be seen by others May respond to subpoenas NETSIS (web video conferencing) better than Skype but $$
  81. 81.  Public parts of your Skype profile can be seen by everyone else on Skype. Do not put details in your profile that you do not want to be publicly available. Except as provided below, Skype shall not sell, rent, trade or otherwise transfer any personal and/or traffic data or communications content to any third party without your explicit permission, unless it is obliged to do so under applicable laws or by order of the competent authorities.
  82. 82.  Skype may disclose personal information to respond to legal requirements, to protect Skype’s interests, to enforce our policies or to protect anyones rights, property, or safety. In order to provide you with Skype products you have requested, Skype may sometimes, if necessary, share your personal and traffic data with Skype’s group companies.
  83. 83. Voice Mail, Email, Texting Convenience and efficiency Duty to Care Alternative Backups WHAT ARE YOU RESPONSIBLE FOR?
  84. 84. Holmes v. Petrovich Gina Holmes sued her employer based on allegations of pregnancy disability discriminations. Holmes forwarded e-mails from her employer to her lawyer, and sent documents through the company’s fax machine.
  85. 85.  The Court reasoned that the e-mails sent through her company computer were “akin to consulting her lawyer in her employers conference room, in a loud voice, with the door open, yet unreasonably expecting that the conversation . . . would be privileged
  86. 86.  The Court emphasized that an email communication does not lose its privileged character solely because it is communicated by electronic means, or because persons involved in the delivery, facilitation, or storage of the electronic communication may have access to its content. While Holmes decision was largely impacted by the employer’s policies and employee’s awareness of those policies, a practitioner should assume that any communication through such devises may find itself in litigation.
  87. 87. Informed Consent with Patient Do not SMS or use social network site No Wall postings, @replies or other on line  Not secure,may have to be part of the record  You, patient and server, ie AOL and State of Virginia  All texting in Library of Congress  If need to contact me between sessions, call  DO NOT PUT ANYTHING IN AN EMAIL/TEXT/TWEET THAT YOU WOULD NOT PUT ON A POST CARD  Hush mail is may be a better choice
  88. 88. FACEBOOK Is constantly changing, hard to keep up with all the changes. Business page now can be post on a page. mashable.com/2011/09/28/newfacebook/
  89. 89.  Is friending a patient a multiple relationship? If you friend someone are friending all of their friends as well Avoid social networks with patients. No friending Relationship with patient and internet- pregnancy group therapy Limit emails to administrative,ie appointments Exchange clinical info only in secure manner.  Encryption or landline phone not VOI
  90. 90. Privacy “This Ethics Code applies only to psychologists activities that are part of their scientific, educational, or professional roles as psychologists .... These activities shall be distinguished from the purely private conduct of psychologists, which is not within the purview of the Ethics Code.” Ie, San Fran politics or student applying to grad school
  91. 91.  In the age of Google, the concept of privacy has changed. We all practice in small communities and need to figure out a strategy the maximizes protection of appropriate boundaries. A psychologist has a right to make his/her feelings about invasions of privacy known to his/her clients and this is an appropriate part of the professional conversation.
  92. 92. GOOGLED OR YELPED? How many of you think you patients have googled you? Patients will review sites and other means of electronic criticism, up to cyber attacks Do you respond?
  93. 93.  How many of you have googled a patient? Informed consent Do you have to let them know Difference in forensic cases BUT slippery slope … duty to warn
  94. 94. Security,Record Keeping and Storage Same applicability trigger: electronic transmission in covered transaction Applies only to electronically transmitted and stored PHI Provides a number of steps that each psychologist must take. Scalability for smaller practices More complicated for practitioners with employees
  95. 95.  Conduct a documented risk analysis which must be kept with other HIPAA compliance records. Modify your policies and procedures in order to achieve appropriate compliance. If scaled, document how it has complied with the requirements of the Security Rule. Periodically review risk analysis, policies and procedures and modify as necessary. Appoint someone who is responsible for security (Usually you).
  96. 96.  Develop specific policies for data access to all electronic devices that store data. (Scalable Issues)  Includes not only computers, but PDAs, cell phones and any other wireless device that stores data.  Require passwords that are unique & robust.  Fire walls and virus protection: up to date  Procedure for assigning/changing passwords for those entering practice and changing them when they leave.  Data separation capacity so individuals only have access to the information that is necessary for their responsibilities.
  97. 97.  Train all employees in the Security Rule. Have policies for dealing with security breaches including specific sanctions in personnel policies for employee/IC breaches. Written plan for dealing with emergencies
  98. 98.  Have appropriate facility access controls  Only staff should be able to reach place where EPHI is stored.  Specific rules about removing EPHI from the premises and be conservative. Proof of Client Identity
  99. 99. 2007 APA Recording Keeping Guidelines Electronic records, like paper records, should be created and maintained in a way that is designed to protect their security, integrity, confidentiality, and appropriate access, as well as their compliance with applicable legal and ethical requirements
  100. 100. PA PSYCH REGULATIONS Section 41.57(c) A psychologist shall store and dispose of written, electronic and other records in a manner which insures their confidentiality. 41.57(e)  A psychologist shall provide for the confidential disposition of records in the event of the psychologist’s withdrawal from practice, incapacity or death.
  101. 101. Onsite Back Up External Hard Drive Flash Drives Back up Drives  Tape  Flash Memory  Paper
  102. 102. Off Site Storage http://www.carbonite.com/ http://www.mozy.com/ http://www.backblaze.com/ http://www.crashplan.com/ http://go.iomega.com/en-us/?partner=4760 http://www.ironmountain.com/
  103. 103. ENCRYPTION Stanford Hospital $20M Class Action Law for data breach involving 20,000 patients(San Jose Mercury News) 4.9M Tricare Patients Data Breach: name, Diagnosis, SS#, Address, treatment Info, ect.(San Antonio Express) 14,000 Patient Data Breach: Unencrypted Names, Diagnosis, DOB, Addresses, SS# ect (Minneapolis Pioneer Press) These just in last three weeks
  104. 104. What is Encryption Definition: Encryption is the conversion of data into a form, called a hypertext that cannot be easily understood by unauthorized people. A cipher, often incorrectly called a code, can be employed to keep others from obtaining the contents of transmissions. In order to easily recover the contents of an encrypted signal, the correct decryption key required.
  105. 105. Do You Need Encryption? If you don’t encrypt and there is a breach, you must inform your clients. Unencrypted data breach is more likely to damage relationship with your clients Clients may then want identity theft protection and may want you to pay for it. If clients are harmed, they can probably sue or file licensing boards complaints. If your computer has more than 500 files, you have to inform the media.
  106. 106.  TrueCrypt (http://www.truecrypt.org/) BestCrypt Enterprise ( http://www.jetico.com/data-protection-encryption ) PGP Whole Disk Encryption ( http://www.symantec.com/index.jsp)
  107. 107. MOBILITY AND PORTIBILITY
  108. 108. PASS RATE ON EPPP Doctoral degree first-time takers: 83% APA/CPA accredited graduates: 78% NON APA/CPA graduates: 53% APA/CPA/APPIC internship: 80% No APA/CPA accredited/APPIC: 54% My impression for the last 12 years in PA are similar to the national numbers
  109. 109.  For those already licensed/registered with no disciplinary sanctions Mechanisms to facilitate mobility:  Certificate of Professional Qualification  Reciprocity Agreement  Mutual Recognition Agreement Interview and jurisprudence exam may be required
  110. 110.  Most new practitioners will relocate at least once in their career Slight variations in registration and licensure requirements can become huge obstacles later Documenting supervised experience, course content, etc. becomes more difficult over time Licensing/registration boards can not accept personal copies of documents because of possible fraud Training programs, internship sites close, supervisors and their records disappear
  111. 111. Certificate of professional Qualification (CPQ) Program of ASPPB Individual must meet requirements for CPQ Includes credentials bank feature Low cost to obtain & maintain
  112. 112.  Accepted by 44 jurisdictions in Canada & United States 3 more jurisdictions in the process of accepting the CPQ for licensure 8 more jurisdictions recognize the CPQ for licensure
  113. 113. Accepting CPQ Jurisdictions in Canada: all 10 provinces Jurisdictions in the United States: AZ, AR, CA, CO, CT, DE, DC, GA, HI, ID, KY, LA, ME, MI, MS, MO, ND, NV, NE, NH, NM, NC, OH, OK, OR, PA, RI, SC, UT, VT, VA, WV, WI, WY
  114. 114.  These jurisdictions have “voted” to accept CPQ, and are in process of making legislative or administrative changes for implementation. US  AK, MN, SD, Canada
  115. 115. Recognize CPQ These jurisdictions may waive at least one requirement for applications who hold a CPQ. US  IA, MD, MA, MT, NJ, TN, WA
  116. 116. Not Accepting CPQ US  NY, FL, AL, IN, IL, KS, PR, VI, GU
  117. 117. ASPPB Agreement of Reciprocity 11 jurisdictions (2 provinces, 9 states) Jurisdiction must meet requirements of Agreement to participate Psychologist licensed with no disciplinary sanctions in one participating jurisdiction may seek registration/licensure in another participating jurisdiction
  118. 118.  Jurisdictions in Canada MB, ON Jurisdictions in the United States AR, KY, MO, MS, NV, NH, OK, TX, WI
  119. 119. Interjurisdictional Practice Certificate (IPC) Accept IPC  Idaho  Georgia  South Carolina  Kentucky  Ohio
  120. 120. National Register The National Register credential is approved or in process of approval in 46 jurisdictions in the US and Canada. The National Register has helped more than 1,300 of our credentialed psychologists easily and quickly apply for licensure in another jurisdiction. BUT must look at each jurisdiction to see what is waived
  121. 121. ABPP
  122. 122. THANK YOU. ASIEGEL@ASPPB.ORG 610 668 4240 in Narberth, PA Pa Licensing Board  ST-PSYCHOLOGY@PA.GOV  717 783 7155(P)  717 787 7769(F)  STATE BOARD OF PSYCHOLOGY  PO BOX 2649  HARRISBURG, PA 17105-2649
  1. A particular slide catching your eye?

    Clipping is a handy way to collect important slides you want to go back to later.

×