Critical Concerns When Incorporating Telepractice in Outpatient Settings and Private Practice

Abstract

Objective:

Technology continuously advances with new innovations and the evolution of existing devices, requiring health service providers to adapt and keep up with these changes in order to provide optimal services to their patients. Expertise limited to a single technological modality or device will quickly become outdated as new revisions, updates, and alternatives are released into the marketplace.

Methods:

This article presents several of the critical concerns and issues practitioners must consider when evaluating their current and future uses of technology within their provision of outpatient or private practice services, particularly as it relates to direct care. Current literature and use of key telepractice resources, such as those from the American Telemedicine Association and the American Psychological Association, are presented, to provide practitioners with advanced knowledge and considerations for evaluating technology within their own practice settings.

Results:

Practitioners can be prepared to remain on top of this “arms race” of technology when they focus on the critical issues related to the selection and use of technology devices, applications, and modes of use; for example, Internet, phone, email, or text message. Two vignettes illustrate how practitioners may implement technology in their practices.

Conclusions:

Technology can be readily incorporated into outpatient settings to augment practitioners' delivery of health services and improve their experience in clinical practice.

Introduction

From the time when telephones hung on the wall and typewriters were commonplace, to today's pervasive use of laptops, smart phones, and tablets across almost every aspect in our society, technology has moved forward in leaps and bounds. Similarly, the provision of mental health services has leapt forward with advances in research and practice across the mental health field. Opportunities to marry technology with service provision have blossomed in the last decade, with research and guidance following more slowly, raising concerns about appropriate use of technology, confidentiality, patient safety, and security. This article identifies and discusses the critical concerns that arise for mental health service providers when using technology in outpatient settings and private practice, from the simpler situation of talking over a cell phone to the complexities of a remote audiovisual session.

Defining telepractice

Defining telepractice, often referred to as “telehealth,” is vital, as the term can be used very narrowly (focused only on the use of computers for face-to-face audiovisual conversations) or very inclusively (encompassing any use of any electronic device). The Center for Medicare and Medicaid Services (CMS) defines telepractice as the use of telecommunications and information technology to provide access to health assessment, diagnosis, intervention, consultation, supervision, and information across distance (Center for Medicare and Medicaid Services 2014). The American Telemedicine Association (ATA) uses the term telehealth interchangeably with telemedicine, which it defines as the use of medical information exchanged from one site to another via electronic communications to improve a patient's clinical health status (American Telemedicine Association 2014). Across practice settings, the American Psychological Association (APA) summarizes the range of technologies used as: “Telecommunication technologies include but are not limited to telephone, mobile devices, interactive videoconferencing, email, chat, text, and Internet (e.g., self-help websites, blogs, and social media). The information that is transmitted may be in writing, or include images, sounds or other data. These communications may be synchronous with multiple parties communicating in real time (e.g. interactive videoconferencing, telephone) or asynchronous (e.g. email, online bulletin boards, storing and forwarding information). Technologies may augment traditional in-person care (e.g., psychoeducational materials online after an in-person therapy session), or be used as stand-alone services (e.g., therapy over videoconferencing). Different technologies may be used in various combinations and for different purposes during the provision of telepsychology services. For example, videoconferencing and telephone may also be utilized for direct service while email and text are used for non-direct services (e.g. scheduling)” (American Psychological Association 2013a, p. 793). Given the lack of a uniform definition and the wealth of technologies being incorporated into clinical practice, the authors rely on the broad definition presented by the Committee on National Security Systems (2010) that presents telehealth as the provision of services using telecommunication technologies; for example, the preparation, transmission, communication, or related processing of information by electrical, electromagnetic, electromechanical, electro-optical, or electronic means. It is important to note that this article focuses on a subset of telehealth that is termed “telepractice.” Telepractice is the use of technology for direct communication with specific individuals as it relates to direct services, rather than technology tools such as the applications (i.e. apps) that might be used in the course of the provision of services, or blogs and social media that might reach a wider audience than specific individuals under the provider's care.

Guidelines, policies, and regulations

Every health professional organization has its own defined ethics that likely have some applicability to telepractice service provision, even if not intended specifically for that purpose. Additionally, some, such as the American Academy of Child and Adolescent Psychiatry (2008), the APA (American Psychological Association 2013a), and the ATA (American Telemedicine Association 2009, 2013, 2014) have broad guidelines on telepractice, whereas others, such as the Federation of State Medical Boards (FSMB) (Federation of State Medical Boards 2014), have model regulations regarding the use of technology. More importantly, there are federal and state laws and regulations that focus on the use of technology and telepractice. Professionals must be aware of the guidance from their professional organizations, as well as federal and state-specific laws and regulations that pertain to them and their provision of mental health services. Several resources are available to guide practitioners. The Telehealth Resource Centers (TRC) (Telehealth Resource Centers 2014) web site summarizes guidelines regarding licensure and scope of practice. The Center for Telehealth and e-Health Law (2011) provides comprehensive updated information on regulatory issues, including credentialing and privileging at the organizational level. The APA's recently published resource guide for psychologists examines relevant state telepractice policies (where they exist) in all 50 states (American Psychological Association 2013b). Some states have no laws, regulations, or rulings regarding telepractice; some states address the matter generally for healthcare; and other states have very specific directions regarding telepractice by discipline. All practitioners need to attend to this changing landscape as professional organizations issue guidance, new legislation specific to telepractice is regularly introduced, and state licensing boards revise regulations to address telepractice.

Some states may have a telepractice statute that defines what constitutes telepractice within the state, which healthcare providers are subject to the statute, what kinds of technology may be used in providing telepractice services, and any additional requirements, such as informed consent requirements specific to telepractice. Other states may include in the profession's defined scope of practice the provision of services through electronic or other means, thereby requiring the provider to be licensed in that state, or, there are a number of states that have enacted insurance mandates, prohibiting insurance companies from refusing to cover healthcare services because they were provided via telepractice if those same services would be covered if provided in person. In the absence of any such policies, individual provider licensing boards may have issued advisory opinions outlining the board's view of telepractice and what it considers to be appropriate. Given the various ways that states may approach defining and regulating telepractice, it demonstrates how difficult it can be for individual practitioners to know what constitutes good practice.

Challenges

As previously noted, awareness of one's own profession's guidance and policies, as well as federal and state laws, regulations, guidelines, and policies, is a vital task for all mental health service providers. However, once aware of what is, and is not, addressed by the various guidelines, regulations, and laws, providers must then consider these key challenges that one can encounter while engaged in any form of telepractice:

• When to use (and not use) technology

• Increased risks for loss of confidentiality

• Truly informed consent

• Required understanding of the technology

• Patient logistics and technology

• Patient's safety

When to use, and not use, technology

Adults, children, and adolescents, may want (and expect) there to be some component of technology included in the provision of health services (Berner and Moss 2014). Mental health providers must first consider why and how technology may be added to the intervention process. The practitioner should have an understanding of the professional literature and any strengths or limitations of the technology as it relates to the provision of clinical services. Although research cannot address all problems in all populations, existing research provides information regarding the usefulness of telehealth and telemental health interventions specific to some services, disorders, and populations of adults (Ruskin et al. 2004; Fortney et al. 2007; O'Reilly et al. 2007; Kessler et al. 2009; Richardson et al. 2009; Morland et al. 2010; Hilty et al. 2013), and, to a lesser extent, children and adolescents (Nelson et al. 2003; Yellowlees et al. 2008; Himle et al. 2012; Myers et al. 2013; Xie et al. 2013; Comer et al. 2014).

Deciding to use technology should be informed by emerging research, changing laws and policies, the unique provider–patient relationship, and objective information about the benefits of technology to this particular intervention. Practitioners should discuss with their patients why (or why not) technology is being incorporated into the treatment and should be able to evaluate the effectiveness and usefulness of continuing to use the technology. As with any treatment modality or intervention, it is incumbent upon the provider to monitor and actively decide to continue, modify, or discontinue that particular use of technology.

Increased risks for loss of confidentiality

When practitioners decide to incorporate technology into their treatment process, it is also important for them to be aware of the increased risks to patient confidentiality associated with the use of that technology (American Telemedicine Association 2013). In addition to adhering to federal and state patient privacy requirements, additional risks appear if technology is involved. For example, not all audiovideoconferencing platforms are equal. Whereas web-based platforms such as Skype® or FaceTime® are readily available, neither purports to be compliant with the Health Information Portability and Accountability Act (HIPAA) nor do they provide the practitioner with the necessary access or audit controls to protect against unauthorized disclosure, as required under the Health Information Technology for Economic and Clinical Health Act (HITECH) (Health Information Technology for Economic and Clinical Health Act 2009). More importantly, neither offers a business associate agreement as is generally recommended for third parties that may have access to patient information maintained by the practitioner. It is important that providers research what other web-based videoconferencing options may be available that are more compatible with privacy and security requirements. The same holds true for email and text messaging. Even when the program/application selected for use is rated at the highest level of security for transmission and privacy, potential risks for loss of confidentiality remain based on how the device or software may be used. For example, any time patients list the provider by name (and specialty) in their cell phones, leave the program running on the “family” computer, do not disengage their social media connections, or do not have any form of password protection on their devices, they run the risk of others accessing personal treatment information. Similarly, providers must also be discreet with content on their own laptops/cell phones/tablets, not share protected information on public computers, and utilize password protections across all technological devices. An additional area to consider is the security of the location where the patient and practitioner are situated when engaged in telepractice, making sure that it is private and secure. And, if any electronic protected health information is created as result of the encounter, the practitioner needs to be very clear about how that information is stored and who might have access to it. Considering each of these concerns and discussing them with the patient prior to embarking on the use of technology within the treatment process ensures that all parties are aware of risks and taking appropriate precautions.

Truly informed consent

All ethical standards clearly state that informed consent informs patients in language they understand about the services being provided and their limitations. Introducing technology to the provision of mental health services requires that the patient understands the rationale, use, and potential loss of privacy inherent in the technology selected. This understanding of technology goes well beyond the “turn on and use” functions and the legal disclaimers found with the majority of devices and methods available for communication. The patient must clearly understand the risks of the selected technology and the steps taken to protect the potential loss of confidentiality and security. Inherent in the issue of a patient's understanding of the risks when incorporating technology is the practitioner's responsibility to ensure that the patient is able to competently use the specific technology as well. Once patients are informed of all the inherent risks and benefits, only then can they actually provide informed consent for the use of the technology. It is of note that practitioners are responsible for using due diligence in selecting and using technology consistent with HIPAA guidelines.

Required understanding of the technology

Closely related to the critical issue of informed consent in telepractice is the practitioners' own understanding of the technology they are employing. Does the practitioner understand the numerous aspects related to security of the information created, delivered, and/or stored by the technological device or medium (data creation, maintenance, and storage)? For example, when using a videoconferencing mechanism to provide direct services to a patient, how secure is the system? This same question can be asked of cloud-based data storage systems, apps, and other technologies that might supplement direct service provision, and other technology that practitioners might use to best meet patients' care needs. Also, who has access or rights to the content conveyed or the data stored in the system? Is it only the individual who owns the account or does the company have access as well (access to information)? Another example is if patient records are maintained on a practitioner's cell phone or tablet, what safeguards has the practitioner enacted to protect or wipe clean the files if the device is lost or stolen (data security)? If patients are using their own devices, what level of security and protection should the practitioner discuss with them to protect against the potential loss of information and confidentiality resulting from actions or lack of actions by the patient (data protection by the patient)? Furthermore, does the practitioner understand laws and regulations that relate to telepractice (legal and regulatory requirements)? For example, if a patient is a Medicare beneficiary, CMS mandates specific requirements as to the location at which the patient may receive telepractice services; for example, patients cannot be located at their homes (Center for Medicare and Medicaid Services 2014). Therefore, the practitioner must not only know specific information about the devices, programs and apps that they use, but must also know the research that supports (or does not support) the use of specific telepractice services, and relevant federal and state laws as they relate to each patient (data-based decision making).

Patient logistics and technology

When practitioners begin to use technology to provide mental and behavioral health services, they must reconsider, and most likely revise, usual office practices related to informed consent, billing, scheduling, and communications between appointments. When technology is introduced into an existing treatment relationship, these issues must be revisited. For example, provider and patient must agree on how disruptions in service will be handled while using any web-based audiovideoconferencing platform. If the Internet connection or device fails, what procedures will be followed to reestablish the connection? Is there another method established as a fallback when the primary method of connection is disrupted? Will patients be billed for the time they are offline but scheduled to be connected? Does the patient plan to pay out-of-pocket for services provided via telepractice, or use insurance benefits; and how will the services be billed? If the patient plans to use insurance coverage, it is important to note what the payer policies are. Addressing these logistical questions prior to the engagement of telepractice with a patient can prevent later misunderstandings. Further, as more and more practitioners turn to email and text messaging as additional mediums for communicating with their patients, a discussion in advance about how often the practitioner checks messages, the timeframe when patients may expect responses, and if there will be fees charged for the time the practitioner is involved in these electronic communication processes is also useful.

Patient safety

Although patient safety is listed as the last challenge for practitioners engaged in telepractice, it is by far one of the most critical ones, because of the potential for actual harm to the patient. The incorporation of telepractice into the provision of mental health services requires the practitioner to consider the myriad of potential problems related to the patient's safety, and plan how these might be addressed. For example, when services are being provided via audiovisual connections at a remote location, the practitioner must develop and discuss with the patient the various steps that could occur if the patient was deemed to be a danger to self or others. The practitioner should identify in advance the appropriate emergency contacts where the patient is located and have emergency phone numbers readily available for referrals and resources local to the patient. Ultimately, when engaged in telepractice across any distance, the practitioner needs to use reasonable efforts to prepare and plan for potential emergencies that may arise, using the patient's local resources and contacts (Luxton et al. 2010).

Moving Forward

Practitioners must carefully consider each of the challenges discussed, and then take actions to ensure the safety and well-being of their patients when providing telepractice services. How one begins to address these challenges is outlined in Table 1, which contains key questions for each challenge area the practitioner should address in order to move forward with the decision to engage in telepractice. Asking each question and weighing the responses can guide practitioners' decisions before they begin using technology.

Table 1.

Sample Questions to Consider for Each Challenge

Challenge	Sample questions
When to use (and not use) technology	• Why incorporate the use of technology with this patient? Specifically, is the patient's clinical status suitable for telepractice services?
	• Is technology suitable for this patient's cognitive abilities and degree of technical sophistication?
	• Does the research literature support the use of the selected telepractice with the patient's diagnosis and population?
	• Are there more effective/efficacious alternatives than the incorporation of technology with this patient?
	• (After each patient visit) Should I continue, modify or discontinue the use of technology with this patient?
Increased risks for loss of confidentiality	• Does the use of this particular technology adhere to federal and state privacy and security requirements?
	• What potential risks to the loss of confidentiality does the use of this particular technology have?
	• What security measures do I have on my technology devices and programs/applications to restrict access to any data they contain related to the patient?
	• What security measures does the patient have on his/her technology devices to restrict access to any data they contain related to the patient?
	• In the event of theft or loss of devices with telehealth information contained on them (e.g. cell phone, tablet, laptop), what preventative steps have been taken to allow for a remote removal of data the device contains?
	• Have I discussed steps that the patient must take to ensure that all electronic communications are private, from the patient's side, e.g. private location for telephone or audiovisual communications?
	• Have the patient and I discussed rules regarding the recording of any telepractice communications and are we in agreement as to whether any aspect of the session will be recorded by either party?
Truly informed consent	• Does the patient understand the rationale and use of the technology selected?
	• Does the patient understand the increased potential for loss of privacy inherent in the technology selected?
Required understanding of the technology	• Do I understand the devices, programs, and applications well enough to explain to the patient the potential for loss of security or confidentiality?
	• Am I experienced and competent to use the selected technology?
	• Have I reviewed and ensured that I am in compliance with all federal and state laws as they relate to telepractice?
Patient logistics and technology	• What procedures will be taken if the connection between devices fails to connect, or disconnects during the telepractice session?
	• What will and will not be billed with regard to time spent with technology and the patient?
	• Will the patient use his/her insurance benefits or does the patient plan to pay out-of-pocket? In either instance, how will I invoice the telepractice services?
	• In what time frame can a patient expect a response to electronic communications, e.g. emails, text messages?
Patient safety and crisis planning	• What are the local police and emergency numbers for the patient?
	• Who is an alternative person to contact that is in close proximity to the patient in the event of an emergency that would require another person to connect with the patient?
	• Based on the different locations of the practitioner and the patient, what specific emergency procedures need to be discussed and agreed upon to ensure the safety of the patient?

Practitioners considering adding telepractice to their services are likely to be motivated by one of two reasons. The first reason is that patients in their existing private practice or organizational setting are expressing a desire for telepractice. For these individuals, who might already have a well-established relationship with the practitioner, an occasional session via technology because the patient is traveling, temporarily residing elsewhere, or unable to consistently attend in-person appointments, might be a strategy to ensure continuity of care and meet the needs of existing patients. The second common reason is to reach new markets. For example, the practitioner might have a reputation for expertise in treating a particular problem or in working with specific patient populations, and technology might enable that practitioner to reach a wider number of individuals who would benefit from the specific expertise (see Comer and Barlow 2014). Other reasons might prompt practitioners to consider adding telepractice services as well. The questions posed previously must be considered when implementing such a change, whatever the reason. The following scenarios illustrate the complexities and procedures involved in these considerations.

Case Scenarios

Scenario 1

In one scenario we find Dr. T., a mental health provider who has an established private practice and long-term relationships with many of his patients. Because of requests from several of his patients, Dr. T. is now considering providing services via telepractice as a supplement to his current in-person care provision. He has decided that telepractice is appropriate for his practice in three categories. The first is for patients whose periodic travel, as required by their employment, interferes with their routine appointments. A second group of Dr. T.'s patients includes high school-aged adolescents, who upon graduation will attend college out of town. Finally, there are those patients whose therapeutic sessions are interfered with because of temporary situations; for example, injury, illness, or lack of transportation if their vehicle is disabled. Dr. T. has determined that patients in these categories still require ongoing treatment, but when their routine, in-person schedule of appointments is not feasible or possible, he will then offer a telepractice option.

With Dr. T.s decision to incorporate the provision of telepractice services as an adjunct to his office mental health services, he must now determine how to begin the process of using telepractice. However, as noted in this article, there are several things Dr. T. must first consider and put in place prior to his very first telepractice session.

First, Dr. T. must determine what type of technology he wants to add to his practice and the resources needed to support this technology. He decides that he will only engage in audiovisual telepractice sessions. He must then consider when he will, and will not, use the telepractice sessions. Dr. T. decides that this will only be an option for existing patients with whom he has an established relationship. He further decides to determine use on a case-by-case basis depending upon several factors, including patient diagnosis, therapeutic rationale to maintain his therapeutic relationship versus transferring the patient to a “local” provider (e.g., college students), and the length of time the patient is unable to attend in-person sessions. Dr. T. continues to monitor professional journals and research to stay abreast of the efficacy of telepractice with various diagnoses.

Dr. T. then reads his state licensing board rules, regulations, and policies related to the use of this type of technology. He also contacts his professional association to learn of any established policies regarding telepractice. He learns that he may not be allowed to provide his services to patients outside of his state because he does not hold licenses to practice in any other states. Therefore, he will only provide services within-state.

He next consults with colleagues to see if others are engaged in a similar use of technology in their practices. He finds a nearby colleague who has been providing telepractice services similar to his plan for several years. This colleague is excited to hear about Dr. T's interest in adding this option to his practice and provides Dr. T. with an abundance of helpful information and support, including helpful web sites. This includes sample consent forms and other documentation for record-keeping, as well as advice on insurance billing issues related to telepractice. Dr. T.'s colleague describes the process she goes through to obtain information about local (for the telepractice patient) resources and emergency services, and the specific issues she covers when obtaining consent from her patients, as it relates to the telepractice services. She further outlines the key points she stresses to her patients when describing confidentiality and security issues specific to telepractice. Dr. T also consults relevant telepractice web sites (http://ctel.org) for guidance, and adapts his colleague's forms for use in his practice and updates informed consent with each patient with whom he begins a telepractice relationship. Because Dr. T. does not have regular legal counsel, Dr. T. contacts his liability insurer to ensure that his forms are appropriate and that his coverage includes telepractice.

In choosing the software program, Dr. T. reviews several options, but decides to use the program recommended by his colleague. He checked to ensure that the program contains several layers of security for added privacy and that the vendor has a business associate agreement conferring many of the obligations and liabilities under HIPAA to the vendor, not just the practitioner. He determined the procedures for obtaining technical support and their user-friendliness for both the provider and patient. After selecting the software, Dr. T. reviews and revises his informed consent documents to discuss consistently with all patients the increased risk for loss of security and confidentiality inherent in the use of technology. He also created a checklist of key points to discuss with each patient regarding their actions necessary to maintain the expected level of confidentiality and security. An additional step Dr. T. takes is to ensure that patents understand how to use the selected technology and are able to take appropriate steps to safeguard their confidential information, such as using passwords and maintaining the overall security of the devices.

The final step for Dr. T. is to remember to place a note in each patient's file, reminding him that the telepractice option will be reviewed prior to every session to determine whether it is still viable. Dr. T. now has the software selected, policies and procedures in place, and a full understanding of the telepractice process being incorporated into his practice.

Scenario 2

In a different scenario, we have Dr. P., an early career mental health provider interested in developing her practice to reach a certain patient demographic through the use of telepractice services. Her practice focuses on treating adolescents, for a variety of issues such as depression, anxiety, agoraphobia, posttraumatic stress disorder (PTSD), and obsessive-compulsive disorder (OCD) often in the context of existing physical health problems. However, Dr. P. notices that physical health problems interfere with patients' ability to attend sessions and she sees telepractice as an opportunity to expand her practice. Dr. P. also knows that her patients are active on social media and many seem to be very knowledgeable regarding the use of technology across many aspects of their lives. After reviewing the current literature, Dr. P. decides that she would like to market a telepractice component of her practice to patients with serious or chronic medical conditions such as cancer, who may experience greater difficulty in getting mental health services because of their health issues. She would like to offer telepractice services to this particular patient demographic so that patients can either receive services in their home or from another provider's office where they may already be receiving other health services. She is aware that there are state laws and professional guidelines advising that the initial patient assessment may need to be done in person.

As an early career provider, Dr. P. is very interested in trying to leverage social media as part of her marketing and outreach efforts. Social media can be a powerful tool, but it is critical that Dr. P. understand her professional ethics and legal requirements as they relate to advertising and professional boundaries. For example, if Dr. P. decides to develop a social media presence (such as a Twitter account, Facebook page, or practice web site), her professional profiles need to be separate from all personal use of social media. Additionally, Dr. P. will want to give very careful thought to how she uses social media to ensure there are no foreseeable risks to patient confidentiality. For example, it would be unwise to accept Facebook friend requests from patients or former patients, to follow any patients or former patients on Twitter, or to provide a section for online comments or feedback on her professional practitioner web site. It would be worthwhile for Dr. P to discuss with her adolescent patients at the outset her need to maintain their privacy as her patients, which is why she will not accept friend requests from them or choose to follow them on Twitter, Instagram, or any other social media platform. Dr. P also understands that adolescents may be more comfortable with using technology, and elect to communicate via email or text messages. If she opts to use secured, encrypted email or text messaging with her adolescent patients, she needs to decide whether to limit those communications to administrative matters (e.g., rescheduling appointments) rather than discussing private issues, and to talk with her patients about reasonable expectations for when she might respond to their emails or text messages in order to maintain appropriate boundaries.

Nevertheless, Dr. P. could use social media to share educational materials relevant to her targeted patient demographic (e.g., people with cancer) and to share her interest in offering telepractice services. She could “like” or follow organizations or issues, such as the American Cancer Society, the National Cancer Institute, or more targeted groups such as Stupid Cancer. She might look for local cancer support groups where she could offer to talk about how mental health providers can be helpful in coping during the treatment process and how telepractice can make accessing services easier, and in some circumstances, she can provide telepractice services to patients at home.

Aside from social networking, Dr. P. decides to network with other providers to develop patient referral sources. Therefore, she decides to contact local hospital cancer centers and local oncologists and radiologists to alert them to the fact that she can offer telepractice services to their patients who may benefit from receiving telepractice services in their homes or the other provider's office.

Now that Dr. P. has figured out how she would like to incorporate telepractice into her practice, she needs to consider several additional issues. First, what kind of telepractice platform will she use? What is financially feasible relative to the size of her practice? There are a growing number of vendors that have developed web-based videoconferencing platforms marketed to healthcare providers (see www.americantelemed.org/). The costs for such services vary, as some offer per-session fees for those providers who use videoconferencing sporadically, whereas others offer tiered monthly subscriptions. Dr. P. may opt for a videoconferencing service that offers per-session fees, similar to cell phone/data plans, as she may initially use this service sporadically as she develops her practice; or she may prefer a service offering monthly subscriptions tiered to the number of sessions she anticipates using on an average monthly basis.

In reviewing providers, Dr. P. knows to identify a service that is HIPAA-compliant and offers a business associate agreement consistent with the requirements of HITECH/HIPAA. As part of Dr. P.'s checklist, she also wants a product that offers ongoing customer service and technical support to help with any troubleshooting. She decides to take advantage of free demonstration offers so that she can see the quality of the video resolution for effective patient interaction, learn how a platform functions, and understand any of the additional features offered, such as a secure messaging portal or interactive calendar through which patients can request appointments.

Another issue that Dr. P. considers is her patients' payment for telepractice services. The families of her patients may opt for a fee-for-service or self-pay model, but many may want to use insurance benefits or even Medicare coverage. Because Dr. P. accepts insurance for her current patients, she decides that she will also accept insurance for her telepractice patients. She realizes that third-party payers may have certain rules or billing procedures for telepractice services, such as adding a “GT modifier” to the billing codes (http://www.cms.gov/Telemedicine/; http://ctel.org). In particular, Dr. P. must provide telepractice services to Medicare patients at an authorized clinical setting. She understands that for patients with third-party coverage she cannot charge for her videoconferencing costs. Therefore, she decides that she will not pass on her technology-related costs to her patients whether or not they use insurance. Rather, Dr. P. views these costs as part of her practice overhead costs.

As she begins laying the groundwork for expanding her practice to include telepractice, Dr. P is also consulting with her licensing board, professional organization, colleagues, and liability insurer to develop appropriate informed consent and related documentation for the telepractice component of her practice. Dr. P. knows that she will need to be explicit regarding her use of technology, the patient's obligations, and the limitations. Dr. P. is also aware of the multilayered process of consent required for those under the age of majority, with the legal right for consent remaining with the parents to make healthcare decisions on their children's behalf, as well as the importance of obtaining the consent of the adolescents or children themselves to comply with treatment. She knows that the addition of telepractice must be clearly understood by both the parents and their adolescent or child in order to be most successful. She will also review with parents and their adolescent or child how to protect the privacy of the therapy session, even when conducted via technology. She is committed to ensuring that this new practice opportunity will result in a greater number of individuals accessing high-quality services previously unavailable because of the limitations imposed by their health conditions.

Deciding when and how to engage in telepractice will vary based on the individual patient, the practitioner's understanding and level of comfort with the technology, laws and regulations related to telepractice, and research around the selected technology. However, practitioners will find that by asking key questions, they are then self-directed to an informed and appropriate decision regarding the use technology in their practice. As required by the HIPAA Security Rule (Health Insurance Portability and Accountability Act 2003) and the HITECH Act (Health Information Technology for Economic and Clinical Health 2009), practitioners should engage in regular assessment about the technology they use, the protocols for securing patient information, and the relevant laws governing telepractice.

Conclusions and Future Directions

Technology advances and evolves. To keep from being lost in the wake of the past, there are five major areas of which practitioners ought to be aware as they move forward with telepractice. First, practitioners should remain familiar with new devices, programs, and uses of technology in providing telepractice services. Next, practitioners should keep current their personal knowledge of the research and practice of telepractice. Third, as technology becomes more integrated into clinical practice, third-party payers will likely increasingly support telepractice, thereby offering practitioners greater opportunities for telepractice. Fourth, practitioners should stay abreast of the evolving efforts at the federal and state levels to provide directives, guidance, and regulations for telepractice.

As the marriage of technology with service provision grows, mental health service providers in outpatient and private practice settings will grow as well. Ensuring and maintaining competency is a core ethical behavior, and is critical to appropriate delivery of telepractice. Awareness of key critical concerns that arise when using technology allows practitioners to make truly informed decisions regarding the use of technology to enhance the services they provide to their patients.

Footnotes

Disclosures

No competing financial interests exist.

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