TELEHEALTH: BENEFITS, BARRIERS AND ETHICAL ISSUES
Christina Armstrong, Ph.D.
Long History, Strong Evidence, Provider and Patient Benefits The use of telecommunications technologies to provide care at a distance, or telehealth, has a long history with the first telephone “house call” in 1879 (Aronson, 1977), and the first video telepsychiatry link in 1959 from the Nebraska Psychiatric Institute to state mental hospital 112 miles away (Liebson, 1997). Research has shown that telehealth is appropriate for many populations, including: children and adolescents (Nelson, & Sharp, 2016), adults (Mitchell et al., 2008), older adults (DiNapoli et al., 2017), ethnically diverse populations (Dwight-Johnson et al., 2011), veterans (Wierwille et al., 2016), and active duty service members (Luxton et al., 2016). Telehealth services have been successfully administered for medication management, cognitive behavioral therapies, peer support, anxiety disorders, bipolar disorder, depression, posttraumatic stress disorder, obsessive compulsive disorder, panic disorder, and substance abuse (Andrews et al., 2010; Bensink et al., 2009; Brand & McKay, 2012; Cambell et al., 2014; Choi et al., 2013; DilliFraine & Dansky, 2008; Sloan et al., 2011).
Benefits of telehealth include reduced patient cost (time away from work, lost wages, child/elder care, etc) (Hilty et al., 2007; Simpson et al., 2005), reduced cost to the provider and clinic, including, resources (equipment/infrastructure) shared between providers, reduced office space needs, reduced need for translation services, triage provided remotely without an automatic in-person visit, access to specialists/consultation services who can serve a broader population. Increased patient safety including with elderly patients at risk for fall, or with patients engaged in risky driving, as well as increased provider safety for those that treat patients who are at risk for acting aggressively. The Department of Health Care Services of CA considers telehealth “a cost effective alternative to health care provided in person, particularly in underserved areas.” Regular use of telemental health is also positively correlated to ratings of provider satisfaction (Modai et al., 2006), with satisfaction levels increasing as clinician experience is gained.
Bypassing Barriers to Implementation Telehealth services are in great demand and research supports telehealth as an effective method of treatment delivery. What are the barriers in telehealth implementation for psychologists, and can they be bypassed to deliver the highest quality care possible? Barriers for psychologists include lack of training and competence regarding legal and ethical policies and utilization of technology platforms involved. It is now possible to deliver telehealth securely and relatively inexpensively, and there is a strong evidence base supporting it as a viable delivery method. Excellent training and education opportunities are available, and state and federal guidelines exist. If you have been considering leveraging telehealth to meet the needs of your patients, it is likely that you have many questions. Below are some common questions that California psychologists have, and policies and guidelines that have been developed to guide practice:
Q: Are there California Business & Professional Codes specific to telehealth? A: Yes, per California Business & Professional Codes §§ 2904.5, 2290.5. This code states that “Prior to the delivery of health care via telehealth, the health care provider initiating the use of telehealth shall inform the patient about the use of telehealth and obtain verbal or written consent from the patient for the use of telehealth as an acceptable mode of delivering health care services and public health. The consent shall be documented.” Failure to obtain patient consent in advance constitutes unprofessional conduct. Psychologists need to be licensed in the state that they are providing the services, the informed consent needs to be documented in the patient’s records. Q: Is the practice of psychology in California defined to include specifically telepsychology? A: Yes, Cal. Bus & Prof. Code § § 2904.5 – Applicability of Telemedicine Provisions of Section 2290.5.
Q: Can private payers require in-person contact between a health care provider and patient or limit the type of setting where services are provided before payment is made for covered telehealth services, subject to coverage terms and conditions? A: No, per the Telehealth Coverage Mandate Cal. Health & Safety Code § 1374.13; Cal. Ins. Code § 10123.85; Cal. Welfare & Institutions Code §§ 14132.72, 14132.725. It is important to note that although California has legislation requiring insurance to cover telehealth (video) sessions, not all companies nor group policies will cover this even if prior approval is obtained by that insurance company. For this reason, it is important that you verify in advance with the insurance company any billing procedures that may differ in processing telehealth session claims, and document the call in case the claim is denied.
Q. Can California psychologists provide telehealth services to clients living or visiting other states? A: There are currently no specific guidelines or policies that provide clear guidance on this issue. Your California psychology license permits you to practice within the state of California, and interstate practice via telehealth can be complex. An understanding of the state licensing laws in the state in which your patient is physically located (Place of Service (POS)) is required by the provider, and consultation with your malpractice insurance carrier is recommended. In 2013 the APA published a 50 state review of telepsychology legal and regulatory issues that can provide some guidance (http://www.apapracticecentral.org/advocacy/state/telehealth-slides.pdf), however, due to rapidly changing regulations in this area it is recommended that providers check current regulations. For example some states have guest licensure provisions, allowing out-of-state psychologists to practice for short periods of time (10-30 days, depending on the state) within the state where they are unlicensed. However, a recent article by Wilson and colleagues (2017) evaluated telehealth-related mental health service claims from 2009-2013 across Aetna, Humana, and United Health and found that although there has been increased adoption of telehealth services, that the reimbursements for these services actually decreased over that time period.
Q: Does the California Licensing Board have any Advisory Opinions on telehealth services? A: Yes, see California Board of Psychology’s “Notice to California Consumers Regarding the Practice of Psychology on the Internet” available online at http://www.psychboard.ca.gov/consumers/internet-thrpy.shtml
Q: Does APA provide guidelines on the practice of telepsychology? A: APA Guidelines for the Practice of Telepsychology (2013) offer the following guidance to avoid ethical dilemmas:
Risk Management To reap the rewards of telehealth in your practice, proactively manage the risks. The use of telecommunication technologies to provide psychological services presents unique potential threats to the security and transmission of client/patient data and information. These include computer viruses, hackers, theft of technology devices, damage to hard drives or portable drives, failure of security systems, flawed software, ease of accessibility to unsecured electronic files, and malfunctioning or outdated technology. Patient safety during telehealth, including home-based telehealth, can be effectively managed with appropriate training and safety planning (Gros et al., 2011; Luxton et al., 2010). Although no published studies suggesting that home-based telehealth is less safe than in-office care exist , the fear of potential safety issues may prevent psychologists from providing telehealth as an option for their patients. However, excellent guidance exists, including the ‘How to’ guide “Managing Suicide Risk in Home-Based Telepractice” (Luxton et al., 2014). In this guide Luxton and colleagues suggest: § Determine that patient's condition can be treated safely/effectively via telehealth, including conducting pre-treatment risk/contraindication assessment. § Establish safety plan including who to contact in the event of an emergency. § Discuss technical troubleshooting with the patient and determine method for re-establishing contact during service disruption, involving clinic staff as necessary. § Evaluate patient risk during and after treatment and activate safety plan as necessary. § Obtain alternative contact numbers from patient. Obtain patient’s local emergency contact information and confirm with EMS agency. § Determine how transportation, if necessary, would be handled. § Identify local collaborators that can be called to support patient safety during crisis. § Ensure adequacy of home-environment, technology, and devices. § If indicated by risk level: develop multi-step safety plan and provide patient with a copy. § Address environmental risks to privacy and security for you and the patient, and address limits and potential risks of telehealth in Informed Consent. § Document the rationale for the use of telemedicine in the patient record § Use a secure, HIPAA -compliant health information technology platform
Conclusion While telehealth has been around a long time, it has only been recently that research, technology, and policy guidance fully leverage all the benefits of telehealth, and help to bypass previous barriers to its implementation. Telehealth provides an important option for many patients, so it is important for health care providers to learn to effectively and safely deliver care through telehealth to reduce barriers to patient care.
About the author: Dr. Christina Armstrong is a licensed clinical psychologist in the states of California (#PY28310) and Washington (#PY60216629) and serves on the Los Angeles County Psychological Association Ethics Committee. Dr. Armstrong works for the U.S. Department of Defense (DoD) where, in addition to her role as clinical psychologist, she serves as the lead for an interprofessional education and training program training military clinicians on the safe and ethical integration of technologies in clinical care. In her role in the DoD, she also provides subject matter expertise in the areas of psychological diagnosis and treatment of mTBI and PTSD, suicide risk and prevention, substance abuse, neuropsychological assessment, and the development of behavior change products by leveraging innovative technology solutions to improve mental health in the military community. www.linkedin.com/in/christinaarmstrong www.researchgate.net/profile/Christina_Armstrong_PhD
References: American Psychological Association (2010). Ethical Principles of Psychologists and Code of Conduct. Washington, DC: American Psychological Association. Retrieved from http://www.apa.org/ethics/code/index.aspx American Psychological Association. (2013) Guidelines for the Practice of Telepsychology: Joint Task Force for the Development of Telepsychology Guidelines for Psychologists. American Psychologist, 68 (9), 791-800. Doi: 10.1037/a0035001. Retrieved from http://www.apa.org/pubs/journals/features/amp-a0035001.pdf American Psychological Association Practice Directorate – Legal & Regulatory Affairs (2013). Telepsychology 50-State Review. American Psychological Association: Washington, DC. Retrieved from: http://www.apapracticecentral.org/advocacy/state/telehealth-slides.pdf?_ga=2.231419423.1289051088.1493754869-1635890082.1493749957 American Psychological Association Practice Central – Telehealth http://www.apapracticecentral.org/advocacy/state/telehealth-slides.pdf Andrews G, Cuijpers P, Craske MG, et al. (2010). Computer therapy for the anxiety and depressive disorders is effective, acceptable and practical health care: a meta-analysis. PLoS One 5:e13196, Crossref, Medline Aronson, S. H. (1977). The Lancet on the Telephone 1876–1975, Medical History, 21, 69-87. PMCID: PMC108189 |
