Over the last few years, we have seen significant changes in how healthcare is provided to patients including telehealth, telebehavioral health, and telepsychology services. This has come to the forefront more than ever due to the coronavirus. Allied Healthcare Professionals who previously would not have used telehealth services now have a need to do so. Services are being implemented urgently and being used by providers who may be inexperienced with telehealth.
Hospitals and clinics are limiting or eliminating outpatient or non-essential care. Schools are being closed down in many states and stay-in-place orders have been issued in multiple states. As a result, Allied Healthcare Professionals are undergoing significant changes in their day-to-day practice. Many Allied Healthcare Professionals are now providing or considering services via telehealth. A few examples include:
- Physical therapists who provide hands-on treatment to patients are now providing care via video;
- Speech language pathologists who treat patients with language and cognitive disorders are now implementing these services via video;
- Mental health practitioners who see patients in an office setting are now needing to provide treatment via telehealth; and
- Behavioral health providers who provide in-person sessions are now working with patients over the telephone.
These services are being implemented rapidly and emergently so patients will still have the treatment they need during this time of crisis. Some patients may not be optimal for telehealth services; however, services are being offered to provide continuity of care in these emergency circumstances. These services may not have been previously considered for the population served, and providers are needing to adapt and learn technology quickly to continue providing treatment. These situations raise important considerations of how best to protect and support the patient (see below “Ensure you have a safety plan should a patient decompensate”).
Changing Regulations
The federal government has relaxed restrictions on telehealth services, and many states have also changed their rules to allow services to be provided. Keep in mind that practice is regulated on the state level, so even if the federal government has relaxed restrictions, state law prevails. Previously there may have been restrictions on services leading to potential licensure issues.[1] Further, the federal government has also allowed payment for services through Medicare, and many states have implemented orders for reimbursement for telehealth via public and private insurers and types of services which are reimbursed (telephone sessions)..[2], [3], [4], [5] This is changing minute-by-minute, and it is important to know applicable federal and state regulations. Once the crisis subsides, these rules may change again, and it is your responsibility to be aware of and comply accordingly.
Take note of these risk considerations when implementing telehealth capabilities in your practice:
- Standard of Care. If you use telehealth methods, the same standard of care applies as if the patient is in your office, clinic, or school. It is your responsibility to know the rules and resources (e.g., emergency services) in the area where the patient is located. It is important to seek legal guidance to ensure you know and understand applicable rules and regulations. While the standard of care is usually considered to be where the patient is located, the best risk management strategy is to also ensure that the standard of care is met in your location. This is especially important if the patient is located in a different state than where you are located;
- Continue to adhere to your ethical guidelines. Whether you are a physical therapist, social worker, mental health counselor, or other professional in another area of practice, it is important that you are aware of your profession’s guidance. It is important to review ethical, practice and other guidelines, and resource documents. In addition, it is important to remember that your professions’ overall ethics codes still govern your work when you are providing telehealth services, so you must still practice in compliance with those codes;
- Be aware of licensure requirements. This is an evolving issue given current, developing emergency orders. Know what the rules are concerning providing telehealth services. Know if you are able to practice via telehealth or if your state has specific licensure restrictions/limitations. Regulations can typically be found on state boards of registration websites or your state government website. Being licensed does not automatically authorize you to provide services via telehealth. Some states may have a requirement that a particular level of licensure is required for master’s level clinicians to practice independently, and some master’s degrees may not be recognized to provide independent services, such as telehealth. Emergency orders are being issued and what is in place now, may be drastically different from what was in place previously.[6] It is important to look at your state website for any emergency orders and know which disciplines can and cannot provide services via telehealth. During this time, particularly if you are engaging in telehealth, it is important to check your state website daily for any updates. In addition, if your patient is located in another state, know what the rules are in that state and whether you can or cannot presently practice telehealth in that state;
- Ensure you have an emergency plan in place should your patient require assistance. It is important that you know where your patient is located should he/she present with an issue requiring mandated reporting and what the reporting laws are in that location—they vary across states. This includes reporting obligations such as duty to warn/protect, abuse and neglect against children, elders, disabled persons, or domestic violence. Know what your obligations are, and the steps to take if your patient requires assistance. If you provide behavioral health treatment, this may include hospitalization or referral for evaluation to determine if a higher level of care is required. If your patient is located in another state, there may be differing reporting rules. You are required to know the rules in your state and the state in which the patient is located, should locations differ. Ensure you know your organization’s policy concerning mandated reporting and what the current policy is during this crisis. Talk with other colleagues about their processes and seek legal guidance, if necessary;
- Ensure you have a safety plan should a patient decompensate. These are unprecedented times. Telehealth for particular patients may not have been considered previously; however, in-person treatment may not be an option presently. It is important to have a safety plan in place with each patient should he/she decompensate. Treatment goals will likely need to be adjusted during this time. It is important to determine, ongoing, if telehealth is therapeutic or if additional services are needed. There may be logistical considerations – for example, if you practice in an area where there is a stay-in-place order. Know how to seek services where your patient is should your patient require them;
- Privacy and security regulations must be adhered to. Know applicable state and federal regulations relating to privacy and security and ensure these are followed. Some states have a higher level of protection within their regulations and, therefore, supersede federal regulations. Not all systems (e.g., computer, VOIP, telephones) meet the privacy and security standards required by HIPAA, and it is essential you use one that does. Note, HIPAA privacy regulations have changed during this crisis. The U.S. Department of Health and Human Services (HHS) has user-friendly information online which we encourage you to review. Should you have questions about regulations, seek legal guidance;[7]
- Protect data. Network and software security must be in place to maintain patient confidentiality; the current circumstances could provide significant opportunities for hackers. Your practice should have protocols to guard against inadvertent disclosure. It is important to use a telehealth service that is encrypted and secure. Keep in mind that it is not guaranteed that your patients will have security or virus protection on their systems. Ensure your consent form addresses the importance of your patients’ computers also having adequate protection and explains possible violations of privacy if those protections are not in place;
- Ensure you know how to use the technology. You may or may not be technologically savvy. It is important you are trained in and understand the platform for telehealth services. Have a plan in place in the event of a technological failure. Know who to contact in the event this occurs;
- Ensure your patient knows how to use the technology. Not all patients are technologically savvy. You will need to educate and ensure that your patient knows how to use the telehealth platform comfortably to maximize therapeutic benefit;
- Be aware of others who may be in the room or can overhear the session. Many of us are working remotely and that creates challenges for providers and their families. Children, a spouse, loved one, or roommates may also be in the home during the time when your session is taking place. This could be on the patient’s end as well as yours, and if these individuals are not involved in treatment, it is important to minimize involvement or potential interference. Find a private area to continue to protect patients’ privacy in the same way as if they were in your office. Network and software security must be in place to maintain patient confidentiality. In addition, inquire who else is in the room with your patient, and document this in your note;
- Group therapy has additional considerations. If providing group therapy, ensure you obtain written informed consent from all participants which includes possible limitations to confidentiality. In addition, similar to in-person group sessions, you should set rules at the outset of each session/appointment (including items such as only one person talking at a time, being respectful of one another, etc.);
- Informed consent documents may need to be updated. Prior to using telehealth, it is essential to obtain informed consent in written form. Remember, informed consent is an ongoing process, and the patient may revoke it at any point. Telehealth services are distinct from in-person services, and you should have an informed consent form that addresses the unique aspects of these services in addition to your standard informed consent;
- Documentation is vital. Even when you are working remotely and providing care, it is essential that you document thoroughly and that your documentation meets the standard of care for your profession as well as any additional statutory or regulatory requirements. Some of the following items are extremely important to document:
- Risks and benefits of telehealth and document that it has been discussed with the patient
- Evaluation and assessment, including documentation of each session;
- Security measures implemented;
- Billing documentation. This may identify:
- the type of technology used;
- the type of telehealth services provided;
- the fee structure for each telehealth service including costs for services;
- Method and procedure for how data is disposed; and
- Significant patient changes.
- Ensure you notify all patients of your change in practice to telehealth. When you contact patients, ensure you maintain confidentiality and privacy. Email is widely used to communicate with patients. Consequently, know and adhere to state and federal privacy laws. Even and especially in these challenging times, you are still obligated to protect your patients’ privacy. Understand that if you email your patient at his/her work email, this is not confidential. The email belongs to his/her employer. It is recommended you receive your patient’s consent and communicate via the patient’s personal email address, not his/her work address; and
- Using telehealth brings new responsibilities. Providing telehealth services offers many opportunities for providers and patients, but it also brings a new set of responsibilities and requirements for technical and other competencies. Good risk management means being aware of those responsibilities and requirements to ensure protection of patients and providers.
Additional Resources
The following resources are recommended for further information on telehealth practice. It is important to note, however, that you should know current state and federal regulations as there are emergency orders in place. It is important that you adhere to the strictest regulations applicable.
- American Academy of Child and Adolescent Psychiatry. Practice Parameter for Telepsychiatry with Children and Adolescents: https://www.jaacap.org/article/S0890-8567(08)60154-9/pdf
- American Psychiatric Association, Telepsychiatry resource document, http://www.psych.org/Departments/HSF/UnderservedClearinghouse/ Linkeddocuments/telepsychiatry.aspx
- American Telemedicine Association, Practical Guidelines for Videoconferencing Based Telemental Health, http://www.ATA.org
- Campbell, L. F., Millán, F., & Martin, J. N. (Eds.). (2017). A Telepsychology Casebook: Using Technology Ethically and Effectively in Your Professional Practice. Washington, DC: American Psychological Association
- Center for Telehealth and eHealth Law, http://www.ctel.org
- United States Department of Health and Human Services, http://www.hhs.gov/ocr/privacy
Conclusion
We realize this is not an exhaustive list but rather is an overview of some of the issues to consider when providing telehealth services during this time. We will post additional blogs in the coming days including a sample telehealth consent form which will be in our next Blog post.
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Kristen Lambert, JD, MSW, LICSW, CPHRM, FASHRM
Healthcare Practice and Risk Management Innovation Officer
Trust Risk Management Services, Inc.
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NOTE: This information is provided as a risk management resource and is not legal advice or an individualized personal consultation. At the time this resource was prepared, all information was as current and accurate as possible; however, regulations, laws, or prevailing professional practice standards may have changed since the posting or recording of this resource. Accordingly, it is your responsibility to confirm whether regulatory or legal issues that are relevant to you have since been updated and/or to consult with your professional advisors or legal counsel for timely guidance specific to your situation. As with all professional use of material, please explicitly cite The Trust as the source if you reproduce or distribute any portion of these resources. Reproduction or distribution of this resource without the express written permission of The Trust is strictly prohibited.