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ICA Conference 2014: Legal & Ethical Strategies for Successful Distance Counseling


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ICA Conference 2014: Legal & Ethical Strategies for Successful Distance Counseling

  1. 1. K 'l¥.5.4'. “"‘, '5“’_e"; i‘*_‘-’-‘_—’I*iE"" ’<, =If= ’Ii'i: _rllliiI. ‘_-'i'a3' ‘« I-'l»'ri~'L'= Legal & Ethical Strategies for Successful Distance Counseling IDAHO COUNSELING ASSOCIATION
  2. 2. Tfl wrwrm. HEALTH I H i Y I U T I, teleheaIth. org Learning Objectives ° 1. Describe 3 ethical dilemmas related to Skype, Google and Facebook, blogging and the ethical codes that help practitioners think through those dilemmas. ° 2. Discuss the legal issues related to practicing over state lines or international borders, HIPAA and informed consent when practicing online. ° 3. Outline 3 key elements of a risk management plan for working online with clients to deliver care.
  3. 3. Tfl rurwrm. HEALTH I H i Y I U T I, teleheaIth. org Disclaimer I am an MFT and clinical psychologist, not an attorney, physician or Information Technology specialist. The information I present is my best attempt to bring you timely and relevant information in a rapidly evolving area. I therefore make no warranty, guarantee, or representation as to the accuracy or sufficiency of the information contained in my training. My goal is educational only. I seekto outline the issues and alert you to what's happening, including legal. ethical and other risk management issues. You are encouraged to seek specific advice related to your circumstancefrom your qualified authorities. D2014 TEIEHEMJI Hailifl manna. Inc
  4. 4. - — —~A~—— —« -. .—_—‘-_—. ».—‘—_—_. .‘; ‘i I Housekeeping Schedule Restrooms Questions WiFi Twitter @ica ' = ':'! a=»f, ’ ’*— w ’ ‘”~: ?»—: :”"'-E-. "’. #:_= s.-. ,3 w. I .4 Pl r~ , ’ is ~ 02014 meuemzi mam insrmite, mg I
  5. 5. III. I ' , _ . ..' . ? . _ ,2’! What's going on? T 6 Technology a Health Care Reform -9 Distance Counseling I ll «'- IT . II’ ozou meuemzi mam msmme, inc. I
  6. 6. Our planet is re-tooling - .4, «Q» , j.. /?~* I I / .;= ' I . ~ S I/ ,; asis ‘aj"’a¢ X,2-_/ 5v_, k/_v»! I_; g.. V. y_ V I psychology
  7. 7. ' THEMFNT/ ll. HFALTH ((( l N V; 1 I U T F I telehealtrnorg Real-Time Telemedicine Remote dOCtO1.eXalmneS 3 Patient l111'L11'al ER gets benefit patients inner ear from a remote Qt 10°31 CW3 P133 1'em°_te _ location coiisultatioii with specialists. 0 2011 Tllellemil Health lnsnfle. Inc.
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  9. 9. ( i5.’'. ''‘_*'‘‘. I;'‘‘. ‘;l'‘’§'f_ ‘I a, -.ii: m=r: Il_i’n. ‘_ora. ~ Distance Counseling & Other Services
  10. 10. VIRTUALLY B THE CLINIC Bringing lnleraclive Technology to Be avioral Heallhcare for Treatment and Training News Avatars May Help Children With Social Anxiely T)'1E7f'(fll9 fears 4 till I . /ii1Li. il reality tmnles Pl SI) The Daily I IIEJIIIILI lenr of flying I. -/illi '4 I’) ‘-iIl| llIdI(. )I"- University of Alabama adds VR Exposure to School of Social Work Eiama Piol A‘-m. Tia. lor isn i .3 new»': cimer to using ‘. ‘R in 5-Iicial won and C9I‘l3.‘lOl'EI health 3 e s :9-: -n worrrng . -.IIn ‘(El colleagues lire PSIIICI" EiI: vrdnIr: b' and former CEO hen Grasp tor Iear-5 30 ‘. ‘BI IS pic-ur1iov: onlir. mthai we -VIII be I3-3Il‘. ‘€I| |'lD 3 3.519-rn to 5-. I3D3FT1.3lO(USC‘lI'lII‘I|3 School of Social ‘-'-‘DIV CNECI" CIUI Il'I€ GEIEIIS l‘l£'! E VR based Treatments get "Exposure" on Fox 5 viituall. Better welcomed Nista Litil-Jlielc lI0."l -'-llama 5 For 5 news last week for .3 feature on VR case»: treatments Tnanrs lxnstal Atlanta News -. ‘.‘ealner Traffic and Sports I Fox : PRODUCTS COMPANY ADHD: Not just a school problem. Dimculnes wllh locus '3ieI3Cll'u1I‘r l'Y'lDlJISIv‘é' '5-I-T'v3.‘lC/ TS annincr-: -ssed em: -banal r-2acir. it~. are >: cI'~Irnon SrI'T'l[JI’. ‘VT1S ol ~‘<lIET‘lllOl'l Cl*3llC1I. l'I“IiD€l3ClIIiIv Disorder Ii~DHDI These and other +‘-DHD 3v"lDl0f! l$ can usreai l'l.3‘-DC in -school However School -grades and : I>2I'l3I/ IDIS are noting -uni, areas Il'I1CZiCl€'G andthei are often not even me most negaii-rel, effected Childreri with lI‘il5 disorder are also "wore lirel. to Suffer tram speech
  11. 11. Reviews News Download CNET TV How To Deals 1‘ Log In I Join SAMSUNG The Next Big Thing For Business Is Here - 3 "T A ‘ @un '", llE'i H-'_'»I. 'S L" :3‘. -; SAMSUNG Confirmed: Google Glass arrives me lJe>_<t Big Thing in 2013, and under $1,500 f; O,; §,F§"‘eSS Google s at; gi~>enteci—realitj. ~ soecs are ahead of scrwecluse Are _, ‘OU ready. ‘ ‘ _ f _; a ‘A . ... . 3 to get , .~o-arselt nttec or a se: i» En: Ma-: ‘r. i ‘ ’fi KW _:3 fl lollow 9" fl ‘ '" “ 3 ’ T~'1W~" * ' ' ' 3 3=”“““"‘l? 93 Hottest Rei'ie'. '.‘s ‘ iPhone 5, Finally. everything we r hoped it would be ¢-—- . ‘“«'~ —x’ ' mi: ~ M 5139 99 7 5 ~: «~x~A«~: r ' r i Microsoft Surface Pro Smart _ almoslrlaptop nearly nails it [ ( v Iflrl m, l SSE»-3 99 iriokvi ‘ - - Cliroinebook Pixel Bnlliaiit touch Possibly the 'mu5t—have' gadget lor the 2013 holiday season (Click the image lot a Google Glass slideshow) . ‘ . screen. hefty pnce (Credit Google) " F . . Regular people will be able to purchase Google Glass eyewear by the end of 2013 for less than 31,500 sources have confirmed to CNET . I HIC One wows with stunning & design, premium parts Google originally targeted Elill -l for a consumer release when it revealed Proiect Glass last year,
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  13. 13. <(( 'rE‘L§MH, nA¥HF, N_TH te| ehealth. org 69% I PerVsona_l Robots Group mil media lab i , i Home Welcome to the Personal Robots Group K“) , -
  14. 14. “S I M O The Wood 5 Most Advanced Hu'78DOId Robot Asimo - PEWS EDUCATDN v YRAVELS PSIMO W U GALLERY DOWNLOADS ASIMO IS DESIGNED TO HELP PEOPLE : i c Q i turnwundofltll) UVE SHOW FEATURING GALLERY '-igri O-Juicy Photos of I-SWO r an M DOWNLOADS O1f. u:ia= ASWO C0-'1r'. |c5¢s! cryr. ‘u. 't. taC PC or tNl(‘/ A ‘ I Vilil-1) ms rim ’"‘°"‘”"°”° TRAVELS Now you can see ASIMO See how robots r- Check out rtonda 5 Molly Criect out a veto HSXMY of ye”: C, ‘SRO 5 “Mn Am€_, mn 70“ “pm” K, ms duty at Dsneyianoa develoorrierii now can bring prototypes eriioowered wtn Honda‘: robotics resear. -,n : __m_mm! out the best n us n ttie nature ASi! .!O-denied technoiogy HONDA ‘lIufiwua&Ivn
  15. 15. Electronic Health Records
  16. 16. OCPM: Online Clinical Practice Management Ste 1: Trainin Step 2: Referrals Step 3: Patient Education Step 4: Legalities Step 5: Assessment Step 6: Direct Care Step 7: Reimbursement
  17. 17. TELEMENTAL HEALTH ((( ‘ teIehealth. org . I N S I I I U I E Telehealth vs. Distance Counseling (working model notto scale) Telehealth Regional Professions Information Education Sharing Behavioral Telehealth Disciplines, including Consumer Administration Distance Counseling, Training 8‘ managementfl Supervision Evaluation Research Homeland Security | 0 mt: ‘rtieueini Hum inmle. IIE.
  18. 18. __, . _ i . __ H %'%: a,% What are the Current Models for Distance Services :1“; in Counseling and Other -‘e E) Disciplines? "it at - E E E . . E E. yr _ -. _ : ,_'_. .___ , _ _ . j _. .._. _a ‘C *3» L“r‘’'‘"‘'‘ * m ’ s': "—‘“§, " ozim meuenizi mam lnmtute. int; i
  19. 19. 2 § iii. illfil iii telehealthora ‘ mu Iioivcxtn V Srvtr. ~: :-A; -rrr “(Ky :14 ‘n H; cry‘ 2 {('7"iu7‘ : a' : .~ c. <-r: v~<: u'<~; v.s vex: -:. r're ‘<5! i. rl-a cl‘. :t"'w2‘J! !i < . -we ~imc‘: s--e : 'F' tag, » i -eehmcis T"ie'a: wi BET DA’ :3 E». 'e- : ‘ Jeri st"-st er: -F-: ci. se~: We! ca" «-1- n ‘P no cm . i 1': Ne: fan: ac lbw’; w: . "' : i.. i:-ta sridtri es MQHKIIO ' ‘ . tJIl't'5 ~s. I itr-Mrdi . - see: a aim; m use ‘LE5 . s- aw and Gene . i: -uv - 42- '¢ M”: -r D". '.it . e uca-‘J1 rd :1; wt. ‘ 7': Rt-Inn tic res em ‘or 1-1‘ M 99:. re:
  20. 20. "1=Il= ‘li>i= _?‘3,| liiL‘{V_"l"LI': " in‘»'. r,, ')u: ~ Traditional Behavioral Telehealth Model
  21. 21. THFMFNT/ ll HEALTH ((( I , Y K ‘ _ , teleheaIth. org . F. ‘ ‘— l I Traditional Behavioral Telehealth Model ° Hub-and—spoke model — Only work with previously identified clients/ patients who have had an in—person assessment — Detailed and documented referral requests — Detailed health record at fingertips of clinician — Client/ patient is at the ”originating site" — Clinician is at the ”distant” site — Community collaborator is available ° Client/ patient is pre-trained by staff - Technology is stable — IT staff is available during entire time of connection to client/ patient
  22. 22. ((( TE’. f‘. "if P‘-lTAl llffxl Til telehealthlorg Online Norm vs. Traditional Behavioral Telehealth (or Telemental Health) Traditional Online Therapy Traditional Behavioral Telehealth - Mostly Email & Chat ° Video ° Anonymity ° Verify clients/ patients ° Accept self-referral online - Rely on referrals from clinical 0 Disclaim Responsibility w/ Office-‘5 Website Disclaimers - Use informed consent . No clear Channels for processes/ documentation Mandated Reporting ° Engage in mandated reporting ° No Patient Records ° Document as required by law
  23. 23. rir-. irrm. i um Tl ((( t’ N : ‘ _l_ ' telehea| th. org Online Norm vs. Traditional Behavioral Telehealth (or Telemental Health) Traditional Online Therapy No Contact with Other Treating Clinicians No Authentication of Consumer / Professional No Emergency Backup Procedures Misunderstanding of Clinical Processes (suicide) Scant Research for Unsupervised Settings Traditional Telemental Health Obtain signed releases and collaborate Verify identify of both Consumer and Professional Establish emergency backup plan and personnel prior to delivering care
  24. 24. OCPM: Online Clinical Practice Management What's happening? . 7 0 2014 Telauemal Helm Insmtla. In:
  25. 25. m wrmm llf um ((( teleheaIth. org l? .‘3lli Disruptive Technology Disruptive technology is a term coined by Harvard Business School professor Clayton M. Christensen to describe a new technology that unexpectedly displaces an established technology. Be“)! Frieda" Gloria Steinman 0 1963 book The Feminine ° Sought to transform society MLSTLGE ° Sought to have women be accepted in existing world 0 21114 Telauemzl Health Insmna. Im:
  26. 26. ‘(, =Il= ’li'i= ,'t'llli'il. '_-'1" : Society for Technology & Behavioral Health COMMUMCATIOI-I St Practice ‘°", '.‘_. ’E”, .‘j'; ;;§. §§’°"‘ Science a‘e. g.. Internet, Blogging. Social media, Cvbemetics : e.g. . Biosensings‘ Fee<lI: ad: ,So¢ial netwarltingl COMPUTING ll. '.ETHODOLOGIES i‘e. g.. Artificial Intelligence; TELEEOWW U“: _», m0,_5 I-Iatural Lang. Processing; Robotics; User Computer lnter1ace: [e. g., Cumputer ’isionTracling. Haptic Interfaces} Computer Simulations [e. g.. /irtual Human Agents. " 'atars 3 Environments’; In“ l‘ “kin 1.: hlicrocomputers; 3D lmaging, _ Software [e. g.. ."ideo Games: l| I|_all'. u|t: MIt*: Ifl'. in A rimvllrznir In Education Public Interest HEALTH lT& INFORMATICS ie. g.. Big Data; Contmlled Vocab: [e. g.. ICE‘-10:; Decision '“3l<i"€ -~ 5UPP°"£ D3“ OTHERTECHNOLOGIES Mining; Electronic Health and . Personal Health Records; 'e"ir": ;:'ceh‘I: ‘:I: ';yg" Electronic | ZIataPri an. ‘ . . ' Security 2l'I(HmEgI'lYV: HE3nl1 "a"°mEdm"B" Information Exchange, HITEIZH; Information Storage 3. Retrieval; Interoperability
  27. 27. Tfl FMFNTAI IIFAITH ((( V , teleheaIth. org l? .“1l -. ,li'i Benefits of Traditional Video-Based Telehea| th* - Increased client satisfaction ° Decreased travel time ° Decreased travel, child & elder-care costs ° Increased access to underserved populations 0 Improved accessibility to specialists ° Reduced emergency care costs ° Faster decision—making time ° Increased productivity / decreased lost wages ° Improved operational efficiency ° Maheu, Pulier, Wilhelm, McMenamin & Broxr-/ n—(onnolly. (2004). The mental health professional and the new technologies. Erlbaum, New York. 0 2014 Telemental Health Insmue. In:
  28. 28. "F‘lf'v‘E$TA{HF, m>TH telehealth. org The is Video Teleconferencing (VTC) Effective? ° Yes — Medicare & Medicaid required to pay ° 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. te| ehea| th. ORG/ bibliography ° BUT, traditional VTC isn't the same as Skype
  29. 29. Tri FMTNTAI IIFAITH ((( teleheaIth. org l? .‘3ll, lTi Recent Supporting Research ° Godleski, Darkins & Peters reported in April of 2012 that hospital utilization in psychiatric populations at the Veterans Administration were decreased by an average of 25% since the use of telehealth. It is worthy of note, however, that: — This study focused on clinic—based, high—speed videoconferencing and did not include any home telehealth encounters. Mental health patients were referred for telecare by clinicians. Typically, telemental health services were provided remotely at community—based outpatient clinics by mental health providers of all disciplines located at larger parent VA hospital facilities. Equipment consisted of either room or personal desktop videoconferencing units transmitting at 384 kbps or greater. Godleski, L. Darkins, A. & Peters, J. Outcomes of 98,609 U8. Department of Veterans Affairs patients enrolled in telemental health services, 2006-2010. Psychiatric Servcies, 63(4). 383-385. i O 2014 Telemental Heami Insmue. Inc
  30. 30. Tri FMTNTAI IIFAITH ((( teleheaIth. org l? .‘3ll, lTi Recent Supporting Research Backhaus and colleagues (May, 2012) reported in their abstract of a meta-analysis that: ° 821 potential articles were identified, and 65 were selected for inclusion. - The results indicate that VCP is feasible, has been used in a variety of therapeutic formats and with diverse populations, is generally associated with good user satisfaction, and is found to have similar clinical outcomes to traditional face-to-face psychotherapy. — Videoconferencing psychotherapy: A systematic review. Backhaus, Autumn; Agha, Zia; Maglione, Melissa L. ; Repp, Andrea; Ross, Bridgett; Zuest, Danielle; Rice~Thorp, Natalie M. ; Lohr, James; Thorp, Steven R. Psychological Services, Vol 9(2), May 2012,111-131. doi:10.1037[a0O27924 I O 2014 Telemental Heami Insmue. Inc
  31. 31. gm (“U M telehealtnorg lnrunzm . n. ¢~nn nol—Iu 120! In R(’. '(’lIl' ' .7 . ‘1I'fi('](’ SYNC] IRO. 'Ol'S TE Ll-II IFALTI I T .1 l. '()I. O(jl PSYCI l()'l"l II-iR. »l’Y I-‘OR DF. PRl£SSl(). ': .lF. 'l‘. »—. A. .-I. 'SlS Vlunlr lr lkrututli I‘)! l) _‘ Kairn I t| 'Rrwn. Ph D _ InIl|4'IA | |hllfn, ‘ Hi I) _ m. I Den-l I 'nml: -nxii. I’? ! I). l I'll Bark nd: Man flliflfl 1-5911-(fn-i lryrrmn larb unuulun array : - 9; :5: .1 my-am. -1 rdrbuhb umdabua II um: mrimiimp. ix OD! nhmn n this pullout. Ibn iunman-(rm nnnmtl Jifimnxrt ll m-up nmvi zfiruuyjorpnrhibrr-p alvuiimvnrl iv vynrhvamii rrldrahlt av «on. pad in inabnl uowidrlinlilt nppvutbn. I((hu<l~ ll ’r laarrl H «rain that -In ilrhnai trltnia nftbr I1! 0/: rycdmonlul Mltbalth Ilolalan [at Inm- -um mi-pmd n . uullavl u-mmmim -4.1», minpariul pup. amt. » Ora-II. 1 mumaih u. ..; .'a-z mm-mu 4.5mm Mmrm Mala W1 am not idruiymv (3 — 0 I4. s1»: — nos. 93''. L‘! — / am, 010/. P — mix. I-' . vl9.74". ). Srrnuflrunn normal: nil uucrarrgvndoa : .-cn and In aud_y: ¢ ibr ronmhmny of up: afruupan-tau pup. lltlfl rimon uulvluv. and m. gnarl Inna! btnltb -Imnlut In -alt-urn: of rfinrt nu (IS) rlmnnn 1-I I-mr-gmnlv fvpr afmnupnuu pup lfn(I~tI—[Art xwnw: (IV! -‘I-I—ln bal Ill: n-routs: inflnmrr on ohrnnl brtrnvgrnnn Jud iaodnrirl ibr nnmiwn rs. in only ltmrnlle lqjiwrnrr in rfiraq amt rrunrml ID mum um um! (arr-«mural M II» anpnuou group 11 — 029, sf 7 “NM. 99%. (J ; I'). Itv. on/ . P I .0111. I-‘ s. N'*. i. ('Amdudon& lhx-nil. m-/ and no rrnlnur in gun. mu Ibr lrlrn-77 a/ p:_y. -«ml? -pi m ryxbn-it "mm: -ti mum" T. la! tficrurv dun lonllltlvtallb nunn Ill ma. -nu. lryrunll lynpvu-1. uqm. new nil. -{many IXH-IO. 30! i ruunou : -vi: n-n Huh uni um--an awtonln . - mi-M on-n wt I lit} vu ocds: Jrprnrnn; Iclrbalalr; Idaurnul bulilt; nun -cnlyru lN’I1{( )Dl‘( . 'l1( ), ' )q. m.. .n . . n mm: -1 1" . my -LIKIIXHHI1 mu" . .4 rm-nu] flrlllh. .. .. u . .sm; .m. i. kn esulzlnhut u. - menu, and t. .-nth Ihrn not «rated . ... ..i. n,~ . .. muuu cum ion Vohhodlh -nu ioamanocy. .iu-.1». ..- Ll-In-HtCPIMfl H-umqnm ~ ». t'(dln nl . .. ..-cm. .-. mm: hnrr-r III e. [-Ira: -uni: L‘ P: l. ?-1| and m ». ,< u . 1.. t-, vv: ':u-u u re. .. »_: vI'u¢1-tug o. um I I u. -. z. (.»-. -um .4 i. -.. Anny rm L-mi. .. l»1‘uvI 4 : ».v. :.. ., 4 p- o. .;. m.. «i- .1 n. u.. ... . 'C. -vo| ¢-‘t-)a0.n » _. .—~»-pr c-.44-. ;i« iv» D mt. .. C. » -— L. bur--r v-5 r. .>. -.~. .,. 1113 mm 4.. .. -. L~. ..« unoon um. Irv 1;. .. tm. uT«. u.u mi man 2 ~. .i a-w. ..». '.e. r.». on. mu no uvoi L». Mu. ~.: .. c: um ac-: « Whoa: can» 3: . 1. man: '1»-4 . -:r : ':1L‘ tr, I’; ;,": nT nth-I~c1 run. in ma. -‘run- i am my rxv-curvy u nil lt‘I| ]l mum in. . m4-vrul r. u.. .n. i.. im ur L' Hrpli. .m. .n_ me i: .m. .mta an-J i. :.«. .m. - pirtxlcnm YIILW Q41‘ . lqItr-ua-in In Ihr tmmi . uu-u . .-. - r. and If-_‘ . in h1lH‘l ‘ t--«mart. ‘. ‘ I in Immnr l1‘ up ‘ix .4 lI»n>-ml: inn In ili-iiln-! l)| -l -lnglyv-cs -1 Arum, l('| Il‘Gy'll rm l-tvn urn} h ma s¢. .i. n;_~ v; nr¢- --I . uut. .I. n. ' An-l iii. -prexxu-I: L’-nu uywunit in 40 lullmri lh Izn L~—. irl m In»: and umv in .1.‘ L . ... .~. i sum . t.. u(lI. nAu'l. 1[DIl| tl]k' ul [nnhmbi-upt hm , .n. m. re. . n . is. - . m.n. m. ut slr1>frI-III uslxpnvtxu, ‘ lwm-ri_ 1 Iagrfllflkfllt --nun 04lllr| InpI1lllrIl1olI4r»r)hi’ivIlI¢‘l'It'1iVl'l>IlIph ruin‘! - ip. mu n. » . .: unm | 'i. -u ll unit Ll-mt In T. .. i iuui-ulna.11:-lr; iL-suuil Inllul | :[I rm rr9rrTJI M pmrmnmpt, '- m {I| !i. ‘0| . «.n. ... .-m ixmlinp the uuenu n-pun 1 vrl’fl‘rK‘l'¢ «~ IIII run lunlm. 1'1! . ... -mm . an-in - - l‘nuu All-unr—r~n. uir .4: in HIM: so --’m~. a.~ 7--i urn mllm up i uh m has our [vu‘liutnL “mam. .. .. rm I. ..-n mmumi Hut 4)‘ . ..m. ..« J! rm t nrxrd uit~ hnr I di~~rug. 'e . .. mznul la. -mi. ,. ... ».. Jm, ‘ ma al| mLuz: ~ lI’. |J| '|L‘. l . .. FIDIIIIIOGIOII YMIIHGOIIIUS Ganvnnbnlroanmtomflnmmicnunnllmmausk 0 20M TEIEMENBI Hearth lnsmlflé. lril:
  32. 32. . -lli'u M _ ItZ‘l€I". l3€IIV. l‘i. CllLI SYNCHRONOUSTELEHEALTH TECHNOLOGIES IN PSYCHOTHERAPY FOR . DEPRESSION: A META-ANALYSIS Janyce E. Osenbach, Ph. D., - Karen M. O'Brien, Ph. D., Matt|1eL~v Mishkind, Ph. D., . and Dereltl. Smolenski, Ph. D., IVl. P.H. 'l'. Bl1' l. Publicati--n ni iii“. .. ill Ininuriil. i. i.. Ii. .imi-ii. I I. "'I. 'i I*‘~I| bII ~L. -.. .iiL. a l i l. .iiiiLl. ii. .iiLIIii. iirL l) :1 nLLi, i.iLLi. .ii. |ItIlIlIlq-Ifllun uhpl in nu-Lin ; i.. irLi L: i, -ma. i'. .iii . .Lii. i.L ‘Hus! IIIJI .1. Li Il. LLU« , ¢i. L., ... ... ... ..ii uri r. ..i. i.. i. i.i. i.. mLLiii. ii . i.ii Lit. ..ii (I I Il‘It(ll-iI| iuDAI-IltIli'1lI. I-III mi. ..iLiiii. iii. ii. ..iii. Illtl lll (mi. .. ill ii. ..t. ..i. .. i., ... ... i.. ..i: l| l'I IAVICII LI Li . ,~iir. i iiiimtii . L.. ... .. . .i. .i. ..LiL I III i "(V(VfiiV(rtlt'Il['IxI! |( Illtl i-i. iii. iL. iii. I'iIflV L, »LL». i.. L .1. K’ i. ..i. ... . ii . i i: i-vi IMIILII iii. .. ..i. .i. ..i< ll I'l . ..i i>. ;.. ... i.. |lil 1‘Ml| ui4|Ii ii. ... . . .~. ..x. .i. ¢. . i.ii. . , .ii. . iiL. iL, iL liLi. ii. i II in-iui iianiri . n.. .i. . ( itI‘I | .il. i LL. .1. .L. .ii. ii4.‘ i I. ‘ II(IU (§lIlll|1!I‘ I I. iLliLlIL: 1 iIiLiL, 1u. . . «( ill I "I4! ii. .ut. i, .i. ,,. ,i LHPLIII ii. .. . .i nth I ill’! Lili-«is! I‘ | .‘: In. -L-Itllll-: -4-ix-uh )fI‘lVH| ~IlI II I(I . ‘(Iii-Il‘|1‘I i: i’i . .i Irlll . .a. .ii. , i>. i.. —L. L.-i mil 4 ». .., ..i. n.i. IYIIII‘ . v.= .iii iIl’H'I-4’ iii. .. n; ;.. L.. ..i Iiizxii n. .i. iiiL ll(lVAul lll)I viii. L. .i l'Ul uIu'Ii| ’I- xi. n. i.. L.. i.. mu. “ 4 i. . . ii. iii. rli| I ii | AF| u 4.. .i. i.i. i.. ii-Liii. .rii- (ill! ) . i.. .i. ... ... . "l4(’II . . Liiii. P(IllVvl| lIlyl nuLL‘L2Lu Lll! ll'l L- ll)! "l| I4]llVl “L-Ii--It . ~-. .Li. L.i min til‘! Ilvl mi ll .1 i: <~it. Iur¢UL . umi. ..4 I ti l‘I iii. ,.. ... , -. ..; . in Li ulLmIV . .i i<JKl’Il ‘I’ " 1"1'”‘0 i. .iirii. .LmL LL nun. Illlilu . i.. .i. Li ll ri. .i. i.iL. iii. Li-i . .:i . .. IVliIl i- iii. LiiiLiL. iii. .. mu i. .i. .i. LL tllllllii i‘I-4~‘(I m Illll Iuk Llqucuun urn-i. l I Afls-1V uuul I III I Lupuliu»t>LIiAi«LulILILl>L: l:li -Ltixniit IIJI Lliililnn n. IL| i:uv. inir-Lriuiiu . || ». '| LI: |-inmin Atwsott m. I-Inn ~11: H) i. ... .i. i.. . «. ii-_- , ..i. ..i IrJlIi¢| tn<*VlntrIII| |vr nun» ii. i.. iii. ... .i. ... ... ... ... Liii. ... Li. iism: IIlvmIIiArvrHu4[vqlIrliv . i., ... ... ... i “K! L . i., nnl , .. .L. i.. .ii, .i_in ii. ... i . ... i.. Li i-mis, ..i. i-ii. II HIIIMIIIAIliK}vll*i4I: V<I(i: Vi-ill . .i. It I . ... x.. »i. ... r.. ... -.. a‘. .iiiiL: xi‘! .i. ,i, ... -.. ... ... i.. i.. .L. ..iiiiii. .iiri ll i. i.. ... .i. ... ... lIII i. :.~. i.. .iLi iL. iiii r . .. i.. ... .i: .L. ..L Published in DEPRESSION AND ANXIETY 0021-10 (2013) O 23!-1 TEIEMEFIBI -Ieatm IHSKIIIJIE. In:
  33. 33. Primary Focus: Not the technology, but rather, the service we deliver (also allows for reimbursement) Nonetheless, Different Modalities Require Different Skill Sets __ —/ ° In-person ° Text (email, chat, texting) ° Audio ° Video
  34. 34. . 1,1- ____, ___# _ _ l I Social Media ozim Tueuenizi mam Institute, Int"; I
  35. 35. ((< ”f""”’j""‘f‘f""”" telehealthprg facebook *9; Vc. uleoo¢u'Io, cnil! utwIg,1dItIq askteirimtd realm Ilnvbtr - l Ihlllur I'll Iiaiieiir u Mali. -L_— ( Telunental Healh lnstiute Tlneite ' Now ' Mighights ' Admit Panel ‘'3 *l"*V Q) 33 1;. .. §= I , _. _ D V_ in. . O . I | t is ethical TeleM3gta| Health Isrgtitutegg 5» __ to have a A Hea| t;h= :,z: ;.. ;:g~lr; sEuhacai§§ page on Fa ce boo k 'TiéiéMe"fia"i3°é'i°i"3~'-5.E’i7§ft§, sirg3.. :.9.: ' or a simila r §“§li. ”éfiS£°i$i r3,g22.'§i. <i€? ..+>: .4;. ... ;;; g Tags advertising grrea . 164 * pa 0 n I-~12»: .-L-. . . »., L.~e Telemental Health Institute we a v G 0 I e + ? Slnlus Ft Photo 1 vuieo lvrnI, HI|1-alone 4 2 gm”, Ho S4-(unly has ieIL-new-to Mealh item. Mlvlnt ' 15,201: E mu A fan Pnoc A Sucttss i l“r-2 .0
  36. 36. Google Google Seatcn I'm Feeling Lucky The ptnyqrcum 45 open '9». V m ml ~'-~ um, » mu:
  37. 37. rmwmm llfLTH ((( ml [ : ‘ telehealthorg Social Media Is Not Private - ”Anything you say, post, link to, comment on, upload, etc. , can and may be used against you by your peers, colleagues, employer, potential employers, fellow members, and so on. ” ° APAhttp: //www. apa. org/ about/ social-media—policy. aspx O ZEIIA YEIEMEMEI Heal‘? ! Insmme, In:
  38. 38. THFMFNTAI HFAITN ((( _ _‘ W Y ' _ , teleheaIth. org OCPM Step 1: Professiona| ’s Self Care - Boundanes — Office hours — Unplug - Reputation management 0 Community of| ike— minded pros
  39. 39. E, emu ewwg l l All Existing Legal & Ethical Rules Apply 02014 meuemzn mam mstmlte, Inc; 1
  40. 40. ((( 'E"ME"T"“"“”” teIehea| th. org ’nI, »v; s,a: r; "I'"A'“I'I. ;lfllflsvl'lv‘iI: IllI€vlI§lI’ll: -L5.; ;-’, ]i'§.3‘H-3IIfq": :jl$R3:III‘I» | N"~l ILJTF I. ‘lr. ‘?; ll. lF"I§-1 ". '1>‘l‘= ,l, III‘fi‘l“u-‘I. :»'| .-; ' fglslélf Ii: i;IIlE: !é«iImIiiEir+‘l§i; "!{f: -;; }é: .gI€I§3f; iiVI'1;1it-*5‘ PRAbTIcE GUIDELINES FOR VIDEO-BASED ONLIl, iE MENTAL HEALTH SERVICES Mayima IIIIIIIIIIIII IIIII II’ I I II I I I IIIIIII IIIIIIIII II II I I II II I I ”IVIIIIIliIIIIIIII_I_ III Ii I IIIIIIIIIIIIIIII IIIII I I II 'I____—I. -—-3-— A"“A 1 Amukan Trlemrdldno Anodallan til»: :’: o~3!flii§IIi>II= I.4?. = I‘ -Vflfillui -«'ar: I.-Izu‘-= nII‘m: (—
  41. 41. I-OI-dl-It-it-‘O-OI-II-II-III-I €x. I3/ |&AlI)U-‘$€xl3-’| &IJ')'-‘ GUIDELINI-IS FOR THE PRACTICE OF TELEPSYCHOLOGY Introduction These guidelines are designed to address the developing area of psychological service provision commonly known as telepsychology. Telepsychology is defined, for the purpose of these as the provision of psychological services ming telecommunication technologies as expounded in the “Definition of Telepsychology. “ The expanding role of technology in the provision of psychological services and the continuous development of new technologies that may be useful in the practice of psychology present unique opportunities. considerations and challenges to practice. With the advancement of technology and the increased number of psychologists using technology in their practices. these guidelines have been prepared to educate and guide them These guidelines are informed by relevant American Psychological Association (APA) standards and including the following: Ethical Principles of Psychologists and Code of Conduct (“APA Ethics Code’) (APA. 2002a. 2010). and the Record Keeping Guidelines (APA 2007). In addition. the assumptions and principles that guide the APA's “Guidelines on Multicultural Training. Research Practice. and Organizational Change for Psychologists" (APA
  42. 42. /(crs. -:_= —1;= §:'a'a«f'3r; L:i-=1 . ,q. i.»a; .._a. .., .., . Multicultural Issues & Diversity . .. ..3~‘ '55‘ E - . ,~. .»--. A . ’ . .‘ ‘ - F ‘ . l_ , r u l. __ 1 ‘ K , ‘ I. -c T _. i I , ' ‘ I . 'j ’ an‘ . —!I-fl . x : p—Fg T_ E — pl ‘
  43. 43. THFMFNT/ ll HEALTH ((( I , Y K ‘ _ , teleheaIth. org . F. ‘ ‘— ‘. l I Multicultural / Multlingual Issues Issue How to measure? ° Global nature of the ° Search online for various lnternet— worldwide instrumentsthat might be audiences valid for your population ° Multicultural issues are - Look for English proficiency quite visible in the tests document, but English as a — Free second language issue are — Easyto take nOt mentioned — Get to know the norms ° Rarely mentioned anywhere ° Spoken English is different from written English O 2014 Teleueinil Health Insmua. Inc
  44. 44. ( l'? '§f_5l3l;1li'%‘‘f*'35L1_'’‘l ‘<, =IiaI. u,r: ItiI. .;-m. » In-Person Contact APA Telepsychology Guidelines: is In addition, psychologists may consider some initial in-person contact with the client/ patient to facilitate an active discussion on these issues and/ or conduct the initial assessment. p11
  45. 45. Do you see well enough? -Image Resolution ° ATA Guidelines Are you conducting an intake orfol| ow—up? ° Most of the scientific literature described VTC as being used for follow-up care after a primary licensed professional does an intake. ° How can you compensate for being able to assess glassy eyes, tremors, gait disturbance, sweaty palms, body odor, other signs of poor hygiene or serious mental illness when no local professional is available? . O ZEIIA YEIEMEMEI Health ITISUILIIE, lnl:
  46. 46. T'lF‘. 'l. VNT; '-I IIFAITII (G K’ _; Y : ‘_ telehealthorg 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? 1| Copy right 2011 Telelvlemal Health In nitute. Inc. -‘all rights re served.
  47. 47. K j3,"l, T:. ""_l‘: "l{. "}“f‘l"l’: I3”l ‘r, -.lIiI’r"I= ,r-'l[i’iI. ‘_-I15‘: ‘- I. 'lr. rw, ': ATA Patient Appropriateness for videoconferencing- based Telemental Health * To date, no studies have identified any patient subgroup that does not benefit from, or is harmed by, mental healthcare provided through remote videoconferencing. Recent large randomized controlled trials demonstrate effectiveness of telemental health with many smaller trials also supporting this conclusion. p9
  48. 48. ‘ Pm teleheaIth. org Caution — Consider Context Online Norm vs. Standard of Care — No Contact with Other Treating Clinicians — No Authentication of Consumer / Professional — No Emergency Backup Procedures - Misunderstanding of Clinical Processes (suicide) - Operating w/ o Needed Research for Unsupervised Settings
  49. 49. ( ‘I'v''.9'fl_', *''‘. ‘;3.''L'*7‘‘f*‘*’l‘i‘5'‘‘’ ‘K, ’-lIiIr"I= ,I'lll3iI. ‘_-Iii: Caution — Consider Context Online Norm vs. Standard of Care Mostly Email / Chat vs. Video ° Anonymity / No Patient Records * Avoid Responsibility w/ Website Disclaimers it No Clear Channels for Mandated Reporting
  50. 50. TMHI Client & Patient Selection Study the evidence base (research) People with almost all diagnostic symptoms have been treated with traditional telehealth Treatment to the home has not yet identified which groups are too risky Understand differences between treatment of individuals in 1 setting vs, another (hospital vs. car, park, bed etc. ) Consider compliance problems
  51. 51. OCPM: Online Clinical Practice Management Step 1: Training Ste 2: Referrals Step 3: Patient Education Step 4: Legalities Step 5: Assessment Step 6: Direct Care Step 7: Reimbursement
  52. 52. ( ‘I'v", ¥'. "“_l~"‘7{. "§‘%‘-f~‘~’. *i‘£"" ‘(; —llili"I= r§l[iiI. '_-I'(5‘: ‘- I. 'lr. :w, ': Who is Responsible * . ..if you make a referral to a | ong—trusted ~ ’ , ‘ colleague who suddenly ‘T2 * /5 conducts distance counseling with a client a you referred? ‘ ‘ * . ..what if the client suddenly decompensates and makes a suicide attempt?
  53. 53. ( ‘I‘r''.4'. ‘.'~''‘. ‘»! .''; ‘*_‘-f*‘~’I*i‘§’‘‘’ ‘K, ’-lI= ’I’r"I= ,I'lll‘iI. ‘_-Iii: ‘- I. 'lr. :w, ': Know the Practices of Your Colleagues * Ask ' . * Keep them informed of ‘ .3 I/ ' your practices and I ‘H rationales K’ , ‘ Suggest training when " _j needed _«. ;.fj * Document training suggestions when appropriate
  54. 54. Step 4: Legal Issues Step 5: Assessment Step 6: Direct Care , I_ Step 7: Reimbursement - M‘ P” I "'” ll”s. .,, ll Step 1:Training I Step 2: Referrals 5 : Step 3:C| ient Education "‘ is l I l E35” “"<‘-‘er-— . . I W. ‘ I‘ It till 3 I‘: ‘IN: ’ 9:» ‘l~ I: ozrm reieuenrzi mam Institute, use I
  55. 55. Technical Issues ° Discuss the technical requirements with the patient prior to initiating treatment ° Consider the level of technology experience of the patient (train if needed) ° Have a back-up plan if the video connection is lost — telephone —- landlines are best, but cell phones are better than nothing
  56. 56. m FMFNTAI. HEALTH ((( I r ‘ _ , teIeheaIth. org Tech Check ° Tech check — review potential technology and infrastructure issues prior to initiating the delivery of ca re — adequacy of bandwidth (the rate of data transfer) — reliability of telehealth equipment (computers, monitors, video cameras, audio equipment, etc. ). — loss of connection due to inadequate transmission bandwidth or other equipment failure during a clinical crisis situation — insufficient camera resolution or environmental problems (adequacy of room lighting and microphone placement)
  57. 57. 5: Explain technical aspects {camera position, lighting, audio, noise, clock, etc. )
  58. 58. - ~ —~A~—— —« ~. ——_—¢-. —.»«‘—; q:¢‘i L . I _. .i’_ __. _ . _e___. ‘ ' ‘ ' , '_; _'_'__'__m all’ T *. :. v. . . I It Tell It kl. Ii; I ‘ii I I What are the types of problems that clients / patients have reported when working with clinicians using videoconferencing? _. _._. .—r . ._. _.. r— ' . _, — - Ea‘ ozrm reieuenrzi mam Irtsttlute, use I
  59. 59. Client/ Patient Training ° Email/ Texting/ Telephone/ Video ° Social networking— social media policy ° File exchange ° Computer repair ° Clinicalrecords ° Insurance ° Reports ° Lateness/ Missed sessions ° Non—comp| iance/ Avoidance
  60. 60. m FMFNTAI, HEALTH I H i Y I U T I, teleheaIth. org Clinicians have been reported: ° Eating ° Taking personal cell phone calls from family ° Burping without excusing themselves - Picking teeth ° Combing hair ° Rocking incessantly in their seats ° Putting feet on the desk ° Taking a shirt off - Mindlessly tapping the desk with objects ° Being half way off the screen
  61. 61. - — —~A~—— —« -A—_~¢-. —;». .‘—; .:¢‘i _. _._. .»r . ,___. . _ ' ~__ , What should I do when someone enters a client's/ patient's room during a call? I ozou meuemzn mam mstm; te, int’; i
  62. 62. ((( THFMFNT/ ll HFALTH . I l'I‘ * T ' * teleheaIth. org If someone enters the client/ patient room: ° What would you do in your brick—and—mortar practice? — Stop the session / resume control of the interaction — Ask the client/ patient to speak privately with you ° Obtain permission to continue ° Askfor an agenda ° Reschedule for another day/ time
  63. 63. - — —~A~—— —« -A—_—¢-. —.». .‘—; .:¢‘i _. _._. .»r . ,_, _.. _ v , _V _ What should I do when someone enters my room during a call? I 02014 meuemzn mam lrIsm; te, Inc’; J
  64. 64. ((( THFMFNT/ ll HFALTH . I l'I‘ * T ' * teleheaIth. org If someone enters your room: ° What would you do in your brick—and—mortar practice? — Stop the session / resume control of the interaction — Excuse yourself if it is an emergency and step out ofthe room — Reschedule for another day/ time
  65. 65. - — —~A~—— —« -A-—_«= -.—; -». .‘~; .:¢‘i &____ _g___ V V__Tj_j____T‘_j. g Tu: 3» ' v_ >4 _ , :¢, . arsauhfiwm grf. %: ‘§r—‘-“’. £»'. t.-‘E’-‘.2;-= E.. , X‘ _. _._. .»r . ,_, _.. _ T , _V _ l Why use initial protocols when videoconferencing? "ix ozou meuemzn mam lnmlL; t2. 1111'; l
  66. 66. m FPMNTAI ur um ((( teleheaIth. org : lll Initial Protocols Educate client/ patient about the need for routine opening protocols that might include: Your name and location, name of clinic, hospital, agency ? Client/ patient name and location ? — direct phone number for emergency services of today's location (tested? ) Reason for meeting ? lfanyone else is in the room or within earshot? Are children cared for ? Any expected interruptions ? Door locked? Room scan? — Scan your room with your camera and ask patient to do the same Anything else of note with your population? 0 2014 Telahlemzl Health lnsmney lm:
  67. 67. - — —~A~—— —« -: —_~¢-. —4». .‘—; .:¢‘i i. . I ‘. ..if -_. . . _a___. ‘ ' ‘ ' , '_; _'_'__'__A if T ,3 v. . . l‘ ‘T 12355?‘ I: 2?. ‘ix I ‘ii l _. _._. .»r . ,___. . , — ' ~__ , I Can I get paid for the time used in helping a client/ patient set up and manage their equipment? ozou meuemzn mam Ind1lL;1e, Inc’; I
  68. 68. ((( TFIFMFNT/ ll HEALTH . Ii'. “’—ll‘, ,Ii'f teIeheaIth. org Paid Tech—Time? ° No payment for client/ patient set-up time ° "Facility fees” are available on a per—session basis for Medicare and Medicaid services that are reimbursable — See: Reimbursement Strategies Increasing Authorization and Payment (3 CEs[CMEsl
  69. 69. - — —~A~—— —« -: —_~¢-. —-. ».. ‘—; .:¢‘i _. _._. .»r . ,___. . , — ' ~__ , I How do I handle technical issues created by my video teleconferencing (VTC) system during a call? ké. _V. _:. __. ,_____j__. _., :.. _.: A ’ '€'I""“? §’ ? §’? ?—_"”}‘**“: ’.¥: -_-s. -, X I ozou meuemzn mam Ind1lL;1e, Inc’; I
  70. 70. ( ‘l‘r''.4'. ‘;'~''‘: ‘»! :''; ‘*_‘-f*‘~’I*i‘§’‘‘’ i, '—II= ’Ii'i= ,rlll3n. ‘_-1'15? ‘- w. 'ir. :w, ': Tech Problems During a Call * Practice before you work with clients/ patients ** Relax — trust your training ° Have an agreement with your client/ patient that you will call each other using a designated telephone number A Always have that phone number on hand when you conducta session * Have an agreement about who will call the other
  71. 71. - — —~A~—— —« -A-—_<= -.—= ».. ‘~; q:¢‘i Tu: F. -:——. _.1_ V, g 4 _ 7 :6, . ‘: "$= :. __ % §'‘S‘“*‘_, . . .V_‘ l i E . :‘vL _. _._. .»r . ,___. . I’ ' ~__ — I What is a community champion and when is it appropriate to use one? "ix ozou meuemzn mam Inmuxe, left’; I
  72. 72. m FMFNTAI, HEALTH I H i Y I U T I, teleheaIth. org Community Champion ° Local collaborator can be helpful for: — providing information about the patient's history — monitoring mood and behavior — assisting with treatment planning and coordination — coordination with local 911 service when needed — provide an additional mechanism for contacting patients if a connection becomes lost — provide on-site technical assistance — provide support to a patient during emergency situations
  73. 73. TFIFMFNT/ ll HFALTH ((( I I I I I _ I teIeheaIth. org . F. ‘ ‘— I I Community Champion ° Educate your client/ patient about use of a local collaborator such as a family member or close friend — Enter name and contact information into informed consent document — Stipulate under which conditions these people will be contacted — Outline emergency procedures and when collaborator will be notified — Clearly define expected roles and responsibilities of local collaborators/ champions — Encourage your client/ patient to discuss their choice of champions directly, before you contactthem O 2014 Teleuemal Helm lnsmua. Inc
  74. 74. _: _, . _ I . __ %'T*a§II What are the must—dos for communitychampions and ii; informed consent to -‘e III minimize my risks? : I, L “ . l , i’_ , _ __'__' ' ‘ ', ;;'_; ;___ if ’ ¥'“"‘“*7” ozou meuemzn mam Imm. Inc; l
  75. 75. m EMFNT/ ll, HEALTH I II I I I II I I teleheaIth. org Community Champion ° Assess when using a local collaborator may not be advisable: — Safety of local collaborators must be carefully considered — may be best to rely on trained 911 responders — Be cognizant of potential deleterious effect of disclosures made during emergency management on patient confidentiality and relationships, especially in small communities
  76. 76. Aw I I -—— M. LII, Step 1: Training Step 2: Referrals Step 3: Client Education Step 4: Legal Issues Step 5: Assessment Step 6: Direct Care I. Ste, pI7.: Reimbursement- I 02014 meuemzi mam Institute, Inc; I
  77. 77. ( ‘l'v''.9'II‘l_'I: ''‘: ‘;3:''L'%‘‘f*‘: ’I‘i‘5'‘‘’ ‘K, ’-II£Ii'i= ,l'lll3lI. ‘_-1’(! ? Dr. Trow vs. Oklahoma Medical Board * Relevant law —> The case * Skype ° Lessons to be learned
  78. 78. Full style: State of Oklahoma ex rel. Oklahoma Board of Medical Licensure and Supervision v. Thomas Edward Trow, ll/ l.D. , License No. 10255, case No. 11-11- 4439 (Sept. 12, 2013)
  79. 79. ( ‘l‘r''.4'. ‘'‘; '~''‘7’_: ''; ‘¢_‘-f~‘~’I*i‘§’‘‘’ i, '—II= ’li"L= ,rlll3II. ‘_-1'15? : - I. 'Ir. :II, ': "Physician/ patient relationship” in OK * ”. ..a relationship established when a physician agrees by direct or indirect contact with a patient to diagnose or treat any condition, illness or disability presented by a patient to that physician, whether or not such a presenting complaint is considered a disease by the general medical community. The physician/ patient relationship shall include a medically appropriate, timely-scheduled, actual face-to-face encounter with the patient, subject to any supervisory responsibilities established elsewhere in these rules. ’’ (emphasis added) — OAC 435:10-1-4 — Does not say: "in person”
  80. 80. TFIFMFNT/ II HEALTH ((( I I I I I _ I teIeheaIth. org . F. ‘ ‘ I I IC: OK Telemedicine Act, OAC § 36-6804 ° A. Prior to the delivery of health care via telemedicine, the HCP who is in physical contact with the pt shall have the ultimate authority over the care of the pt and shall obtain IC from the pt. The IC procedure shall ensure that, at least, all the following info is given to the pt: 0 1. A statement that the individual retains the option to withhold or withdraw consent at any time without affecting the right to future care or treatment or risking the loss or withdrawal of any program benefits to which the individual would otherwise be entitled (emphasis added)
  81. 81. K ’l'r".4'. "“, '~'«“’, :"'_‘%‘-’-‘~’I*i‘3"" ‘<, =lt= ’I‘o'i= ,‘r'illi'vI. ‘-'iig‘: ~. l| '), ',I]I’I’ll ' IC: OAC § 36-6804, 2 * 2. A description of the potential risks, consequences, and benefits of telemedicine; * 3. A statement that all existing confidentiality protections apply; * 4. A statement that pt access to all medical info transmitted during a telemedicine interaction is guaranteed, and that copies of this info are available at stated costs, which shall not exceed the direct cost of providing the copies; and ~ 5. A statement that dissemination to researchers or other entities or persons external to the patient- practitioner relationship of any patient-identifiable images or other patient-identifiable information from the telemedicine interaction shall not occur without the written consent of the patient (emphases added)
  82. 82. m EMFNT/ ll. HEALTH I II II I I II I I teleheaIth. org IC: OAC § 36-6804, 3 - B. The pt shall sign a written statement prior to the delivery of health care via telemedicine indicating that the pt understands the written info provided pursuant to subsection A of this section and that this info has been discussed with the HCP or [his] designee. ° C. If the pt is a minor or is incapacitated or mentally incompetent such that the pt is unable to give informed consent, the consent provisions of this section shall apply to the pt’s rep. The consent provisions of this section shall not apply in an emergency situation in which a pt is unable to give IC and the pt's rep is unavailable. .. (emphases added)
  83. 83. m EMFNTAI. HEALTH I II II I I II I I teleheaIth. org IC: OAC § 36-6804, 4 - For purposes of the delivery of mental health care via telemedicine, the use of telemedicine shall be considered a face-to-face, physical contact and in-person encounter between the health care provider and the patient, including the initial visit. — Services provided by the Mental Health Dept. : initial evaluation may be virtual — Mental health services provided by others: initial evaluation must be in—person — Otherforms of health care: initial evaluation must be in- person
  84. 84. K ‘j': i‘! ,3.B‘, l‘: “1": ‘"| Z“: "‘, ":‘£’: ‘! ‘x, -.1tiii"x= ,r= ’I(i‘ui; .'. "., ~,. ~. l| '), '_I]l’I’l: ' Telemedicine for Mental Health (OK 2008 Policy) ° Telemedicine technology is limited to consultations, psychotherapy, psychiatric diagnostic interview examinations and testing, discharge planning and pharmacologic management. An interactive telecommunications system is required as a condition of the use of telemedicine. ~ The following shall n_ot be considered telemedicine: * (1) Phone conversation (including text messaging) * (2) Electronic mail message 6 (3) Facsimile (fax) * (4) Store and forward
  85. 85. ( j3,",3.""_l‘= !'? ’_, ";‘*, “": ““"’: ‘£”‘! ‘<; .Ilil’u"u, r-'l[i‘n. ‘,-1'15‘: ‘- w. 'lr. :w, ': Telemedicine for Mental Health (OK 2008 Policy), 2 * The telemedicine equipment and transmission speed must be technically sufficient to support the service provided. If a peripheral diagnostic scope is required to assess the patient, it must provide adequate resolution and audio quality for decision making substantially equivalent to a face-to-face encounter. Staff involved in the telemedicine visit need to be trained in the use of the telemedicine equipment and competent in its operation. (emphasis added)
  86. 86. m FMFNTAI. HEALTH I H (,7 Y I U T I, teleheaIth. org Telemedicine for Mental Health (OK 2008 Policvl. 3 ° The physician who has the ultimate responsibility for the care of the patient must obtain written consent from the patient, in accordance with state law, that states they agree to participate in telemedicine. The consent form must include a description of the risks, benefits and consequences of telemedicine and be included in the patient’s medical record ° Physicians providing mental health care services via telemedicine shall be held to the same standards of care as required in the medical community. — Emphasis added
  87. 87. ((( TELEMENTAL HEALTH | N __) Y ‘ I U I F ‘ telehealtfnorg
  88. 88. m FMYNTAI ur um ((( teleheaIth. org Iuiltii Trow: OSBMLS Telemedicine Guidelines ° Ok. medical practice act requires initial in—person visit before MD can prescribe Rx — Exceptions: ' Emergencies ° DOS ' Interactivetelecommunications system required — TM network standards: all technical, confidentiality requirements under state and federal law ' Permissibletelemedicine functions: — Consultations — Psychotherapy — Psychiatric diagnosticinterview exams and testing - Dischargeplanning — Pharmacologicmanagement 0 NOT TM: phone, email, fax, store—and-forward O 2014 Teleuemzl Helms Insmna. Im:
  89. 89. mwrunu urmm ((( I , Y ‘ _ , teleheaIth. org . r. ‘ ‘— Y . , l I Trow: Stipulated Facts ° Dr. Trow is an unemployed 65 yo pain management physician ° Orthopedic problems make travel difficult for him — Used mail, fax, and phone from home 0 RN often served as telepresenter at clinics — Records kept there but not, as Oklahoma telemedicine guidelines require, at Trow’s home office 0 10/20/11: DO reported 3 pts getting large doses of Xanax 0 11/8/11: TL, daughter of deceased, addicted, 62 yo pt RC, complained Dr. Trow prescribed CDS for RC — RC died of HBP and COPD ° No toxicology studies 0 2014 Telemental Helm Insmua. In:
  90. 90. m FMENTAI ur um ((( teleheaIth. org Iuiltii Stipulated Facts, 2 ° 8/17/12 Ok. HC Authority (”OHCA”) letter: — No contract with OHCA — Using unapproved equipment — Noinformed consent — Inability to produce 2 of 10 requested charts — Overprescribing CDS — Limited documentation; no physical exam — Verbal orders not countersigned ° 3/13/13: OHCA reported D was — 1) seeing Sooner Care patients via Skype and — 2) writing for controlled substances without an in-person evaluation ° OHCA "is the primary entity in the state of Oklahoma charged with controlling costs of state-purchased health care. ” — SoonerCare: Oklahoma Medicaid l O 2014 Teleuemzl Helms Insmna. Inc
  91. 91. m FMENTAI iir um ((( teleheaIth. org Iniltii Stipulated Facts, 3 ° Dr. Trow caused NO patient deaths ° Dr. Trow billed OHCA for Skype services; not an approved telemedicine modality ° Trow did not see all pts, even by Skype. ° 11/9/12: OHCA letter #2: similar to 1; more detailed — No initial contact with patients — lnadequaterecords — H| PAAvio| ations — Inadequate supervision of nurses — Failing to heed drug screen results — VOs ° 11/15/12: OHCA terminated SoonerCare I l O 2014 Teleuemzl Helms Insmna. Inc
  92. 92. ( ‘l‘r''.4'. ‘'‘. '~''‘7’_. ''; ‘*_‘-f~‘~’i*i‘§’‘‘’ i, -II= ’Ii‘i= ,rlll3‘n. ‘_-1'15? : - i. 'Ir. :w, ': Procedural Posture * Disciplinary matter, not a private (malpractice) claim a -. — ? Possible infuture? I pl’ T ‘ / ‘ Defendant pled guilty — Waived right to full hearing * D admitted violating OHCA telemedicine guidelines: improper equipment; no proper contracts — Stated he thought those duties fell to his employer
  93. 93. ( ‘l‘r‘.4'. ‘'‘. '~''f‘! .'i‘*_‘-f*‘~’i*i‘§’‘‘’ ‘(, -II= ’Ii‘i= ,rlll3‘n. ‘_-1'15‘: :- i. 'Ir. :w, ': Conclusions of Law: Unprofessional Conduct * Dishonorable conduct likely to deceive or harm public * Prescribing without _ ’ . F ” — Proper doctor-patient ,7 Y relationship; == ~ / — Adequate PE * Overprescribing controlled substances — No documentation of medical need * Inadequate records
  94. 94. Consequences : : License suspended ° MD to take prescribing course ’ I! :«~ No CDS prescribing until . — 1. Course completed — 2. Dr. Trow meets with Board Secretary * MD is on probation * Reported to National Practitioner Data Bank
  95. 95. ( ‘E ‘<, =irai. u,r: im. .;-m‘. » New Ok Definition: ”Face—to-Face Encounter” by TM at ’’It is the position of the OSBMLS that the face- to—face encounter required by OAC 435:10-1- 4.. .to establish a physician/ patient relationship includes real-time telemedicine encounters with audio and video capability. ..[T]o qualify as a face- to-face encounter set out in this definition, the telemedicine audio and video capability must meet those elements required by CMS. ” OSBMLS, 9/25/13, — http: //www. okmedicalboard. org/ download/705/Tele medicine PositionStatement. pdf
  96. 96. m FMFNTAI. HEALTH I II I I I II I I teIeheaIth. org Oklahoma Law is In Flux - November 7, 2013: Board held a public forum to discuss the use of telemedicine in Oklahoma - Then, public comment — First public comment period ran overtime; a special session may be needed to complete the process ° Thenzlegislature - Finally, Governor's office
  97. 97. What are the take- home lessons from the Trow case? _ W. llll-l. l, lllli l. I ozim Tueuemzi Realm msmme. inc; I
  98. 98. m FMFNTAI IIF um ((( teIeheaIth. org Iuiltii Take-Home Lessons ° Case reflects Oklahoma law only — But Oklahoma is relatively telemedicine—friendly (”SoonerCare views telemedicine no differently than an office visit or outpatient consu| tation. .” OHCA Policies and Rules, 317:30—3—27, revised 7/1/13) — Other states could do the same or worse ° Tort liability presumably remains possible — Though wrongful death claims might be problematic — is Dr. Trow insured against this risk? ° Determine what establishing the physician—patient relationship requires in the relevant jurisdiction — Is a virtual visit adequate? ' Be sure to perform the type of initial contact required by your state law for distance counseling I O 2014 Teleuemzl Helms Insmna. Inc
  99. 99. m FMFNTAI. HEALTH I II I I I II I I teIeheaIth. org Take-Home Lessons (Cont. ) ° Obtain and document informed consent — In Oklahoma, must be in writing — Check your state's laws ° Maintain proper records - Board's main focus was on excessive prescribing, not Skype per se — Does Oklahoma forbid Skype for telemental health services? ° Nevertheless: Use Skype with caution, if at all — No claim of HIPAA compliance ° Be especially cautious with controlled substances — Potentially acceptable: hospice
  100. 100. YFIFMFNTAI HEALTH ((( I I I I I _ I teIeheaIth. org . F. ‘ ‘— I I FSMB, as of 8/12 - 10 state boards issue a special purpose license, telemedicine license or certificate, or license to practice medicine across state lines ° 57 boards + DC Board require that TM physicians be licensed in the state in which the patient is located - Minnesota allows physicians to practice TM if they are registered to practice TM or are registered to practice across state lines — http: //www. fsmb. org/ pdf/ grpol telemedicine | icensure. |:_) Q‘.
  101. 101. ( ‘l'v''.9'; I‘A_', :''‘. ‘;3.''L'%‘‘f*‘*’I‘i‘5'‘‘’ ‘K, ’-IIiIi"i= ,I'lll3II. ‘_-Tu? Full Discussion A The previous slides were from a webinargiven 1/20/2014 through the TeleMental Health Institute. * Guest speaker for that webinar and author of many of the previous set of slides is Joseph McMenamin, MD, JD, McMenamin Law Offices, Richmond Virginia
  102. 102. Specific Informed Consent Processes and I Documentation
  103. 103. K j3.", T:. ""_l‘: "!. "’_‘*, “f“"I’: ‘3’: ‘! ‘<; .!I£Ii"i= ,I'll[iiI. ‘_-i’(g‘: :- I. 'Ir. III, ': 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 assessmentinstruments and other communication devices.
  104. 104. TEI EMFNT/ II. HFAITH ((( I II I I I II I I I teIeI1eaIth. org 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.
  105. 105. ( ‘i'v''.9'fA_', *''‘, ‘;3,''L'*7‘‘f*‘*’i’i‘5’‘‘’ ‘K, ’-ll: ’ii"i= ,r'lll‘n. ‘_-1'15? Verify with a Local Telehealth Attorney * Use next suggestions, but I am not an attorney. * Develop your document and verify with your own informed, local attorney * Be aware that many association attorneys may not be yet adequately well-versed in telehealth issues ' A good expert should cost you from $500 - $800 to review your agreement
  106. 106. m wmrm, HEALTH l H K‘ Y I U T F te| eheaIth. org Informed Consent - Represents a ”meeting of the minds” — Information is influenced by many factors, including - Client/ Patient’s capacity for absorbing information ° Time limits - C| inician’s schedule — Subject matter is often complex and technical — Clinician thinks she is speaking English — Client/ Patient may be under stress (or may assert so later) — Mental illness - Document only serves as important evidence
  107. 107. ( ‘‘‘r''.4'. ‘;'~''‘: ‘»! :''; ‘*_‘-f*‘~’l*i‘§’‘‘’ ‘K, ’-II= ’Ii"i= ,r= ’ll3n. ‘_-1'15? ‘- w. 'lr. :w, ': Informed Consent: Function of State Law ° Specific statutes govern informed consent in telehealth ° Who's state law controls? ° Solution: assume that the law of the client/ patient residence will most likely be applied * More conservative approach is to determine the law in both your and your client/ patient’s state and follow the mandates of the more stringent law
  108. 108. TELEMENTAL HEALTH ((( l telehea| th. org l N S X I I u T F TMHI Informed Consent Documentation Basics ' Date ° Diagnosis ° Outline of intervention ° Risks and benefits of each technology used - Risks and benefits of competing approaches ° Including no service
  109. 109. ( ‘E ‘<, =iisi. u,r: itiI. .;-m‘. » TMHI Informed Consent Documentation Basics * Emergency Resources and Plan including names and contactinformation for local, trusted person(s) to be contacted at the -4 51 U discretion ofthe clinician . ;. - —‘‘’'T .3 | ° Documentadvantages and E‘ = 0 / Q 9'" . ._. .ai disadvantages of using , . . technology I? " V I} :2» .5, * Documentevidence-base supporting counseling plan I * Document client preferences re: technology
  110. 110. THEMFNT/ ll. HEALTH I r-. ‘ >1 , telehealtnorg IILITF TMHI Informed Consent Documentation Basics Confidentiality and limits thereof as related to mandated reporting (suicide, homicide, abuse) Fees, if any Statements* similar to: My questions have been answered to my satisfaction in language I understand ° As of the time of my signing, all blanks have been filled in Document method & procedures for data storage Document adherence to local and distant regulations '“ Obtain full legal review with a local telehealth attorney prior to using any TMHI sample wording with clients either verbally or in in your informed COIISQIII (lOCLllll€_‘lll. 0 2014 Tllellemal Mqiml Insmne. Inc,
  111. 111. Tfl FMFNTAL HEALTH ((( ‘ _ I, teleheaIth. org Ii’-. ":l ll TMHI Informed Consent Documentation Basics ° Some risks may not yet be unknown * ° No physical exam * ° Identify both the clinician's & client's/ patient’s physical location ° _St tements* suchcfsz Pro essi _nal will rely on in ormation provi ed by he c ient/ patientand by any on-site practitioners or other sources ° Potential problems could arise with electronic transmission in telepractice: ° distortion, delays, interceptions, interruptions ° Document all communications with client (written, audio, video or verbal) * Obtain full legal review with a local telehealth attorney prior_ to usiné any TMHI sample wording with clients either verbally or in in your informe consent document. D2014 TEIEHEMJI Hailtfl lllsmfle. Inc
  112. 112. ' Tsi. Ei. iENTxii. iirALTH ((( N _; X I U T F ( teleheaIth. org TMHI Informed Consent Documentation Basics - Discuss the purpose of remote contact ° Inform clients of who will have access to their email address, phone number, or any other contact information ° Inform the client of who else might contact the client on your behalf - Discuss mu| ti—cultura| and diversity issues O 2011 Talellemzl Htimi Insnfle, Inc,
  113. 113. Tfl FMFNTAL HEALTH I H (,7 Y I U T I, teleheaIth. org TMHI Informed Consent Documentation Basics - Describe the specific roles of any consultant or local referring practitioner and who will have ultimate authority over the client's treatment ° Discuss whether client information will be stored in a computerized database - Provide written procedures for various types of follow-up when client does not appear for remote consultation — Time limit for non-response before collateral person will be contacted if professional is concerned
  114. 114. Tfl FMFNTAL HEALTH I II I I I II I I teleheaIth. org TMHI Informed Consent Documentation Basics - Describe how deficiencies electronic equipment could possibly cause interference with diagnosis or treatment ° Make provision for non-receipt of email, delayed receipt, problems with servers, or unannounced changes in the schedule of email communications ° Mention how easily human error could lead to incorrectly delivered messages or other unforeseen events
  115. 115. rEi EMFNT/ tl. HFAITH ((( I II I I I II I I I telehealtnorg TMHI Informed Consent Documentation Basics ° Document technical requirements with the client prior to initiating treatment ° Document preferences and level of technology experience of the client (train if needed) ° Agree upon alternatives if video or audio connections are lost — telephone —- landlines are best, but cell phones are better than nothing
  116. 116. rir-. i.rini-. i MFA Tl (G I IL‘ ’ teIehealth. org I'. ‘i: i Emergencies Have a plan. ° Discuss carefully ' Write plan in your informed consent document ° Develop prior relationships with local community: Physician Family School personnel Other leaders (AA, religious? ) Emergency response team Know community resources (hospitals, drug/ alcohol treatment facilities, etc. ) Know your local collaborators Know who and when to call for local assistance. 7'. ‘-ll . fii : «1- Z. ° Inform client of when you will Contact local leaders, what you will tell them. - Cover your termination procedure ( i. e., '’I will make 2 telephone calls, leave you 2 messages, send you a Ietterin surface mail with a copy to your physician. ’’) 0 ZDIA TEIEMEMEI Heal‘? ! Irlsmlfle, lnl:
  117. 117. l'IFM¥NTi‘tl llFlTH ((( ‘I II I I III telehea| th. org NBCC: Standards For Distance Professional Services ° NCCs shall carefully adhere to legal regulations before providing . I . ' 1 distance services. This review - ' I shall include legal regulations from the state in which the counselor is located as well as those from the recipient's location. I _ . Given that NCCs may be offering K _ distance services to individuals in - different states at any one time, *’ the NCC shall document relevant state regulations in the respective record(s).
  118. 118. K j3,", T:. ""_l‘: "!, "’_‘*, “f“"i’: ‘3’: ‘! ‘(; —ilili"‘i= ,r§l[iii. ‘_-i'(5‘: ‘- i. 'ir. rii, ': NBCC: Standards For Distance Professional Services * Boundanesof competence — NCCs shall provide only those services for which they are qualified by education and experience. NCCs shall also consider their qualifications to offer such service via distance I means. ‘ _ «- — Are counselors competent to deliver traditional service in technical environments? Technical and clinical training may be needed.
  119. 119. ( j'v''.9'fA_', *''‘, ‘;3,''L'*7‘‘f*‘*’i’i‘5'‘‘’ ‘K, ’-li= ’li‘i= ,rlll3h. ‘_-1'15?’ Privacy, Confidentiality, Diversity * Privacy& Confidentiality T, , ‘ ll — Understand your ‘ technology (email, texting, video) and its clinical repercussions related to privacy and technology * Diversity — Multi-cultural, multi- lingual, religious, LGBT, and other issues
  120. 120. ((6 ‘’‘? '9??1t‘'7%'. ‘¥'%‘“T; ‘’? ‘5f’‘‘ W-‘i<~ti~~<. -It-e‘«» Service to the ”Home” t Scientific evidence base i for contact to the home is , » r much thinner, less S reliable than traditional telehealth 4° Risk management is a serious concern ~° Likelihood of lurkers, intruders or interruptions is increased -9 Develop signs, code words or phrases to signal something is amiss
  121. 121. /j(¢ ‘*%'%jf{§f! f€f—ff3§E"‘ ‘<, -!l= ’ti"x= ,i'Jlli'oi; _-mu TMHI Clinical Competence Client Selection * Study the evidence base (research) * People with almost all diagnostic symptoms have ‘ , To been documented as N, ' ' _ - successfullytreated with l traditional telehealth / ' + Clients experiencing severe i_ l A anxiety, flagrantly psychotic _~{~_. —— symptoms or suicide/ homicide intent may not be optimal choices while symptom patterns are exacerbated
  122. 122. _ ‘“"' i; -!l£t’u"i= ,r-'lli'n. ‘_-1‘(! ? TMHI Clinical Competence Client Selection Most of the studies mentioned above include the assistance of a local collaborator Treatment to the home has 4. T"? not yet identified full range of , ‘ risk Understand differences when / 4 delivering care to clients in (it, different settings (hospital vs. _ A _ car, park, bed etc. ) Establish procedures to minimize attendance & compliance issues
  123. 123. Interjurisdictional Licensure Issues 1 trlfcvwmrts . I . .. .uu. E kl‘
  124. 124. ABOUT THE INFORMATION IN THIS REPORT The information in this report mu compiled through a survey ofslatc counselor licemure board» conducted in full M2009. Stzitc-by-state analysis of lain‘ and administmtitc nrles was also conducted to add to the survey data. especially for lhc mo jurisdictiom. —Gcorgia and Pucrto Rico-that did not submit infomiation in response to our request. Every effort has been mitdc to ensure the accuracy of the information presented here. but. due to the complexity of laws and regulations. and the frequency with which state regulations can and do change. we cannot guarantee that this report is completely without error. Rc.1ders are eriootintged to bring any errors. omissions. or changes to our attention. For any questions or corrections regarding this chart. please contact: American Counseling Associattion Ethics and Professional Standards 5999 Stevenson Avenue Alexandria. VA 22304 Web site: tiwtw. counsellng. og U. S. toll~l'nce: X00/3-17-6647. xll-8 I DC amt: 703/823-9800. x314 Fax: 703/823-3760 E-mil: stlitncemnmdlnnnm For additional informsrtion. or clarifie. -tliori or interpretation of any of the laws and regulations sumntirized in this report. please contact the appropriate state licensing board. Written and edited by Christie Lum. ACA Oflice of Public Policy & Legislation. Howard B. Smith. Ed. D. NCC. CCMHC. LPC (License M920 Louisiana) reviewed and reviurd Appendix D: Aecredit. 'ition. Ccnification and Licensure Defined and (. 'onl'identi; tlity/ l"ri‘ileg. 'td ('unimunii: .itiun. Copyrighu‘Z0|0 by the American Counseling A-ssnciation. Amerlcsn Counseling Assoclatlon 5999 Stevenson Avenue Alcundrtn. VA 12304 (800) 341-6647 . ‘m! .-§lt. ttll8.llIl£&l!
  125. 125. ALABAMA AL Board of Examiners in Counseling 950 22nd Street North. Suite 765 Birmingham. AL 35203 800/822-3307 205/458-8716 205/458-8718 (fax) www. abec. alabama. gorv Application packet (if mailed): 325 Application fee: S200 LPC License fee: $300 ALC License fee: S150 Liceuxurt Requlremenlsfar Pr0frs. rinnuI Crmn. elar. r - 2010 Credential Tltle(s) Educational Experiential Exam Requirements Requirements Re - uired Licensed Professional Counselor (LPC) A person licensed to render professional counseling services in private practice for a tee. Associate Licensed Counselor (ALC) A person licensed to render professional counseling services in private practice for a fee while under board approved supervision. Masters degree or higher in counseling lrom a CACREP or CORE accredited program. or the content equivalent. with a minimum of 48 graduate semester hours (or 72 graduate quarter hours) from a regionally accredited academic institution. 3,000 hours of supervised experience in professional counseling with board approved supervision. An applicant may subtract 1.000 hours of the required professional experience tor every 15 graduate semester hours (or 22.5 quarter hours) obtained beyond the masters degree from a regionally accredited academic institution. provided that the coursework is clearly related to the field of professional counseling. This formula may be used for up to 2,000 hours.
  126. 126. K‘ ’<, :ll: ’li'i: _rlltih. ‘_-'i’rg‘. v 20/20: A Vision for the Future of Counseling 4) Creating a portability system for licensure will benefit counselors and strengthen the counseling profession.
  127. 127. ‘*‘¢'%j; '4{%%‘: {l‘i‘§‘—f; ‘~’; E"‘ -. ,4.q-. -—. -ii. -ll: -.. .-, ..-. ,~. . Inter-jurisdictional Practice Licensing Boards that may assertjurisdiction: ° The one in the professiona| ’s state(s) of Iicensure * The one in the client/ client's state of location at time of call ° Both Safest Practice: * Provide services only where licensed ° Require client to attest to his or her location on every call
  128. 128. ‘<, -ll= ’l’u"i= ,r-'Iliil. ‘_-m‘: Inter-jurisdictional Practice (cont. ) Spedalufleheahhandinrnanycases "telemedicine” laws have led the way ° Prescription-writinginitiativesled to devdopnmntoHam5inthe9O% ° Reimbursement practices for Medicare7 Medicaid ° 32 states now mandate in-person assessment prior to distance contact ° Special informed consent laws also rapidly evolving ° Regulatory Case ° Oklahoma case of Dr. Trow ° No in-person assessnwent ° No informed consent v No HIPAA-compliant technology(he used Skype)
  129. 129. rm'. isrm. i llf»lTil (( , , ‘ _ telehealthorg Licensure Requirements for Professional Counselors — 2014 What's New for 2014 (page 4) Distance Counseling, Technology, and Social Media Information In response to the increased use of social media and technology within the counseling profession, state Iicensure boards continue to develop rules and regulations regarding distance counseling. It should be noted, however, that these guidelines are in their initial stages of development and are therefore changing rapidly; always check with your specific state for comprehensive guidelines before engaging in any distance counseling activities. 4° Seventeen (17) states (Alaska, Arkansas, Califomia, Colorado, Iowa, Louisiana, Massachusetts, Minnesota, Nebraska, New York, North Carolina, Oregon, South Carolina, Ohio, Texas, Utah, and West Virginia) do regulate electronic communications for counselors, but only within their particular state. The general rule is that to practice distance counseling in these states, the counselor must be licensed and follow the regulations of that state. Colorado makes the recommendation that the first session should be face-to-face and to meet periodically face-to-face with the client. 0 ZEIYA TEIEMEMEI Heart? ! ITISULLIIE, lnl:
  130. 130. ((6 ‘‘‘t'? ?,‘l‘ ~‘Jl»n, ‘.‘I3;I5J= l i, ‘-IIiIi"t= .F’lljii{_II'(5} r Licensure Requirements for Professional Counselors — 2014 What's New for 2014 (page4) °. ° Twenty (20) state counseling boards (Alabama. , Arizona, Connecticut, Delaware, , Florida, Georgia, Hawaii, , Kentucky, , Maine, Michigan, , Missouri, New Hampshire, North Dakota, Oklahoma, Pennsylvania, Rhode Island, South Dakota, Vermont, Washington and Wyoming) and the District oI'Columbia report an absence of any law. rule, or regulation addressing the use of the intemet with clients. It is therefore assumed that these states treat electronic messages between counselor and client the same way that they treat face-to-face communication. '4' One (I) state, Arkansas, has an addendum to their Iicensure requirements specifically geared towards technology assisted therapy: The Technology Assisted Counseling Specialization license requires additional education and supervision. ‘a’ Five (5) states (Maryland, New Mexico, Tennessee, Virginia and Indiana) specifically state that they do not support electronic communications under their scope of practice for professional counselors. ‘a One (I) state (Mississippi) will only grant Iicensure to state residents and/ or those who pay state income tax. '5 One (I) state (Kansas) allows distance supervision provided that the supervision is conducted via confidential electronic communications. '2' One ( I) state (Louisiana) allows for 25 of the required I00 clinical supervision hours to be conducted via videoconferencing. -2- One (I) state (Ohio) defined one continuing education hour as I0,000 words with regards to distance leaming courses. ' 13,5 .
  131. 131. ( ’’3_5r7,‘‘l5”Ji‘%‘-f-‘3€‘3’‘’ ‘<, =lt= ’l‘o'i= ,i'-'lli'n. ‘_-'iig? Special Telehealth Licenses or Certificates Licenses could allow an out of state provider to render services via technology in a foreign state, or it allows a clinician to provide services via telehealth into a state if certain conditions are met (such as agreeing that they will not open an office in that state. ) http: //www. fsmb. org/ pdf/ grpo| _telemedicine_licen sure. pdf
  132. 132. ( ‘l'v''.9'fA_'. *''‘g‘;3g''L'*7‘‘f*‘*’l‘i‘5'‘‘’ ‘K, ’-llilfur-’ll3h. ‘_-1'15?’ States with Laws Mandating Private Insurance Coverage of Telemedicine Telemedxcme Parity Law Proposed Parity Lfgflldtlon No Pamy Legislative Action
  133. 133. ( ‘l‘r‘§'. ’‘, '3'f‘!7i‘*_‘-f*‘~’f‘§’‘‘’ i, "-ll= ’li"x= ,rlll3n. ‘_-1’(e‘: ‘- w. 'ir. :w, ': Special Telehealth Licenses or Certificates * Alabama * New Mexico to Louisiana * Ohio * Minnesota * Oregon Montana 4' Tennessee * Nevada * Texas http: //www. fsmb. org/ pdf/ grpo| _telemedicine _licensure. pdf
  134. 134. ( i'T'Tf_”}“;17i'%“f*'35L1_"‘l ‘<, =itai. u,r: ILil. .;-m‘. » Innovative Models * National Council of State Boards of Nursing (NCSB) * Federation of State Medical Boards (FSMB) * Association of State and Provincial Psychology Boards (ASPPB)
  135. 135. Licensure Portability Legislation I’ I I . ,a‘*- _
  136. 136. ms, -mum urum ((( , ‘ T teiehealtnorg l'. ‘—l 2010 Innovatjye Met_h_ods " 1'? " The Regulation of Technology-Assisted Distance Counseling and Supervision in the United States: An Analysis of Current Extent, Trends, and Implications Charles R. Mc/ idams III & Kristi Lee Wyatt Counseling Iicensure boards report emerging needs to regulate technology- assisted distance counseling and supervision. An analysis of published regulations and telephone interviews with board administrators nationwide suggests that boards agree generally on 7 aspects of technology-assisted distance practice that need to be regulated. 0 21114 Teieuemzi Health Insunnei Inc
  137. 137. lfl FMF Nlfll HF ‘K TH ((( fl telehea| th. org illl TABLE 1 Current Extent otTechnoIogy-Assisted Distance Counseling (TADC) and Technology-Assisted Distance Supervision (TADS) Regulation (N = 46) TADC TADS Extent of Flegulation No. of States % No. of States % Regulations were in place 14 30 6 13 Regulations were under development 5 11 4 9 Regulations were under discussion 15 33 14 30 TADC and TADS were prohibited as illegitimate activities 10 22 19 41 TADC and TADS had not arisen as issues 2 4 3 7 0 21114 Telemental Health lnsmne, lm:
  138. 138. ( ‘l'v''.9'fA_', *''‘. ‘;3.''L'*7‘‘f*‘*’l‘i‘5'‘‘’ i, '—llili‘t= ,l= ’ll3ti. ‘_-1'15? TELEmedicine for MEDicare Act, 2013 1* HR 3077, the ”TELE-MED Act” was introduced Sept. 10 in the House by Reps. Devin Nunes, R—Calif. , and Frank Pallone, D-N. J. Nicknamed the TELE-M ED Act, seeks to update current Iicensure laws for Medicare beneficiaries, the number of whom is expected to rise to 81 million by 2030
  139. 139. Vii, -.irNTAl llFiTH ((( Q _ ‘T telehea| th. org l’. ‘ I TELEmedicine for MEDicare Act, 2013 In the case of a Medicare participating physician or practitioner who is licensed or otherwise legally authorized to provide a health care service in a State, such physician or practitioner may provide such a service as a telemedicine service to a Medicare beneficiary who is in a different State, and any requirement that such physician or practitioner obtain a comparable license or other comparable legal authorization from such different State with respect to the provision of such health care service by such physician or practitioner to such beneficiary shall not apply. If passed, the bill will give licensing or authorizing states enforcement powers and require the Secretary of the Department of Health & Human Services to solicit input from ”relevant stakeholders” in order to provide telemedicine guidance for states. 0 21114 Telemental Health lnstmne, lm:
  140. 140. X. ‘J lU. S.-CONGRESSMAN MIKE THO _‘REPRESENTl G CAi ifORllli'+ S HFTH DISTRICT E mail | '.liln'i: - lle-'. '.~sletlr_-i Signtlp Reqtie-st a Flat) PRESS RELEASES nee. MIKE THOMPSON mmoouces BILL IMPROVING ACCESS TO MENTAL HEALTH cm: H D 1‘: >3 Washington. DC. Dec 6l 1 comments U S Rep l. lir. e Thompson iCA'«-SN introduced cipamsan legislation ewpanding access to mental health care for Medicare recipients H R 3.2 the Llental Health -‘CC9SS lmprorement -‘-, ct will and thousands of night, qualified Iicenseo mental health counselors and marriage and lanllli therapists il. lFT3l to the nether. Q(pr0u1'39lS eligioie to ser. -:- Llecicare "eneticlanes "Access to quality mental health care shouldri‘t be dependent on how old you are. where you live or how much money you make. ” sai-3 Thompson ‘This legislation will allow thousands of mental health care professionals to provide quality. alloraable care to people on Medicare. and it will save money. Right now. there are more than 600 licensed l. lFTs in my congressional aistnct and more than 31.000 licensed l. lFTs in Calilomia that can provide quality mental health services. Our goal should be to expand access to these prolessionals and the comprehensive and quality care they provide. not limit it. " l. lecii: are currentl. recov; ni: es CSyCl'll3lf| SlS, pshzholo-gists clinical social wcrliers and psichiatric nurses ti: provide coiereo mental health semces How-: mental health counselors anc l. lFTs who hate eouualent education and training to clinical sccial worters and prance taught. 4.’) percent of mental health st-races are not eligible to se reimriursed n. l. l-ecicare H R 3662 would fix this oiscrepanc, 3. ma-mg "ienlal health counselors and l. lFTs eligisle to sene Lleoicare tieneliciai-es aaairig; morethan 15-5.000 licensee practitioners to the Lleoicaie program that are not part of the normal aging process such as depression anriet. mood disorders and suicide Llani ol these mental illnesses can ae diagnosed and propetli treated ilthe appropriate care is at-ailacle sought anc accessed However illefl unheated it can lead to higher ’l‘lel‘JICal costs and negaliie health effects Curr-: -ntlr l. lecii: are ceneficianes who were seeking mental health S9l'y1C§SllDF"I mental health counselors at l. ll-’Ts prior to their ellglflllllv tor Lledicaie oft-: —n stop recei.1ngtreal't‘. c-nt because their eiusting pron-Jet is not under Medical? Thompson 5 legislation will ensure that seniors hate cornpt-: —hensi. ‘e access to qualiliec mental health protiders 3. increasing the pool olrnental health prolessionals that are eligiole to sene Medicare seneliciaries
  141. 141. SEARCH FOR BILLS CONNECT refit! E-NEWSLETTER SIGN-UP Medicare currentty recognizes psyichiatnsts. psychologists. clinical social workers and psychiatric nurses to provide covered mental health services However, mental health counselors and Ml-‘Ts. who have equivalent education and Stues have shown l . geniors in l e Medicare program are 0 en . i e highest its for mental ea i pro that are not part otihe normal aging process such as depression, anxiety, mood disorders and suicide Many oi these mental illnesses can he diagnosed and property treated it the appropnate care is 3'lr'3l|3DtEi sought and Currentty. Medicare benetidanes who were seelung mental health senrices from mental health counselors or MFTS prior to their eligibility for Medicare. ohen stop receiving treatment oecause their eiiishng provider is not under Medicare Tliompsons legislation will ensure that seniors have comprehensive access to qualified mental health providers by increasing the pool oi mental health proiessionals that are eligible to serve llledicare henelicianes ‘The National Board tor Certified Counselors (NBCC) applauds Representative Thompson tor his commitment to ensuring a robust mental health woridorce ior older krriericans. ‘ said Thomas W. Ctawson. President and CEO oi the National Board for Certified Counselors. ‘Medicare provides healtti care to over 49 rniition people and research r than 40% oi older adults with mental or suoslance use disorders ootain treatment The Seniors ss ImprovementActwiII increase access to needed care or expanding the pool at qualified mental Adding mental health counselors and rnarnaoe and family therapists as eligible providers will , tensed proiessionals immediately available to the Medicare population This addition will expand ~ 55, and reduce oosts o - ovidin care in the commurii _ and aroldin e ensiie in atientselvices. NBCC 'tternoers oi the Calrtomia Association oi Mamaoe and Family Therapists enthusiastically applaud and support Congressman Mike Thompson's bill to provide greater mental health senices to our eldeiiy population. ‘ said Guileiino Alvaiel, Chairman of the Caliiomia Association oi Marriage and firmly Therapists ‘By allowing Licensed tlarnage and Family Therapists to become Medicare providers. many calilomiaiis will oenehitiom their expertise in treating a vanety or mental health issues. ‘ H R, 3662 is oo-authored by Repuolican Congressman Chris Gibson (NY-19), The oilt has been referred to the House Committees on Energy and Commerce and Ways and Means. oi which Thompson is a senior member Congressman Alike Thompson is proud to represent Caiifornias 5th Congressional Dismct wihich include: art or part or Contra Costa Lake Napa So-‘ano and Sonoma Counties He is a senior membero! the House Ways and Means Committee and the House Permanent Select Committee on intelligence Rep Thompson is also a memoerof the fiscally conservahve Blue Dog Coalition and chairs the bipartisan oicerneral Congressional Wine Caucus $33
  142. 142. M15-L'i'i; ‘i ii. I I’ II 1:: Iii I (:1v. vic Blll tackles telehealth reimbursement, Iicensure . :L to iVTDl'0vE M-_— mare and Mediraid '9 coverage 01 telehealth This it-Fl I new. tenitor. ‘ for “ rhompson, he mtrodut-Ed some nL}0T -Ealth ' €~i-qis|3ti-: -n as 3 Cahiorrua State Senator In the 19905 = The latest hi" 5 defin tion of ’telehv3a! th" COvE'f5 . arious h-227th s-gm: -as dei . -area remoteh, mclu-ding i‘ < > reniot-2 nC4|'H{O’1|'a and . ideoconfer'ncxnq. both for r home care use. and to -: -nab! -3 sno: -cialists to zvrtuaili practice at hospitals . i.h-: -re they re needed Jonathan L| |'1V. OU5.Ch| €'€! ECUth'E ciflrc-: -r of the ‘ ‘ . '.rneri<an Telemedzzine Associaumn -j. '.T. '.‘i, tc-id i MobiH-2.31: ‘ that en tel‘ ‘aim was WV KS mfanc, , ieg . . tors --vom~: -d about abuse or that it wouidnt be cost-eff-scti. -9 and they hmited Me i and Medicaid ccwersoe to .2" narticutor cases -— only patients in runs? areas could be r-: -inibursed (or am‘ tel-= u Thorr*pson‘s bi", >- r ‘:4. ca‘¥ed Yhe Teleheaith Oromotion Act of 2012, slim mates an» such ‘arb Lrar‘. co. =rage restrict: -:»ns, ‘ amending the Sozial Securm Act to assert that teleheaith must be to. : 0 in any case in i. -/hrch the corresponding in-person treatment mould be COME are Linlrous said It 5 the nah! time for .1 change in t earth palm, due to a combination of the technoiogy ICS-E" irnorounq and becoming cheaper and the tact that teieh-sa’th is a more prowen technologv now. Threats or abuse or wast-: = have not materiahzed, he said. even uwouoh some )0 nii iron people are b-; -in-3 s-; -r. -ed by tel-an . -one todax. Another bio D70-ISIC-V1 c-! the bin stfiat it i. ‘.c-uld 3!‘-3.-. Dh': ‘:’-VCIEUS to pram»: -:~ (‘31v‘: nV-Ed : in. :« across state lines‘ thou! h3.| l'| Q to be hzensed in both states. something . ~.ha: h AYA estimates costs ohm tians about $300 muion a ‘year ‘For Durvoses of remrbursemenn ‘censure. professional IISDVMH‘, and other purposes under this mix; »‘.4lh f>':5E~. CI to the pro. ' ': -ith 5-mic-as, Dhvfiiizxans. Dramti-an-zrs. n<i H tn h: - fiirn. <5* m1 (Hfh : .:r‘ lth s-emits that r-zquired pat: -:~nt-phtsic-an interaction. for insmncvz. «yr-u—-vu . ..| . Jarfzo 20}: cm é. .1. mar‘ im, iP1' , _'L «"1: ‘Li. Fe: 35 ‘Mi: .'. asnirician DC Fe: 23 - 27 2); i.i C)7r1.1ndc’ Fran .13
  143. 143. (( tcansrclannu. 3:11: uzu Connect] [Inc ahe v. s. Governnchi-. Pnnuhg ounce] (L1. 6719 lanodaced an Emu: (13)) 112:3 COIIGIISS Z6 suntan H. R. 5715 T9 9:3“ and Ixpuad the Ayplaunon at tchhulca made: Roman and other reaenl. health one program, And to: other aux-pelu. IN ‘BIG HWSZ O! IKIIISEHYAXXVIS mafia: 30. 2011 Xx. Thomlea at Calxlexnza xhuoducld the tonmuhw bun vhxch vu relenea ID the cauuuee on Energy and counezee. and La Adfliilen to the Ccuuceco on II: I and Menu. Ovczswht cad Gavvnncn: luau. Arne Bcrvxcu. Ind Voceunr lttuu. to: I Mrxed to he luhlcflutnclv necexnuaea by the Speaker. 3.: eneh en: 10: cenexneznuea at such pxovxnann 2.2.1 vxthan can junldxcncn at ch: cwnnen ccnccncd 9 protect and expend the hwlxcncaen at tlllhtllbh usdcz flndscln And other federal heuth caxe program, and to: ache: yurpaaea. 3: 3: uuctld by tat Sums: I-A HUBII at Runncntltavcl at the and sun: at inane: In Cohan tabled. zcrzoa 1. $80!? TIYLI: TABLE 0!‘ CONTESTS. In) 3210:: 21:10.--than Act My be sand on the ‘ ‘fnlchculth naocxon An: 9! 20:1". ch) run: at Con: u:: A.~-The uhle at eonaenu a! thin Ac: 1.: u Sec. 1. Shot: tack: eabxe 9: contents. TITLE I--RDNVIIM nun»? COVERABZ RESTRICTIONS ON TIQRILLTH HM! IIIIZRM’. BILL! !! (122 PIIOGIIAHJ sec. 101. Ihuure: ltedxeud: can. See. 102. Federal enoloyees hunch, dental, And vxsxan benefits pxowxu-. |. see. IDS. TIICABZ. sec. 109. Health care pxovxded by the Department at Veeczhns Mints. sec. 105. zltccuvn den. TXTZZ I1--IDDITXOIIBL IHPIOVDEVIS 1'0 HZDICRRI sec. 20:. Pounve xncci-inn to: uedxun I hunxuz. zcouxuaxena ZEQICELOB ~- -
  144. 144. i I counscrmo ms HEALTHCARE Q aIe TECHNOLOGY COMMUNITY Home t. lews&Comrnentar_. -‘tumors Slloeshows Video Reports ‘. '.’hl!9 Papers Events tnterop +W: »li. :i. :. ’. -- - ' - '-*-l ‘ SOVFWARE SECURITY CLOUD MOBILE BIC DATA INFRASTRUCTURE GOVERNMENT SMART l I II S HEALTHCARE 1/ POLICY & REGULATION Bill Seeks To Clean Telehealth State mu¢moNA. _,u; som. ¢;s Regulations Mess , , Telehealth regulations differ in each of the 50 states, inhibiting » '8'-t Puressrstems -Hamil; olEvm: -nlnlecratec use of technology to treat patients, say proposed law‘: 3"“°"“ PM E‘”""'5° sponso, -3_ )9 Oracle Enadata and tau Pureoata $_. stem tor Anai, tics Compared The Big Data 200 ~ Taming the Beasts :9 IBM Tetaaata Compared -'«‘I’otaI Costot ken Tm’ Representatives Doris Llatsui t'D4CAl and Bill Ownersmn Study Johnson (R»OHl have introduced a hill in » Opegauona] . »‘n3m, c5 mom Mo 2 Congress that creates a tecteral oetinilion or A telehealth and that provides guidance to wow states on how to regulate this burgeoning a . held Telehealth is a major contributing lactor to lncreased health care quality convenience ‘tr and lower costs “ m§jnm ot the hill h V stated “'r-loivever there currently are :70 f3._ separate sets of rules [in different states] as to . vhat type of care can be provided This otten ‘ t geayeg Dom provlgeyg and panems ln 3 state itweet : i of uncertainty The Telehealth Modernization m sham »3g§_', 'i'iII provide guidance to states as they look to UII|1Z€' telehealth 6 technologies in the satesi most secure manner possible " Move to the cloud 3" he t. latsui-Johnson oill grew out ol legislation that was rgggntty adgptgg in Watch tBI. t Business Pannets asmey-talk accutnoi. -1 Clout} Comourlng has czcugnz about traristo'mat<~nai change tc thew chents cusmesses California Among other things that state law broadens the detinitlon ot telehealth to include store-and-ton-lard technology and home monitoring of patients It also allows the state's htedicaict program to cover doctonpatient communic ations that take place outside 0! hospitals physician offices and killed ntirsirlc tacllities
  145. 145. THFMFNTAI HEALTH ((( I , Y K ‘ _ , teleheaIth. org . F. ‘ ‘— i i Legal Suggestions ° Counsel each other & ° Write to your malpractice document those carrier and describe your conversations proposed service before . Communicate Often to investing too much time your local, state and 0’ 5$ national professional ° Check with an informed, associations— let them local attorney who know what you need specializes in telehealth ' Put information in writing '50 verify that 3” aspects of your telepractice are in compliance with state law
  146. 146. Other Legal & Ethical Issues for Distance Counseling ~- — ———— — er s"'r'°fi‘ "“‘ V ; fi , /iv 31, “i
  147. 147. ( ‘l‘v", ¥'. "“_’~"‘7’_. "§‘%‘-f~‘~’. *i‘£"" z, -.uaa‘x= ,r: ua*. ..‘, -my. » ‘- w. 'lr. :w, ': 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 A _ Professions Code Sections 4989.54 (cont. ) l 1 S
  148. 148. ( ‘t'v''.9'ft_'. *''‘. ‘;3.''L'*7‘‘f*‘*’l’i‘5'‘‘’ A1,’-Il= TI"(= ,l= ’llih{_Il'(! ‘f Practical Application: Check on Technology ° Tech check — review potential technology and infrastructure issues prior to initiating the delivery of care - bandwidth (the rate of data transfer) — reliability of equipment (computers, monitors, video cameras, audio equipment, etc. ). — loss of connection due to inadequate transmission bandwidth or other equipment failure during a clinical crisis situation — insufficient camera resolution or environmental problems (adequacy of room lighting and microphone placement)
  149. 149. THFMFNTAI urmm ((( I , Y ‘ _ , teleheaIth. org . n ‘— l . , l I Opening Protoco| * ° Identify yourself and your geographic location ° Ask your client/ patient to do the same 0 Audio/ video check (e. g., Do you hear & see me clearly? ) ° Is there anyone in your room or within ear—shot today? (Agree on safety code words, signals or phrases) 0 Is there anything else I might notice andfind of interest if! were in the same room with you today? ° Has there been an emergency in your environment today? 0 Is there anything else I should know about before we begin ta/ king today? * Obtain full legal review with a local telehealth attorney prior to using any TMHI sample wording with clients either verbally or in in your informed consent document. 0 2014 Telauemal Helm Insmua. In:
  150. 150. r(_c Local Collaborators or Champions
  151. 151. m FMFNT/ II ummc ((( , teleheaIth. org I? .“3li, Iii Mention Other Safety Issues - Have an addendum to your informed consent document — Include social media policy statements*that fit your client population, such as: — Iwill not ”friend” you on Facebook or other social media sites — Iwill not respond to you on sites such as Yelp * Obtain full legal review with a local telehealth attorney prior to using any TMHI sample wording with clients either verbally or in in yo consent document. ur informed
  152. 152. ( ‘t‘r''.4'. ‘'‘. '~''‘. ‘»! .''; ‘*_‘-f*‘~’I*i‘§’‘‘’ ‘K, ’-II= ’Ii"i= ,r'lllth. ‘_-1'15‘: :- i. 'ir. :ii, ': Safety Issues to Consider ** Is there access to firearms in home-based care? * Discuss firearm ownership, safety, and the culture of firearms ° Be prepared to negotiate firearm disposition with patients and consider involvement of family members when appropriate rt Use of trigger safety lock devices is an option
  153. 153. «( TFIFMFNTIUHFALTH . I . -.i »* I ' * teIeheaIth. org Safety Issues to Consider ° Assess potential technology and infrastructure issues prior to initiating the delivery of care — adequacy of bandwidth (the rate of data transfer) — reliability of telehealth equipment (computers, monitors, video cameras, audio equipment, etc. ). — loss of connection due to inadequate transmission bandwidth or other equipment failure during a clinical crisis situation — insufficient camera resolution or environmental problems (adequacy of room lighting and microphone placement)
  154. 154. «( TFIEMFNTN. HEALTH . I F-. ‘ " ‘ ' teleheaIth. org Safety Issues to Consider ° Identify and use of a local collaborator such as a family member or close friend of a patient — Enter name and contact information into informed consent document — Stipulate under which conditions these people will be contacted — Outline emergency procedures and when collaborator will be notified — Clearly define expected roles and responsibilities of local collaborators — Consider discussing these issues with family members directly
  155. 155. Tfl FMFNT/ II. HEALTH I H (,7 Y I U T I, teIeheaIth. org Safety Issues to Consider ° Local collaborator can be helpful for: — providing information about the patient’s history — monitoring mood and behavior — assisting with treatment planning and coordination — coordination with local 911 service when needed — provide an additional mechanism for contacting patients if a connection becomes lost — provide on-site technical assistance — provide support to a patient during emergency situations
  156. 156. m EMFNT/ II. HEALTH l H K‘ Y I U T F teleheaIth. org Safety Issues to Consider ° Assess when using a local collaborator may not be advisable: — Safety of local collaborators must be carefully considered — may be best to rely on trained 911 responders — Be cognizant of potential deleterious effect of disclosures made during emergency management on patient confidentiality and relationships, especially in small communities
  157. 157. Safety Issues to Consider ° Discuss the technical requirements with the patient prior to initiating treatment ° Consider the level of technology experience of the patient (train if needed) ° Have a back-up plan if the video connection is lost — telephone —- landlines are best, but cell phones are better than nothing
  158. 158. m FMFNTAI IIF '«ITH ((( teIeheaIth. org Iuiltii Intake Summary - Explain & sign informed consent document - Conduct a formal intake — no shortcuts - Meet in~person or video, identify geographic location, organizational culture, take full history, medications and medical conditions, mental status and stability, use of substances stressors, treatment history, support system, use of other technology, suicide/ homicide intent - Identify psychological diagnosis - Decide if then which technology is appropriate / Assess technical competence / ability to arrange appropriate setting - Obtain names of all other key providers, get appropriate releases - Verify contact information (address, phone, email) - Have emergency plan in writing I O 2014 Telauemzl Helms Insmna. Im:
  159. 159. OCPM: Online Clinical Practice Management Telemental Health: HIPAA, HITECH & Your State Law
  160. 160. Three HIPAA Rules: - Transmission - Privacy - Security as‘-', ‘.~rm" '3
  161. 161. ( it ‘t, -IIéIu‘i= rilli'n. ',-1'15‘: HIPAA Privacy Rule 4* Data are ”individually identifiable” if they include any of the 18 types of identifiers, listed below, for an individual or for the individual’s employer or family member, or if the provider or researcher is aware that the information could be used, either alone or in combination with other information, to identify an individual: