This document provides an introduction to telemental health, including definitions of key terms, a brief history, efficacy research findings, opportunities and challenges, best practices, and legal/ethical considerations. The agenda covers synchronous and asynchronous communication, opportunities and challenges of telemental health, familiarity with the practice, and understanding ethical and legal issues. Case vignettes are also presented and discussed.

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Into the Great Wide Open
Introduction to Telemental Health
Aaron George, LMSW, CAADC
October 9, 2019

3. Disclosures
There are no disclosures to report.
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Agenda
1. Define synchronous and asynchronous communication
2. Explore opportunities and challenges presented by telemental health
3. Increase familiarity with telemental health practice
4. Increase understanding of ethical and legal issues of telemental health

6. Telemedicine Definition
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“Telemedicine is the use of telecommunication technology to connect a
patient with a health care professional in a different location” (Center for
Connected Health Policy, 2019).

7. Efficacy
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Telemental health care can provide effective and adaptable solutions to
the care of mental illnesses universally. While being comparable to in-
person services, telemental health care is particularly advantageous
and inexpensive through the use of current technologies and adaptable
designs, especially in isolated communities (Langarizadeh et al., 2017).

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Telemental health is effective for diagnosis and assessment across
many populations (adult, child, geriatric, and ethnic) and for disorders in
many settings (emergency, home health) and appears to be
comparable to in-person care. In addition, this review has identified
new models of care (i.e., asynchronous, mobile) with equally positive
outcomes (Hilty, et al., 2013).
Efficacy, Continued

9. Brief Timeline of Telemedicine
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1906 – William Einthoven used telephone wires to record electrical
cardiac signals of patients in a hospital 1 ½ km away.
1920 – Norwegian doctors provided medical advice to ill ship crew
members at sea via radio link.
1967 – Audiovisual microwave circuit was established between
Massachusetts General Hospital doctors and ill employees and
travelers at Logan Airport.

10. Brief Timeline of Telemedicine
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1970s-early 2000s – Many countries launched their own e-health
programs, combining medical informatics, public health, and
business (Strehle & Shabde, 2006).

11. Telehealth Expansion
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▪ American Reinvestment and Recovery Act of 2009 devoted $19.2
billion for implementation of Electronic Medical Records
▪ Healthcare providers had until 2014 to convert to EHRs
▪ Must demonstrate meaningful use:
▪ a certified EHR that serves to improve health quality
▪ Improve health safety
▪ Improve health delivery efficiency
▪ Reduce disparities in health care
▪ Advance coordination of medical care
▪ Secure & keep private information contained in the patient’s EMR

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Synchronous Communication
Real-time communication between two people.
▪ Face-to-face
▪ Phone
▪ Skype
▪ Facetime

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Asynchronous Communication
Exchange of messages by reading and responding as schedules permit
rather than according to a clock that is synchronized between sender and
user in real-time.
▪ Texting
▪ Email
▪ Social media messaging/posts

14. Advantages of Telemental Health
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▪ Increases access to care for people in remote areas
▪ Convenient and affordable
▪ Accessible for people with health problems
▪ See and assess patient in real-time: Mood, affect, speech, thinking,
grooming/hygiene, eye contact, etc. (with synchronous
communication)

15. Disadvantages
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▪ Not covered by many insurances
▪ Out of state providers not allowed by some states
▪ Privacy, confidentiality concerns, security breaches and hacks
▪ Technical glitches
▪ Crisis intervention more difficult

16. Best-Practices in Video-Based Telemental Health
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▪ Roles, responsibilities (i.e., daytime and after-hours coverage),
communication, and procedures around emergency issues.
▪ Agreements to assure licensing, credentialing, training, and
authentication of practitioners as well as identity authentication of
patients according to local, state, and national requirements.
▪ A systematic quality improvement and performance management
process that complies with any organizational, regulatory, or
accrediting, requirements for outcomes management.

17. Best Practices, Continued
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▪ Patient-Provider Identification: All persons at both sites of the
videoconference shall be identified to all participants at the
beginning of a telemental health session. Permission from the
patient should not be required if safety concerns mandate the
presence of another individual or if the patient is being legally
detained.

18. Best Practices, Continued
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▪ At the beginning of a video-based mental health treatment with a
patient, the following information shall be verified and documented:
The name and credentials of the provider and the name of the
patient. The location(s) of the patient during the session.
Immediate contact information for both provider and patient (phone,
text message, or email), and contact information for other relevant
support people, both professional and family.

19. Best Practices, Continued
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▪ Expectations about contact between sessions shall be discussed
and verified with the patient, including a discussion of emergency
management between sessions (American Psychiatric Association,
2018).

20. Michigan Law
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▪ Michigan Medicaid reimburses for live video telemedicine for certain
healthcare professionals, for patients located at certain originating
sites for specific services (Center for Connected Health Policy,
2019).
▪ Telemedicine services must be provided by a health care
professional who is licensed, registered or otherwise authorized to
engage in his or her health care profession in the state where the
patient is located (Department of Community Health, Medicaid
Provider Manual, p. 514, 2019).

21. Michigan Law, Continued
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Behavioral health therapy: Must be fully licensed in MI or be a
practitioner who holds a limited license and is under the direction of
a licensed psychologist (Department of Community Health,
Medicaid Provider Manual, p. 514, 2019).

22. Educate Patients on What to Expect
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▪ Introduce patient to the technology before the visit
▪ Explain the process of conducting a telemed visit
▪ If possible contact patient 30 minutes prior to start of session on the
first visit

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Patient Education

24. Legal and Ethical Considerations
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How do we ensure the platform/EHR is HIPAA-compliant?
1. Look for HIPAA-compliant seal
2. Sign a Business Associate’s Agreement:
A contract, generally required by HIPAA, that ensures that the
business associate will appropriately safeguard protected health
information (adapted from HHS.gov, 2013).
3. “End-to-end encryption,” “banking-grade security”
4. SSL encryption

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(Green House Data, 2019)

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(ShareSecurely.com, 2019)(Divvycloud.com, 2019)

27. Ensure HIPAA-compliance on our end
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▪ No texting or emailing with patients
▪ Screen lock/log-off your computer/devices while away
▪ Use passwords and change them periodically
▪ No communication with patients in public places
▪ No use of public wifi networks while accessing PHI
▪ Conduct video/virtual visits from private, secure space
▪ 360-degree scan of room

28. Interjurisdictional Considerations
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Definition: Across state or country (boundary lines).
Relevant in situations where the patient and the practitioner are not in
the same state or even the same country.
Concerns whether the practitioner in State A can treat the patient in
State B when the two are in different states and the practitioner is not
licensed in the state where the patient is located.

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“Remarkably, no two states are alike in how telehealth is treated
despite some similarities in the language used. For example, some
states have incorporated telehealth-related policies into law, while other
states address issues in their Medicaid program guidelines. In some
cases, CCHP discovered policy inconsistencies within a single state.
This variability creates a confusing environment for those who use (or
intend to use) telehealth, especially health systems that provide health
care services in several states” (Center for Connected Health Policy,
2018).
“Fifty States, Fifty Approaches”

30. Pending Legislation Nationally
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(Center for Connected Health Policy, 2019)

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(Center for Connected Health Policy, 2019)
Pending Legislation - Michigan

32. Vignette 1
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A new patient is scheduled for an intake teletherapy session. The
problem list in the chart reads “Suicidal” with no further information.
How might you proceed?
▪ Contact the referral source to gather more information
▪ Attempt to schedule the patient in-person for the first visit
▪ Engage in safety planning with the patient the first session
▪ Obtain current location (address) and contact (phone) information,
including information of support people
▪ Assess whether the person is appropriate for teletherapy going
forward

33. Vignette 2
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A patient you’ve been seeing in-person is moving to Ohio but wants to
continue seeing you via telehealth. What factors should you consider?
▪ Is the patient appropriate for telemedicine?
▪ What is the patient’s insurance?
▪ Are you licensed in the state he is moving to?
▪ Provide resources for in-person or telehealth providers in his new
area

34. Vignette 3
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An elder, established patient who is benefiting from therapy wants to
continue but can no longer consistently attend in-person visits due to
her physical health. You practice teletherapy, but she reminds you of an
older relative who is not very tech savvy. How can you problem-solve
her access to treatment issue?
▪ Don’t assume! Briefly explain the service and see if she’s interested
▪ If interested, explain the process to her in detail, including potential
benefits and risks
▪ Ensure understanding
▪ Schedule the patient for teletherapy if appropriate

35. Vignette 4
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When you join a video session, you see that the patient is outside
in her yard and wants to conduct the session there. Do you
proceed with the session?
NO!!!

36. Telemental Health Legal/Interjurisdictional Resources
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Office of the National Coordinator for Health Information Technology
https://www.healthit.gov/
Center for Connected Health Policy: The National telehealth Policy
Resource Center
https://www.cchpca.org/telehealth-policy/state-telehealth-laws-and-
reimbursement-policies-report
National Consortium of Telehealth Resource Centers
https://www.telehealthresourcecenter.org/updated-redesigned-fall-
2018-edition-of-the-50-state-telehealth-laws-and-reimbursement-
policies-report/

37. Questions???
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38. References
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American Psychiatric Association. (2018). Best practices in
videoconferencing-based telemental health. Retrieved from
https://psychiatry.org/File Library/Psychiatrists/Practice/Telepsyc
hiatry/APA-ATA-Best-Practices-in-Videoconferencing-Based-
Telemental-Health.org
Center for Connected Health Policy: The National Telehealth
Policy Resource Center. (2019). Legislation and regulation tracking.
Retrieved from https://www.cchpca.org/telehealth-policy/legislation-
and-regulation-truacking?utm_source=Telehealth=Enthusiasts&utm
_campaign=393d1a27d8-EMAIL_CAMPAIGN_2018_10_23_04_07
&utm_medium=email&utm_term=0_ae00b0e89a-393d1a27d8-3532
23937

39. References, continued
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Center for Connected Health Policy: The National Telehealth
Policy Resource Center. (2019). State telehealth and
reimbursement policies report. Retrieved from
https://www.cchpca.org/telehealth-policy/state-telehealth-laws-
and-reimbursement-policies-report.
[Digital Seminar] Legal and Ethical Issues with Technology in
Mental Health, PESI, Joni Gilbertson, MA, NCC, LCPC, 2018.
Divvycloud.com. (2019). Retrieved from http://www.divvycloud.com/
product/compliance/hipaa-compliant-logo/

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Green House Data. (2019). Epic systems healthcare hosting. Retrieved
from https://www.greenhousedata.com/application-
hosting/enterprise/epic-systems-healthcare-hosting
HealthIT.gov. (2019). News and updates. Retrieved from
https://www.healthit.gov
HHS.gov. (2013). Business associate contracts. Retrieved from
https://www.hhs.gov/hipaa/for-professionals/covered-
entities/sample-business-associate-agreement-provisions/index.html
References, continued

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Hilty D, Ferrer D, Parish MB, Johnston B, Callahan ED, Yellowlees PM.
The effectiveness of telemental health: A 2013 review. Telemedicine
Journal and E-Health. 2013; 19(4): 444-454.
IGI Global. (2019). What is synchronous communication. Retrieved
from https://www.igi-global.com/dictionary/synchronous-
communication/28968
Kids React! Technology. (2014). Rotary phones. Retrieved from
https://www.youtube.com/watch?v=XkuirEweZvM
References, continued

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Langarizadeh M, Tabatabaei K, Tavakol K, Rostami A, Naghipour M,
Moghbeli F. Telemental health care, an effective alternative to
conventional mental care: A systematic review. ACTA Informatica
Medica. 2017; 25(4): 240-246.
Langarizadeh M, Moghbeli F, Aliabadi A. Application of ethics for
providing telemental health services and information technology.
Medical Archives. 2017; 71(5): 351-355.
MedCity News. (2014). EMR and the American Recovery and
Reinvestment Act of 2009. Retrieved from
https://medcitynews.com/2014/03/emr-ehr_arra-2009/?rf=1
References, continued

43. References, continued
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MedNow. Spectrum Health. (2019). Meetings I hosted. Retrieved from
https://telehealth.webex.com/webappng/sites/telehealth/
insight/home
Michigan Department of Community Health. Medicaid provider
manual. 2017; 514.
ShareSecure. (2019). Retrieved from https://www.google.com/search?q
=ssl+256+encryption&safe=strict&source=lnms&tbm=isch&sa=X&ve
d=oahUKEwiqm6fTsHkAhUMPKOKHYKUDGgQ_AUIEygC&biw=15
36&bih=755#imgrc=JSbE1TSbJoTy7M:

44. References, continued
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Strehle, E M and Shabde, N. One hundred years of telemedicine:
Does this new technology have a place in paediatrics? Archives
of Disease in Childhood. 2006 Dec; 91(12): 956–959.
The Linus Information Project. (2005). Asynchronous communicaton
definition. Retrieved from http:www.linfo.org/asynchronous.html
Very Well Mind. (20). Advantages and disadvantages of online
therapy. Retrieved from https://www.verywellmind.com/advantages-
and-disadvantages-of-online-therapy-2795225