Consumers have forged fake ID cards for decades. Even high school kids know how to use phoney ID cards to gain entrance to clubs with bouncers directly examining those IDs with flashlights. Is it adequate for us as mental health professionals to simply ask a distant client to fax, scan or mail a driver’s license for online therapy when we haven’t met them in-person? Given that the populations we serve can include people with characterological disorders as well as serious mental illness, most institutional-based telehealth programs such as those now commonplace in the military, the Veteran’s Administration, teaching and private hospitals usually require at least a single in-person identification process to be conducted by a responsible party before telehealth services are rendered.
  Most often conducted by an admin or a nurse, close examination is made of the client or patient, as well as one or more forms of identification. Required forms of ID often include a driver’s license and an insurance card. Next of kin are named and contact numbers are requested. Medical records are accessed. Release forms, HIPAA agreements and multiple other documents are signed. Slip-shod and unprofessional procedures exist in some places, but they certainly are not the norm.
  If we look beyond our own arena, we can see that other professions also require more reliability in their identification processes, too. For example, in the legal world the signing of legal documents is taken quite seriously. Notaries are trained and licensed to verify ID in person, take a thumb print, and only then sign a document verifying that we are indeed who we say we are. Why should our professional requirements be any more lax?   Given that we most of us don’t know ahead of time when we are working with a potentially lethal or abusive client, I can only recommend that mental health professionals working online proceed with caution. Although some professionals have gotten away with “caution” being the posting a website disclaimer asking such distraught patients to go elsewhere, those disclaimers aren’t likely to release any professional from responsibility if something goes wrong and charges get filed with either a licensing board or a civil court. We are duty-bound to conduct proper screening or assessment everywhere we practice.

On the other hand, if we get a referral from an internist or other reliable professional who has identified the client using standard in-person procedures, that might be defensible. Such professional-to-professional referrals are commonplace in telehealth, but they are quite different from relying solely on an emailed statement from a client naming themselves and faxing a ID card of some type. Even a video impression augmented by an ID card can be arguably inferior to an in-person ID process. Similarly, if the referral comes from an EAP, or directly from an employer, an in-patient treatment facility, a hospital, a church or some other source where the client has been fully identified, that might be considered adequate, too.

Accepting referrals straight off the net raises many red flags and can leave us vulnerable if we get brought up on charges for any reason. I’d encourage everyone to ~not~ take any one’s word on this issue, no matter how informed they seem. Write to your licensing board and ask them if they consider it legal for you to simply ID someone online using a faxed ID, combined with email correspondence, video interview or whatever system you want to use. Be specific in your inquiry. If you want to use Skype, name it. State boards are the ones who have rules defining legal practice in your state, so I’d encourage you to write and get your answer from your own state board.

(Please post your view on this matter below, or if you have information from your state board, please let us all know what they have said.) 

~

Marlene M. Maheu, Ph.D. is the Executive Director of the TeleMental Health Institute, Inc., offering a Certificate training program in TeleMental Health for telepsychiatry, telepsychology, telesocial work, and online counseling. Academic books authored by Dr. Maheu and colleagues include eHealth, Telehealth and Telemedicine and The Mental Health Professional & the New Technologies. Follow her on Facebook, LinkedIn or Twitter.

In response to a question about licensing as posed by a new member of our  LinkedIn group, called “TeleMental Health Institute,” I wrote this recent recap of my views:

Kudos for seeking clarification of current licensing issues. If you want to work with clients who have moved out of state, you might consider contacting the licensing board in their new state of residence. Simply ask for their permission to work in their state with the client in question, and explain why (client isolation and specific need, continuity of care, unavailability of local specialists, etc.). In most cases (not all), foreign licensing bodies will grant you permission if you register with them ahead of time as I am suggesting. In all cases, seek ~written~ authorization to go over your state line with your license.

Also you probably want to write to your own board and let them know of the permission you’re seeking in these foreign states, and ask for their authorization to proceed. That’s the “best and suspenders” approach to licensing, and will give you the most reliable responses.

I strongly suggest you do rely on professional associations or simply read their “guidelines” to give you assurances about licensure. Associations are not decision-makers when it comes to licensing.  Some professional association representatives I’ve spoken with just in the last couple months are woefully under-informed. Get your licensing information straight from all directly involved licensing boards.

The other base to cover is with your malpractice company. CC them all the permissions you get and ask them to give you written assurance that they will honor your policy if you get in trouble for practicing over state lines under your specific circumstances, as detailed in your permission requests (outlined above). I hope you can read between the lines here…it might not be enough to ask if they will cover you for “online counseling”  or  “online therapy.” Describe the specific technology you plan to use (email, video, telephone, chat, texting), as well as your rationale for each client. ~Put it all in writing.~

Remember how insurance companies maintain their high profit margins…. Make sure you get their response in writing — all of it. (A phone discussion of your benefits won’t help you a year from now.)  Read their written response from the perspective of an attorney using their written statement to deny your benefits. If you are unsure of the meaning of their response, run it by your own attorney.

For example, I’ve consulted with professionals who get written responses that say, “We’ll cover you for everything you do that is comparable to face-to-face practice.” In a courtroom, it would be easy for their counsel to take the position that your email or chat-room interventions are a far cry from in-person care, largely because the literature supporting such treatment is sparse and often poorly designed.

Finally, you may want to be even more cautious if they say they will cover you for licensing board infractions — but not for civil suits. Licensing board infractions are relatively inexpensive to defend, so sure, a malpractice company may cover the cost of those complaints for you… but those are not your biggest liability. Civil suits can be the most expensive, especially when they involve a patient or client who has suicided or homicided. In consumer protection states, such as California, those civil suits can be quite expensive to not only defend, but losing them can actually cost you a fortune.

If you need better malpractice coverage, petition your professional association to arrange that for you and your colleagues as a group. They have the power to make these pivotal changes happen. We don’t have much power with malpractice companies as individuals. (Having collective power is why most of us join professional associations….)

In sum, I’d suggest you get permission in writing from all foreign states you wish to serve, your own state, and your malpractice carrier. You might also want to consider involving your professional association when necessary to collectively find malpractice coverage for us to manage our risk when using evidence-based, proven effective telehealth strategies and protocols.

Search this blog site for other posts about licensing — and please let me know what you think by commenting below.

~ Marlene M. Maheu, Ph.D. is the Executive Director of the TeleMental Health Institute, Inc., offering a Certificate training program in TeleMental Health for telepsychiatry, telepsychology, telesocial work, and online counseling. Academic books authored by Dr. Maheu and colleagues include eHealth, Telehealth and Telemedicine and The Mental Health Professional & the New Technologies. Follow her on Facebook, LinkedIn or Twitter.

Did you know that as of Q3, 18% of U.S. residents under 18 had a smartphone? Or that the iPhone operating system for smartphones (OS) had 28% market share and Android had 43%?

Ready for a glimpse into the future?Read a few sample predictions from a recent blog post by Arthur C. Clarke:

By 2015, I expect apps that will automatically identify the food you are eating if you whip out your smart phone and take a picture of it, estimate the calories and other nutritional information and keep tabs on them for you!

By 2015, my smartphone will recognize the bluetooth chip in each of the exercise machines and automatically transfer my exercise information, showing me up-to-date graphs of my exercise regimen!

By 2015, I expect these kinds of ratings and quality surveys by healthcare providers becoming standard operating procedures using smartphone apps.

By 2015, I think you will be able to look up on your smartphone, stats and efficacy about the treatment you are undergoing! With the patient being expected to pay more of treatments going forward, they will demand this kind of information if it is available, and medically valid and sound.

Do you agree, disagree — or is your head still spinning?

~

Marlene M. Maheu, Ph.D. is the Executive Director of the TeleMental Health Institute, Inc., offering a Certificate training program in TeleMental Health for telepsychiatry, telepsychology, telesocial work, and online counseling. Academic books authored by Dr. Maheu and colleagues include eHealth, Telehealth and Telemedicine and The Mental Health Professional & the New Technologies.

Increasingly, the Technical Marketplace Changes Standard Therapy Models.

FREE 1-hour Training Webinar (LIVE)

Wrap up this year with an essential discussion of current events to predict next year’s focus on telemental health and online therapy. This month’s guest will be Tania S. Malik, J.D., Founder and President of COPEtoday. As Dr. Maheu’s guest, she will discuss the rapidly changing legal and marketplace issues related to increasing access to mental health via technology.

In particular, we will be reviewing the nationwide repercussion of various legal changes, including the new California Telehealth Advancement Act of 2011; changes in CPT codes for counseling through telehealth and pivotal corporate shifts in how mental health care will be approached in the United States.

This discussion will focus on recent events in California law, Medicare & marketplace shifts to address:

• reimburseable forms of telehealth
•  the future of home-based care with the elimination of the “in-person” requirement for intakes
• reducing certification requirements for practitioners
• the role of iPhone and other smartphones in the healthcare marketplace
• HIPAA-compliance & the use of Skype
• added value services for platforms that serve as alternatives to Skype
• possible repercussions of Wal-mart’s plans to be the biggest primary care provider in the U.S.

December 13, 2011
2 p.m. Eastern or 11 a.m. Pacific

FREE recording will be made available for 48 hours after LIVE event.

Thereafter, recording and 1 CE is available for $27

Register:

http://telementalhealth.com/webinars

Potentially suicidal clients and patients pose one of the most rigorous challenges faced by telemental health professionals. This brief article will give a glimpse of the advance preparation you might consider.   Institutional Telemental Health Practice Many institutional work settings already have emergency response systems in place. Examples of such organizations include the military, the Veterans Administration, hospitals, clinics, employee assistance vendors (EAP), suicide hotlines, etc. They are organized with local community networks to help you with suicidal threats or attempts.
  Independent Telemental Health Practice If you are a solo, small group or agency,  you may have few if any emergency response systems in place for delivering services outside your local community. If you have nothing but a Google search to help you find an appropriate rescue team or other resources in a far-away location, you may find yourself not only panicking when faced with a suicide threat or attempt, but unsuccessful. Traditional telehealth systems have consistently operated with emergency safety as a first priority, and expanding telehealth access as a second priority. With that in mind, you may want to consider taking these preparatory steps:

1. Understand emergency telehealth protocols by reviewing the related scientific literature, as well as relevant state and local law. Study the ethical codes from your professional association(s). If their specificity is lacking, write to them and urge them to support your attempts to expand your income sources and be more detailed now. Do not rely on a website disclaimer telling consumers to go elsewhere in case of an emergency.
2. Briefly write your practice plan, including the technologies you plan to use, populations you wish to serve, and your emergency response in cases of suicide, homicide and abuse reporting. Submit this plan to your malpractice carrier, licensing board, and professional association ethics board(s). Ask for approval. Some such groups will tell you they can’t give you approval, or that you don’t need to go to those lengths. That’s ok. Even if they inform
   you that they can’t approve of your work, these communications will legally document that you have sought the advice of your peers, which can be one of your best protections in court. This process will also help you clarify your own thinking about
   appropriate professional behavior, and let them know they need to address telehealth more comprehensively. Be an advocate.
   
3. Consider how you operate in your brick-and-mortar office to prepare for suicidal patients. Do the same online. For example, take a medical history, obtain records, discuss your suicide, homicide and abuse procedures up front. Engage in an informed consent process that includes a discussion of risks and benefits. Discuss  your policies regarding failure to appear for sessions, failed technology, and an alternative way to establish contact (telephone). Go a step further and obtain names and contact numbers of a local family member and medical provider; and ask your patient to document the conditions under which you will contact these parties.
4. Get all tax, ethical and legal advice in writing. Then show that written statement to your legal counsel. Some legal verbiage is subtle. Take the opening of an online office  seriously and invest the up-front dollars needed to manage your risk. After all, you will not have much office overhead to pay.
5. Conduct a traditional in-person intake unless you can thoroughly document your reason for not doing so. Make sure your rationales for deviating from this standard are supported by research, and not just the fact that someone is ready to pay you for services, or that you want to help them. If you can’t render full professional services online, work with someone who will, and serve as their specialty consultant (such as described in this webinar and other available models.)
6. Arrange for a practice session with all new clients first, so you both won’t be impeded by the technology during in-session time. (Some affordable vendors will conduct this practice session for you.)
   
7. Get to know your clients’ community emergency backup systems, as telehealth practitioners have done for decades. Most consumers, even in rural  areas, have physical access to some type of clinic, nurse or other healthcare service. Focus on serving a limited number of distant communities and develop your referral networks in those communities. Enjoy the freedom and diversity allowed by telepractice, and sleep well at night.

Is Studying Telehealth Worth the Trouble?
  Telehealth is one of the most rapidly growing areas of healthcare. Technology-based healthcare is poised to be a 6-billion dollar industry by 2020. Handling emergencies in telehealth is nothing new. Existing telehealth emergency models were developed decades ago — and are both safe and effective. It’s time mental health practitioners look at evidence-based, reimbursable models, and find their place in this exploding industry.   Start now by studying existing suicide prevention models for telehealth or join a well-coordinated telehealth training program to guide you. Take advantage of our free webinars and other training. Consider these recent articles:
            Luxton, David D., June, Jennifer D., & Jinn, Julie T.  Technology-Based Suicide Prevention:  Current Application and Future Directions.  Telemedicine and e-Health, January 2011, Vol. 17, No. 1: 50-54.             Luxton D.D., Sirotin A.P. &, Mishkind M.C. Safety of telemental healthcare delivered to clinically unsupervised settings: A systematic review. Telemedicine Journal and E-health. 16(6). 2010 Jul-Aug, 705-11. ~ Marlene M. Maheu, Ph.D. is the Executive Director of the TeleMental Health Institute, Inc., offering a Certificate training program in TeleMental Health for telepsychiatry, telepsychology, telesocial work, and online counseling. Academic books authored by Dr. Maheu and colleagues include eHealth, Telehealth and Telemedicine and The Mental Health Professional & the New Technologies.

The recent Penn State child sexual abuse tragedy points to a fundamental problem that seems to be going unnoticed by many online practitioners who practicing with anonymous clients and patients. That is, the professional does not obtain the full identify and contact information prior to delivering care.

This is a practice that I have repeatedly commented upon. There is nothing innovative or professional about failing to meet our legal responsibilities as mandated reporters, despite the fact that some of our colleagues think they are better serving clients and meeting an “unmet need.”

If you aren’t aware of the sexual abuse story that has been emanating from Penn state, you may want to have a quick look at this New York Times article for a summary.

While different states have slightly different legal codes when it comes to reporting abuse, for the most part, they are similar to that of Pennsylvania, where the following groups are classified as “required reporters” of child abuse – a licensed physician, medical examiner, coroner, funeral director, dentist, optometrist, osteopath, chiropractor, psychologist, podiatrist, intern, registered nurse or licensed practical nurse; hospital personnel engaged in the admission, examination, care or treatment of persons; and a Christian Science practitioner, member of the clergy, school administrator, school teacher, school nurse, social services worker, day care center worker or another child care or foster care worker, mental health professional, peace officer or law enforcement official.

The Pennsylvania law goes on to say that required reporters are to “immediately notify the person in charge of the institution, school, facility or agency or the person in charge’s designee of suspected abuse. The person in charge, or the designee, shall be responsible and have the obligation to make a report of the suspected child abuse to ChildLine [Pennsylvania's child abuse reporting system] immediately.”

Legislative Change?
It’s only a matter of time before we start seeing stories of online mental health professionals failing to meet their legal requirements with regard to abuse, homicide and suicide reporting and management. Let’s remind any online colleagues working with anonymous clients and patients that we all are mandated reporters, regardless of the anonymous platforms various businesses may offer us. Such companies may consider their bottom line more important than our laws, but we can’t.

Any action that we fail to do individually will not only reflect poorly on all of us who are working diligently to legitimize online practice, but also may seriously harm uncounted innocent children or elderly persons.

What Else Can We Do?
Pennsylvania is responding to the recent media attention to this problem with legislative attention: Penn State case spurs movement for new child abuse reporting laws.  The federal government is also examining the issues: Mandatory Reporting Laws Under Scrutiny.

Anyone active in the recent legislative up swell of attention to child abuse reporting may do us all a favor by encouraging the need for legislation to explicitly extend the definitions of mandated reporting to online work as well as in-person care.

 

Legal and Ethical Strategies

 FREE 1-hour Training Webinar (LIVE)

November 17, 2011

2 PM Eastern, 11 AM Pacific

Interested in starting a telemental health practice but not quite sure how to get started?

Familiarize yourself with a successful online practice model that is HIPAA compliant and reimbursed by third-party payors. Identify resources to increase the success of your telemental health practice.

This interview of Mindy Mueller Psy.D. and Dawn Sampson, LCSW will examine their forward-looking business model for practicing telemental health that is both HIPAA compliant and consumer-oriented.

Learn:

• History and development of a practical and effective telemental health practice model
• Legal and ethical alternatives to SKYPE
• Intake procedures, informed consent, and patient education for maintaining a telemental health practice
• Treatment protocols, guidelines, and regulations relevant to telemental health
• Managing mental health crisis for telemental health patients
• Scheduling, record keeping, and billing issues
• Imperative business and professional relationships

Register here: http://telementalhealth.com/webinars

~

Marlene M. Maheu, Ph.D. is the Executive Director of the TeleMental Health Institute, Inc., offering a Certificate training program in TeleMental Health for telepsychiatry, telepsychology, telesocial work, and online counseling. Academic books authored by Dr. Maheu and colleagues include eHealth, Telehealth and Telemedicine and The Mental Health Professional & the New Technologies.

Do we need to conduct in-person assessment before delivering telemental health or online therapy? Is reimbursement for home-based telehealth still prohibited from federal reimbursement? Answers depend on your state law.

For Californians, state law just changed, making home-based telehealth care of many types not only feasible, but reimbursable. The Telehealth Advancement Act of 2011 was passed in September of 2011. Repercussions are far-reaching, and open the door to home-based practice state-wide.

While the entire law can be seen here, I will re-post a few key sections for your convenience:

2290.5. (a) For purposes of this division, the following definitions shall apply: (6) "Telehealth" means the mode of delivering health care services and public health via information and communication technologies to facilitate the diagnosis, consultation, treatment, education, care management, and self-management of a patient's health care while the patient is at the originating site and the health care provider is at a distant site. Telehealth facilitates patient self-management and caregiver support for patients and includes synchronous interactions and asynchronous store and forward transfers. 1374.13. (a) For the purposes of this section, the definitions in subdivision (a) of Section 2290.5 of the Business and Professions Code shall apply. (b) It is the intent of the Legislature to recognize the practice of telehealth as a legitimate means by which an individual may receive health care services from a health care provider without in-person contact with the health care provider. (c) No health care service plan shall require that in-person contact occur between a health care provider and a patient before payment is made for the covered services appropriately provided through telehealth, subject to the terms and conditions of the contract entered into between the enrollee or subscriber and the health care service plan, and between the health care service plan and its participating providers or provider groups. (d) No health care service plan shall limit the type of setting where services are provided for the patient or by the health care provider before payment is made for the covered services appropriately provided through telehealth, subject to the terms and conditions of the contract entered into between the enrollee or subscriber and the health care service plan, and between the health care service plan and its participating providers or provider groups.

Again, the link to the original document is here. 

This law will set the tone for telehealth practice across the country, forcing other state legislator to consider the many restrictions they are putting on their practitioners. For some of us, this has been a long time coming. For consumers who have been denied care despite their desperate need, this is a God-send.

California legislators are to be heartily congratulated for having the education, vision, and courage to enact a law that will reduce the suffering and thereby give hope to the people who now can access affordable healthcare.

That’s my opinion. What’s yours?

~

Marlene M. Maheu, Ph.D. is the Executive Director of the TeleMental Health Institute, Inc., offering a Certificate training program in TeleMental Health for telepsychiatry, telepsychology, telesocial work, and online counseling. Academic books authored by Dr. Maheu and colleagues include eHealth, Telehealth and Telemedicine and The Mental Health Professional & the New Technologies.

Dear Colleagues:

Broad deployment of telemedicine requires common approaches and uniform practices. For over ten years ATA has been developing practice guidelines for the delivery of safe and effective healthcare via telemedicine. These guidelines are developed in cooperation with leading practitioners, researchers, societies and vendors. Nine such guidelines have been formally approved by the ATA Board of Directors and many more are in development. To help guide the future direction of this important initiative, they are conducting a survey of all professionals across the spectrum of telehealth.

Please take a few minutes to complete this brief survey (5-10 minutes) by visiting the link below:

http://www.surveymonkey.com/s/ZTMK9LF

Surveys will be collected through Friday, November 18th.

~

Marlene M. Maheu, Ph.D. is the Executive Director of the TeleMental Health Institute, Inc., offering a Certificate training program in TeleMental Health for telepsychiatry, telepsychology, telesocial work, and online counseling. Academic books authored by Dr. Maheu and colleagues include eHealth, Telehealth and Telemedicine and The Mental Health Professional & the New Technologies.

Two years ago, we at the TeleMental Health Institute published an article about safeguards to use while texting: http://telehealth.net/texting

Some of our colleagues scoffed at our “paranoia,” including a malpractice carrier. Now that several more companies have developed text-encryption and other security/privacy services, and HIPAA violations are being punished, we see more responsible attention to the matter.

For instance, see the recent article below, entitled, Physician texting provides quick communication — and an easy way to violate HIPAA

After years of using pagers, and constantly waiting on return calls, physicians now consider texting to be an efficient and fast way to connect with colleagues.

Although the technology may result in faster and better communication, physicians who text other doctors could be exposing themselves to privacy and security violations of the Health Insurance Portability and Accountability Act.

Though many electronic medical record systems come with secure messaging components, using them requires logging into that system. Sending a simple text from a smartphone — which more than 80% of doctors now carry — is much simpler.

“Physicians are not so much concerned with HIPAA compliance as they are about work flow and physician communication,’ ” said James French, MD, executive director of the hospitalists group at the Cone Health System, a five-hospital system in Piedmont, N.C., during a webinar on texting.

See this webpage for the remainder of the article:

http://www.ama-assn.org/amednews/2011/10/31/bica1031.htm#top

~

Marlene M. Maheu, Ph.D. is the Executive Director of the TeleMental Health Institute, Inc., offering a Certificate training program in TeleMental Health for telepsychiatry, telepsychology, telesocial work, and online counseling. Academic books authored by Dr. Maheu and colleagues include eHealth, Telehealth and Telemedicine and The Mental Health Professional & the New Technologies.