Originally published in Counseling Today

Providing Therapy Services Via Telelhealth

Evidence is mounting that, under the right circumstances, telehealth can be as effective as in-person delivery of services (see bit.ly/15XL8or). Consequently, interest in this mode of service delivery has been increasing swiftly and exponentially. Even the Department of Veterans Affairs (VA), known by counselors to be slow to effect change, has been significantly involved in the implementation and growth of telehealth services. For those interested in pursuing this relatively new paradigm, there are multiple factors to consider and, in some cases, significant barriers to overcome.

Telehealth (also known as telemental health, e-therapy, distance counseling, “Skype therapy” and telemedicine) is the delivery of medical or counseling services via email, chat, telephone or synchronous video chat. The majority of current focus is on the use of synchronous video because it provides the experience closest to in-person sessions.

Telehealth is a growing trend that holds much promise for the growth of mental health care, in part because of the convenience it offers to clients. However, several technical, legal and ethical issues must be addressed. This article provides only a brief overview — a jumping-off point, if you will. I encourage all counselors who are thinking about offering telehealth services to fully educate themselves on the full range of implications.

Following are some initial factors to consider when exploring options for providing therapy in a digital environment.

Benefits of Telehealth

There are several potential benefits to providing therapy services via telehealth. Among them:

• Increased access – Telehealth services may remove barriers to access for clients who have disabilities or who live in remote rural locations.
• Convenience – Telehealth services reduce or eliminate travel time for both clients and clinicians and can remedy scheduling issues.
• Cost savings – In addition to the savings related to travel and time, telehealth can provide significant savings in business costs for clinicians who may be able to work from a home office.
• Barrier removal – Some people are more likely to participate in online counseling because of the perceived stigma associated with seeing a mental health clinician. In addition, those who struggle with social anxiety, agoraphobia or similar conditions might feel less threatened by online counseling than by in-person sessions.

Technology/HIPAA

It should go without saying, but you will need to use reliable technology for the delivery of telehealth services. A connection that “breaks” regularly in the middle of sessions won’t be conducive to productive counseling work. In addition, if you are a covered entity under the Health Insurance Portability and Accountability Act (HIPAA), you must heed HIPAA regulations when conducting e-therapy.

Whether you provide telehealth through video, chat or email, you must heed the privacy and security specifications of HIPAA and HITECH (the Health Information Technology for Economic and Clinical Health Act) and, if applicable, have a business associate agreement with the vendor of the technology you are using. You may recall from the Technology Tutor column in May that a “conduit exception” to this rule exists if you can ensure the vendor does not have access to the data or encryption keys. Your privacy, security and informed consent documents should also cover these services. Even if you are not a covered entity under HIPAA, some laws and insurance panels require that you use an encrypted solution. In some cases, synchronous video is the only allowed or reimbursable delivery method.

Licensure Portability

Many of us are painfully aware that most states do not have reciprocity agreements when it comes to counseling licensure. Most of us are licensed only in our state of residence, while a few may also carry licensure in one or two other states. Some state licensure laws not only prevent licensees from practicing outside of the state, but also specifically prevent those who don’t hold licensure in that state from practicing telehealth with residents of the state. This means that you may put your licensure in danger if you practice telehealth across state lines.
Before offering telehealth services, be sure to consult the licensure laws in your state, the laws of other states where your potential telehealth clients reside and an attorney.

Ethics

There are additional ethical considerations when conducting counseling via telehealth. Following are just a sampling of important issues to consider.

• How will you handle informed consent?
• How will you verify the identity of the client you are working with?
• How will you handle crisis/emergency situations with distant telehealth clients?
• What are the implications of counseling without some of the typical interpersonal cues and dynamics that exist in an office setting?
• Are you competent in the use of technology and delivery of counseling via electronic means?

One way to ensure that you stay within legal and ethical boundaries is to pursue continuing education. For example, the Center for Credentialing and Education, an affiliate of the National Board for Certified Counselors, offers a distance credentialed counselor certification (see cce-global.org/DCC/Training). Although not strictly required in most cases to practice telehealth, the credential is a way to document that you have the experience and training to practice telehealth professionally, legally and ethically.

Insurance Reimbursement

Depending on the state in which you practice, insurance may reimburse for telemedicine. At last count, around 20 states had passed some form of legislation requiring private insurance to reimburse for telemedicine (see bit.ly/15XAWMJ and bit.ly/15XCuGq), and proposals have been put forth in at least another dozen states. In most states, Medicaid regulations are addressed separately and may differ from those for private insurance companies.

The laws vary widely from state to state. Some are so specific as to allow only certain professionals to practice in very specific circumstances (for example, only when the recipient lives in a remote area). Others require that the fees charged must be equal to those for face-to-face care. Many laws, passed and proposed, require the services to be delivered via synchronous video.

In states where legislative mandates have not been passed, it is rare to find a private insurance company that will reimburse for telehealth counseling. When insurance companies do allow for it, extensive restrictions are often applied.
This is a very active topic legislatively. At the time this column is being written, bills are under consideration in several states as well as at the federal level. It’s possible that even more states will have adopted laws regarding telehealth by the time this is published. Be sure to investigate the laws in your state and the policies of your paneled insurance companies before proceeding.

The Cutting Edge

From a business standpoint, telehealth is currently a much more viable option for coaches or counselors who do not deal with insurance because they will have fewer barriers to cross. Those barriers are lessened in states where insurance must reimburse at a competitive rate.
Regardless, telemedicine is a potential avenue for growth because it can involve less overhead cost, while greatly increasing your potential market. In addition, new areas are being explored and researched for their effectiveness, including avatar therapy, in which the counselor and/or client operate in a virtual world. This can be as straightforward as avatars representing the counselor and client meeting in an online virtual world such as Second Life (secondlife.com/). It can also be something more akin to play therapy, where assessments are made or therapeutic goals achieved as a client interacts with a virtual environment and the objects within.

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Want to learn more? Here are some other sites that provide great resources on the topic

• TherapyTech with Rob And Roy (Episode 105) – Free podcast about technology in private practice.  Episode 105 deals with telemental health!
• Telemental Certification Institute – Telemental Health Training site.
• 50 State Survey of Telemental/Telebehavioral Health  — This report by Epstein, Becker and Green is a survey of the telehealth laws for various professions in each state.
• Behavioral Health Innovation (telementalhealthcomparisons.com): Features independent comparisons of available telemental health technologies
• American Telemedicine Association (americantelemed.org): International professional organization promoting telemedicine
• International Society for Mental Health Online (ismho.org): International community exploring and promoting mental health in the digital age