Overview
CE credits: 1
Learning objectives: After reading this article, CE candidates will be able to:
- Identify the pitfalls psychologists might encounter if they want to use telehealth with patients while traveling.
- Consider how legal and ethical issues affect a therapist’s ability to work with clients across jurisdictional boundaries.
- Discuss the importance of getting training in telehealth before pursuing it.
For more information on earning CE credit for this article, go to www.apa.org/ed/ce/resources/ce-corner.
Atlanta clinical psychologist Jennifer F. Kelly, PhD, travels about once a month for meetings and speaking engagements, often for work related to being on APA’s Board of Directors. Thankfully, a colleague at her private practice helps fill in if her clients need to be seen while she’s on the road. But it would certainly be convenient, as well as beneficial to providing more continuous patient care and a boost to Kelly’s income, if she could treat clients remotely, via telepsychology, when she’s away from her office.
"It would be really nice if I could do a couple of therapy sessions when I’m gone to ease some of the financial burden that comes from serving APA," Kelly says. "But I don’t because of all the constraints that exist in terms of providing therapy sessions across state lines."
Jennifer Sweeton, PsyD, a private practitioner in the Kansas City, Kansas, area, does provide telepsychology services when she’s out of town for conferences, speaking engagements and even vacations. She uses Doxy.me to conduct sessions, though it requires due diligence before and during each trip to ensure she’s up on all the legal, ethical and clinical considerations she might encounter. That includes researching the licensing laws in the state she’s traveling to and ensuring any client she’s treating via the telepsychology platform has signed an informed consent form that details the limits of confidentiality when using technology to conduct a psychotherapy session.
"Before I travel, I always check out APA’s telepsychology guidelines, as well as the website of the licensing board where I’m traveling, so that I’m aware of what the regulations are," Sweeton says. "You always want to know ahead of time what you’re dealing with."
Not all psychologists are as conscientious, says Alex Siegel, JD, PhD, director of professional affairs at the Association of State and Provincial Psychology Boards (ASPPB).
"Psychologists often just don’t know the rules to follow or the questions to ask, so they just assume they can do whatever they want," Siegel says.
But until more states adopt laws that enable telepsychology over state lines (see "State compact seeks to ease restrictions"), practitioners who want to provide telepsychology on the road must first determine the jurisdictional issues of the "originating site," which is where the client is located, and the "distant site," which is the therapist’s location, and what state laws apply.
The practitioner's legal obligations
Psychologists need to be aware of the temporary privilege laws in the distant site they’re visiting, Siegel says. While some licensing boards give psychologists free rein when it comes to practicing temporarily from their states, others provide it for a limited time frame (anywhere from a few days to a few weeks) and still others don’t allow it at all. Some boards require a fee and others expect the practitioner to take the state’s jurisprudence exam.
Sweeton says the best approach is to review the analysis of telemental/telebehavioral health regulations developed in 2017 by the health-care law firm Epstein Becker Green to find out what a state’s policy is, and then verify that the rule hasn’t changed by going to the state’s licensing policy page. If that doesn’t provide a clear answer, it’s in the psychologist’s best interest to reach out to the licensing board—by email or telephone—for clarification, says Marlene Maheu, PhD, executive director of the Telebehavioral Health Institute.
"The bottom line is that the clinician has to be in compliance with their own legal code as well as that of the state where the patient is located at the time of the contact," she says.
To minimize risk, Maheu explains, psychologists should be aware of and in compliance with the laws ruling the discipline wherever the client or patient is located at the time of the contact, and not just in their state of residence. State laws differ from one state to another in many important respects, she adds. "If something goes wrong and you are not in full compliance with the correct state law, you can incur some unwelcome consequences." This may include losing one’s license or some other disciplinary action by the state psychology board.
It’s also important to consider the type of telehealth situation that the psychologist is attending to, says Deborah Baker, JD, director of legal and regulatory policy in APA’s Practice Directorate. "It’s one thing if you’re triaging a patient over the phone in the midst of a crisis and helping them get emergency care, as opposed to just conducting business as usual via telepsychology because you didn’t want to miss patient appointments or lose revenue when you’re on vacation or traveling for work," Baker says. "The risks to the client of a therapist not taking the call in the first instance may be far greater than taking it and being considered practicing without a license for 10 minutes in a certain jurisdiction."
Ethical considerations
Outside of the legal considerations, practitioners must also ensure they are following APA’s Ethics Codeopens in new window when using telepsychology with clients.
For example, in Standard 2.01: Boundaries of Competence, the code advises psychologists to only provide services within the boundaries of their competence based on their education, training, supervised experience, consultation, study or professional experience. This means that practitioners can’t provide telehealth without any training, Maheu says. They need to make sure they are competent to do therapy over videoconferencing, ensure that they understand the equipment, are ready to deal with technology breakdowns and have a back-up plan if the session gets disconnected.
"Practitioners need at least an introductory course on telepsychology so they can understand the basic competencies needed," Maheu says. Such training can help psychologists better understand the privacy concerns inherent in using technology, as well as how practitioners can safeguard confidentiality and protect patient information. That includes making sure they use platforms that comply with the Health Insurance Portability and Accountability Act (HIPAA) and insisting on business associate agreements with these companies, just as they would for a billing company or legal firm, Baker says.
Being sure to only use secure internet connections is also crucial. Hotel and café Wi-Fi, for example, are not secure. Instead, psychologists should use a virtual private network (VPN) to create a secure, encrypted connection between the practitioner’s computer and a server operated by the VPN service before accessing the telepsychology platform, Sweeton says. She recommends that practitioners avoid free VPN services as they often don’t provide adequate protection. It’s also important to research whether the VPN is known to be good for travel specifically, she says.
"You need to be able to take it with you, and it needs to have servers in many places across the country, as well as air-tight security," she says.
It’s also critical that if practitioners are considering using telepsychology, they have patients sign an informed consent that discusses the limitations of the therapist in terms of where he or she is licensed and that telehealth can never be 100 percent confidential, says Linda Campbell, PhD, a former chair of APA’s Ethics Committee and co-chair of APA’s Telepsychology Task Force.
In addition to having patients sign an informed consent, it’s also important that psychologists educate patients about the importance of maintaining, as much as possible, the professional nature of the session via telepsychology, just as they would at in-person therapy sessions, says Lindsay Childress-Beatty, JD, PhD, APA’s interim ethics director. Additional direction on this can be found in APA’s Guidelines for the Practice of Telepsychology.
"As soon as you move therapy to a different environment, patients might start to respond more casually," she says. "They may not consider who might walk by and interrupt the session or whether their clothing is appropriate for therapy when they’re having a session through telehealth."
Clinical and reimbursement considerations
It’s also important for the psychologist to examine any possible clinical concerns there may be from using telehealth. It’s certainly not for every client, says Campbell.
"Some clients may not have the ability to or want to work through technology," says Campbell, a psychology professor at the University of Georgia. "Practitioners really need to think about each client individually, and whether therapy can be effective through video and telecommunications means."
If a client does seem to benefit from telepsychology once in a while, the psychologist needs to take the time to talk this option through with the client to explain all that’s involved as well as the limits of confidentiality. In such cases, the client should sign an additional informed consent if the therapist’s current informed consent doesn’t already address telepsychology.
Psychologists are also advised to educate themselves on telehealth reimbursement policies. Similar to interstate licensing laws, every jurisdiction and insurance company has a different policy when it comes to paying for these services.
Regardless of whether psychologists choose to provide telehealth while traveling, it’s always important to have back-up coverage in place, Campbell says. Ensuring there’s a colleague or another psychologist in an affiliated practice who can see clients during an absence can help put the psychologist and clients more at ease. It also gives practitioners a greater opportunity for getting a true break during vacations. Helen L. Coons, PhD, an APA board member and president and clinical director of Health Psychology Solutions, always alerts her patients when she is going to be gone for work or vacation and sets up her voicemail to indicate the name and phone number of a colleague who will be covering for her while she’s gone. She also lets her referral sources know if she is going to be away.
"I want them to know that there’s going to be a delay," Coons says. "That’s just good for patient coordination and collaborative care."
