by David Nickelson, Psy.D., J.D.
Practitioner Focus, August 1997
Public Relations and Communications
Practice Directorate
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The health care marketplace continues to evolve, presenting an ever-widening range of professional practice challenges and opportunities. One example is the increasing use of advanced computing and communication technologies by health systems to track patients, analyze data and support clinical service delivery. To ensure that psychology remains on the cutting edge of such technological developments, APA governance and the Practice Directorate recently began examining the potential impact of the rapidly evolving fields of 'telehealth' and 'behavioral telehealth' on psychology practice.
Telehealth and behavioral telehealth involve the use of telecommunications and information technology to provide access to health assessment, diagnosis, intervention, consultation, supervision, education and information across distance. This includes e-mail and Internet searches via desktop computer as well as real-time, full-color video and stereo audio teleconferencing hookup via mobile satellite downlinks.
The Practice Directorate's first effort related to telehealth was to support the APA Board of Professional Affairs' (BPA) response to a Board of Director's request for 'recommendations regarding the development and implementation of association policy related to on-line psychotherapy and counseling.' BPA appointed a six-member task force, which met once in December of last year. The task force reviewed journals, publications, legislation and other sources of information regarding telecommunications and health, and developed its 'On-Line Psychotherapy and Counseling Task Force Report.' This past June, BPA accepted the task force report and forwarded it to the APA Board of Directors.
Overall, the task force report concluded that 'health care technology and application are evolving rapidly, and that attempting to offer recommendations regarding on-line therapy without taking into account a broader set of issues would not be an ideal use of resources.' The broader issues identified by the task force included the impact of proposed, pending and existing telehealth and telecommunication legislation.
For example, the task force learned about a recent California law that prohibits insurance companies from refusing to pay for clinical services provided via telehealth technology. Clinical psychologists are specifically included on the list of providers eligible for reimbursement. The task force also learned about a number of bills pending in the U.S. Congress that attempt to craft solutions to issues such as telehealth reimbursement through Medicare, harmonization of professional licensure requirements, privacy and confidentiality. Additional legislative proposals would create new practice opportunities for mental health providers in rural and underserved communities.
Licensure and Malpractice Issues Surface
The task force noted that legal and regulatory issues thus far have received the most state and federal attention, particularly licensure and malpractice issues. Telehealth effectively removes travel from a patient's or provider's decision about whom to consult, and raises the issue of which state has the power to regulate or discipline a provider who enters a state to 'practice' via telehealth technology. Additionally, the question arises about which state or jurisdiction would be the reasonable place for a provider to answer a telehealth malpractice claim.
The task force report also raised issues around which APA governance could provide guidance to members who encounter and use telehealth technology. These include ethical concerns around competence and technological skills, distance learning and educational (including continuing education) opportunities, and privacy and confidentiality of mental health records and telehealth services.
While enthusiastic about telehealth's potential, the task force offered a number of caveats, emphatically stating that, 'nothing available in today's market can replace the face-to face interaction of patient and health care providers.' The task force expressed a concern that wide-scale adoption of behavioral telehealth technology could exploit practitioners or force them only to see patients online in an effort to reduce costs.
In order to take advantage of the BPA task force's various recommendations, APA governance is currently exploring the best mechanism for carrying this group's work forward.
More recently, in an effort to ensure that BPA and other APA governance leaders are provided with timely expert information regarding state, federal, and private industry telehealth policy developments, Practice Directorate staff have begun taking part in work groups that support the federal Joint Working Group on Telemedicine (JWGT), an interagency work group coordinating almost all federal administrative telehealth activity. Recently, the JWGT published a 'Telemedicine Report to Congress,' considered by many to be the single most important compendium of telehealth benefits and business.
By participating in these work groups and staying abreast of developments in federal and state telehealth activity, Practice Directorate staff will be in a position to facilitate the work of BPA and other governance telehealth-related activities. At the same time, APA will play a role in providing the JWGT with information on the unique needs of behavioral health consumers and practitioners.
(Editor's Note: The 'Telemedicine Report to Congress' is available on-line at http://www.ntia.doc.gov/reports/telemed/cover.htm)
