Cover Story

As more psychologists enter the realm of telehealth services, the profession is facing myriad legal and regulatory issues. Since 1996, APA's Board of Professional Affairs (BPA) has held discussions on such topics as telecommunications for therapy, professional relationships, informed consent, electronic medical records and their security, e-mail, electronic claims submission and other issues. Other APA governance bodies are expected to take up the issues in the next few months.

Perhaps the most pressing is whether it is legal for a psychologist licensed in one state to treat a client in another state by telephone or over the Internet. Must the practitioner be licensed in the state where the client lives? If a malpractice issue should arise, which state would have jurisdiction?

"As the nation turns more to an Internet culture, the professions are going to need to address this issue," says David Nickelson, PsyD, JD, director of technology policy and projects in APA's Practice Directorate. "Otherwise the marketplace will address it for them. And likely address it badly."

So far, no state legislature has addressed telehealth as it relates to psychology. Some states have, however, begun restricting physician practice across state lines. A number of others are considering such laws, according to the federal Office for the Advancement of Telehealth.

Meanwhile, a task force of the Association of State and Provincial Psychology Boards (ASPPB) plans this year to propose model regulations for state licensing boards that would address telehealth practices.

In 1997, ASPPB added language to its model state act on psychology practice indicating that a psychologist licensed in good standing could practice in another state for 30 days a year, either by physical presence or telecommunications. As yet, no state has enacted that provision. ASPPB's model language seeks to make it clear that in telehealth situations, the practice of psychology occurs where the client is and the psychologist brings herself or himself under the jurisdiction of that board.

Telehealth issues raise some thorny and unprecedented problems, notes Emily Bentley, ASPPB associate general counsel: What psychological services can be competently provided via telehealth? If no one knows who is treating whom, how do you ensure quality service? If a psychologist does not know where a patient is, how can the practitioner call for help in the case of an emergency, such as suicidal threats?

And, as if the complex issues for all health-care practice were not enough, telehealth has implications for the nation's balance of political power.

"Historically, the states have had the authority to regulate activities affecting the health, safety and welfare of their citizens," the federal Office of Advancement of Telehealth notes in an update report on the issue.

That includes regulating and licensing health professions. If states now have to cede that power, or use it only in concert with other states, that could undermine their authority on other regulations, in commerce and many aspects of the new telecommunication economy.

Nevertheless, Nickelson says, due to the demands for services, many telehealth issues will be settled in this decade. It's preferable, he says, that they be settled by the deliberation of the professions and not because of a crisis, such as Congress acting after people are hurt.

Russ Newman, PhD, JD, APA executive director for practice, adds that "the need for ethical standards, laws or regulations is seriously complicated by the exponential development of the technology. The application of telecommunications technology to the delivery of health-care services is likely to be far more advanced in a few years. What we need is a framework--one might say a constitution--to apply no matter what form the technology takes, rather than many discrete laws addressing the current technology in concrete ways."

Further Reading

For more information on telehealth regulation, visit the Office for the Advancement of Telehealth online at http://telehealth.hrsa.gov.