Good afternoon to those of you in the mountains Central and Eastern time zones. And good morning to those of you calling in from the Pacific time zone. Welcome to the second of two very interesting and timely webinars on the topic of telebehavioral health. These webinars are brought to you by the SAMHSA behavioral health information technologies and standards initiative. My name is Alan Mogul with Abt Associates part of the BHITS team. Last week’s webinar examined telebehavioral health from the consumer standpoint.
Today’s session will examine this technology from the provider’s perspective. Now as usual a PDF of this PowerPoint presentation will be emailed to all registered participants for this webinar. The webinar is being recorded and will be posted to SAMHSA’s YouTube page located at www.SAMHSA.gov. Please note that all lines are muted and you can submit comments via the chat box feature typically found in the lower right portion of your screen.
We’ll save all questions that come in for the final 15 minutes of our hour together. And so with that let me introduce our speaker Dr. Marlene Maheu serves as the executive director of the tTelebehavioral Health Institute, Incorporated located online at Telhealth.org where she oversees the development and delivery of professional training in behavioral health via an e-learning platform that has served consumers and clinicians from over 70 countries. The focus for Dr. Maheu has been legal and ethical risk management related to the use of technologies to better serve behavioral health patients. She served as a consultant researcher author trainer and keynoter.
And with that Dr. Maheu the floor is yours thank you Dr. Mogel I’m delighted to be here today and I’d like you to understand my role is one of the educator. I am a licensed psychologist and a licensed marriage therapist. I’m not an attorney. I am not an IT specialist and I’m not a physician so I’m here just to educate and to help point you to some of the materials that we have available to us today and to help you hopefully get get interested in this area so that you can pursue more training.
We have 45 minutes for me to give you a very quick overview and I’ve had to select just some topics but there are many involved and I’ll give you a sort of an aerial view of what the topics might be as we go as well The main question I get from clinicians is is telebehavioral health really safe? What’s the efficacy Does it really work? So safety net to see two big issues. The first thing that I encourage people to think about is that behavioral health is largest and that health care needs in the United States.
So the need is huge and we have a database that we’ve accumulated, our institute the telebehavioral Health Institute of 4,200 articles that talk about the safety and effectiveness of telebehavioral Health. It’s peer reviewed articles and books that can give us a lot of information in a lot of different areas. The problem is that when people go looking at some of this data they are looking in the wrong discipline so they might be looking in psychology or looking in counseling or nursing and they may not find the parameters of what’s out there so I’m giving you some of the common terms and frankly we have a colleague who has documented that that the licensing boards alone for behavioral health care use no less than 25 different terms.
So if you’re in your state are calling it tele mental health another state might be calling it telebehavioral Health. Another one in the counseling world this distance counseling. So in the literature that I started I started publishing this field in 1997 that was my first textbook. We talked about behavioral telehealth. So you see you might think you’re looking up what you need to be doing but using long term. So overall the concept that we use at the Institute is telebehavioral Health because SAMHSA decided several years back that they were going to try to de-pathologize The terms substance abuse and mental health combined them into a term called behavioral health if go to the SAMHSA website which I really encourage you to do you’ll see that they use behavioral health everywhere you might find another slide set that talks about mental health.
But all in all these terms are getting replaced by tele by behavioral health and then by default everything you find in the sense of Web site. We’ll be talking about the links and all the things that are current. We talk about telebehavioral health so there’s been an evolution of the terms and hopefully a coming together of different opinions about which term to use to follow we decide to do at the end of which is follow the lead of the government. If the government can’t figure out what to call this we are really lost.
Now gets when you go round you’ll see that your board might call this digital therapy or I just spoke in Ohio. I believe they called it electronic healthcare delivery. So be aware that there is a body of literature out there and it’s very well documented. I’ll give you some resources to find out later. Now I’m going to also give you some of the key terms and concepts and a very fundamental one as the issue of distance site versus originating site in the literature when you go look things up and see distant site is us OK it’s the clinicians in our minds that’s not intuitive! We think we’re the center of the world we’re not actually we’re in an era of patient centered health care.
And so the originating site is where the patient is. The service originates from that patient onto clinicians and that the care originates from the patient forwards. So originating site refers to the patient site and you’ll see a bunch of derivations of this as well. But for the most part people understand now this is us originating as a patient or the client. Now I’m also going to talk to you a little bit about the classic model versus what we see online through the Internet because there are two very different worlds.
And when I started writing in 1997 the only model out there was what we call now classic model traditional model and it was very much steeped in the medical world. Actually my first textbook was actually my second textbook was an attempt to bring tele psychiatry to the allied health fields that was published in 2004. And so there’s been a lot of change since 2004 but nonetheless I think it really helps people understand this classic model versus the idea of hub and spoke there will be an urban center a city.
And it would connect out to practitioners in rural areas. And so the hub was the urban center and the spokes were these rural areas And then we started doing that through phone lines and then transmitting video very slow moving video through the phone lines and they could do that for behavioral health care because we don’t move a lot. This is not dance therapy for the most part we’re talking and most of us are safe staying stationary. The other thing that they would do is they would work with previous identified clients so the person in a remote site would say you know I can have the most the traffic coming through our doors.
But you know if you present your folks I really don’t know how to differentiate this this diagnosis that when I need an outside consult. So this consultative of model started up where they would send information about the person they had met in person in the flesh and they sent information up to a consultant in one of these hub urban centers and say What do you think can you help me with this diagnosis and treatment plan. And so that is is how it evolved and that is a classic model that still was alive today in a lot of telehealth systems that are funded by the federal government by state governments.
So there is oftentimes in in person assessment when you look at literature then these are reporting distinctions because jumping online with an online employer is very different than what I’m talking about. And every step you take away from the classic model you are increasing your risk not just the patient. The risk for the patient but your professional risk in trying to do here today is give you a quick overview of how to manage your risk and deliver good quality care the same time. So they would get each other documented referral requests they would have the entire health record at the fingertips that they look up when they;re doing this consult. And oftentimes it was a community collaborator.
Not only was there referring party in that local community but they also engaged somebody else in the community to sort of be boots on the ground and help the clinicians by knocking on the door by making doing wellness check by going and just prodding the person and getting them on-board. Getting another opinion of what’s going on. So when you’re not in the community and you can’t see what’s happening it can be very helpful to get that kind of collaborator.
So the client the patient as well has been pre-trained by the local staff so they knew what to do. There was a power outage or you know there was a backup system. The technology was very stable because it was an IT staff and technology staff available during the entire time. So a lot of this we documented in my 2004 book. But you know these classic models I’m going to rapidly move forward to 2012 when Godleski Godleski the psychiatrist and colleagues reported about a study that they had conducted at the V.A.
Now if you look at the reference on this. You’ll see that in the title outcomes of 98,609 U.S. Department of Veterans Affairs patients. That’s a sample size 98,609 patients were in the study. That’s pretty remarkable study and what they found was that using telehealth over a four year period decreased hospital utilization by 25 percent. It’s these numbers that started making health care reform including telehealth really started making this come alive because obviously it saves money it saves time and it helps people in ways that couldn’t be helped before. So the thing about Dr. Godleski’s study is that she very clearly in the last paragraph of that whole article talks about service to the home was the next frontier.
So if you think about service to the home being the next frontier and that was at that point on research relatively on research in 2012. then you have to start wondering about a lot of the things that we see clinicians doing on line in terms of the safety of what’s happening and where where are these ideas coming from. If they’re not following an evidence based classic model now there’s hope so don’t give up hope. I want to show you how the evolution is.
In 2013 Dr. Hilty and his colleagues who did. the first meta analysis that I was aware of remarkable study looked at 755 And they threw out all but 85 the studies and what they came up with was that across many populations many many settings outcomes are comparable to in person care. They also looked at new models of care collaborative care asynchronous care which means not in real time of text messages asynchronous it doesn’t happen in real time. It can but we can also wait and then respond the next day. Mobile health so are positive outcomes.
The only caveat is that these are very highly controlled studies where you’ve got once again a hub and spoke model and urban center typically affiliated with the university conducting the study and they get participants from physicians offices psychotherapy offices drug and alcohol treatment facilities. And they selected the mild to moderately depressed or anxious group of people they give them manualized care as say a 12 session model and then they they look at the results. After all the clinicians in this 12 session model have been coached in how to deliver this exact protocol.
It’s not somebody sitting around and just talking as they would in an open psychotherapy session. This is highly protocol. And then of get these really high outcomes studies. So when people talk about evidence base I would encourage you to think about three things. One of the scientific literature. What are you reading about the science that’s out there that makes you believe that it’s effective. Does what you’re reading makes sense compared to these classic models. And then of course evidence based means it has three components so you look at the literature.
Number two you passing it to the filter of your eyes your brain your interaction with this patient or this client and what they need. And thirdly you look at their input on that Evidence based is not just oh you looked at of a couple of research articles it’s his entire process as the entire three step process that we’re responsible to do. So you can’t automatically generalize from what these these classic studies have then to yeah I can just jump on the Internet and hey I’m good. The text messaging only I don’t have to talk to the person and I don’t have to do any of those things.
That is completely wrong. So you cannot generalize from those control studies to what a lot of people are doing on the Internet. So you’ll give you a few steps that you can do to help yourself out here. Number one that your own literature review. Identify five to ten articles of direct relevance to a your setting and b your population. A lot of people fail to recognize that the setting is crucial here. This is about telehealth it’s about tele it’s about going across distances But what about that setting.
Can you control that setting with that patient that client is in if you can’t then you can’t you’re not controlling your own session. You have to be in control of your setting meaning your family members aren’t coming into your office mates aren’t banging on the door to say hello because they don’t realize you’re int there working and you have to be able to control the patient to the client’s site as well. And if they show up in the backseat of the cab they need to know what to do to stop that session and make sure that they get to secure environment. Now from the literature that I’m encouraging you to find.
Get your own list of to-dos and then build those into your protocols because you want to be able to demonstrate that you’re following a protocol and you’re not just chit chatting. Now if you stop and think well how big is this lliterature base as I mentioned earlier we the institute have more than 4,200 references. There is a free list of those available for you to search online and to give you the URL here at our Web site which is telehealth.org. So the place to go search for these is telehealth.org/bibliography. Now another complicating factor is that unlike ophthalmology or dermatology we have at least nine disciplines within the behavioral world and it’s been dismaying to me during my lifetime to see the turf wars that are going on between these groups. It’s as if we preach getting along we teach.
We we teach and we preach how to get along with the psyche familly systems are or social skills. And yet we have a lot of difficulty sitting at the same table. So a large part of my focus as a professional in the telebehavioral world is to try to bring these groups together I’m going to give you a little smattering of what this looks like. We have nine disciplines addictions professionals behavior analysts behavioral nurse practitioners counselors marriage and family therapist psychologist psychiatric nurses psychologists social workers each of which has its own literature.
So something may have been published in the psychology literature but does it show up in the counselor literature or the social work literature or the psychiatric nurse literature. So you see when you look online it’s better to go to places like Google Scholar where they will look for articles for you and what persons discipline is relevant or go to a librarian and ask them to conduct this research.
The research projects for you. Which more that they’re typically more than happy to do. Now what we did and I’ve done a lot of research through my time I did a study that was published in the year 2000 looking at the the psychology world and their understanding of legal ethical obligations. And frankly it was abysmal. About two thirds of the people responded had no clue that there were any legal or ethical issues that were involved practicing and that they thought they could just do whatever they felt like. So we read this study 15 years later I did this. So an update on this study with some colleagues and we just publish it a few months ago.
So this was like two months ago. And I’m just going to quote for you what what we found although most psychologists 80 percent consider it ethical for licensed mental health professionals to deliver telebehavioral health only 58 percent were aware. State or federal laws or regulations governing such activities. Not even two thirds knew that there were state and federal laws involved. That means a third more than a third thought they still do whatever they pleased and that nothing is further from the truth. Now what might happen is that in their state they may have a law and they don’t know what it is. OK. They haven’t bothered to think about it or look at it.
They may be calling it slightly different in their state. The state may be mute on that. On the topic but it doesn’t mean they don’t have to adhere and extrapolate out to all the existing rules. So I’ll give you an example. Privacy we’ll get some more of these in a minute. But you have to maintain that privacy that is protect the privacy of people you treat now that obligation’s called confidentiality to maintain confidentiality. So privacy belongs to the patient and your job is to protected that privacy and that’s called confidentiality. Any confidentiality. Now it doesn’t say you have to do that when you talk. Doesn’t say you can only do that when you see it from somebody it just says you have to do this.
OK. Now how you choose to deliver that care is up to you. There is no state law that says you cannot do telehealth in this country. It may not mention telehealth but you still you can choose it practice anyway you choose. Just you better be adhering to a lot of these things like privacy documentation. You know just some of these will get through. So it’s your job whether you know it or not.
All right. Ignorance is not a defense in the case of the law. We’re talking about understanding of the law here. So now we’re going to move into the ethical issues and we’ll roll back around to the law. So ethics builds on the law. Right. So the first precept of any ethical code is that you follow all of the applicable laws. A lot of people don’t understand the law that we just established. It says that you really can’t be practicing ethically because they don’t even know that any law applies.
Now I’ve gone through a number of of the disciplines and I pulled out for you the code of ethics. You’ll see a picture of a screen shot on the right side here of what that page looks like on the Internet. And I typed it out for you if you want to go look if you happen to be an addiction specialist an addiction professional then you know where to go to get the stuff. So NAADAC has a code of ethics that is relevant. It actually has a section about this the American Counseling Association has a section section H that’s relevant to practicing the technology. The American Psychological Association has an ethical code but also come up with a guideline of 2013.
This entire thing is about working with technology mostly mostly data counselling marriage The Association of Marriage and Family Therapy has a code of ethics in 2015 that also has a section that talks about using technology. The American Telemedicine Association has three guidelines actually two for 2009 and this one that I was on a team to help develop looking specifically at video based online mental health services. So there’s a lot in this particular one that I think could be of relevance to you. Now we go into nursing there is this is actually their sixth edition of the nursing telehealth guidelines.
Well they call it standards so the difference between standards and guidelines by the way is that standards aren’t requirements your ethical code. in an association. And whether you’re a member of the association or not something goes wrong for you to protect yourself. You need to adhere to those things in a court of law. You will be held to that standard. Either you don’t pay the dues and belong dissociation so and some state laws have actually adopted the ethics code of discipline as part of the state law for that discipline to you really need to understand these rules and operate by them. Now I see you. Nursing has your own Consensus statement about telehealth.
You may want to take a look at that. If you’re an ICU nurse the American Psychiatric Association just came out with something in April 2018. They collaborated with the American Telemedicine Association for telepsychiatry best practices. So my point here is a not all the disciplines have something. Social work technology standards. This is the most thorough one that I’ve seen. And it was just published in summer of 2017 and it looks at not only the individual partition but also the agency.
So what’s my obligation if I’m an agency worker. What if I run an agency. What do I have to do above and beyond what the individual practitioner will have to do is very well thought out. And I’m going to give you an idea here of one of these areas which is competence so every single one of them does the disciplines that I’ve mentioned has a section that has a preamble to their code of ethics that talks about having integrity and not committing fraud and being transparent and social justice in just general values if you will and then they get into specific standards. They also not only mention the values that they want the professionals to have but also competence. And how do you define competence.
Now no group had come up with that before. But it’s important that you think about not only following the laws and then having been competent in your regular treatment area let’s say it’s working with depressed people or PTSD clients patients whatever your specialty is the area of focus but also complex and telebehavioral health. And this is one of the biggest issues that I’m excited about helping people get because we have a tremendous workforce that is just on the verge of being involved with telehealth we have at any given point in time in Congress about 12 at least 12 bills on the floor to open the floodgates for funding for licensure to standardize practice across disciplines team based approaches accountable care organizations. Medicare Medicaid.
There are there are bills that have bipartisan support. And this is just a matter of a very short amount of time compared to the twenty four years I put into this field. But things are right about to break loose and most of the workforce not only isn’t competent telebehavioral but they don’t even understand that they need to be competent so no preaching to the choir if you’re here but hopefully to help spread the word.
Competence is a very big deal because all the ethical codes that I just look at start there you gotta be competent in whatever you do. So let let’s just think about this for a moment. How does competencies fit into the picture states of established laws like privacy and the regulatory boards or licensing boards come down and say OK the way you’re going to maintain privacy as a physician or as a social worker or whatever that can’t be board is you going to follow these documentation guidelines Needs a signed — Depending on the state needs a signed note, you need to date it. You need to track someone’s homicidal who’s suicidal or there’s a plethora of things that different states require as part of the documents for any specific discipline. So those are regulatory codes. OK.
Now medical standards say OK you have to adhere to all of that and we’re going to talk about the discipline the discipline of course being social work counseling and MATV addictions all the things that list earlier. Now guidelines are an distillation of the literature that’s way more specific and standards more specific than the ethical code. So the ethical code is general the guideline would be recordkeeping guidelines.
OK recordkeeping guidelines for tele health. Give me another specialty topic. Yes the sections about that in these guidelines that I mentioned earlier out of that should come competencies. Out of competencies should come training an hour of training a professional service delivery. Unfortunately many clinicians in our countries don’t have all this backwards they just do whatever and then they think about the rest of us later.
So now we’ve got a much bigger push and in terms of the federal government the two instances 2001 saying all training needs to be competency based. So a team of researchers and I came up with interprofessional team made six different disciplines involved and we spent four years looking at competencies and they came up with what we call CTiBS Interprofessional framework and telebehavioral our competencies we’ve identified seven domains five subdomains 51 objectives for telebehavioral health and then a hundred forty nine practices and I’m going to just walk you through some of the practices because I just don’t have time to go through a whole lot of detail about everything.
But these practices are designed for the novice, the student, in essence the trainee the intern the proficient which is a licensed person or supervisor and then the authority somebody who’s a researcher in a field someone who is a consultant you know that that line. So we have across the domains now what I want to encourage you to do is to not only see training but seek training to be a competent behavioral telebehavioral professional.
And think about it in these five steps so there’s a road map for you in terms of develop your own competence. One understand the basic standards guidelines or competencies for your field. As I said no other group has developed competencies only CTiBS which is a Coalition of Technology and Behavioral Science by the way. You’ll find them at CTIBS.org that’s Coalition for Technology and Behavioral Science and they come up with these camps these competencies. and that’s a group. I helped found years ago so you can get that document. I’ll also give you a link to that as through the through this particular program and then decide on the training you need.
Look at the competencies that are needed to telebehavioral health and then get some training that you decide you need to that your state decides you need. Some states now require certain amounts of hours for training and telebehavioral health and then come up with your own “to do” list without a “to do” list. your training is worthless frankly. It’s an exercise but if you don’t get a to do list that you follow up then your exercises aren’t going to lead to anything. Right. So get yourself a “to do” list. Get yourself a pad electronic or a written pad and the right stuff down. I’ve got to do this guy that look for a program that gives you checklists.
Yeah. The developers of a training program should give you a checklist. Make this easy free when you buy training. It’s sort of like buying graduate education. They drag you through this my opinion graduate education or medical education drags you through material that you otherwise never do on your life because that is potentially not inherently all it is them that inherently interesting. So walk away the checklist and then make that checklist even more specific for every technology because you may choose to use a video may choose these apps you may choose to use email texting each one of those has its own ins and outs telephones. Another one. Many states include telephone the definition of telehealth these days. So you want your checklist specific to the technology because they all have their own risks and benefits.
And then add the to-dos for your own specific population. Now I’m going to take you on a little bit deeper dive given the overall overall overview and we’ll get into more specific things like legal issues first on the list of many questions I get is practicing on state or national borders. What’s the reality here is that you’re licensed in one state if at the time of passing your licensing exam you said Oh thank you for that California license to the practice in New York with that now or in Greece because I have to be Greek in origin and I speak Greek and I can I can get people who pay me from from Greece they probably get the license back from me.
It’s oh you can’t practice over state lines and a lot of places think that licensure has to do with them. Back to what I was telling you earlier about the originating site licensure really travels with the client. So on the patient. So if you’re client or patient is working with you will say your licensed in California like I am. And they go to Nebraska for a month because mom had a heart attack. They want to take care of her. Are you licensed in Nebraska? No you’re not.
When you’re practicing in Nebraska you have to be licensed in Nebraska for most of these disciplines and there it’s on you to find out what you need to do for your discipline. Now if you say well my person is is a resident of California so it doesn’t matter where they are right now. That’s been changed. OK. Now the states have become much more aware of these issues. And like I said earlier the vast majority of them I think I know one state that doesn’t require this in all the disciplines involved here. You have to be licensed where the patient is at the time of contact. Now do you not take a call someone calls you? Of course you do!
We always have. Responded to emergencies. But we don’t do our regular Tuesday afternoon at 3:00 o’clock appointment. When we work with somebody who’s over state lines at the time of contact. And there are many ins and outs to this kind of these kinds of questions. But basically what I need you to understand is that the state laws are designed to protect consumers of that state. Much like traffic laws do you when you go to New York state or you go to Florida or you go to California. Some states let you turn on a right make a right turn on a red light. Some states don’t.
You see? You have to follow the law of where you are. That’s how this is with licensure. You have to follow the law of the state you entered into with technology. Even with an app. So if your app collects information from people when they’re in Iowa or Nebraska and they’re transmitted to you technically you’re practicing illegally over statelines. Now keep in mind is that reform is coming. Like I said earlier there are a bunch laws in Congress right now there’s a lot of people pushing on this but we’re not there yet. So the only thing you can do is educate yourself about the requirements for each state and country that you just enter.
And that means contacting the board of the discipline for that state. And if you say well they don’t answer the phone if they don’t that’s they’re not responding to me, they don’t answer email best avenue now is email because then you have a paper record of a time stamp with a name. But if they don’t respond to that then send them an e-mail and summarize what you think is going on at least you established a paper trail. If you want to go into other countries then what you can do is talk to the embassies of those countries and at least make an effort to find out what that local authority needs you to do. You want to go to Greece.
I just spoke in Ohio two months ago and there was a woman psychologist from Japan who said that there was a she had to go to Japan has a Japanese psychology licensing exam. So many countries do have licensing exams even if you’re not aware of it. As I said earlier ignorance is not a defense in the face law. So you need to be mindful of that. It’s not that someone’s going to come and drag you out of bed in the middle of the night throw you in jail if you don’t pay attention these things. It’s that if there’s a complaint against you all of this comes up and you can be held against you. And there again licensure is nothing to play with.
OK. This is your meal ticket. So this allows you to practice. So you need to take your state’s jurisprudence exam then you take it. A lot of them are open book. It’s not that prohibitive. And all they want you to deal in most cases if they want you to get licensed in their state is to show to them that you understand their state law because they have laws that they think are really important over here what we are saying OK documentation requirements are also part of this licensure thing.
People think oh I just practice where I went. There’s a lot more involved than liscensure. There are many requirements that go along with it so documentation kind of helps you get clear about it. And the thing is they can differ from one state to another. They can state they can differ from one technology to another. So the requirements for what you do with the telephone can be different than what you have to do in email versus what you have to do in video. OK so informed consent we have to have an intake and an assessment your progress and intake assessment note. Right. So an assessment process including psychological testing or mental status exam. All these things have been shown as being effective through technology.
What you have to understand the protocols and the models as I mentioned earlier. Do your lit review or buy some training that will help you get through that easily. You have to have progress notes that are unique to various states as well. Many states have specific kinds of termination notes and they may want to take into account as well doing telehealth. What about the mandated reporting. Some states Tarasoff states duty to warn states others are not. You have to know that. Don’t want to be reporting somebody if they don’t require you to do that because then they could sue you for breach of confidentiality. So you see there’s ins and outs there really means you have to understand what’s going on in the state.
Then there also are organizational and administrative requirements so URAC, JAYCO Joint Commission. CARF. There are many groups that have their own requirements on top of all of this for your being in their group. Now I’m going to drill down to one of those documents with informed consent. We actually have a lot of literature about informed consent. So there’s this very complex area but I’m going to just hit it really quick.
So informed consent document only serves as evidence that a process took place. The process is a meeting of minds. You have to be reasonably assured that the person you’re working with understands what you’re going to do and accepts that.
So if you just have them sign a document done! That it’s not adequate and in court that could really hurt you in these requirements. Informed consent also differ from state to state. So also whatever it is you decide to work with in terms of an informed consent document you want a mobile attorney to review it because like I said the laws change from state to state. There’s also this idea of active versus static informed consent so active meaning an ongoing let’s say you start with video when you decide you want to use an app.
Now we’ll get three four sessions down the line or 10 or whatever then you can document that you talked about the app and how to put it on the person’s phone and what it’s supposed to do and privacy protections and all the stuff that goes around introducing an app. But that’s active informed consent it’s a dynamic process it’s not a one time you sign a stock… Got to go and talk about any other safety measures with informed consent so to help you get going with this.
We have a library of 50 clauses that we, in our trainings, encourage people to look at to consider with their population so I’m happy to make that available to you. And for anybody just like to email@example.com and then take your base telebehavioral health informed consent document and look at it in terms of which these causes would be helpful? Maybe you’ll find 3. Maybe you’ll find 10. It’s up to you depending on A your setting and B your population.
Two critical factors that I mentioned earlier Let’s talk about HIPAA a little bit. If you recall 1996 HIPAA talked about three laws transmission privacy security. Lot of people don’t understand the privacy law 18 types of privacy issues that you need to be aware of as a clinician. There again we can’t get into a whole lot of it.
But you have to as one of these factors choose HIPAA compliant technology so you’re a covered entity if you’re a practitioner you’re a covered entity and using electronics and you’re covered entity then you have to use of a compliant technology and the term HIPAA compliant is a misnomer A technical way to talk about this is that it’s HIPAA compatible because HIPAA does not sit around and check off this company’s good this one’s good what it does is it issues a set of standards.
And so companies then can claim that they are compatible with these standards. But now the nomenclature has evolved so that compliance is the term if a company is HIPAA compatible or HIPAA compliant whatever terms they need to use then they will tell you that this is not a mystery they probably pay a lot of money to reach those that of level standards. So they will advertise that. And then of course you want to get a business associate agreement that says that there’s a BAA that says that they will defend you in a court of law if they are not really compliant.
So you want a BAA. When you work with a technology company and the word there is don’t work. your brother in law’s company get a company that is a substantial one. Now if you want to know more about this we’ve created a directory of teleHealth.org There again that’s free to you to go look up different technologies. Sort of a buyer’s guide and it helps you identify some companies. At the time we catalog them were claiming HIPAA compliance or HIPAA compatibility yet again. Buyer beware to check out your own. You want to make sure that they’ve got A BAA to help you out.
Now another issue about computer repair security. Not a good idea to leave your good equipment at a repair shop overnight or even during the day if you have a bunch of patient information on there. You can have your repairs conducted in your office where you can at least monitor your eyeball with what’s going on and then use that kind of equipment. Some people just get a phone for your practice so you’re not giving out information about your clients as do they kind of come up and go and light up your screen to your child or your teenager because they need to make a quick call.
So get your own laptop get your own computer and keep that secure. Keep that away from everybody else in your family and your friends. So in summary here for HIPAA there are requirements. Look these terms up: risk assessment business association agreement and office policies Office policies I’ll just give a little bit more on you have to have a written written evidence of having developed some policies and educated your team about those policies.
And they have to be of that repair staff training breach notification. What will you do if there is a breach. What’s going on. You also need to engage in a fair amount of client patient training. I’m taking a slide or two. You probably know you’re out of topics that may have 10 or 20 or 30 slides in my entire training deck for a two day training Just to give you a little smattering computer repair consersations also make sure that their computer they understand Whatever they put in their computer you can’t protect them from that because they they might be sharing that with other people and you have to tell them who’s going to see whatever records you keep and getting work to the supervisor or you have a tech team that has access to this. Are you working for an on line company who can see what you write in those notes what’s their clearance.
So you need to check a lot of the stuff. What about recording the number one issue that clients have is they’re concerned about the privacy of what they tell you and that being recorded and going out and showing up on YouTube or some place. Now as far as client patient assessment and screening they are setting specific. Key factors are the location of the client the patients. When you think about screening and says a professional setting that classic model right?
A person with a doctor’s office. or a psychologists office. And they would be able to be in a controlled environment. So pretty much any diagnosis can be treated there and actually the initial work in tele psychiatry was with psychotic patients bipolar patients on locked units. When the local people didn’t know what to do then they might have been in a prison cell. They didn’t know what to do. So they went and got a consultation.
So yes telebehavioral health can be conducted with people all kinds of diagnoses but the setting is controlled. So the more severe the diagnosis the more control and setting When we go into the home better to keep to the less severe diagnoses and exclude the more difficult diagnoses to manage depression severe anxiety depression anger those kinds of things not that great an idea to start developing online training sorry online interventions for people like that without a whole lot of control in your platform and a lot clinicians involved in every disciplines to help you think that through Now public settings.
Not a good idea to do psychotherapy in a public setting. Not a good idea to do psychotherapy when someone sitting on a park bench talking to you on their phone either or backseat of a cab. Or underneath a bridge with a group of people around them so unless you’ve got a special arrangement not that great. Boundaries. Be aware of potential boundary violations with using emoticons or abbreviations. We’re not here to be friendly with people we’re professionals.
Maintain your professional stance. Ok don’t get too much about your home yourself. Make sure that things are not visible on your camera you don’t want the exercise equipment with your gym clothes hanging off in the background things like. Make sure your camera’s properly positioned away from an opening door. So the family never comes running through the door. They’re not going to be on camera. Be aware of when you share your screen you might (Oops!) show them things that you really didn’t mean to show anybody. So be very careful with screen sharing and how you portray yourself in social media licensing boards are reacting to lots of social media complaints.
So be very careful about that. Telepresence. You can slow down as I just did right now when you’re trying to make a point. We want to show empathy. You can lean forward like this and look directly into the camera to see that shows interest and shows concerns as opposed to leaning back putting your feet up on the desk swiveling in your chair. You know just tapping your desk. There are lots of things that people do that are extremely annoying to the person other end because of what the camera and the microphone do to us. So be very aware of telepresence presence. Handling emergencies Know your community resources.
Do not shot gun your services out on the Internet. You’re responsible to know community resources according to a lot of guidelines that I showed you earlier. Having proper informed consent that gives you emergency contact numbers. Family and friends of people that you’re working with and an agreement as to what you will tell those people and when. Regarding agreements regarding children and other vulnerable parties like a sitter for children so that they aren’t banging on the door and then come up with a written and agreed upon safety plan safety plan can be of some kind of progress a work in progress where you work collaboratively with clients and patients to come up with safety.
Make sure that a firearm is secured. If someone has firearm in a home. Drugs and alcohol are managed. Continue with risky behavior assessments and documentation every session is it still appropriate not appropriate. And then this plan of who are you going to contact and when. I’m going to give you quickly some resources and turn it back over to Doctor Mogul to take your questions. So the resources that there are many of them on the internet.
I’m just going to give you some of the high points. There is a group of federally funded resource agencies called telehealth resource centers. The geographically located this one in particular Center for Connected Health Policy focuses on policy and they have a report that is available to you for free on their website. And it’s called the State Telehealth Laws and Reimbursement Policies. Once again the Center for Connected Health Policy Those are your tax dollars at work. They can help you understand not only current law but of the pending law in your state. Very useful if you’re trying to develop a program. Also Centers for Medicare Medicaid Services has a brochure that they give out called telehealth services.
This is updated every year. This is the 2018 version and it will tell you about Medicare reimbursement. Medicare is a precursor to a lot of other insurance plans is always useful. take a look at this. It identifies who gets reimbursed where they have to be the patient has to be and a lot of other details about billing and including CPT Codes. The U.S. Department of Defense mobile Health practice Guide. This is a wonderful document that I just discovered recently It was just published in 2017 that helps you think through how to use an app not only with your population but in an agency setting and with your coworkers.
Another resource that I will tell you about is the resources we have at our institute the Telebehavioral Health Institute which is at telehealth.org We have a blog with over 400 blog posts related to telebehavioral health and we have a free weekly newsletter that goes out through email to help you keep current we’ve got we gather the news and telebehavioral health every week and then we send it out to you in this email form.
So with that I’m happy to take some questions. With one caveat and that is that I and SAMHSA cannot endorse any specific service for teleheath so please don’t ask the questions about what do think about this platform or that platform because we can’t really get into those. that level of advocating one of the other. So with that Dr. Mogol let’s turn the microphone back over to you. (Dr. Moghul) Thanks Dr. Maheu. As you can imagine you stimulated much much interest across the country. So let’s try to get through our questions in the order they were received. How do DEA guidelines including Dillon’s law impact prescribing medications with telehealth?
(Dr. Maheu) The DEA has been at the forefront of discussions with the American Telemedicine Association and I’ve been a very active member of the American Telemedicine Association so they’ve actually come out and participated on panels and a lot of this focus is on the Ryan Haight act and that requires the Ryan Haight Act required that prescribers OK have an in person session and before they prescribe. So for Telehealth through to telehealth platforms of any type. And the DEA has been working with this because lots of complaints about that. And as technology improves our ability to diagnose and treat is getting better and better.
Our assessment tools are getting better and better so the DEA is at the forefront. That is something that to stay current with is a task and I want to encourage you to to go and research that and talk with them directly they are very very open. I’ve had a number of conversations with the director there. And so it’s a very big area. If you look at some states New Jersey for example just passed a telemedicine market the entire states that impacts counselors psychologists as well as all of the medical — all the health care groups and they do require in person assessment for telehealth.
But these things are also getting revised so they’ve put a stake in the ground and one issue is that it’s getting challenged and getting overturned. Like I said lots of changes right now in the works. (Dr. Moghul) Thanks. As you use the term telebehavioral health does it include psychopharmacology (Dr. Maheu) Absolutely. Psychopharmacology is part of behavioral healthcare. So anything that has to do with technology then we’re including in the telebehavioral — anything of a distance that actually transmits that as the “tele” part. Tele us a Greek word for across… distance.
Okay so Absolutely. Psychopharmacology could be referring to — I’m not too sure about the question or there but to prescription privileges some medical psychologists. I’ve been very active working with them and I’ve just had a panel of the psychological association last last week about prescription privileges and working and working within a state as well as over state lines which you certainly covered over state lines.
Let me just clear up that in terms of that there are prescribers out there that are doing this type of psychopharmacology work. You can practice over state lines you have to be licensed or registered in a foreign state which may sound easy but it is a rigmarole into the paperwork and fees. But certainly one of the gals on the panel that we had last week was licensed, I think, in five states and another one into two states. So this is happening more and more. (Dr. Moghul) Thank you. I believe you touched upon this a little earlier. If the originating site is in the patient’s home how can those safety and I.T. concerns be insured.
How can the provider ensure service is private and HIPAA compliant. (Dr. Maheu) This is a really good question. The thing is you need to know what you’re doing. OK. So I can’t just get this as part of a very detailed training. And there are many many things you can do. There are agreements that you have to have a clear code words that you have to the person to let you know something’s up on there end and they want to discontinue.
So there are lots of ways to do that. Ask people to do a room check with a camera So that’s a very very long answer. I mean it could be a very long answer but that’s why people would need to get training because it’s very difficult to control that. And the truth is as I mentioned earlier someone has a worse severe diagnosis. You can’t control that! you cannot control someone’s psychosis in their living room. I don’t care how good you are. This is not a matter of getting your your skills it’s a matter of physical capability. You just can’t do that. So your job is to make sure that you are properly screening people.
I just did a presentation up in Vancouver for a forensic psychologist that works for the province of British Columbia. And their job is to do assessments over video. Very complex issue because these are these can be life altering decisions that they’re making is this person incarcerated for the next 20 years or not. You see? So but that is — these are much full of discussion. (Dr. Moghul) Indeed. Thank you. If I reside in one state but the patient is in another state and I am licensed in that other state but not in the one I reside in can I work with them through telehealth? (Dr. Maheu) I love these questions! In most states the answer is that you can work with their citizens. If you’re licensed with that board once again licensure follows the pace the need for licensure follows the patient or the client OK?
But there are some states that say no you can’t do that. OK. Alaska in some disciplines does not want you to be out of state and working with Alaskans and the many reasons for this but one is that they don’t want people from other states overrunning jobs that are available to the local people. OK then you say well, gee the person has travel a thousand miles to get to me. So this is all getting hammered out. In another state when you look at a different set of parameters is Florida Florida literally doubles in size in the winter in terms of the population.
So we have the Florida Boards now saying if you come into our state then you need to be licensed with us because we want you to understand our rules because there’s a lot of way too much is happening for that. And so you really the best thing I can say no matter what your question is about interjuridictional practice is A look up that term in a jurisdictional practice. Get our newsletter and wait for us to send you news about that because we will include that regularly and then contact the board of every discipline for every state you want to go — I’m sorry, I’ll say that again a different way.
Contact the boards for your discipline in every state you want to enter. And if you think well I’m not going to wait six months to get an answer be able to demonstrate that you tried and get some consultation. In that case if you can’t get through to that to that board then get consultation and speak to a lawyer about that as well. At least document that you tried. (Dr. Moghul) 42 CFR Part 2: Is that more strict than HIPAA?
Actually it can. So for those of you that are unaware of the 42 CFR Part 2 has to do with substance use addictions treatment. It in many ways parallels it OK. But there are issues related there that you need to be aware of. So yes if you’re working in that world that is one of those administrative issues that I mentioned earlier are state specific issues. So you need to take the time to read that and if you don’t understand it get some training so that you really do understand it. (Dr. Moghul) Can medication assisted treatment MAT be offered via telehealth for example the prescribing of Suboxone. (Dr. Maheu) Absolutely!
What you think about the classic telehealth model. There is an in-person assessment by a local person and a consultant is brought in to advise now the treatment can be transferred over to the consultant or can continue with that consultative model but the local practitioner does prescribe it. So this can be done over state lines if the consultant in some states needs to be licensed in that state or might just happen to be in that same state. So it doesn’t matter what the issue is. I don’t care if you’re working with substance use if you’re working with A.D.H.D PTSD — regardless of the issue. Telehealth is available and is appropriate.
The thing is you as a clinician need understand the ins and outs of the treatment that you’re offering when you’re working with a addicted patient an opioid addicted patient for example like in this case where in the trigger process are they are they getting assessed are they still in those initial months of admitting that they have an issue or is this aftercare? Aftercare is a lot safer because this person’s literally been in very intensive treatment and there is a clinical staff involved that clinical staff can be involved in the aftercare whereas up until telehealth they couldn’t be if that person came from out of state they had to release the person to go back to their state of origin and they couldn’t follow up because the state laws. But now somebody can be licensed in a facility and they can do aftercare.
They’re licensed and they can get licensed in these foreign states as well. So yes any sort of treatment can be done. I know that the opioid issue is a very big one right now. But medically assisted treatment is a very hot topic and we’ve used typically focus on that as well. (Dr. Moghul) Absolutely. Well I think we’ll have time for one more question. So what if a telehealth visit is not completed for technical or other reasons and a diagnosis or treatment couldn’t be delivered at the end.
Are there any protocols. Can the patient still be billed is the provider under any obligation to arrange for a face to face visit. (Dr. Maheu) These are good questions and I and I’m going to refer you back to the in-person session. Let’s say you have a session with somebody in your office and something happens like this. The session there’s a firedrill and or there was a fire in the building. And you have to leave the building.
Is it legitimate for you to bill for that session? The reference point is always in person care no matter what the question is. What’s a corollary in person. Would it be legitimate for you to bill for the entire whatever it is you know sessions all the minutes of that’s because you know the sessions because you have minutes associated with them. Did you deliver that care. Yes no. All right. Then you have to make that decision about what you’re going to do. And I want to encourage you to have these discussions with your colleagues. This is not just something that there is a rule book about.
OK. But many of these things are little nuances that if you have a full discussion with the training group or with a collegial group a professional situations group forums and groups where you can get some feedback about this kind of thing because you know most of us would like to bill but today I only delivered 23 minutes I didn’t deliver the full session. (Dr. Moghul) Thank you very much. Well speaking a full sessions…
I fear we’ve reached our our limit here. We could probably do this all afternoon. Thank you to all the callers and participants who wrote in questions I fear that we could not get to all of them. However I would encourage all callers to visit the Web site at www.telehealth.org There are a number of resources there. One may also register for online courses and we encourage you to do avail yourself of those resources there.
So with that Dr. Maheu a profound thanks for your very stimulating and informative discussion today on telebehavioral health from the clinicians perspective. I’d like to thank everyone for for calling in this afternoon. I’d like to wish you all on behalf of the BHITS team and on behalf of SAMHSA a very good afternoon. Take care.