Telehealth Service Agreements

Mental health is moving into the digital era with increasing use of telehealth services. In preparing my own practice for this new form of service delivery, I have reviewed some 20 separate sets of office agreements by mental health professionals across the country. Despite the variety of forms, a number of principles emerge that seem to be setting a standard for the use of this modality.

Definitions
Sometimes called telemedicine, teletherapy, distance therapy, e-therapy, internet therapy, or online therapy, telehealth involves using electronic media to provide interactive, real-time mental health services remotely, including consultation, assessment, diagnosis, treatment planning, counseling, psychotherapy, coaching, guidance, psychoeducation, and the transfer of medical information. Telehealth includes both video and audio communication, either over the phone or over the Internet using videoconferencing software. Telehealth services don't include email or texting, however.

Basic Standards
Telehealth is covered by the same laws and ethics that guide in-office, in-person, face-to-face mental health service. Therefore, policies and consents already in use in the professional's office will apply to telehealth services. However, there are additional components to cover the unique characteristics of telehealth services.

Advantages and Disadvantages
Proper informed consent should include a balanced disclosure of the potential advantages and disadvantages of this form of service delivery. The chief advantage is that telehealth can provide continuity of care flexibly when an in-person service cannot be conducted. However, telehealth is not a universal substitute for in-person mental health service. Telehealth services may not provide the same level of comfort when talking about personal matters. Misunderstandings can occur, and this may have an impact on the therapeutic relationship.

Contraindications
Some presenting problems will not lend themselves well to telehealth services. These may include overwhelming or potentially dangerous circumstances––for example, psychosis, suicidality, or other clinical emergencies in which in-person assessment or intervention may be necessary.

Only a Part of Care
Under many if not most circumstances, telehealth may be best to augment services to established patients who continue to have at least intermittent contact in the office with the clinician. Consequently, telehealth is frequently used when the patient is unable to come in to the office due to temporary limitations. Examples of these limitations include medical conditions that prevent physical mobility, distance due to travel, and scheduling conflicts. If periodic in-person sessions cannot be arranged, the clinician might discuss referral to another appropriate provider who is more accessible or local.

Licensure
An important limitation in telehealth service is that services are being provided under a state-regulated license. This is generally interpreted to mean that both patient and therapist should physically be located within the state of licensure at the time that service is rendered. However, many states do allow mental health professionals licensed in another state to provide a limited number of hours of service within their state. So, there may at times be a conflict between licensing jurisdiction and the best interest of the patient. The best interest of the patient should come first. An example is when a patient is temporarily out of state but would suffer clinically from the lack of continuity of care with a provider who is familiar with the patient's history, circumstances, and mental health needs.

Confidentiality
The laws that protect confidentiality also apply to telehealth sessions, including mandatory and permissive exceptions. Because of a greater risk of being overheard by a third party on either end of a telehealth session, the consent should include a recommendation that the session be conducted in an enclosed private room and with no one else present or observing without the other's consent. Moreover, a thorough consent may include a statement that both patient and psychotherapist agree to not record a telehealth session without prior written consent of both parties.

Security
No electronic transmission system can be considered completely safe from intrusion. Electronic media and the internet pose inherent risk for release of private information, including audio and images. The patient should be advised that they are responsible for the security of their own laptop, tablet, or smartphone.

While a variety of software programs are available for videoconferencing, such as Skype, FaceTime, or GoToMeeting, not all are encrypted––or compliant with federal law to protect the privacy of healthcare information. Look for software that is HIPAA-compliant.

Scheduling
Just like an in-person appointment, telehealth sessions are generally scheduled in advance. Prior arrangement should be made about who will initiate the session. The therapist should establish a policy regarding technical difficulty in establishing a connection, for example, how long or how many times the therapist will attempt to reach the patient and when the therapist will discontinue if a connection is not established, analogous to an unkept appointment.

Telephone
When using a telephone to provide telehealth services, not all phone calls are equally secure. A landline is preferable because it is more secure, more reliable, and often offers clearer audio quality.

Video Conferencing
A telehealth agreement may stipulate that the patient is responsible for their own hardware and software, audio and video peripherals, and conductivity and bandwidth considerations. In the event that a video telehealth session is interrupted after several reasonable attempts by technical difficulties, it is recommended that the patient be open to having a telephone session as a backup.

Payment
A thorough consent may clarify that telehealth is a professional service and that a fee is charged, either at the same or a different rate than in-person services. A consent may also caution that while health insurance often covers in-person services, health insurance may limit or deny coverage for telehealth services. It is wise to remind the patient they are responsible to know in advance what their insurance may or may not cover. For example, videoconferencing may be covered while telephone sessions are not. If their insurance does not cover telehealth services, specify how services will be charged.

Technical Instructions
In preparing for an initial telehealth session, provide some specific technical instructions to the patient in advance. Video conferencing software may be recommended.  Instructions for set-up can include taking time to learn and test the software ahead of time, exchange login information, and conducting a brief test call.

Videoconferencing requires attention to video and audio quality, including sufficient light and minimal glare, camera angle so faces can be seen, and freedom from extraneous noise. The most critical part of a video conference is not the picture but the sound. A headset or earbuds are often better than a speaker and microphone. "Doubletalk" is a phenomenon when people at both ends of the conference speak at the same time. Doubletalk may cause audio feedback, echo, or clipping because audio has a very slight delay.

Conclusion
While telehealth is a new and flexible vehicle for providing mental health services, think through a fully-informed consent to address the unique characteristics that telehealth creates.

Jim De Santis, Ph.D., is a clinical psychologist in full time private practice in Glendale and Glendora. He has been licensed thirty years. He offers talks, workshops, and individualized consultation to mental health professionals on building a private practice. Dr. De Santis has authored the marketing text, “The business of practice: Building an optimal private practice for mental health professionals.” He is President of the Glendale Area Mental Health Professionals Association (www.gamhpa.org) and the East San Gabriel Valley Mental Health Professionals Association. Dr. De Santis can be contacted at www.JJDeSantis.com.mailto:JJDeSantis@aol.com. A version of this article was originally printed in the ESGV Newsletter, Autumn 2017. This article does not serve as legal advice..